Which radiological investigations should be performed to identify fractures in suspected child abuse?

AIMS

To determine which radiological investigations should be performed and which children should be investigated.

MATERIALS AND METHODS

An all language literature search of original articles; from 1950-October 2005. Two reviewers independently reviewed each article. A third was carried out on disagreement. Each study was assessed using standardised data extraction, critical appraisal and evidence forms.

RESULTS

Thirty-four studies were included. Fifteen addressed the question: which investigation has a higher yield, skeletal surveys (SS) or bone scintigraphy (BS)? Studies gave conflicting results. Overall neither investigation is as good as the two combined. BS predominately missed skull, metaphyseal and epiphyseal fractures, whereas SS commonly missed rib fractures. Two studies showed that a repeat SS 2 weeks after the initial study provided significant additional information about tentative findings, the number and age of fractures. A comparative study evaluated additional oblique views of ribs in 73 children and showed improved diagnostic sensitivity, specificity and accuracy. Four studies addressed the diagnostic yield for occult fractures with respect to age. This was significant for children under 2-years old.

CONCLUSIONS

In children under 2-years old, where physical abuse is suspected, diagnostic imaging of the skeleton should be mandatory. SS or BS alone is inadequate to identify all fractures. It is recommended that all SS should include oblique views of the ribs. This review suggests that the following options would optimize the diagnostic yield. However, each needs to be evaluated prospectively: SS that includes oblique views, SS and BS, a SS with repeat SS or selected images 2 weeks later or a BS plus skull radiography and coned views of metaphyses and epiphyses.

Safety of surfaces and equipment for children in playgrounds

BACKGROUND

The safety of playgrounds is important to protect children from injury, but studies are mostly done mainly under laboratory conditions without epidemiological data. We investigated the safety of different playground surfaces, and types and heights of equipment in public playgrounds in the City of Cardiff, UK.

METHODS

We did a correlational study of 330 children aged between 0 and 14 years. All children were hurt when playing in playgrounds in Cardiff and presented to the Accident and Emergency Department in Cardiff Royal Infirmary during summer (April to September) 1992 and 1993, and the whole of 1994. We studied the children's hospital records to establish the type of injury and interviewed their parents to find out the playground and type of equipment involved. The main outcome measures were the number of children injured whilst playing, and injury rates per observed number of children on different surfaces, types, and heights of equipment.

FINDINGS

Children sustained significantly more injuries in playgrounds with concrete surfaces than in those with bark or rubberised surfaces (p < 0.001). Playgrounds with rubber surfaces had the lowest rate of injury, with a risk half that of bark and a fifth of that of concrete. Bark surfaces were not significantly more protective against arm fractures than concrete. Most injuries were equipment related. Injury risk due to falls from monkey bars (suspended parallel bars or rings between which children swing) was twice that for climbing-frames and seven times that for swings or slides. The height of the equipment correlated significantly with the number of fractures (p = 0.005) from falls.

INTERPRETATION

Rubber or bark surfacing is associated with a low rate of injuries and we support their use in all public playgrounds. Bark alone is insufficient, however, to prevent all injuries, particularly arm fractures. Rubberised impact-absorbing surfaces are safer than bark. We believe that playing on monkeys bars increases the risk of injury in playgrounds and that they should generally not be installed. Safety standards should be based on physical and epidemiological data. Our data suggest that the proposed raising of the maximum fall height from 2.5 m to 3.0 m in Europe is worrying.

Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation

OBJECTIVES

To investigate outcome, management, and prevention in Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.

DESIGN

Ascertainment through British Paediatric Surveillance Unit and questionnaires to responding paediatricians.

SETTING

The UK and Republic of Ireland, September 1992 to August 1994.

SUBJECTS

Children under 14 years diagnosed with the above.

MAIN OUTCOME MEASURES

Placement and child protection measures for victims and siblings; morbidity and reabuse rates for victims; abuse of siblings; prosecution of perpetrators.

