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Metz JB, Otjen JP, Perez FA, Done SL, Brown ECB, Wiester RT, Jenny C, Kelton MC, Ganti SN, Feldman KW. Are Complex Skull Fractures Indicative of Either Child Abuse or Major Trauma in the Era of 3-Dimensional Computed Tomography Imaging? Pediatr Emerg Care 2022; 38:e200-e204. [PMID: 32868622 DOI: 10.1097/pec.0000000000002214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The aim of the study was to determine whether complex skull fractures are more indicative of child abuse or major trauma than simple skull fractures. DESIGN This is a retrospective chart and imaging review of children diagnosed with a skull fracture. Subjects were from 2 pediatric tertiary care centers. Children younger than 4 years who underwent a head computed tomography with 3-dimensional rendering were included. We reviewed the medical records and imaging for type of skull fracture, abuse findings, and reported mechanism of injury. A complex skull fracture was defined as multiple fractures of a single skull bone, fractures of more than 1 skull bone, a nonlinear fracture, or diastasis of greater than 3 mm. Abuse versus accident was determined at the time of the initial evaluation with child abuse physician team confirmation. RESULTS From 2011 to 2012, 287 subjects were identified by International Classification of Diseases, Ninth Revision, code. The 147 subjects with a cranial vault fracture and available 3-dimensional computed tomography composed this study's subjects. The average age was 12.3 months. Seventy four (50.3%) had complex and 73 (49.7%) had simple fractures. Abuse was determined in 6 subjects (4.1%), and a determination could not be made for 5 subjects. Adding abused children from 2013 to 2014 yielded 15 abused subjects. Twelve of the abused children (80%) had complex fractures; more than the 66 (48.5%) of 136 accidentally injured children (P = 0.001; relative risk = 1.65 [1.21-2.24]). However, among children with a complex fracture, the positive predictive value for abuse was only 7%. CONCLUSIONS Complex skull fractures frequently occur from accidental injuries. This study suggests that the presence of complex skull fractures should not be used alone when making a determination of abuse.
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Affiliation(s)
- James B Metz
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT
| | | | | | | | - Emily C B Brown
- Children's Protection Program, General Pediatric Division University of Washington, Seattle Children's Hospital
| | - Rebecca T Wiester
- Children's Protection Program, General Pediatric Division University of Washington, Seattle Children's Hospital
| | - Carole Jenny
- Children's Protection Program, General Pediatric Division University of Washington, Seattle Children's Hospital
| | | | | | - Kenneth W Feldman
- Children's Protection Program, General Pediatric Division University of Washington, Seattle Children's Hospital
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Metz JB, Otjen JP, Perez FA, Done SL, Brown ECB, Wiester RT, Jenny C, Ganti S, Feldman KW. Fracture-Associated Bruising and Soft Tissue Swelling in Young Children With Skull Fractures: How Sensitive Are They to Fracture Presence? Pediatr Emerg Care 2021; 37:e1392-e1396. [PMID: 32205799 DOI: 10.1097/pec.0000000000002058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine how reliable scalp bruising and soft tissue swelling/cephalohematomas (STS) are for underlying young child skull fractures. METHODS This was a retrospective clinical and imaging review from 2011 to 2012 of children younger than 4 years with skull fractures from 2 tertiary care hospitals. Imaging was reread by 3 pediatric radiologists. Descriptive statistics were utilized. The retrospective review had institutional review board approval. RESULTS We identified 218 subjects for review: 210 unintentional and 8 abusive. One hundred forty-three had available 3-dimensional computed tomography reconstructions: 136 unintentional and 7 abused. Two-thirds were younger than 1 year. Twelve subjects had visible scalp bruising, but 73% had clinically and 93% radiologically apparent fracture-associated STS. There was no difference in clinical STS with simple (79%) versus complex (68%) fractures. Nor was there difference in subjects with fractures from minor (77%) versus major (70%) trauma. Unintentionally injured infants did not differ from abused for detectable STS (74% vs 50%). Parietal and frontal bones most frequently sustained fractures and most consistently had associated STS. CONCLUSIONS Clinically apparent STS is present in approximately three-fourths of children with skull fractures. It may not be important to consistently identify skull fractures in unintentionally injured children. Point-of-care ultrasound may be adequate. For abuse concerns, it is important to identify skull fractures as evidence of cranial impacts and intracranial hemorrhages. The most sensitive, widely available imaging technique, cranial computed tomography scan with 3-dimensional skull reconstruction, should be utilized. Scalp bruising is present in a minority of young children with skull fractures. Its absence does not exclude cranial impact injury.
