Slide 1:RADIOLOGY OF NON-ACCIDENTAL INJURY


INTRODUCTION :INTRODUCTION Child abuse defined as any abuse that poses serious risks to a child’s development and /or physical safety Includes direct physical injury such as beating, whipping, biting, shaking, beating, but also indirect injury such as smothering, drowning, poisoning or burning Originally described in 1860 by Tardieu


Slide 3:Much insight obtained through John Caffey who described the whiplash-shaken baby syndrome in 1946 Affects 1/1000 children each year in the UK, of which 1/10 000 sustains fatal injuries Often a missed diagnosis due to low index of suspicion Imaging may provide first indication of non-accidental injuries; thus mandatory that all radiologists be familiar with imaging manifestations of NAI


EPIDEMIOLOGY :EPIDEMIOLOGY Highest incidence under 1 year; often younger than 6 months Young parents Unstable family situations Low socio-economic status Disability / prematurity of child Perpertrators in descending order of frequency fathers, boyfriends, female babysitters and mothers


FACTORS TO INCREASE SUSPICION :FACTORS TO INCREASE SUSPICION Of critical importance is history, with clues to NAI being Discrepancy between reason for consultation and clinical picture Delayed presentation Psychomotor abilities inables child to perform activities parents give as reason for injury Fast improvement in hospital with rapid deterioration upon discharge


SPECTRUM OF MANIFESTATIONS :SPECTRUM OF MANIFESTATIONS Neurologic Skeletal Visceral Thoracic Genito-urinary Soft tissue and skin Emotional


NEUROLOGIC MANIFESTATIONS :NEUROLOGIC MANIFESTATIONS Whiplash-shaken baby syndrome SDH Contusion Laceration Petechial hemorrhage Cerebral oedema SAH Intraventricular blood


WHIPLASH-SHAKEN BABY SYNDROME :WHIPLASH-SHAKEN BABY SYNDROME Described by Caffey in 1946 Constellation of infantile SDH /SAH & massive cerebral edema & retinal hemorrhage & rib # / metaphyseal injury in the absence of external signs of cranial trauma – original description Average age of affected babies 5 months


MECHANISM OF INJURY :MECHANISM OF INJURY Young child have relatively large head; weak neck muscles and large CSF spaces Shaking produces rotational acceleration / deceleration forces, with or without impact injury of head striking another surface Accidental head injury in this age group most often due to fall from height, causes linear force which produces different injury


CLINICAL PRESENTATION :CLINICAL PRESENTATION 50% have severe neurological impairment 40-70% present with seizures Other common symptoms include lethargy, irritability, vomiting, poor feeding, full fontanelle


RETINAL HEMORRHAGE :RETINAL HEMORRHAGE 65-95% of patients Uni- or bilateral / may be associated with retinal detachments Pathogenesis (theories): due to increased retinal venous pressure extravasation of SAH traction on retinal vessels due to rotational forces In isolation not specific for NAI, can also occur with accidental injury, ressuscitation, papilledema, severe hypertension and coagulopathy


CT OF SHAKEN BABY SYNDROME :CT OF SHAKEN BABY SYNDROME Most common modality used in acute setting Findings include Subdural hemorrhage Cerebral contusions/ lacerations Petechial hemorrhage Cerebral oedema Reversal sign


Slide 13:SDH Most consistent finding Finding that most strongly suggests NAI in cranial imaging in young children; seen rarely in accidental trauma Often bilateral If within posterior interhemispheric fissure has particularly high specificity Most commonly seen in the temporal lobes


Slide 18:CEREBRAL CONTUSIONS / LACERATIONS/ HEMATOMAS CEREBRAL OEDEMA Usually in subacute stage PETECHIAL HEMORRHAGE Especially at gray-white matter interface and corpus callosum Result of DAI due to shearing forces


Slide 21:REVERSAL SIGN Result of cerebral oedema which progresses to hypoxic-ischaemic injury ; described by Han in 1990 CT features are that of diffusely decreased density of cerebral gray and white matter with loss of gray-white matter differentiation and relative increased density of the thalamus, brainstem and cerebellum


Slide 22:Can also be seen in other conditions,eg Accidental injury Birth asphyxia Status epilepticus Status asthmaticus Near drowning Meningitis and encephalitis Carry a poor prognosis due to irreversible brain damage . Highly specific for NAI especially if associated with interhemispheric SDH