RESULTS

Outcome data for 119 with median follow up of 24 months (range 12 to 44 months). No previously diagnosed factitious disease was found to have been caused by genuine disease. Forty six children were allowed home without conditions at follow up. Children who had suffered from suffocation, non-accidental poisoning, direct harm, and those under 5 years were less likely to go home. Twenty seven (24%) children still had symptoms or signs as a result of the abuse at follow up; 108/120 were originally on a child protection register and 35/111 at follow up. Twenty nine per cent (34/118) of the perpetrators had been prosecuted and most convicted; 17% of the milder cases of Munchausen syndrome by proxy allowed home were reabused. Evidence in siblings suggests that in 50% of families with a suffocated child and 40% with non-accidental poisoning there would be further abuse, some fatal.

CONCLUSIONS

This type of abuse is severe with high mortality, morbidity, family disruption, reabuse, and harm to siblings. A very cautious approach for child protection with reintroduction to home only if circumstances are especially favourable is advised. Paediatric follow up by an expert in child protection should also occur.

Patterns of injuries to children on public playgrounds

The incidence and pattern of injuries to children in public playgrounds presenting to the accident and emergency department were reviewed over two six month summer periods in Cardiff. A total of 178 children (mean age 7.5 years) attended with a playground injury representing 1.1% of all the children attending. One hundred and five children fell from equipment, of which the commonest was the climbing frame; 125 children had playground surface related injuries, 86 on bark and 30 on concrete. The pattern of injuries on the playground surfaces was different: fractures and sprains were more common on bark surfaces and lacerations and abrasions on concrete surfaces. Comparison of total injury rates showed there were fewer injuries on modernised playgrounds than expected but these differences were not significant. Modernised playgrounds are more popular, have new exciting equipment, and offer good play opportunities for children. However, the high fracture rate on modernised bark playgrounds is concerning and requires further research.

The incidence of severe physical child abuse in Wales

OBJECTIVES

The purposes of this study were: (1) to ascertain the incidence and nature of severe physical child abuse in Wales; (2) to ascertain the incidence of all physical abuse in babies under 1 year of age; and (3) to determine whether child protection registers (CPR) accurately reflect the numbers of children who are physically abused.

METHODS

This is a population-based incidence study based in Wales, UK, for 2 years from April 1996 through March 1998. Children studied were under the age of 14 with severe physical abuse consistent with the criminal law level of Grievous Bodily Harm. This included seven categories of injury (death; head injury including subdural hemorrhage; internal abdominal injury; physical injury in Munchausen Syndrome by Proxy including suffocation; fracture; burn or scald; adult bite). Cases were ascertained by a pediatrician surveillance reporting system (WPSU). A criterion for inclusion was multidisciplinary agreement that physical abuse had occurred (at case conference, strategy meeting, or Part 8 Review). The incidence of all babies under 1 year of age with physical abuse was also studied. Ascertainment of babies under the age of 1 year was undertaken from CPR as well as the WPSU.

RESULTS

Severe abuse is six times more common in babies [54/100,000/year (95% CI +/- 17.2)] than in children from 1 year to 4 years of age [9.2/100,000 (95% CI +/- 3.6)]. It is 120 times more common than in 5- to 13-year-olds [0.47/100,000 (95% CI +/- 0.47)]. This is mainly because two types of serious abuse (brain injury including subdural hemorrhage and fractures) are more common in babies under the age of 1 year than older children. Using data from two sources (the WPSU and CPRs), the incidence of physical abuse in babies is 114/100,000 (CI 114 +/- 11.8) per year. This equates to 1 baby in 880 being abused in the first year of life. The largely rural Health Authority area in Wales had incidence figures for abuse in babies that were 50% of the three other predominantly urban Health Authority areas. Boys throughout the series were more at risk of being severely abused than girls (p < .025). Only 29% of the babies under 1 year of age on the CPR had actually been injured. Thirty percent of abused babies under the age of 1 year and 73% of severely abused children over the age of 1 year had caused previous concern to health professionals regarding abuse or neglect.

