Metaphyseal Lesions Research Articles

Improving the radiographic image analysis of the classic metaphyseal lesion via conditional diffusion models

The classic metaphyseal lesion (CML) is a unique fracture highly specific for infant abuse. This fracture is often subtle in radiographic appearance and commonly occurs in the distal tibia. The development of an automated model that can accurately identify distal tibial radiographs with CMLs is important to assist radiologists in detecting these fractures. However, building such a model typically requires a large and diverse training dataset. To address this problem, we propose a novel diffusion model for data augmentation called masked conditional diffusion model (MaC-DM). In contrast to previous generative models, our approach produces a wide range of realistic-appearing synthetic images of distal tibial radiographs along with their associated segmentation masks. MaC-DM achieves this by incorporating weighted segmentation masks of the distal tibias and CML fracture sites as image conditions for guidance. The augmented images produced by MaC-DM significantly enhance the performance of various commonly used classification models, accurately distinguishing normal distal tibial radiographs from those with CMLs. Additionally, it substantially improves the performance of different segmentation models, accurately labeling areas of the CMLs on distal tibial radiographs. Furthermore, MaC-DM can control the size of the CML fracture in the augmented images.

The incidence of fractures in children under two years of age: a systematic review

BackgroundEpidemiological research on fractures in children under the age of two is of great importance to help understand differences between accidental and abusive trauma.ObjectiveThis systematic review aimed to evaluate studies reporting on the incidence of fractures in children under two years of age, excluding birth injuries. Secondary outcome measures included fracture location, mechanisms of injury and fracture characteristics.MethodsA systematic literature review (1946 to February 7th 2024), including prospective and retrospective cohort studies and cross-sectional cohort studies, was performed. Studies including children from other age groups were included if the actual measures for those aged 0–2 years could be extracted. We also included studies restricted to infants. Annual incidence rates of fractures were extracted and reported as the main result. Critical appraisal of was performed using the Appraisal tool for Cross-Sectional Studies.ResultsTwelve moderate to good quality studies met eligibility criteria, of which seven were based on data from medical records and five were registry studies. Studies investigated different aspects of fractures, making comprehensive synthesis challenging. There was an overall annual fracture incidence rate of 5.3 to 9.5 per 1,000 children from 0–2 years of age; with commonest sites being the radius/ulna (25.2–40.0%), followed by tibia/fibula (17.3–27.6%) and the clavicle (14.6–14.8%) (location based on 3 studies with a total of 407 patients). In infants, the reported incidence ranged between 0.7 to 4.6 per 1,000 (based on 3 studies), with involvement of the clavicle in 22.2% and the distal humerus in 22.2% of cases (based on 1 study). Only a single metaphyseal lesion was reported (proximal humerus of an 11-month-old infant). Fracture mechanisms were detailed in four studies, with fall from chair, bed, table, own height or fall following indoor activities causing 50–60% of fractures.ConclusionsThere is a paucity of good quality data on fracture incidence in children under the age of two. Larger, prospective and unbiased studies would be helpful in determining normal pattern of injuries, so that differences from abusive trauma may be better understood.

Deep generative model of the distal tibial classic metaphyseal lesion in infants: assessment of synthetic images.

The classic metaphyseal lesion (CML) is a distinctive fracture highly specific to infant abuse. To increase the size and diversity of the training CML database for automated deep-learning detection of this fracture, we developed a mask conditional diffusion model (MaC-DM) to generate synthetic images with and without CMLs. To objectively and subjectively assess the synthetic radiographic images with and without CMLs generated by MaC-DM. For retrospective testing, we randomly chose 100 real images (50 normals and 50 with CMLs; 39 infants, male = 22, female = 17; mean age = 4.1 months; SD = 3.1 months) from an existing distal tibia dataset (177 normal, 73 with CMLs), and generated 100 synthetic distal tibia images via MaC-DM (50 normals and 50 with CMLs). These test images were shown to 3 blinded radiologists. In the first session, radiologists determined if the images were normal or had CMLs. In the second session, they determined if the images were real or synthetic. We analyzed the radiologists' interpretations and employed t-distributed stochastic neighbor embedding technique to analyze the data distribution of the test images. When presented with the 200 images (100 synthetic, 100 with CMLs), radiologists reliably and accurately diagnosed CMLs (kappa = 0.90, 95% CI = [0.88-0.92]; accuracy = 92%, 95% CI = [89-97]). However, they were inaccurate in differentiating between real and synthetic images (kappa = 0.05, 95% CI = [0.03-0.07]; accuracy = 53%, 95% CI = [49-59]). The t-distributed stochastic neighbor embedding analysis showed substantial differences in the data distribution between normal images and those with CMLs (area under the curve = 0.996, 95% CI = [0.992-1.000], P < .01), but minor differences between real and synthetic images (area under the curve = 0.566, 95% CI = [0.486-0.647], P = .11). Radiologists accurately diagnosed images with distal tibial CMLs but were unable to distinguish real from synthetically generated ones, indicating that our generative model could synthesize realistic images. Thus, MaC-DM holds promise as an effective strategy for data augmentation in training machine-learning models for diagnosis of distal tibial CMLs.