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Affiliation(s)
- James B Metz
- From the Children's Hospital, Department of Pediatrics, University of Vermont, Burlington, VT
| | | | | | | | - Emily C B Brown
- Children's Protection Program, University of Washington, Seattle Children's Hospital
| | - Rebecca T Wiester
- Children's Protection Program, University of Washington, Seattle Children's Hospital
| | - Carole Jenny
- Children's Protection Program, University of Washington, Seattle Children's Hospital
| | | | - Kenneth W Feldman
- Children's Protection Program, University of Washington, Seattle Children's Hospital
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Metz JB, Otjen JP, Perez FA, Done SL, Brown EC, Wiester RT, Jenny C, Ganti S, Feldman KW. Delays in care seeking for young children with accidental skull fractures are common. Acta Paediatr 2021; 110:1890-1894. [PMID: 33176011 DOI: 10.1111/apa.15660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/02/2020] [Accepted: 11/05/2020] [Indexed: 11/29/2022]
Abstract
AIM We sought to determine the frequency and patterns of delayed medical care seeking for young children with skull fractures. METHODS We identified accidental skull fractures <4 years old, 2011-2012. Child abuse paediatricians abstracted retrospective data and paediatric radiologists re-reviewed images. 'Delays' were defined as presentation at ≥6 h. 'Minor accidents' included falls <4 feet and low force trauma, while 'major accidents' included higher height falls and major force events. We studied the frequency and duration of care delays, the signs or symptoms leading to care, and the duration of delays after signs or symptoms developed. RESULTS Two hundred and ten children had accidental skull fractures. Delays were less likely with major accidents (4.9%), than with minor accidents (25.8%) (RR = 0.32 [0.15-0.70]). Children came to care for scalp swelling (STS) (39%), the injury event (36.2%), altered consciousness (15.2%) and vomiting (10.5%). Delayed onset of STS (78.6%) caused most delayed care. Early STS was firm, (17.6%) versus delayed (5.0%), as opposed to soft or fluctuant. CONCLUSION Delayed care seeking is common for minor, but not major accidental infant and toddler skull fractures. Most followed delayed onset of signs and symptoms. Delayed care seeking alone should not imply child abuse.