DIFFERENTIAL DIAGNOSIS :DIFFERENTIAL DIAGNOSIS Constellation of radiological signs may be highly specific for abuse Main differential is from Herpes Simplex Encephalitis – may get hemorrhagic changes in the cortex that may superficially resemble NAI. Presence of skin lesions further complicates picture. Differentiating feature is presence of SDH – do not occur in HSV encephalitis and is highly specific for child abuse


PROPOSED PROTOCOL FOR IMAGING NAHI :PROPOSED PROTOCOL FOR IMAGING NAHI Many cases of poorly or incompletely evaluated children with suspected NAI have led to diagnostic errors with potentially tragic outcome as children are returned to abusive environment Article was published July 2002, where a protocol for imaging of these patients were proposed, based on clinical and medico-legal experience


PURPOSE OF CRANIAL IMAGING :PURPOSE OF CRANIAL IMAGING Diagnosing presence of intracranial injury Establish need for surgical intervention Provide documentary evidence for potential social or forensic investigation


ROLE OF IMAGING MODALITIES :ROLE OF IMAGING MODALITIES SKULL RADIOGRAPHY Skull vault fractures often best appreciated on plain films Main indication is forensic Sutural diastasis may be indirect sign of raised intracranial pressure No other information about intracranial content obtainable


Slide 29:ULTRASOUND Limited role May show presence of extra-axial collections or parenchymal injury, though sensitivity not comparable with CT and MRI and therefore seldomly used COMPUTED TOMOGRAPHY Primary imaging tool High sensitivity in detecting bone trauma, hemorrhage, edema and hypoxic-ischaemic injury


Slide 30:May however miss skull fracture if fracture is orientated parallel to scan plane Variable appearance of hemorrhage on CT, depending on age of hemorrhage. Individual variations exist, but generalised guidelines:


Slide 31:Variation from this may occur due to factors including: Active bleeding Low haematocrit at time of injury Serum extrusion associated with early clot retraction Fresh bleeding into pre-existing collection Leakage of CSF into subdural space through tear in arachnoid mater


Slide 32:MRI Multiplanar and multisequence capacity of MRI improves sensitivity of most pathologies encountered in NAI with exception of bone injury Acute hemorrhage difficult to demonstrate but sequences such as T2*W and FLAIR increases sensitivity Superior to CT in delineating exact extent of SDH, especially in posterior fossa and temporal lobes Low sensitivity for detecting SAH Most sensitive modality for diagnosing ischaemic change, especially with DWI Cytogenic edema seen earliest on DWI


RECOMMENDED IMAGING PROTOCOL :RECOMMENDED IMAGING PROTOCOL Applies to cases with high clinical suspicion of non-accidental head injury DAY OF PRESENTATION CRANIAL CT As soon as child is stable If normal, no further investigations indicated


Slide 37:DAY 1-2 SKELETAL SURVEY, including skull films and cranial ultrasound Plain films necessary to diagnose skull fractures DAY 3-4 MRI If initial CT abnormal, or if child develops neurological symptoms and signs MRI becomes more reliable at detecting subacute rather than acute hemorrhage


Slide 38:More accurate at defining extent of SDH, particularly adjacent to calvarium or in posterior fossa DWI of value in detecting ischaemic change CT If MRI unavailable If this CT / MRI normal, no further investigation indicated


Slide 39:DAY 10 CRANIAL CT If abnormalities detected at the day 3-4 CT / MRI Optimal time for assessment of secondary brain damage Hemorrhagic laminar cortical necrosis is characteristic feature of NAI and develops 7-10days after injury


Slide 40:2 – 3 MONTHS If early imaging revealed parenchymal brain injury or in case of persistent neurological abnormality, follow-up MRI should be done To evaluate extent of end-stage damage, especially those that may require surgical intervention eg Enlarging chronic SDH / effusions Hydrocephalus Leptomeningeal cyst (growing fracture) In latter case, CT with bony window settings and follow-up skull Xray also indicated


SKELETAL MANISFESTATIONS :SKELETAL MANISFESTATIONS Fractures occurs in 1/3 of abused children Age important 50% 5yrs and are extremely rare in infants


FACTORS TO RAISE SUSPICION :FACTORS TO RAISE SUSPICION Discovery of old fractures on Xray not reported previously Coexistence of other injury esp SDH , skin lesions Bilateral fractures of different age Fractures with advanced healing Old, consolidated fractures


Slide 43:Kleinman classified radiological appearance of fractures into categories with high, moderate and low specificity for child abuse, to be used in children < 3yrs only HIGH SPECIFICITY FINDINGS Classic metaphyseal lesions Rib fractures, especially posterior Scapular fractures Spinous process fractures Sternal fractures


