0:00

This is Pediatrics week 2 case number

0:03

two, and the diagnosis were considering here is non-accidental

0:06

trauma.

0:08

Now this is obviously a sobering case but it

0:11

is something that is encountered in multiple

0:14

settings in multiple areas of

0:17

healthcare and it's something that the Pediatric radiologist or

0:20

any radiologist needs to be aware of No Matter

0:23

What study that they're reading now, once

0:26

the suspicion of non-accidental trauma has

0:29

been raised a skeletal survey ought

0:32

to be performed and the idea with a

0:35

skeletal survey is not to fit as many bones onto

0:38

the radiograph as possible. But rather to

0:41

obtain dedicated views of all of the axial

0:44

and appendicular skeleton in order to have

0:47

the highest degree of sensitivity.

0:50

When we're detecting fractures and Bone injuries, and

0:53

then as a radiologist, your knowledge

0:56

will help with your specificity to identify. What is

0:59

a normal variant or what is a non-concerning

1:02

finding.

1:04

So the typical skeletal survey should consist of multiple

1:07

radiographs and when I protocol a

1:11

skeletal survey, I like to get radiographs obviously

1:14

not just of the chest but in addition to

1:17

that oblique images that help with identification of

1:20

rib injuries.

1:22

Also AP and lateral views of the cervical

1:25

thoracic and lumbar spine, which is what

1:28

you're seeing here.

1:29

And then

1:31

AP and lateral views of the pelvis and of

1:34

the long bones, so here we've

1:37

got the upper extremities.

1:41

And then the more distal aspects of those upper

1:44

extremities.

1:46

and hands

1:48

and then the same goes for the lower extremities and in the appendicular

1:51

skeleton. It's especially important to

1:54

look at the metaphaseal ends of the

1:57

long bones because that is the location where the

2:00

classic metaphysical lesion which is been well described

2:03

in the literature can be found and

2:06

The benefit of identifying a classic metaphysical lesion

2:09

is that it can really zero in

2:12

the diagnosis not just a fracture but of non-accidental

2:15

injury and that's because the velocity required

2:18

to create the injury that

2:21

we call a classic metaphysical lesion

2:24

or sometimes it's described as a corner fracture or

2:27

sometimes it's described as a bucket handle fracture the velocity

2:30

of acceleration deceleration a

2:33

whipping injury. You might say is only

2:36

possible when a very large human being like an

2:39

adult.

2:40

Creates that force on a very small human being

2:43

like an infant and that's why at some

2:46

point in the past. This diagnosis was called shaken baby

2:49

syndrome. We don't use that term anymore, but it

2:52

does describe the mechanism of injury.

2:55

And when the limbs are flailing back and forth, it can

2:58

create that injury to the metaphysis. So there's the

3:01

final AP and lateral images of the lower extremities and

3:04

the bones of the feet. I'm going to skip all the way

3:07

back to the beginning of this skeletal survey because I want

3:10

us to look at the ribs and in particular, I want

3:13

us to focus on the posterior ribs, and you may notice

3:16

if you've already been paying attention that we've got

3:20

a posterior rib fracture right here

3:23

And if you imagine this is a morbid thought

3:26

but it's valuable for the diagnostic radiologist. If you

3:29

imagine an adult holding on to the thorax of

3:32

an infant the thumbs would wrap around to

3:35

the front of the chest and land about where the

3:38

clavicles are and the fingers would wrap

3:41

around to the back.

3:43

And touch the posterior ribs right where we see

3:46

this fracture here, so that type of injury is

3:49

due to the grip often of the person

3:52

who is inflicting this non accidental injury.

3:56

And that's why we look especially carefully at the posterior

3:59

ribs and also at the anterior ribbons. And

4:02

so the anterior kind of at the

4:05

costochondral junction can also sometimes show

4:08

a bulbous enlargement so you can see here and

4:11

here they're slightly greater bone.

4:15

Area then on these more distal lower

4:18

ribs, and if we look back onto the

4:21

first chest radiograph we can see as

4:24

well that there's some small difference at

4:27

the anterior rib end here. Then there is here but

4:30

it's a little more difficult to perceive. So we obtain

4:33

a bleak views to look at the ribs. And when we

4:36

do have those oblique views, we can see not just

4:39

the posterior healing rib fractures, but we

4:42

can also see some lateral rib fractures and there are

4:45

several others on this film as well. Moving ahead to the

4:48

appendicular skeleton.

4:51

We can see on this skeletal series

4:54

that there's an acute fracture at the midshaft of

4:57

the humerus. It's obliquely oriented. There's

5:00

very subtle displacement.

5:02

That injury is not normal, of course, but

5:05

not necessarily specific for child abuse for

5:08

non-accidental trauma. However in this same

5:11

bone if we look proximally back at the

5:14

humeral metaphysis, you can see this thin flake

5:17

of bone and I'm going to magnify that this thin

5:20

flake of bone right here.

5:23

at the very

5:25

proximal aspect of the humerus and that is

5:28

actually a thin bit of the metaphysis.

5:32

That has been peeled back from that acceleration deceleration

5:35

injury that I was describing earlier and

5:38

you can see that there's an almost wispy appearance

5:42

to it where you've got the metaphysical

5:45

margin of the bone here.

5:48

And then if I look with my

5:51

red pen, you can see a very thin little bit

5:54

of bone there and a little bit there and a little bit there and those

5:57

are areas of the metaphysis that have been peeled

6:00

up by that accelerating decelerating

6:03

motion.

6:05

That is a classic metaphysical lesion

6:08

much more specific for the diagnosis of

6:11

child abuse than a mid-shaft oblique fracture.

6:14

But all of these inevitably occurred through

6:17

the same mechanism. We have multiple fractures in

6:20

multiple areas of the body. The only

6:23

other thing that we might look for is fractures that

6:26

various stages of healing and if

6:29

we look at this humorous, we can see an acute fracture

6:32

with no signs of healing or bone callus. But if

6:35

I take us back to these rib injuries, we

6:38

can see here that some healing and callus has

6:41

formed around the ribs and here and here

6:44

as well. So that means that we have acute fractures.

6:47

We have Subacute fractures and this

6:50

complex of findings is very concerning for

6:53

non-excidental trauma, and that's the end of

6:56

the case.