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Affiliation(s)
- James B. Metz
- Department of Paediatrics University of Vermont Children’s Hospital University of Vermont Burlington Vermont USA
| | - Jeffrey P. Otjen
- Department of Radiology Seattle Children's HospitalUniversity of Washington Seattle Washington USA
| | - Francisco A. Perez
- Department of Radiology Seattle Children's HospitalUniversity of Washington Seattle Washington USA
| | - Stephen L. Done
- Department of Radiology Seattle Children's HospitalUniversity of Washington Seattle Washington USA
| | - Emily C.B. Brown
- Children’s Protection Program Seattle Children's HospitalUniversity of Washington Seattle Washington USA
| | - Rebecca T. Wiester
- Children’s Protection Program Seattle Children's HospitalUniversity of Washington Seattle Washington USA
| | - Carole Jenny
- Children’s Protection Program Seattle Children's HospitalUniversity of Washington Seattle Washington USA
| | - Sheila Ganti
- Clinical Research Coordinator Seattle Children's Hospital Seattle Washington USA
| | - Kenneth W. Feldman
- Children’s Protection Program Seattle Children's HospitalUniversity of Washington Seattle Washington USA
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Abstract
OBJECTIVES Skull fractures can be difficult to recognize on radiographs and axial computed tomography (CT) bone windows. Missed findings may delay abuse diagnosis. The role of three-dimensional (3-D) reconstructions in child abuse evaluations was retrospectively evaluated. METHODS Twelve exemplary cases between August 2006 and July 2009 are described. All, except 2 medical-legal cases, were clinical abuse consultations. With the use of a 1-to-3 scale, ease and accuracy of interpretation of findings between plain films, bone windows, and 3-D CT images were independently assessed by 2 radiologists. RESULTS In 7 cases, skull fractures were missed on initial review of skull films and/or bone windows. Three children sustained additional abusive injury before 3-D CT reconstructions demonstrated subtle skull fractures, though imaged, were missed on initial readings. Three children with initially unrecognized fractures had timely 3-D reconstructions confirming fractures, allowing protective intervention before additional injury. An unrecognized ping-pong fracture was discovered on 3-D reconstructions with an inflicted subdural hemorrhage, defining the injury as an impact. Two 3-Ds demonstrated communication of biparietal fractures along the sagittal suture. This changed interpretation to single, rather than 2 separate, concerning impacts. Three potential skull fractures were found to represent large sutural bones. In all cases, ease and accuracy of interpretation scores were highest for 3-D CT. CONCLUSIONS Without increasing patient radiation exposure, 3-D CT reconstructions may reveal previously unrecognized skull fractures, potentially allowing abuse diagnosis before additional injury. They may clarify normal skull variants and affirm accidental injury causes. We now routinely include 3-D reconstructions on cranial CTs for children younger than 3 years.
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Affiliation(s)
- Marguerite T Parisi
- From the Departments of *Radiology, and †Pediatrics, ‡Seattle Children's; §University of Washington School of Medicine; and ∥Harborview Hospital, University of Washington School of Medicine, Seattle, WA
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Darling SE, Done SL, Friedman SD, Feldman KW. Frequency of intrathoracic injuries in children younger than 3 years with rib fractures. Pediatr Radiol 2014; 44:1230-6. [PMID: 24771095 DOI: 10.1007/s00247-014-2988-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 02/11/2014] [Accepted: 03/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Research documents that among children admitted to trauma intensive care units the number of rib fractures sustained indicates the child's likelihood of having and severity of intrathoracic injury. This has been misused in court to argue that children with multiple rib fractures who lack intrathoracic injury have abnormal bone fragility rather than inflicted injury. OBJECTIVE To determine frequency of intrathoracic injuries in children younger than 3 years with rib fractures in cases of child abuse and accidental trauma. MATERIALS AND METHODS We conducted a retrospective review of rib fractures caused by documented abuse or accidents from 2003 to 2010 in children treated at Seattle Children's Hospital and Harborview Medical Center. A senior pediatric radiologist and radiology fellow independently reviewed the imaging. Children with bone demineralization were excluded. Descriptive and simple comparative statistics were used. RESULTS Seventy-two percent (47/65) of infants and toddlers with rib fractures were abused. Abused children had more rib fractures than accidentally injured children (5.55 vs. 3.11, P = 0.012). However intrathoracic injuries as a whole (55.6% vs. 12.8%, P < 0.001) and individual types of intrathoracic injuries were more common with accidents. Rates of other thoracic cage injuries did not differ substantially (27.8% accidents vs. 12.8% abuse, P = 0.064). Intracranial and intra-abdominal injuries and skull fractures were equally frequent, but other extrathoracic fractures were more common with abuse (70.2% vs. 16.7%, P < 0.001). CONCLUSIONS Abused infants and toddlers have fewer intrathoracic injuries but more rib fractures than accidentally injured peers. This likely reflects different injury mechanics. Lack of intrathoracic injuries in abused children with rib fractures does not imply bone fragility.