Slide 44:MODERATE SPECIFICITY Multiple fractures, especially bilateral Fractures of different ages Epiphyseal separations Vertebral body fractures and subluxations Digital fractures Complex skull fractures COMMON BUT OF LOW SPECIFICITY Subperiosteal new bone formation Clavicular fractures Long bone shaft fractures Linear skull fractures


METAPHYSEAL FRACTURES :METAPHYSEAL FRACTURES Through weakest part of developing skeleton, through the zone of provisional calcification Due to a twisting, shearing force, produced by jerking child on arm or leg Classic metaphyseal lesions (CML) are discovered in up to half of abused children less than 18 months of age and do not occur > 2yrs CML is regarded as the most specific radiographically detectable injury in abuse Most frequent in the knees, ankles and shoulders, and less frequent in other joints


Slide 46:Typically described as corner, or bucket handle, or metaphyseal lucent line (as in leukemia) Heals with range of appearances depending on associated subperiosteal bleeding and elevation. Florid new bone is seen at one extreme Subtle alteration in contour and "squaring" off of the corner of the bone without periosteal new bone at other extreme. Difficult to date as callus formation do not always occurs and healing occurs by gradual bony consolidation.


DIAPHYSEAL FRACTURES :DIAPHYSEAL FRACTURES Most common fracture in child abuse. 4x more common than metaphyseal fractures, though much less specific Most commonly involves femur, humerus and tibia Significance of diaphyseal fractures increases i.c.o. Multiple / bilateral fractures Fractures in state of healing


Slide 51:Fractures of different ages Fractures through callus Fractures in association with other injuries specific for abuse Spiral fractures more common than transverse fractures in both accidental and non-accidental injury Produced by twisting / pulling force, and are suspicious of abuse especially when involving the humerus


Slide 52:Common accidental injuries to be differentiated from abuse include: Toddler’s fracture – fine spiral fracture of tibia Supracondylar fracture Metaphyseal torus fracture


IMPACTION FRACTURES :IMPACTION FRACTURES Due to impaction forces when child is forcibly thumped unto legs on a hard surface Commonly occurs at metadiaphyseal junction of distal femur or proximal tibia Can also occur in the spine Anterior buckling of cortex as well as incomplete crush fracture of shaft occurs Need to be differentiated from accidental torus fractures that also occur at metadiaphyseal junction


EPIPHYSEAL FRACTURES :EPIPHYSEAL FRACTURES Epiphyseal and true Salter-Harris type fractures rare compared to accidental injury Usually fracture separation of epiphysis Proximal femur and humerus are commonest sites In humerus mechanism is external rotation of forearm, which is displaced medially; in accidental injury, forearm usually displaced laterally


PERIOSTEAL NEW BONE :PERIOSTEAL NEW BONE Physiological periosteal new bone is present between ages of 6 weeks and 6 months and has a lamellar appearance, is usually symmetrical and confined to diaphysis, and shows no increased uptake on scintigraphy If present 6 months, is always pathological and usually seen in association with fractures Can occur due to gripping / twisting force or acceleration-deceleration force without presence of fracture


Slide 59:Periosteum only loosely attached to underlying bone in young children and may become loosened with subperiosteal hematoma Periosteal reaction becomes visible on X ray after 7-10days Increased uptake on nuclear scintigraphy Extensive periosteal reaction that cloaks the bone is characteristic of abuse and occurs due to repetitive injury, non-immobilisation of fractured limb or sever twisting


VERTEBRAL INJURY :VERTEBRAL INJURY True incidence in NAI unknown, thought to be rare Frequently missed Mechanism of injury include hyperflexion and hyperextension as result of direct trauma or impaction against a hard surface Most commonly compression fractures of thoracolumbar region.