CONCLUSIONS

Physical abuse is a significant problem in babies under the age of 1 year. Very young babies (under 6 months old) have the highest risk of suffering damage or death as a result of physical abuse. Severe abuse, in particular subdural hematoma and fracture, is much more common in babies than in older children. There is evidence of failure of secondary prevention of child abuse by health professionals, with a greater need to act on concerns regarding abuse and neglect. Interagency child protection work in partnership with parents should focus more on protecting babies under age 1 year from further abuse than on maintenance of the infant within an abusive home. The CPR is not intended as an accurate measure of children suffering abuse. It is a record of children requiring a child protection plan and must not be used as a measure of numbers of abused children.

Are abused babies protected from further abuse?

A cohort of 69 physically abused babies under 1 year was followed for three years after the incident. Of the 49 babies who returned home following child protection investigations, 15 were further abused in the three year period, a re-abuse rate of 31%, which is grossly higher than the abuse rate in the general population.

Head injury and limb fracture in modern playgrounds

There were no serious head injuries in modern Cardiff municipal playgrounds with safety surfaces over five years injury surveillance. The literature suggests serious head injuries did occur before the introduction of safety surfaces.

Differences in protein kinase C and estrogen receptor alpha, beta expression and signaling correlate with apoptotic sensitivity of MCF-7 breast cancer cell variants

Widespread use of MCF-7 human breast cancer cells as a model system for breast cancer has lead to variations in these cells between different laboratories. Although several reports have addressed these differences in terms of proliferation and estrogenic response, differences in sensitivity to apoptosis have just begun to be described. Based on the possible differences in apoptotic sensitivity that may arise due to the existence of MCF-7 cell variants, we determined the relative sensitivity of MCF-7 cell variants from three established laboratories (designated M, L and N) to known inducers of apoptosis. Consistent with our previous studies we demonstrate that differences exist among these variants in regards to tumor necrosis factor alpha (TNF)-induced cell death and inhibition of proliferation in a dose-dependent manner. To establish if the difference in apoptotic susceptibility was specific to TNF, the three MCF-7 cell variants were tested for their response to other known inducers of apoptosis: okadaic acid, staurosporine and 4-hydroxy-tamoxifen. Viability and DNA fragmentation analysis revealed a similar pattern of resistance to apoptosis by all agents in the MCF-7 M variant. The MCF-7 L variant was resistant to okadaic acid and 4-hydroxy-tamoxifen but not staurosporine. In contrast, MCF-7 N cells were sensitive to induction of apoptosis by all agents. The role of both protein kinase C (PKC) and estrogen signaling in the regulation of cell survival prompted investigation of these pathways as a mechanism for differential sensitivity of MCF-7 cell variants to apoptosis. While both estrogen receptor alpha (ERalpha) and ERbeta were expressed in MCF-7 M and N cells, the absence of ERbeta in MCF-7 L cells correlated with decreased estrogen responsiveness of the L variant. Variations in estrogenic responsiveness and PKC isoform expression may account for the enhanced susceptibility of both the L and N variants to staurosporine.

Combined Motor and Sensory Intraoperative Neuromonitoring for Cervical Spondylotic Myelopathy Surgery Causes Confusion: A Level-1 Diagnostic Study

STUDY DESIGN

Level-1 diagnostic study.

OBJECTIVE

The purpose of this study was to evaluate the sensitivity and specificity of combined motor and sensory intraoperative neuromonitoring (IONM) for cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

Intraoperative neuromonitoring during spine surgery began with sensory modalities with the goal of reducing neurological complications. Motor monitoring was later added and purported to further increase sensitivity and specificity when used in concert with sensory monitoring. Debate continues, however, as to whether neuromonitoring reliably detects reversible neurologic changes during surgery or simply adds set-up time, cost, or mere medicolegal reassurance.

