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Non-accidental trauma is a very important topic

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that I will not be spending a lot of time on here,

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but something to always keep in the back of your mind.

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In pediatric patients, particularly very young toddlers

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or infants, sometimes we encounter evidence

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of non-accidental trauma on dedicated skeletal surveys

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or bone surveys that are done specifically to evaluate

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for abuse due to clinical concern.

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But sometimes we catch evidence

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of non-accidental trauma on imaging done for other reasons,

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such as failure to thrive, lethargy, cough,

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or poor appetite.

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And so it's important to recognize the types of findings

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that you might encounter on airway and chest imaging.

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The first case I'll show you is of an infant.

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This patient did have dedicated

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non-accidental trauma skeletal survey imaging,

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and we're focusing on the chest.

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I'm going to focus on this frontal chest radiograph

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and zoom in a little bit right off the bat.

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There are a couple things to note.

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The hum eye are within the field of view of this patient,

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and you can see that there's a displaced fracture of

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that right humerus in a non-ambulatory child.

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Any fractures are highly suspicious

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for non-accidental trauma,

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although it's not always the case.

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Certainly accidental trauma does happen in

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non-ambulatory babies.

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However, you have to have some level of concern to talk

1:32

with the clinicians just to make sure we don't miss it.

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So in addition to that humeral fracture, we have

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multiple rib fractures.

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If you are unaccustomed to looking for rib fractures,

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you want to look for both acute

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and healing changes of rib fractures

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in non-accidental trauma.

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Very frequently these fractures will be of the posterior

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or lateral ribs.

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We can see multiple areas of callus

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in the bilateral ribs,

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both posteriorly like here and here and here,

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but also laterally in multiple ribs as well.

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In the protocol for a skeletal survey, often we will get

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oblique images of the ribs to further evaluate

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for any subtle fractures.

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So again, on that right side, we see healing callus

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of multiple fractures.

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It's important not to confuse the ossification centers

2:38

of the sternum with fractures.

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Sometimes these round ossification centers happen

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to be superimposing directly over a rib.

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Don't confuse that for a healing fracture.

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This is an incomplete fused sternum

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with its ossification centers.

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When in doubt you can always go to another view. So here's

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The opposite oblique,

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and again, we can see not only the healing callous

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of these fractures, but you can even see the original

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lucencies in these fractures.

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And so again, it's important to look for acute

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fracture lines like we see in the humerus

3:17

elsewhere in other bones,

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but it's also important to look for healing fractures.

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The final image here is kind of of the full chest

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and abdomen.

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So we can zoom in

3:29

and we see many of the same fractures a little bit better.

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We might see this left sided fracture posteriorly.

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So when you see one or multiple healing and

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or acute fractures, you should be on high alert

3:43

for non-accidental trauma.

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This particular patient did have additional fractures

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throughout the skeleton, including

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multiple classic meta aile lesions,

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which is described in child abuse

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and will not be getting into that in detail with this case.

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But we'll briefly mention it in the next case.

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This next case is another patient,

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and we will zoom in a little bit here

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on the chest radiograph.

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And what I really wanna illustrate here is

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that if you have a patient who comes in for cough

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or respiratory symptoms, don't forget to look

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outside of the thorax.

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So in addition to looking at all the structures

4:20

that you would normally look at within the thorax,

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make sure you look at every single structure

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that is captured on that radiograph.

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That includes all of the bones, all the way out

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to the edges of the film.

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So when you do that with this patient, you'll notice

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that the left humeral metaphysis looks abnormal

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and asymmetric to the right.

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If we zoom in further, we can see

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that there's some irregularity

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and some separation between this little slip

4:48

of bone from the rest of the metaphysis.

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This looks different than the other side.

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We have normal ossification centers of the humeral head here

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as we do here and here.

4:59

But then we have this extra little sliver of bone that is

5:05

the classic metaphyseal lesion

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or sometimes called a bucket handle tear of the metaphysis

5:11

that can occur in young babies due to non-accidental trauma.

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The mechanism is thought to be due

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to an excessive pulling mechanism that just vols

5:21

that metaphysis.

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And in this particular patient,

5:24

likely this is in early stages of healing with a little bit

5:27

of callous forming around it, not available on your viewer,

5:31

but this is an additional image of that same patient.

5:34

And you can see again the irregularity

5:36

and the thickening of the metaphysis with this little bit

5:39

of a vols bone fragment due to

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a meta fassil corner fracture,

5:45

also called a classic meta fassil lesion.

5:48

And then finally, this is another case of a patient

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for whom you don't want to ignore findings

5:55

outside of the thorax. So

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In addition to whatever we would say about the

6:00

intrathoracic findings, note that this patient

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when we zoom in, has an asymmetric fracture

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of the distal right clavicle with some healing changes.

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It looks different than the left side, and that's

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because it's fractured and it's healing.

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This is important because like with the other cases,

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these patients can sometimes present

6:23

with seemingly unrelated symptoms.

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And so you wanna make sure that you look at every single

6:28

structure on the film, including all the bony structures

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to exclude any kind of fracture

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or any other unexpected finding.

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There are a number of other findings that we can see

6:41

with non-accidental trauma throughout the skeleton,

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but for the purposes of this talk,

6:46

we'll focus on making sure that you

6:50

evaluate all the bones on the film, whatever they happen

6:52

to be, and make sure they look normal

6:55

and symmetric to the other side.