Slide 62:Other spinal injuries include spinal ligament rupture, vertebral dislocations, disc herniation, and avulsion of posterior elements which could lead to paraplegia Lateral spine radiograph mandatory in suspected cases MRI indicated if + neurology


RIB FRACTURES :RIB FRACTURES Rib fractures in child is almost always caused by child abuse Incidence of 5-27% Usually in children <2yrs 80% clinically occult Often multiple and bilateral, affects mostly the necks and posterior shafts, especially medial to the costotransverse articulation


Slide 66:commonly occur when the child's chest is squeezed by adult hands (as during shaking injury and therefore important due to potential of associated head injury) May not be visible on the initial chest X-ray, and repeat film should be done in one week. Subtle signs of rib fracture include expansion and widening of ribs, especially at the neck Late sequelae include cyst-like radiolucencies causing “hole-in-the-rib” sign


CLAVICULAR AND SCAPULAR FRACTURES :CLAVICULAR AND SCAPULAR FRACTURES Accidental injury of the clavicle is common, being the most commonly fractured bone associated with birth injury and also commonly injured in mobile children (>3yrs). Accidental clavicular injuries most commonly involves the midshaft. Clavicular fractures associated with abuse, more commonly involves the medial and outer thirds of the clavicles.


Slide 69:Fractures of lateral third is highly specific for abuse. Scapular fractures are rare but very specific for abuse Acromion is most commonly injured site in scapular fractures May be difficult to detect on plain films and might only be picked up on scintigraphy


SKULL FRACTURES :SKULL FRACTURES Usually results from impact trauma to the head Any type of fracture can occur in abuse with no single type being pathognomonic Factors that should raise suspicion for abuse include Multiple and diastatic fractures Fractures of differing ages Complex fractures involving both sides of the skull


Slide 71:Depressed fractures Non-parietal fractures, especially involving the occiput Important to differentiate skull fractures from normal variants and sutures that may mimic fractures in a rotated patient Dating of skull fractures difficult since they do not heal with callus formation Edges becomes smooth and rounded if >2 weeks Recent fractures usually accompanied by overlying hematoma


DIFFERENTIAL DIAGNOSIS OF BONY LESIONS / FRACTURES :DIFFERENTIAL DIAGNOSIS OF BONY LESIONS / FRACTURES Metaphyseal fractures can occur with difficult deliveries Scurvy Rickets Congenital syphilis Leukemia Physiological thickening of the periosteum Copper deficiency


Slide 73:Osteogenesis imperfecta – look for family history, blue sclerae, hearing loss, abnormal teeth and on Xray noticable osteopenia, thinned cortices and bowing of long bones with fractures Caffey’s disease – infantile cortical hyperostosis affects infants < 6 months with periosteal reaction and cortical thickening affecting multiple bones.


IMAGING THE SKELETAL MANISFESTATIONS OF NAI :IMAGING THE SKELETAL MANISFESTATIONS OF NAI Proposed protocol for imaging suspected victims of non-accidental head injury included a skeletal survey at day 1-2 (after initial stabilisation) Other methods of investigation include scintigraphy and ultrasound


SKELETAL SURVEY :SKELETAL SURVEY It does not include a babygram, but rather high technical quality specific views of target areas within the bony skeleton Coned views using detail film is required to increase diagnostic yield Skeletal survey should include AP chest AP both upper limbs AP both lower limbs


Slide 76:Abdomen and pelvis Coned lateral of knees and ankles Lateral of thoracolumbar spine AP and lateral of skull, with added Townes view if suspected occipital injury AP hands and feet Skeletal survey should be checked before patient leaves department Repeat radiographs in 10 – 14 days will increase sensitivity and enhance detection of especially occult rib fractures


SCINTIGRAPHY :SCINTIGRAPHY Is valuable as a supplementary examination in cases with high suspicion of abuse but negative skeletal survey Increase sensitivity between 25-50% in detecting both bony and soft tissue injury Strict quality control is necessary to produce adequate images eg High resolution technique eg 3mm pinhole Adequate count density


Slide 78:Adequate patient immobilisation and good positioning Separate imaging of trunk from limbs Placement of limbs in same position bilaterally Separate imaging of metaphysis and diaphsysis increases sensitivity in detecting metaphyseal corner fractures Most sensitive in detecting rib, scapular, spinal, diaphyseal and pelvic fractures Less reliable than plain films in detecting skull fractures due to poor lesion to background ratio


DATING OF FRACTURES :DATING OF FRACTURES Important in evaluating suspected child abuse due to high specificity for fractures of different ages. Precise dating not possible Becomes more difficult as time interval between injury and initial radiograph increases


VISCERAL ORGANS INJURIES :VISCERAL ORGANS INJURIES Injuries to internal visceral organs form a relatively small proportion of reported cases (contribute to less than 2% of NAI cases) Usually not specific for abuse Mostly the result of blunt trauma such as punch or kick. Penetrating injuries rare but do occur Injuries to the abdomen are the second leading cause of fatal child abuse Mortality from abdominal injuries from NAI has been estimated at 40% to 50%.


