Diagnosis Of Non-accidental Injury Research Articles

Non accidental injury in disguise; a Paediatric Enigma

Aims: Non accidental injury (NAI) is defined as any abuse inflicted on a person or knowingly not prevented by a care giver. The injury is not consistent with the account of its occurrence. We describe an unusual case that presented with symptoms suggesting immunodeficiency with significant initial diagnostic dilemma. Methods: Clinical data, laboratory and radiological records of our case were reviewed. Results: A 15 month old girl presented with alopecia, recurrent infections comprising left dacryocystitis with subsequent preseptal cellulitis, left maxilla zygomatic abscess and left suppurative otitis media occurring within the preceding 3 months. She also had several episodes of swelling and bruising in various body parts. There was an initial strong suspicion of an underlying immunodeficiency or autoimmune disorder. She was reviewed extensively by multiple disciplines with a battery of blood investigations which was not in keeping with either. Chest radiograph was normal but surprisingly revealed fractures of both proximal humeral metaphyses beyond the field of focus. Further radiological investigations including skeletal surveys showed multiple healing fractures without evident osteopenia. These events in retrospect were closely linked to the period of care by a close care giver. She made an excellent recovery evident on 5 months follow up. She is well known to child protection services. Conclusion: The diagnosis of NAI is complex; this will ultimately depend upon evidence collected from all agencies involved in the care of the child. The thorough investigation of children with suspected NAI is critical to assure their safety.

A novel ex vivo model of compressive immature rib fractures at pathophysiological rates of loading

IntroductionCompressive rib fractures are considered to be indicative of non-accidental injury (NAI) in infants, which is a significant and growing issue worldwide. The diagnosis of NAI is often disputed in a legal setting, and as a consequence there is a need to model such injuries ex vivo in order to characterise the forces required to produce non-accidental rib fractures. However, current models are limited by type of sample, loading method and rate of loading. Here, we aimed to: i) develop a loading system for inducing compressive fractures in whole immature ribs that is more representative of the physiological conditions and mechanism of injury employed in NAI and ii) assess the influence of loading rate and rib geometry on the mechanical performance of the tissue. MethodsPorcine ribs (5–6 weeks of age) from 12 animals (n=8 ribs/animal) were subjected to axial compressive load directed through the anterior–posterior rib axis at loading rates of 1, 30, 60 or 90mm/s. Key mechanical parameters (including peak load, load and percentage deformation to failure and effective stiffness) were quantified from the load–displacement curves. Measurements of the rib length, thickness at midpoint, distance between anterior and posterior extremities, rib curvature and fracture location were determined from radiographs. ResultsThis loading method typically produced incomplete fractures around the midpoint of the ribs, with 87% failing in this manner; higher loads and less deformation were required for ribs to completely fracture through both cortices. Loading rate, within the range of 1–90mm/s, did not significantly affect any key mechanical parameters of the ribs. Load–displacement curves displaying characteristic and quantifiable features were produced for 90% of the ribs tested, and multiple regression analyses indicate that, in addition to the geometrical variables, there are other factors such as the micro- and nano-structure that influence the measured mechanical data. ConclusionsA reproducible method of inducing fractures in a consistent location in immature porcine ribs has been successfully developed. Fracture appearance may be indicative of the amount of load and deformation that produced the fracture, which is an important finding for NAI, where knowledge of the aetiology of fractures is vital. Characteristic rib behaviour independent of loading rate and, to an extent, rib geometry has been demonstrated, allowing further investigation into how the complex micro- and nano-structure of immature ribs influences the mechanical performance under compressive load. This research will ultimately enable improved characterisation of the loading pattern involved in non-accidental rib fractures.

Should bone scintigraphy be used as a routine adjunct to skeletal survey in the imaging of non-accidental injury? A 10 year review of reports in a single centre

To retrospectively analyse the bone scintigraphy (BS) and skeletal survey (SS) data to evaluate the role and limitations of BS in the diagnosis of non-accidental injury (NAI). All SS and BS performed over a 10 year period, for possible NAI, in children under 2 years old were retrospectively reviewed. Reports were compared in cases where both studies were performed and findings classified into one of three groups: (1) congruent: both reports agreed; (2) BS added confidence to the SS findings; (3) BS demonstrated a new finding. False-positive and false-negative rates for BS were calculated. One hundred and sixty-six patients had both SS and BS. The findings were congruent in 74% of cases. BS added confidence to the SS findings in 8% and revealed a new abnormality in 4% of patients. BS demonstrated false-positive and -negative rates of 2% and 13%, respectively. Occult bony injury was detected in 12% of the 237 patients imaged. When used as an adjunct to SS in the investigation of NAI, BS can aid the confidence of diagnosis or identify new findings in 12% of cases. In centres where nuclear medicine is readily available and there is appropriate expertise in paediatric BS, this modality provides a time-effective alternative to follow-up SS at 10-14 days.

