Follow-up Skeletal Surveys Research Articles

Fluorine-18 NaF PET imaging of child abuse

We describe the use of 18F-NaF positron emission tomography (PET) whole-body imaging for the evaluation of skeletal trauma in a case of suspected child abuse. To our knowledge, 18F NaF PET has not been used in the past for the evaluation of child abuse. In our patient, this technique detected all sites of trauma shown by initial and follow-up skeletal surveys, including bilateral metaphyseal fractures of the proximal humeri. Fluorine-18 NaF PET has potential advantage over Tc-99m-labeled methylene diphosphonate (MDP) based upon superior image contrast and spatial resolution.

“The Roentgen Manifestations of Unrecognized Skeletal Trauma in Infants”—A Commentary

559 or thoracic compression and is often seen in infants dying of inflicted head injury [4]. In all three cases, he noted metaphyseal lesions, curious injuries that Caffey [5] latter classified as “corner” and “bucket-handle” fractures. These classic metaphyseal lesions have distinctive radiologic and histopathologic features and in otherwise normal infants are strong indicators of inflicted injury [6]. Silverman’s [1] description in case one of a proximal femoral epiphyseal separation illustrates how this injury can easily be confused with a dislocated hip when the femoral head is not yet ossified—without the aid of sonography or MRI! He stressed the importance of followup radiography to document injuries that are inapparent or confusing on initial radiographs. Subsequent studies have shown the utility of follow-up skeletal surveys in suspected infant abuse, and this approach is now recommended by the American College of Radiology and the American Academy of Pediatrics [7, 8]. Despite a rigorous clinical approach to his subject, one cannot mistake the deep personal interest shown by Silverman [1] in these three injured infants. In case two, he noted, “The roentgen diagnosis of traumatic lesions in the skeleton was strongly resisted by pediatricians and orthopedists interested in the child.” This led him to a personal interview with the parents, during which a “long series of episodes of trauma was discovered.” These seminal observations were followed by Silverman’s collaboration with the noted pediatrician, Henry Kempe, and their work culminated with the landmark article, “The Battered Child Syndrome” published in 1962 in the Journal of the American Medical Association [9]. “The Roentgen Manifestations of Unrecognized Skeletal Trauma in Infants”—A Commentary

ANALYSIS OF RESULTS OF FOLLOW-UP SKELETAL SURVEYS IN SUSPECTED CHILD ABUSE CASES.

The skeletal survey is an important imaging technique used in the evaluation of suspected child abuse. It is particularly helpful in the identification of fractures that are not clinically apparent in infants and young children. The American Academy of Pediatrics (AAP) recommends skeletal survey in cases of suspected child abuse for children less than 2 years of age. The AAP further recommends that the skeletal survey be repeated 2 weeks after the initial skeletal survey in cases in which child abuse is strongly suspected. The follow-up skeletal survey allows for identification of fractures that may have had too subtle a radiographic presentation to be seen when imaged acutely. Objective The purpose of this study was to further clarify and assess the additional information gained from a repeat skeletal survey in identifying and characterizing skeletal injury for cases in which child abuse was strongly suspected. Materials and Methods In this retrospective study, 27 infants and toddlers suspected of being physically abused had a recommended initial skeletal survey and underwent a follow-up examination approximately 2 weeks after the initial examination. The Child Protection Medical Team evaluated all children suspected of possible physical abuse. Nonaccidental trauma was determined by the Child Protection Medical Team. The medical records and radiologic reports of the 27 children with follow-up skeletal surveys were reviewed over a 3-year period. The number and location of the fractures were identified for the initial skeletal survey and for the follow-up skeletal survey in each case. Results The follow-up skeletal survey yielded additional information regarding skeletal injury in 7 (29%) of 24 cases. A different pediatric radiologist evaluated the initial and subsequent repeated study in 19 of the 24 cases. In all but one of these cases, at least one fracture was visible on the initial study. Follow-up study increased the number of definite fractures detected from 72 to 82 (14%). These additional injuries were either rib fractures (30%) or long bone injuries (70%). The majority of the long bone injuries were classic metaphyseal lesions (5/7, 71%). Conclusion A follow-up skeletal survey identified additional fractures or added additional information for findings in children who were suspected victims of physical abuse. It is recommended that a repeat skeletal survey 2 weeks after the initial skeletal survey be conducted for concerning cases of suspected child abuse. The addition of oblique views of the ribs may also enhance detection of occult rib fractures.