DUODENUM :DUODENUM Probably the most common intra-abdominal injury in blunt trauma to the abdomen Includes duodenal haematomas or transection Intramural hematoma most common injury Ligament of Treitz is relatively fixed - allows compression of the duodenum against vertebrae Vascular injuries associated in 1/3rd, causing submucosal and subserosal bleeding leading to luminal obstruction


Slide 84:Associated with injuries to the adjacent organs (in 65%) due to significant force required. Often delays in making the diagnosis 33% of patients become symptomatic > 48 hours after injury because of increasing hematoma and obstruction. Clinical findings include abdominal pain and tenderness and may be subtle and overshadowed by other injuries esp intracranial Raised amylase should raise suspicion


Slide 85:Radiographic findings include: Plain films Free intraperitoneal air i.c.o. intraperitoneal rupture – not always present distended stomach or "doublebubble" sign Free fluid Thumbprinting due to ischemia Contrast meal and follow-through Fold thickening, intramural mass effect, a coiled spring appearance, or complete obstruction


Slide 86:Ultrasound Transverse, hypoechoic hematoma may be seen in the region of the pancreas CT Retroperitoneal perforation most accurately diagnosed using CT scan with intravenous and oral contrast – this will also allow detection of injuries to adjacent organs Heterogeneous or high-attenuation mass in the wall of the duodenum, diffuse fold thickening with proximal obstruction


MESENTERIC INJURIES :MESENTERIC INJURIES Avulsion of mesenteric vessels with mesenteric ischemia and intraperitoneal hemorrhage – rare but high mortality Ischemic bowel strictures if child survives Lymphatic rupture with chylous ascites rare


PANCREAS :PANCREAS Second most common visceral injury Often in association with duodenal injury Diagnosis frequently delayed due to slow evolution of symptoms and associated injuries Raised serum amylase should prompt investigation


Slide 90:In NAI pancreas usually injured by blow to abdomen, compressing pancreas against the lumbar vertebral bodies. Junction of head and neck most frequently involved Pancreatic laceration and pseudocyst formation most common. Acute pancreatitis, pancreatic abcess and necrosis are known sequelae Hemorrhagic pancreatitis highly suggestive of abuse in absence of hereditary pancreatitis and accidental injury


Slide 91:US will show enlarged hypoechoic pancreas with duct dilatation. CT with thin slices are most sensitive imaging tool, but will still miss 1/3rd of pancreatic injuries


LIVER AND SPLEEN :LIVER AND SPLEEN Liver more frequently injured in NAI whereas reverse is true for accidental injury where spleen much more commonly injured Rupture of especially the left lobe Tearing of bile duct, gastro-hepatic ligament or mesentery Splenic rupture Raised transaminase levels indicate liver trauma and should prompt investigation by abdominal CT which has reported accuracy of 98%


RENAL TRACT :RENAL TRACT Renal contusion or laceration Avulsion or thrombosis of renal vessels Acute renal failure can occur secondary to major soft tissue injury with resultant rhabdomyolysis and myoglobinuria Injury to the bladder rare and usually associated with pelvic fractures Clinically these injuries present with hematuria


Slide 95:Investigation of choice for suspected upper tract injury is contrast enhanced CT Ultrasound will detect contusions, lacerations and perinephric collections but provides no functional information


ADRENAL INJURIES :ADRENAL INJURIES May be isolated or occur in conjunction with other organ injury, especially pancreas, kidney and spleen If unilateral, usually right-sided and asymptomatic Bilateral adrenal hemorrhage causing adrenal insufficiency will become clinically evident On CT appears as low density within the adrenal medulla extending into cortex Neonatal adrenal hemorrhage usually resolves within weeks after delivery


THORACIC INJURIES :THORACIC INJURIES Thoracic injuries with the exception of rib fractures are rare Pneumothorax and pleural effusions are uncommon in NAI Pulmonary contusion has delayed radiographic appearance and become evident on CxR only after 6 hrs CT indicated if plain film suggest intrathoracic injury


CONCLUSION :CONCLUSION “Careful observation of radiologic findings and their correlation with the proposed mechanism of injury and with the developmental capabilities and clinical status of the child are imperative in the evaluation of any child, lest we overlook an important clue to the inflicted nature of an injury and return a child to an abusive environment, with potentially disastrous consequences.” Thus it is imperative that all radiologists be familiar with findings which point to possible NAI, in order to prevent avoidable tragedies


THE END :THE END