Unilateral Retinal Hemorrhages with Subarachnoid Hemorrhage in a 5-Week-Old Infant: Is This Nonaccidental Injury?

Retinal hemorrhages are an important sign in the setting of nonaccidental injury (NAI) (abusive head injury) in young infants and form a very important part of the evidence in support of the diagnosis. The diagnosis of NAI has serious social and legal implications. Other causes of retinal hemorrhages in an infant, such as birth trauma, accidental head injury, subarachnoid hemorrhage, other less common disorders of clotting, leukemia, and infections such as endocarditis, need to be considered and ruled out in making a diagnosis of NAI. Descriptive case report. A 5-week-old child presented with rapid onset of symptoms of drowsiness and hypotonia, unilateral retinal hemorrhages, and an intracranial hemorrhage in the posterior fossa. NAI was high on the list of differential diagnosis, which caused considerable anxiety in the parents. The cause of the intracranial hemorrhage only became apparent at repeat neuroimaging several weeks later. The case is presented to point out arteriovenous malformation as a possible cause of retinal hemorrhages in this age group where an early diagnosis of the etiology is often not possible. A diagnosis of NAI, commonly associated with a similar clinical presentation, can have serious social and legal implications.

Infant Acute Life-Threatening Event—Dysphagic Choking Versus Nonaccidental Injury

A 4-month-old male infant presented to the emergency room with a history of choking while bottle feeding at home, and was found by emergency medical services (EMS) to be apneic and pulseless. He subsequently developed disseminated intravascular coagulopathy and died. Computed tomography (CT) and magnetic resonance imaging (MRI) showed subdural hemorrhages (SDHs), subarachnoid hemorrhage (SAH), and retinal hemorrhages (RHs), along with findings of hypoxic-ischemic encephalopathy (HIE). The caretaker account appeared to be inconsistent with the clinical and imaging features, and a diagnosis of nonaccidental injury with "shaken baby syndrome" was made. The autopsy revealed diffuse anoxic central nervous system (CNS) changes with marked edema, SAH, and SDH, but no evidence of "CNS trauma." Although NAI could not be ruled out, the autopsy findings provided further evidence that the child's injury could result from a dysphagic choking type of acute life threatening event (ALTE) as consistently described by the caretaker.

Vitrectomy in Cases of Nonaccidental Injury

Nonaccidental head injuries may present in several ways, requiring prompt recognition and management because of the risk of death or permanent neurologic and visual impairment. Dense amblyopia and high anisometropic myopia induced by prolonged occlusion of the macula by hemorrhage is a concern in these infants, although the prognosis also depends on the extent of associated brain injury. There are few reports of the visual and general outcome of children with a diagnosis of nonaccidental injury who have undergone vitrectomy. This report describes the outcome in six eyes of four patients diagnosed as having nonaccidental injury who underwent vitrectomy. The results are more favorable than in previous reports.

Imaging of non-accidental injury

The term ‘non-accidental injury’ implies the physical abuse of a child by a person or persons (usually adult) in whose care that child is placed. The vast majority of child abuse and neglect fatalities are less than 5 years old, and a significant number (41%) are less than 1 year old. Skeletal, neurological and organ damage may be present in the absence of clinical signs. The radiologist therefore plays a crucial role in the diagnosis of non-accidental injury. The key imaging modality in suspected cases is plain radiography in the form of a ‘skeletal survey’. Cross-sectional imaging (ultrasound, computed tomography and magnetic resonance imaging) also has a role, particularly in neurological assessment and exclusion of visceral injury. Radioisotope imaging is less commonly employed.