Utility of follow-up skeletal surveys in suspected child physical abuse evaluations

Objective To evaluate the utility of a follow-up skeletal survey in suspected child physical abuse evaluations. Methods In this prospective study, follow-up skeletal surveys were recommended for 74 children who, after an initial skeletal survey and evaluation by the Child Abuse Team, were suspected victims of physical abuse. The number and location of the fractures were recorded for the initial skeletal survey and for the follow-up skeletal survey in each case. Results Forty-eight of the 74 (65%) children returned for a follow-up skeletal survey. The follow-up skeletal survey yielded additional information in 22 of 48 patients (46%). In three patients (6%) the additional information changed the outcome of cases; child abuse was ruled out in one of these patients and abuse was confirmed in two cases. In three other patients, the follow-up skeletal survey refuted tentative skeletal findings, but did not change the outcome because of other physical findings. Conclusion A follow-up skeletal survey identified additional fractures or clarified tentative findings in children who were suspected victims of physical child abuse. The follow-up skeletal survey should be completed on all patients who have an initial skeletal survey performed for suspected physical child abuse and for whom child abuse is still a concern.

Follow-up skeletal surveys prove to be valuable in evaluation of child physical abuse

Follow-up skeletal surveys prove to be valuable in evaluation of child physical abuse

Fractures of the hands and feet in child abuse: imaging and pathologic features.

To determine the imaging and histopathologic appearance of fractures of the hands and feet in abused infants. The imaging findings in 11 abused infants with fractures of the hands and feet were examined retrospectively. All 11 infants underwent skeletal surveys; five infants also underwent nuclear bone scanning. Postmortem radiographs of the specimen and histopathologic data were available in two infants. A total of 22 fractures were noted. Six infants had fractures of the hands: six metacarpal and nine proximal phalangeal fractures. Five infants had fractures of the feet: six metatarsal fractures and one proximal phalangeal fracture. Torus fractures predominated, and these patterns were confirmed at the histologic examinations. These morphologic features were consistent with a mechanism of forced hyperextension. Oblique views of the hands and follow-up skeletal surveys aided in detection of these injuries. Four of six metatarsal fractures involved the first ray. Seven patients had three or more additional fractures that involved the long bones of the upper and lower extremities, and seven patients had additional fractures of the ipsilateral extremity. Fractures of the hands and feet are subtle but important injuries in abused infants. Well-collimated, high-detail radiographs of the hands and feet should be included in the skeletal survey performed for suspected child abuse.

Follow-up skeletal surveys in suspected child abuse.

The purpose of this study was to assess the additional yield of a repeat skeletal survey in identifying and dating skeletal injury for cases in which child abuse was strongly suspected. Twenty-three infants and toddlers strongly suspected of being physically abused on the basis of findings on the initial skeletal survey, other imaging studies, history, or physical examination underwent a follow-up examination approximately 2 weeks after the initial examination. The high-detail imaging system included a single-emulsion, single-screen combination with a low-absorption carbon-fiber cassette. The skeletal survey protocol entailed tightly collimated anteroposterior views of the appendicular skeleton and anteroposterior and lateral views of the axial skeleton. Between the two studies, all children were in Department of Social Services custody or living in a safe home. The follow-up skeletal survey yielded additional information regarding skeletal injury in 14 (61%) of 23 cases. Follow-up study increased the number of definite fractures detected from 70 to 89 (27%) (p = .005). Most of these additional injuries were classic metaphyseal lesions or rib fractures. In 13 of the 70 fractures previously detected, the follow-up skeletal survey also provided important information about the age of those injuries. When child abuse is strongly suspected on the basis of the findings on the initial skeletal survey, other imaging studies, history, or physical examination, a follow-up skeletal survey is recommended to provide a through and accurate assessment of osseous injuries.