Post-mortem skeletal survey (PMSS) versus post-mortem computed tomography (PMCT) for the detection of corner metaphyseal lesions (CML) in children.

Corner metaphyseal lesions (CMLs) are specific for child abuse but challenging to detect on radiographs. The accuracy of CT for CML detection is unknown. Our aim was to compare diagnostic accuracy for CML detection on post-mortem skeletal surveys (PMSS, plain radiography) versus post-mortem CT (PMCT). A 10-year retrospective review was performed at a children's hospital for patients having PMSS, PMCT and histopathological correlation (reference standard) for suspected CMLs. Twenty-four radiologists independently reported the presence or absence of CMLs in all cases in a blinded randomised cross-over design across two rounds. Logistic regression models were used to compare accuracy between modalities. Twenty CMLs were reviewed for each of the 10 subjects (200 metaphyses in all). Among them, 20 CMLs were confirmed by bone histopathology. Sensitivity for these CMLs was significantly higher for PMSS (69.6%, 95% CI 61.7 to 76.7) than PMCT (60.5%, 95% CI 51.9 to 68.6). Using PMSS for detection of CMLs would yield one extra correct diagnosis for every 11.1 (95% CI 6.6 to 37.0) fractured bones. In contrast, specificity was higher on PMCT (92.7%, 95% CI 90.3 to 94.5) than PMSS (90.5%, 95% CI 87.6 to 92.8) with an absolute difference of 2.2% (95% CI 1.0 to 3.4, p < 0.001). More fractures were reported collectively by readers on PMSS (785) than on PMCT (640). PMSS remains preferable to PMCT for CML evaluation. Any investigation of suspected abuse or unexplained deaths should include radiographs of the limbs to exclude CMLs. In order to avoid missing evidence that could indicate child abuse as a contributory cause for death in children, radiographs of the limbs should be performed to exclude CMLs, even if a PMCT is being acquired. • Corner metaphyseal lesions (CMLs) are indicative for abuse, but challenging to detect. Skeletal surveys (i.e. radiographs) are standard practice; however, accuracy of CT is unknown. • Sensitivity for CML detection on radiographs is significantly higher than CT. • Investigation of unexplained paediatric deaths should include radiographs to exclude CMLs even if CT is also being performed.

Diagnosis of metaphyseal fractures in infants and young children with suspected inflicted injury: a systematic review of cross-sectional imaging techniques

To compare the diagnostic accuracy, advantages, and disadvantages of different medical imaging techniques for detecting metaphyseal fractures (also known as classic metaphyseal lesions [CMLs]) in infants and young children with suspected inflicted trauma. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist and Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool criteria. Predefined keywords were used to search online databases for English articles published between 1 January 1980 and 31 March 2023. The initial search revealed 83 studies, only five of which met the inclusion criteria. The sensitivity and specificity of positron-emission tomography (PET) were 67% and 99%, respectively. The sensitivity and specificity of ultrasound were 55-61% and 96-97%, respectively. The sensitivity of magnetic resonance imaging (MRI) whole-body screening was 31%. The sensitivity of bone scintigraphy was 17% in one and 35% in a second study. Computed tomography was not used to detect CMLs in any diagnostic accuracy study. This systematic review has identified only a small number of relevant studies. In addition to the skeletal survey, PET and ultrasound may be helpful for the diagnosis of CMLs in infants and young children with suspected abuse; however, ultrasound has greater potential than PET due to its higher specificity, lack of radiation exposure, low cost, and wider availability.