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Affiliation(s)
- Stephen E Darling
- The Department of Radiology, Kapiolani Children's Hospital, Honolulu, HI, USA
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Marquardt ML, Done SL, Sandrock M, Berdon WE, Feldman KW. Copper deficiency presenting as metabolic bone disease in extremely low birth weight, short-gut infants. Pediatrics 2012; 130:e695-8. [PMID: 22869833 DOI: 10.1542/peds.2011-1295] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Copper deficiency can cause bone lesions in infants, which might be confused with child abuse. Two extremely low birth weight preterm infants had complicated medical courses requiring prolonged parenteral nutrition for short-gut syndrome, which led to the development of cholestasis. Both had spent their entire lives in the hospital. They had been on prolonged ventilator support for chronic lung disease. They developed signs of copper deficiency between 5 and 6 months of age, initially raising child abuse concerns. Musculoskeletal discomfort led to the recognition of radiographic findings of metabolic bone disease. Included were osteoporosis, metaphyseal changes, and physeal disruptions. Copper levels were low; both low copper parenteral nutrition and gut losses from refeeding diarrhea likely contributed to their deficiency. Therapeutic supplementation with copper corrected their deficits and clinical and radiologic findings. The information from these cases, in particular, their radiologic findings, indicate the need to monitor copper status in at-risk premature infants. These findings may aid prevention and earlier recognition of copper deficiency. Their specific radiologic and clinical findings should aid differentiation of such children from abused infants.
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Affiliation(s)
- Michelle L Marquardt
- Department of Pediatrics-Graduate Medical Education, Seattle Children’s Hospital, The University of Washington School of Medicine, Seattle, Washington, USA
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Walker CM, Takasugi JE, Chung JH, Reddy GP, Done SL, Pipavath SN, Schmidt RA, Godwin JD. Tumorlike Conditions of the Pleura. Radiographics 2012; 32:971-85. [DOI: 10.1148/rg.324115184] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Muensterer OJ, Berdon WE, Lachman RS, Done SL. Pseudoachondroplasia and the seven Ovitz siblings who survived Auschwitz. Pediatr Radiol 2012; 42:475-80. [PMID: 22426567 DOI: 10.1007/s00247-012-2364-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 01/02/2012] [Accepted: 01/06/2012] [Indexed: 12/31/2022]
Abstract
This historical report focuses on the first clinical description of pseudoachondroplasia and its radiographic findings. Only half a century ago, pseudoachondroplasia was recognized as a genetic disorder with a distinct but variable phenotype of short stature, normal facial features, and progressive joint problems starting in adolescence. Radiologically, the disease is particularly intriguing because the patients appear normal at birth. The patients develop the typical gait disturbances when they begin to walk. Radiographs show the characteristic anterior tongue-shaped lumbar vertebral body changes that develop after the first year of life. This account presents the most well-known group of individuals affected by pseudoachondroplasia, the Ovitz family, who narrowly escaped death in the concentration camp of Auschwitz in 1944 because of SS physician Dr. Josef Mengele's fascination with dwarfs. It was not until 1995 that the underlying genetic defect in the COMP gene was identified on chromosome 19.
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Affiliation(s)
- Oliver J Muensterer
- Division of Pediatric Surgery, Department of Surgery, Komansky Center for Children's Health, Weill Cornell Medical College, New York Presbyterian, 525 E. 68th St., New York, NY 10065, USA.