METHODS

Neuromonitoring data using combined motor and sensory evoked potentials for 540 patients with CSM undergoing anterior or posterior decompressive surgery were collected prospectively. Patients were examined postoperatively to determine the clinical occurrence of new neurologic deficit which correlated with monitoring alerts recorded per established standard criteria.

RESULTS

The overall incidence of positive IONM alerts was 1.3% (N = 7) all of which were motor alerts. All were false positives as no patient had clinical neurological deterioration post-operatively. The false-positive rate was 1.4% (N = 146) for anterior surgeries and 1.3% (N = 394) for posteriors with no statistical difference between them (P = 1.0, Fisher exact test). There were no false-negative alerts, and all negatives were true negatives (N = 533). The overall sensitivity of detecting a new neurologic deficit was 0%, overall specificity 98.7%.

CONCLUSION

Combined motor and sensory neuromonitoring for CSM patients created a confusing choice between the motor or sensory data when in disagreement in 1.3% of surgical patients. Criterion standard clinical examinations confirmed all motor alerts were false positives. Surgical plan was negatively altered by following false motor alerts early on, but disregarded in later cases in favor of sensory data. Neuromonitoring added set-up time and cost, but without clear benefit in this series.Level of Evidence: 4.

Overutilization of bracing in the management of penetrating spinal cord injury from gunshot wounds

OBJECTIVE

Penetrating gunshot wounds (GSWs) to the spinal column are stable injuries and do not require spinal orthoses or bracing postinjury. Nonetheless, a high number of GSW-related spinal cord injury (SCI) patients are referred with a brace to national rehabilitation centers. Unnecessary bracing may encumber rehabilitation, create skin breakdown or pressure ulcers, and add excessive costs. The aim of this study was to confirm the stability of spinal column injuries from GSWs and quantify the overutilization rate of bracing based on long-term follow-up.

METHODS

This retrospective cohort study was performed at a nationally renowned rehabilitation center. In total, 487 GSW-related SCI patients were transferred for rehabilitation and identified over the last 14 years. Retrospective chart review and telephone interviews were conducted to identify patients who were braced at the initial treating institution and determine if late instability, deformity, or neurological deterioration resulted in secondary surgery or intervention. In addition, 396 unoperated patients were available for analysis after 91 patients were excluded for undergoing an initial destabilizing surgical dissection or laminectomy, thereby altering the natural history of the injury. All of these 396 patients who presented with a brace had bracing discontinued upon reaching the facility.

RESULTS

In total, 203 of 396 patients were transferred with a spinal brace, demonstrating an overutilization rate of 51%. No patients deteriorated neurologically or needed later surgery for spinal column deformity or instability attributable to the injury. All patients had stable injuries. The patterns of injury and severity of neurological injury did not vary between patients who were initially braced or unbraced. The average follow-up was 7.8 years (range 1–14 years) and the average age was 25 years (range 10–62 years).

CONCLUSIONS

The incidence of brace overutilization for penetrating GSW-related SCI was 51%. Long-term follow-up in this study confirmed that these injuries were stable and thus did not require bracing. No patients deteriorated neurologically, whether or not they were initially braced. The unnecessary use of spinal orthoses increases costs and patient morbidity. Reeducation and dissemination of this information is warranted.

American Spinal Injury Association A (sensory and motor complete) is not different from American Spinal Injury Association B (sensory incomplete, motor complete) in gunshot-related spinal cord injury

BACKGROUND CONTEXT

We receive a large number of patients with spinal cord injury (SCI) due to penetrating gunshot wounds (GSW) at our national rehabilitation center. Although many patients are labeled American Spinal Injury Association (ASIA) B sensory incomplete because of sensory sparing, especially deep anal pressure, with purported prognostic value, we have not observed a clinical difference from patients labeled ASIA A complete. We hypothesized that sensory sparing, if meaningful, should reduce the occurrence of pressure ulcers.