Common tasks and problems in paediatric trauma radiology

Scope of this article is to give practical hints for the most common, typical and important topics of trauma radiology in children to those radiologists who are not exclusively occupied with paediatric imaging. Due to the increased radiation sensitivity of children compared with adults balancing radiation protection and necessary image quality is of utmost importance. Outlines for this optimisation process are given. Especially in imaging of the extremities perhaps the greatest difficulties are posed by the dynamically changing face of the immature, growing, only partially ossified skeleton. Lack of experience must be compensated by meticulous comparison with the normal skeletal development as shown in standard textbooks, and by knowledge of the radiological image of the developmental variants. Besides general remarks about paediatric trauma radiology, some important topics are discussed into more detail. Especially the elbow joint poses a challenge for those less experienced with its radiological appearance in children. More than in adults, ultrasound should remain the primary imaging modality of choice especially in the assessment of abdominal trauma, and CT be tailored to radiological and clinical findings. Imaging and diagnosis of non-accidental injury (NAI) may be a less common task for the general radiologist, however, the severe social implications of physical child abuse mandate a basic knowledge about the radiological symptoms and the imaging management of this problem for all physicians occupied with paediatric radiology.

Apnoea and brain swelling in non-accidental head injury

Aims: (1) To identify whether infants and young children admitted to hospital with subdural haematomas (SDH) secondary to non-accidental head injury (NAHI), suffer from apnoea leading to radiological evidence of...

Fractures in Children Younger Than Age 1 Year: Importance of Collaboration With Child Protection Services

The medical records of all children less than 1 year of age presenting to the Accident and Emergency Department over a 5-year period (1995-1999) with a fracture were retrospectively reviewed for possible abuse. Seventy-four children presented with fractures during the study period, with a mean age at presentation of 5 months (range 2 weeks to 1 year). Of these children, 46 had skull fractures and 28 had long bone fractures. Children were classified into one of seven categories: definite abuse, likely abuse, suspicious, likely accident, definite accident, neglect, or unknown cause. A three-tier system of grading for possible abuse was then used to analyze variance. The first tier consisted of the initial assessment by staff clinicians, the second retrospectively by an orthopaedic registrar, and the third retrospectively by a designated doctor in child protection (consultant pediatrician), all using the same information from the case notes. The use of the three-tier system of grading demonstrated a variance in the diagnosis of nonaccidental injury. The possibility of abuse was underestimated at the time of the original injury in over a quarter of cases (28.4%) when compared with the assessment by the consultant pediatrician. In 34 children (46%), there was no written documentation that nonaccidental injury was ever considered. While management depends on local guidelines and arrangements, the authors would advise that all children under 1 year of age with a fracture should be admitted to the hospital and referred to a pediatrician for child protection assessment.

Testing for osteogenesis imperfecta in cases of suspected non-accidental injury

To evaluate if laboratory testing for osteogenesis imperfecta (OI) identifies children unrecognised by clinical examination in instances where non-accidental injury (NAI) is suspected as the likely cause of fracture, we...

Doubt, difficulties and practicalities in the diagnosis of non-accidental injury—a personal view

Non-accidental injury (NAI) should be considered when children present with unexplained injuries. Multiple unexplained rib fractures, classic metaphyseal lesions and complex skull fractures (without a history of severe trauma) have a high specificity for abuse. Single long bone and skull fractures occur commonly in the non-accidentally injured child. Scintigraphy may be helpful in confirming the presence of significant abnormality when the initial radiographic abnormality is subtle. Abdominal injuries are easily overlooked in children presenting with skeletal or soft tissue manifestations of NAI. The differential diagnosis of abnormalities thought to be due to NAI should be considered carefully before reaching a conclusion that an injury has occurred non-accidentally. The skeletal survey should be performed by radiographers experienced in the examination of children in order to provide images of the highest quality.

Child abuse diagnosis and the emergency department chart

Failure to uncover and report nonaccidental injury may have serious consequences for the child and the physician. To determine if the information recorded in the emergency department record was adequate to eliminate the possibility of nonaccidental injury, the charts of 333 children under five years of age were reviewed. No charts contained all the information deemed necessary; in 12.6% a diagnosis of nonaccidental injury could not be eliminated. In three cases, the injury was inconsistent with the history. Missing historical information included where the injury occurred, the presence of witnesses, notation of previous injuries, and old chart review. Information regarding size, color, and age of the injury was incomplete. A complete examination was recorded 22.3% of the time. The private-pay category charts and those recorded by staff were most complete. Remedial actions, guided by periodic chart reviews, are suggested.

The risk of ocular involvement in non-accidental injury.

A consecutive group of 22 children admitted to our hospital with a diagnosis of non-accidental injury, underwent detailed ophthalmic examination within 24 hours of their admission. Five of these children had obvious periocular soft tissue injury, but only two had serious ocular involvement. The indications for ophthalmic examination in cases of suspected non-accidental injury are discussed in the light of these findings.