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Done SL. Fetal and neonatal bone health: update on bone growth and manifestations in health and disease. Pediatr Radiol 2012; 42 Suppl 1:S158-76. [PMID: 22395728 DOI: 10.1007/s00247-011-2251-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 08/02/2011] [Accepted: 08/30/2011] [Indexed: 12/19/2022]
Abstract
The neonatal period is classically described as the first 28 days of life, but owing to the fact that changes in skeletal tissue occur at a somewhat slower pace than those of other organ systems, events of the first few months are considered herein. Neonatal bone health is a problem of growing interest and concern because of the increasing recognition of its impact upon childhood, adolescent and even adult bone health. Osteoporosis in adulthood often has its roots in childhood and some forms may be prevented by proper attention to neonatal and childhood bone health. The premature infant likely suffers lifelong decreased bone mineral density as a result of its early birth and lack of adequate mineral stores that are typically present in full-term infants. Adequate embryogenesis, growth and development of the skeletal system are multifactorial and under the influence of a host of genes, growth factors and enzymes. The evaluation of skeletal dysplasias and their recognition are beyond the scope of this paper and will not be considered in this discussion. Here the focus will be on the adequacy of mineralization and metabolic aspects of the growth and development of the fetal and neonatal skeleton, the effect of birth, both preterm and term, maternal illness and health as well as infant diseases.
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Affiliation(s)
- Stephen L Done
- Department of Radiology, Seattle Children's Hospital, University of Washington, R5417, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
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Abstract
Computed tomographic (CT) scans of 24 bronchopulmonary sequestrations in 23 patients were reviewed. Seventeen sequestrations were diagnosed at surgery, three at angiography, and four on the basis of radiographic or CT findings combined with appropriate history. Sixteen sequestrations were intralobar, and eight were extralobar; 21 were posterobasal. Seventeen occurred on the left side and seven on the right. Anomalous systemic arterial supply was demonstrated by CT in 16 sequestrations. In the others, a systemic artery was not shown, presumably because of unfavorable orientation or small size of the vessel. The lung abnormalities shown by CT were classified into three types: A = cysts containing air or fluid (n = 8), or soft-tissue masses (n = 2); B = emphysematous lung surrounding cysts, and/or soft-tissue nodules (n = 13); and C = lung hypervascularity (n = 2). In only three cases did the chest radiograph show the emphysematous lung tissue. Such emphysematous lung has rarely before been reported as a CT finding, and lung hypervascularity has not, to the authors' knowledge, been reported. The authors conclude that CT can be helpful in the diagnosis and evaluation of bronchopulmonary sequestration. Characteristic manifestations are (a) a complex lesion containing solid or fluid components combined with emphysematous lung or (b) any basal lesion supplied by a systemic artery.
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Affiliation(s)
- J Ikezoe
- Department of Radiology, University of Washington, Seattle 98195
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McAdams HP, Geyer CA, Done SL, Deigh D, Mitchell M, Ghaed VN. CT and MR imaging of Canavan disease. AJNR Am J Neuroradiol 1990; 11:397-9. [PMID: 2107726 PMCID: PMC8334709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- H P McAdams
- Department of Radiology, Walter Reed Army Medical Center, Washington, DC 20307
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Abstract
The polysplenia syndrome is the association of multiple spleens, situs inversus, congenital heart disease, and azygous continuation of the inferior vena cava. Magnetic resonance (MR) is a noninvasive imaging modality which can easily confirm the multiplicity of spleens, situs inversus, and identify complex congenital cardiovascular malformations. The anomalies of the polysplenia syndrome as imaged by MR are presented.
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Affiliation(s)
- J S Jelinek
- Department of Radiology, Walter Reed Army Medical Center, Washington, D.C. 20307-5001
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Abstract
The purpose of this report is to call attention to the clinical, myelographic, and computed tomographic appearance of a very rare type of dural cyst within the lumbosacral spinal canal. We report this condition in three unrelated boys who presented with symptoms of cauda equina compression. Our experience suggests that these cysts are congenital in origin. Anatomically, the cyst wall consisted of a dura-like layer without arachnoid. There was a small ventral defect allowing incomplete communication with the compressed subarachnoid space. Cerebrospinal fluid-like fluid accumulated within the interdural cyst as a result of this communication. Treatment consisted of obliteration of the point of entry between cyst and subarachnoid space in all cases and partial cyst wall excision in one case. After operation, the two patients who had presented with long-standing sphincter disturbance had partial improvement in function and the child with a pain syndrome was completely relieved of symptoms.
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