Yield of Postmortem Skeletal Surveys in Infants Presenting to Emergency Care With Sudden and Unexpected Death.

Child abuse should be considered in cases of sudden unexpected infant death (SUID). Postmortem skeletal surveys (PM-SS) are recommended to evaluate for abusive fractures in SUID. Little is known about the yield of PM-SS among infants presenting to emergency care with SUID. Our objectives were to (1) describe the presentation and care of infants with SUID at a tertiary children's hospital emergency department and (2) report PM-SS use and findings. We performed a retrospective study of infants younger than 12 months with SUID presenting to an urban emergency department from 2007 to 2019. We describe their presentation and care, including PM-SS performance and findings, referrals to the medical examiner, and reports to child protective services (CPS). We assessed for associations between race, payer, and presentation with reports to CPS. Of 73 infants with SUID, concern for unsafe sleep was documented in 45 (61.6%) and 71 (97.3%) underwent cardiopulmonary resuscitation by a medical professional. All 73 (100%) underwent PM-SS and were referred to the medical examiner. Twelve definite fractures (11 rib, 1 classic metaphyseal lesion) and 8 possible fractures (7 rib, 1 classic metaphyseal lesion) were identified among 6 (8.2%) infants. Forty-three (58.9%) were reported to CPS. There were no associations between race, payer, age, or history of unsafe sleep and CPS reports. One in 12 cases of SUID had a possible and/or definite fracture identified on plain radiography. Multicenter studies are needed to compare yield across different postmortem imaging modalities and populations.

Iatrogenic Flexion-Related Classic Metaphyseal Lesion of the Distal Tibia: Three Cases

BackgroundClassic metaphyseal lesions (CMLs) should raise concern for nonaccidental trauma. However, iatrogenic causes for CMLs have increasingly been described and warrant close consideration. Increasing the clinical understanding of CML mechanics and their relation to often routine medical procedures will enhance provider awareness and expand the differential diagnosis when these otherwise highly concerning injuries are identified. Case ReportsWe describe three clinical cases where suspected iatrogenic dorsiflexion or plantar flexion resulted in an isolated distal tibia CML. Respectively, we present heel-stick testing and i.v. line placement as clinical correlates of these two mechanisms. Although prior reports have aimed to describe iatrogenic CML etiologies, they have not focused on dorsiflexion or plantar flexion as predominant mechanisms of injury. Why Should an Emergency Physician Be Aware of This?Emergency physicians are critical to the surveillance and identification of nonaccidental trauma. Given that children oftentimes present to the emergency department with subtle yet concerning signs of maltreatment, an emergency physician must be aware of the potential causes of injury as well as the recommended response. Although avoiding missed cases of abuse and improving the detection of injuries is crucial for child health and well-being, failing to consider or recognize alternative explanations could also have serious implications for a child and their caregivers.

Giant cell tumor of bone in the pediatric population: a retrospective study highlighting cases of metaphyseal only location and increased local recurrence rates in skeletally immature patients.

To describe the presentation of giant cell tumors (GCT) of the bone in the pediatric population to (1) improve the differential diagnosis of pediatric bone tumors and (2) identify the origin of GCT. Understanding the origin of bone tumors assists in establishing appropriate diagnoses and recommending treatment options. This is particularly important in children, where evaluating the need for invasive procedures is balanced with the desire to avoid overtreatment. GCT have historically been considered epiphyseal lesions with potential metaphyseal extension. Therefore, GCT may be inappropriately excluded from the differential diagnosis of metaphyseal lesions in the skeletally immature. We identified 14 patients from 1981 to 2021 at a single institution who had histologic confirmation of GCT and were less than 18years old at diagnosis. Patient characteristics, tumor location, surgical treatment, and local recurrence rates were collected. Ten (71%) patients were female. Eleven (78.6%) were epiphysiometaphyseal (1 epiphyseal, 4 metaphyseal, 6 epiphysiometaphyseal). Five patients had an open adjacent physis, of which three (60%) had tumors confined solely to the metaphysis. Of the five patients with open physis, four (80%) developed local recurrence while only one patient (11%) with a closed physis had local recurrence (p value = 0.0023). Our results illustrate that for the skeletally immature, GCT can (and in our results more commonly did) occur in the metaphyseal location. These findings suggest that GCT should be included in the differential diagnosis of primary metaphyseal-only lesions in the skeletally immature.