PURPOSE

To determine if ASIA classifications A and B are important distinctions for patients with SCIs secondary to civilian gunshot wounds.

DESIGN/SETTING

A retrospective chart review was performed on all patients with civilian gunshot-induced SCI transferred to Rancho Los Amigos Rehabilitation Center between 1999 and 2014. Outcome measures were occurrence of pressure ulcers and surgical intervention for pressure ulcers.

PATIENT SAMPLE

We included a total of 487 patients who sustained civilian gunshot wounds to the spine and were provided care at Rancho Los Amigos Rehabilitation Center from 2001 to 2014.

OUTCOME MEASURES

Occurrence of pressure ulcers and surgical intervention for pressure ulcers among patients who suffered civilian-induced gunshot wounds to the spine.

METHODS

Retrospective chart review identified 487 SCIs due to gunshot wounds that were treated at Rancho Los Amigos from 2001 to 2014. Injury characteristics including ASIA classification, pressure ulcers, and pressure ulcer surgeries were recorded. Comprehensive surgical data were obtained for all patients. Chart reviews and telephone interviews were performed to determine the occurrence of any pressure ulcers and pressure ulcer surgeries. Statistical analysis was performed to compare data by spinal region and ASIA grade. There were no conflicts of interest from any of the authors, and there was no funding obtained for this study.

RESULTS

There was no statistical difference for cervical ASIA A versus ASIA B for the occurrence of pressure ulcers or the percentage requiring surgery, nor for thoracic A versus B. When grouped, there was a statistically higher occurrence of pressure ulcers in cervical A or B classification than in thoracic A or B classification, but a higher rate of surgery for thoracic A or B classification. Lumbosacral cauda equina levels were not statistically different in occurrence of pressure ulcers or pressureulcer surgery by ASIA grades A-D. Overall, when grouped C1-T12, cord-level cervicothoracic A and B classifications were statistically equivalent. C1-T12 cord level C or D classification with motor sparing had statistically lower occurrence and need of surgery for pressure ulcers and were equivalent to lumbosacral cauda equina level A-D.

CONCLUSION

ASIA A and B distinctions are not meaningful at spinal cord levels in the cervicothoracic spine due to gunshot wounds as shown by similar occurrence of pressure ulcers and pressure ulcer surgery, and should be treated as if the same. Meaningful decrease of pressure ulcers at cord levels does not occur until there is motor sparing ASIA C or D. Furthermore, cauda equina lumbosacral injuries are a lower risk, which is independent of ASIA grade A-D and statistically equivalent to cord level C or D. Motor sparing at cord levels or any cauda equina level is most determinative neurologically for the occurrence of pressure ulcers or pressure ulcer surgery.

Paraplegic patients: how to measure balance and what is normal or functional?

PURPOSE

To review the current understanding and data of sagittal balance and alignment considerations in paraplegic patients.

METHODS

A PubMed literature search was conducted to identify all relevant articles relating to sagittal alignment and sagittal balance considerations in paraplegic and spinal cord injury patients.

RESULTS

While there are numerous studies and publications on sagittal balance in the ambulatory patient with spinal deformity or complex spine disorders, there is paucity of the literature on "normal" sagittal balance in the paraplegic patients. Studies have reported significantly alterations of the sagittal alignment parameters in the non-ambulatory paraplegic patients compared to ambulatory patients. The variability of the alignment changes is related to the differences in the level of the spinal cord injury and their differences in the activations of truncal muscles to allow functional movements in those patients, particularly in optimizing sitting and transferring. Surgical goal in treating paraplegic patients with complex pathologies should not be solely directed to achieve the "normal" radiographic parameters of sagittal alignment in the ambulatory patients. The goal should be to maintain good coronal balance to allow ideal sitting position and to preserve motion segment to optimize functions of paraplegia patients.