Aneurysmal Bone Cyst (ABC), A Rare Diagnosis in Oral Pathology Based on Our 15-Year Institutional Experience

Abstract Introduction/Objective Aneurysmal bone cyst (ABC) is a rare, benign bone lesion that was first described by Jaffe and Lichtenstein in 1942. Primary ABC usually affects vertebrae and metaphyseal regions of long bones, particularly femur and tibia. Only 2-3% of ABCs occur in the head and neck region, with the mandible and maxilla being the most common. It arises mostly in children and young adults, mean age 20 yo, with no gender predilection. ABC can manifest with pain, swelling, and pathological fractures. Radiographically, it appears as a metaphyseal expansile lesion that thins the cortex and has a sclerotic rim. Lesions containing “fluid-fluid” levels are best appreciated on MRI. Approximately 70% of primary ABCs have rearrangements of the USP6 gene. The most common translocation seen in primary ABCs is t(16;17) (q22;p13) leading to the fusion of the cadherin 11 gene with USP6 gene. The USP6 gene product inhibits the differentiation of osteoblasts and dysregulates bone morphogenetic protein signaling pathway. Methods/Case Report A retrospective chart review of all oral pathology cases referred to our institution between 1996 and 2022 was performed; three patients diagnosed with primary ABC were identified. Patient demographic data, clinical presentation, treatment, slides, and pathologic features were reviewed. Results (if a Case Study Enter NA) We report of three primary ABCs of the mandible and maxilla. The mean age was 39 yo (range, 26-59 years). The mandible was affected in two cases, and the maxilla involved in one. Female: Male ratio was 2:1. All lesions were primary ABC, with no other associated lesion - they showed pseudocystic structures with fibrous stroma and a variable numbers of multinucleated giant cells in relation to sinusoidal blood spaces, as well as irregular trabeculae of osteoid and reactive woven bone. Conclusion Primary ABC is a rare tumor in oral pathology. The importance of this study is to increase awareness of this neoplasm in the head and neck region, as well as delineate features that help differentiate ABCs from other fibro- osseous lesions of the mandible and maxilla.

Additional Imaging is of Limited Value in Traumatic Hip Fractures With a History of Distant Malignancy and No Suspicious Lesion on Plain Radiographs.

To determine the value of obtaining additional preoperative imaging in patients with a traumatic hip fracture and a history of malignancy in whom plain radiographs show no lesion suspicious for metastases. Retrospective review. Teaching NHS Trust in the United Kingdom, over an 8-year period treating 4421 hip fractures. Three hundred sixty-seven patients with hip fracture and a history of malignancy at a site distant to the hip. Three hundred thirty patients had a history of trauma and no lesion on the plain radiograph suspicious for metastases. Whether obtaining additional imaging preoperatively (MRI, CT, and bone scan) identified metastases or affected management. 32/330 patients had further preoperative imaging, none of which demonstrated a pathological fracture secondary to malignancy. On follow-up, 3/330 (0.9%) cases were found to have occult metastasis at the hip fracture site. All 3 had only plain radiographs before surgery. In 2, this was identified on histological examination of intraoperative samples, and in 1, radiologically as a metastatic metaphyseal lesion 18 months after a hemiarthroplasty. Only in the latter case, preoperative identification of hip metastasis could have altered surgical management. Patients undergoing further preoperative imaging waited significantly longer for surgery (35 ± 26 vs. 51 ± 26 hours, P = 0.0011). In the absence of a suspicious metastatic lesion on initial plain radiographs, further preoperative imaging is unlikely to identify a lesion that will affect management and confers significant delays to surgery. Sending intraoperative histological samples may help guide postoperative oncological management, but further work is needed to prove its utility. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Unusual Cause Of Knee Pain Impacting An ICU Nurse’s Ability To Run For Codes

History: A 49 yo active female ICU nurse who enjoys hiking presented with right achy knee pain that hadstarted 6 months prior, but worsened 3 months ago when she twisted her knee playing with her nephewin the pool. The pain was worse with prolonged time on her feet preventing her from exercising andimpacting her ability to work, particularly running to code blues. She also noted pain in her distal thighand intermittent swelling with increase in venous distension. PHYSICAL EXAMINATION:Right Knee examAppearance: No skin abnormalities. Mild varum deformity. Small effusion. Gait: Antalgic Palpation: Lateral joint line tenderness to palpation Range of motion: Normal range of motion, pain with flexion. Meniscal testing: Positive McMurray’s, Thessaly, and bounce test. Ligament testing: Negative Lachman’s, anterior drawer, posterior drawer. Pain but no laxity with varusstress at 30 degrees. Patellar testing: Positive inhibition Strength/Function: 5-/5 quadriceps strength DIFFERENTIAL DIAGNOSIS:1. Meniscal tear 2. Venous thromboembolism 3. Malignancy 4. Osteoarthritis Tests/Results:XR 3V Right Knee:There are small spurs along the lateral and patellofemoral compartment. The joint spaces are normal.There is a small right effusion. There is a 2.4 cm focus of ill-defined sclerosis in the distal femoral shaft.This was not evident on the comparison study. MRI Right Knee without Contrast:There is a distal femoral metaphyseal lesion with chondroid matrix measuring 28 mm. There is a 2 mmextraosseous component anteriorly at the prefemoral fat pad.There is a T2 hyperintense focus in the proximal fibula which may represent a intraosseous ganglionversus an additional small cartilaginous lesion. FINAL DIAGNOSIS:Chondrosarcoma of the femur TREATMENT/OUTCOMES:The patient was referred to Orthopedic Oncology. Follow-up CT scan of the femur and chest showed nometastasis. The patient’s case was reviewed with the medical tumor board and she was scheduled fordistal femur replacement.

Revisiting the differential diagnosis of the lucent bone lesion: A case of fibrous dysplasia discovered in a Polish medieval osteological collection

AbstractIn the short report published by Siek and Spinek, the femoral metaphyseal lesion in question was described as potentially the first described case of a simple bone cyst (SBC) from a Polish background. However, on review of the single radiograph available, we feel the primary and differential diagnoses offered are misleading from a radiographic perspective, with the imaging features overall favoring fibrous dysplasia—probable cystic subtype. As magnetic resonance imaging (MRI) or a histological diagnosis would not be possible in skeletonized remains, the diagnosis must rest on opinion‐based radiology. In this commentary, we illustrate why fibrous dysplasia is the most likely radiological diagnosis and describe why the differentials offered in the original article should not be entertained.

How to ensure that rib fractures and classical metaphyseal lesions are caused by traumatic shaking?

How to ensure that rib fractures and classical metaphyseal lesions are caused by traumatic shaking?

Potential influence of factors for genu valgus with hereditary multiple exostoses.

Genu valgus is one of the most common limb deformities in hereditary multiple exostoses (HME). However, it is easily concealed and may account for subsequent osteoarthritis of the knee. The knees of 56 patients (33 men and 23 women) with HME were investigated bilaterally. Knee valgus was described by the mechanical axis deviation (MAD), mechanical lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA). We investigated sex, age, BMI, total number of palpable osteochondromas, number of radiographic osteochondromas around the knee, forearm deformities, morphology and distribution of lesions, and correlations between these factors and genu valgus. The measurement of LDFA and MPTA was performed to identify the sources of genu valgus deformity. Based on the measurement of the mechanical axis, limbs were classified as genu valgus (n = 22) or normal mechanical axis groups (n = 90). The different severities of the genu valgus patients were classified by MAD. By bivariate logistic regression, genu valgus was significantly associated with more sessile and flared metaphyseal lesions. However, only the number of flared metaphyseal lesions had a significant influence on the severity of genu valgus. By analyzing the LDFA and MPTA, it was found that abnormalities of both proximal tibia and distal femur play important roles in genu valgus. Early detection of sessile and flared metaphyseal knee lesions in patients with HME can contribute to early intervention of genu valgus. Level of relevance: Level 2.

Machine learning to identify distal tibial classic metaphyseal lesions of infant abuse: a pilot study.