CONCLUSION

Current available literature data have not defined normal sagittal parameters for paraplegic patients. There are significant differences in postural sagittal parameters and muscle activations in paraplegic and non-spinal cord injury patients that can lead to differences in sagittal alignment and balance. Treatment goal in spine surgery for paraplegic patients should address their global function, sitting balance, and ability to perform self-care rather than the accepted radiographic parameters for adult spinal deformity in ambulatory patients.

Patterns of spinal cord injury in automobiles versus motorcycles and bicycles

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To examine the patterns and relative rates of occurrence of spinal cord injury (SCI) in automobiles compared to motorcycles and bicycles.

SETTING

Los Angeles County, California.

METHODS

A retrospective chart review of SCI consults at Rancho Los Amigos National Rehabilitation Center in Los Angeles County, California between 2003 and 2013 were selected and screened for a mechanism of injury involving a vehicular accident. Chart review was performed to determine neurological levels and extent of impairment, which were graded according to the International Standards for Neurological Classification of Spinal Cord Injury.

RESULTS

We identified 398 cases of SCI from 2003 to 2013 that fit the inclusion criteria. Overall, the relative percentages of ASIA impairment scale (AIS) A/B/C/D did not differ statistically across automobiles, motorcycles, or bicycles. When stratified by spinal region, motorcycles had a higher percentage of thoracic SCIs compared to automobiles. Automobiles resulted in more cervical SCIs with few injuries in the lumbar region. Bicycle patterns followed automobiles, not motorcycles. Thoracic SCIs were more likely graded motor complete than cervical or lumbar injuries, regardless of the mechanism.

CONCLUSIONS

Automobile, motorcycle, and bicycle related SCIs occur primarily in the cervicothoracic region. SCIs due to motorcycle accidents have a higher predilection for the thoracic region, and there is a statistically higher percentage of motor complete injuries. A higher percentage of cervical SCIs occur as a result of automobile and bicycle accidents. Extrapolations from motor vehicle usage data suggest that the relative rate of occurrence of SCI for motorcycles is higher than for automobiles.

Non-locality and the misdiagnosis of Spinal Cord Injury Without Radiographic Abnormality: proof of concept

Study Design

This is a retrospective review.

Objectives

To validate the concept of "non-locality" to explain cases of Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) previously deemed inexplicable. To investigate and challenge the source data for the SCIWORA hypothesis which has the built-in assumption that a traumatic spinal cord injury (SCI) can only be caused by a local or adjacent spinal column injury and which, therefore, postulates that the pediatric spinal column is inherently more flexible than the spinal cord to explain SCI whenever a local spinal column injury is not detected.

Setting

A National Rehabilitation Center, one of fourteen which reports to the Spinal Cord Injury Model System.

Methods

We examined all residual SCIWORA cases over a 5-year period. In addition, we performed an extensive literature search to trace the evidence supporting the SCIWORA hypothesis that children's spinal columns are inherently lax and may stretch more than the spinal cord prior to disruption.

Results

Six SCI patients with a residual diagnosis of SCIWORA were identified, 3 pediatric and 3 adult. All had injuries fitting non-locality. None were an actual SCIWORA. Source data do not appear to support the SCIWORA hypothesis.

Conclusion

Borrowing from quantum mechanics, we reveal non-locality as a real entity in the spine. The assumption of locality-only is invalid and likely contributed to the SCIWORA hypothesis for the pediatric spine. Misdiagnosis and misunderstanding of SCIWORA may lead to improper treatment and increased cost. Awareness may facilitate search for adequate explanations for difficult cases rather than mere assignment as SCIWORA.

Assessment of an Opioid Stewardship Program on Perioperative Opioid Prescribing in a Safety-Net Health System

This quality improvement study involves comparison of opioid prescription data before and after implementation of an opioid stewardship program in a safety-net medical system.