The classic metaphyseal lesion (CML) is an injury that is highly specific for infant abuse, and the distal tibia is one of the most common sites of occurrence. A machine learning tool that identifies distal tibial CMLs on infant skeletal surveys could assist radiologists in the diagnosis of infant abuse. To develop and evaluate a machine learning-based classification algorithm to identify distal tibial CMLs on skeletal surveys performed for suspected infant abuse. We reviewed medical records of infants (≤1year old) who had skeletal surveys for suspected abuse at a large tertiary children's hospital over the past 13years to identify those at low and high risk for abuse. Normal distal tibial radiographs from the low-risk group formed the normal study cohort; radiographs with distal tibial CMLs from the high-risk group formed the abnormal study cohort. We used these two cohorts to train a machine learning algorithm to classify distal tibial radiographs as normal or abnormal. We systematically evaluated this algorithm using a fivefold cross-validation procedure and statistically analyzed the results. The normal study cohort consisted of 177 radiographs from 89 infants, and the abnormal study cohort consisted of 73 radiographs from 35 infants. Our machine learning algorithm showed an overall performance accuracy of 93% and Kappa of 0.84. The overall sensitivity and specificity of the model were 88% and 96%, respectively. Our developed machine learning model shows encouraging results as an automated tool to identify CMLs of the distal tibia on skeletal surveys performed for suspected infant abuse.

Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study

Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.

A Girl with Limp and Rash on the Palms and Soles.

A Girl with Limp and Rash on the Palms and Soles.

Guideline adherence and quality assurance in radiological diagnostics in cases of suspected child abuse in Germany

HintergrundDie bildgebende Diagnostik nimmt in der Evaluation nichtakzidentieller Verletzungsfolgen im Kindesalter eine Schlüsselrolle ein. Frakturen sind nach Hautläsionen wie Abschürfungen oder Hämatomen die zweithäufigste Folge körperlicher Kindesmisshandlung. Mit Hilfe radiologischer Kriterien können nichtakzidentielle von akzidentiellen Frakturen differenziert werden. Spezielle Frakturtypen wie die klassische metaphysäre Läsion können nur bei hoher Bildqualität differenziert werden.FragestellungIn einer prospektiven Analyse sollten Leitlinientreue und Qualitätssicherung der radiologischen Diagnostik bei Misshandlungsverdacht in Deutschland erfasst werden. Dazu wurden Quantität und diagnostische Qualität in der universitären und nichtuniversitären Versorgung sowie in Abhängigkeit einer vorhandenen kinderradiologischen Fachabteilung analysiert.Material und MethodenEs wurden 958 Röntgenuntersuchungen von 114 vermuteten Misshandlungsfällen (46 Mädchen, 68 Jungen) bewertet. Insgesamt 42 Fälle aus universitären, 42 aus maximalversorgenden und 30 aus regelversorgenden Kliniken mit einem medianen Alter von 6 Monaten (3 Wochen – 3. Lebensjahr) wurden als DICOM-Daten von 3 Kinderradiologen im Konsensverfahren hinsichtlich Leitlinientreue und verschiedener Qualitätsparameter beurteilt. Ein Begleitfragebogen sollte die theoretischen Kenntnisse mit der jeweiligen praktischen Umsetzung vergleichen.ErgebnisseJe Fall wurden im Mittel 8,4 Röntgenaufnahmen (1–22) angefertigt. In 12 von 114 beurteilten Fällen (10 %) lag ein vollständiger Skelettstatus nach S1-Leitlinie GPR vor. In 13 Fällen (10,5 %) wurde ein Babygramm durchgeführt. Abteilungen mit kinderradiologischem Schwerpunkt fertigten signifikant mehr Röntgenaufnahmen je Skelettstatus an als Einrichtungen ohne Schwerpunkt (p < 0,05). Eine signifikant höhere qualitative Umsetzung wurde in Universitätskliniken verzeichnet (p < 0,001). Eine Übereinstimmung von Fragebogenantwort und vorliegendem Bildmaterial zeigte sich unabhängig der Institutionsart nur marginal.DiskussionIn Deutschland fehlt bislang mehrheitlich ein leitliniengerechtes Vorgehen bei Misshandlungsverdacht. Es bleibt abzuwarten, ob sich dies mit der breiteren Implementierung von Kinderschutzgruppen und der 2019 verabschiedeten S3-Kinderschutzleitlinie (AWMF-Registrierungsnummer: 027-069) zukünftig ändern wird. Die Etablierung von Referenzzentren für Zweitbefundung und Empfehlungen zur Aufnahmetechnik können zusätzlich die Versorgungsqualität nachhaltig verbessern.

Whole-body MR imaging in suspected physical child abuse: comparison with skeletal survey and bone scintigraphy findings from the PEDIMA prospective multicentre study.

To assess the contribution of whole-body magnetic resonance imaging (WBMRI) and bone scintigraphy (BS) in addition to skeletal survey (SS) in detecting traumatic bone lesions and soft-tissue injuries in suspected child abuse. In this prospective, multicentre, diagnostic accuracy study, children less than 3 years of age with suspected physical abuse were recruited. Each child underwent SS, BS and WBMRI. A blinded first review was performed in consensus by five paediatric radiologists and three nuclear medicine physicians. A second review investigated discrepancies reported between the modalities using a consensus result of all modalities as the reference standard. We calculated the sensitivity, specificity and corresponding 95% confidence interval for each imaging modality (SS, WBMRI and BS) and for the combinations [SS + WBMRI] and [SS + BS]. One hundred seventy children were included of which sixty-four had at least one lesion. In total, 146 lesions were included. The sensitivity and specificity of each examination were, respectively, as follows: 88.4% [95% CI, 82.0-93.1] and 99.7% [95% CI, 99.5-99.8] for the SS, 69.9% [95% CI, 61.7-77.2] and 99.5% [95% CI, 99.2-99.7] for WBMRI and 54.8% [95% CI, 46.4-63.0] and 99.7% [95% CI, 99.5-99.9] for BS. Sensitivity and specificity were, respectively, 95.9% [95% CI, 91.3-98.5] and 99.2% [95% CI, 98.9-99.4] for the combination SS + WBMRI and 95.2% [95% CI, 90.4-98.1] and 99.4% [95% CI, 99.2-99.6] for the combination SS + BS, with no statistically significant difference between them. SS was the most sensitive independent imaging modality; however, the additional combination of either WBMRI or BS examinations offered an increased accuracy. • SS in suspected infant abuse was the most sensitive independent imaging modality in this study, especially for detecting metaphyseal and rib lesions, and remains essential for evaluation. • The combination of either SS + BS or SS + WBMRI provides greater accuracy in diagnosing occult and equivocal bone injuries in the difficult setting of child abuse. • WBMRI is a free-radiation technique that allows additional diagnosis of soft-tissue and visceral injuries.

Diaphyseal aneurysmal bone cysts (ABCs) of long bones in extremities: Analysis of surgical management and comparison with metaphyseal lesions

IntroductionAneurysmal bone cysts (ABCs) are benign lesions of long bone metaphysis affecting mostly medullary region in younger age below 20 years of life. These may be originated rarely either in the cortex or in the superficial regions of diaphysis. The study highlighted the differences of diaphyseal lesions from the usual metaphyseal ones in view of their clinical, radiological and biological behavior and also discussed their management in brief. Material and methodsWe reviewed a total of 84 aneurysmal bone cysts over the past fourteen years (2004–2017) and evaluated their surgical outcomes retrospectively. Total ten lesions were diaphyseal cortical in location (group I), while 74 lesions were conventional metaphyseal type (group II). ResultsWe observed that cortical ABCs were occurred commonly in diaphysis of femur, humerus, tibia and radius while presentation was at an older age than metaphyseal type. Radiographically these were eccentric lesion and more prone for pathological fractures than conventional type. These are differentiated radiographically from other benign lesions but also mimicking malignant conditions including low grade surface osteosarcoma and telangiectatic osteosarcoma while resemble similar to these on histopathological examination (HPE). ConclusionBiological behavior of cortical lesions does not differ significantly than conventional type but these are more prone for pathological fractures so these eccentric cortical ABC lesions should be treated with adequate internal fixation along with curettage and bone grafting. Although incidence of cortical or surface variety of ABCs is rare but surgeons might evaluate its severity in view of aggressive benign or malignant lesions of diaphysis.