Post by Milisha on Jan 14, 2009 13:20:24 GMT -5
Non Accidental Injury (Battered Baby Syndrome)
Also known as:
Ambroise Tardieu's syndrome
Caffey's syndrome II
Caffey-Kempe syndrome
Silverman syndrome
Definition
The clinical presentation of child abuse: various injuries to the skeleton, soft tissues, or organs of a child sustained as a result of repeated mistreatment or beating, usually by an individual responsible for its care.
Radiographic Appearance
A skeletal survey of the hands, feet, long bones, skull, spine, and ribs should be obtained as soon as the infant's medical condition permits. Skull films complement CT bone windows in detection of skull fractures. In a retrospective series of abused children, skull films were more sensitive and improved the confidence of diagnosis of skull fracture, compared with CT.31 Skull fractures that are multiple, bilateral, diastatic, or that cross suture lines are more likely to be nonaccidental.31 Single or multiple fractures of the midshaft or metaphysis of long bones or rib fractures may be associated findings. Specialized views may be needed to delineate subtle fractures.30 In selected patients, a skeletal survey should be repeated after 2 weeks to better delineate new fractures that may not be apparent until they begin to heal (a process that does not become radiologically apparent for 7-10 days).
CT has the first-line role in the imaging evaluation of a brain-injured child, adequately demonstrating injuries that need urgent intervention. CT often fails to reveal some aspects of the injury, and some false-negative results occur, particularly early in the evolution of cerebral edema.28 The initial CT evaluation should be performed without intravenous contrast and should be assessed using bone and soft-tissue windows. CT is generally the method of choice for demonstrating subarachnoid hemorrhage, mass effect, and large extra-axial hemorrhages.28 CT should be repeated after a time interval or if the neurologic picture changes rapidly.29
MRI is of great value as an adjunct to CT in the evaluation of brain injuries in infants.30 Because of the lack of universal availability of the technology, physical limitations of access to MRI when life support is required for critically ill infants or children, and relative insensitivity to subarachnoid blood and fractures, MRI is considered complementary to CT and should be obtained 2 to 3 days later if possible. Sato et al28 have demonstrated a 50% greater rate of detection of subdural hematomae using MRI, compared with CT. The ability to detect and define intraparenchymal lesions of the brain is substantially improved by use of MRI, yet in the study by Sato et al,28 CT did not miss any surgically treatable injuries. MRI and CT can assist in determining when injuries occurred and substantiating repeated injuries by documenting changes in the chemical states of hemoglobin in affected areas.
Fractures in small children ( Battered Baby Syndrome) - the bone scan is very sensitive for small fractures , and the whole body can be scanned with very little radiation exposure compared with multiple x-rays.
Pathology
Symptoms
The affected child is often undernourished, sometimes grossly, and shows general signs of severe neglect such as dirty skin, nappy rash, dirty and tangled hair, uncut nails, and other signs of lack of care and affection. There may be:
Multiple bruising
Evidence of old injuries
X-ray indication of old or current fractures
Tearing of the central fold behind the upper lip
Cigarette burns
Bite marks
Sometimes indications of bleeding inside the skull or brain
The child may well be withdrawn with a facial appearance of fear called ‘frozen watchfulness’.
Baby battering may involve violent shaking, slapping, punching, throwing or swinging of the baby against a wall, or burning with cigarettes. The child’s head may be struck with an instrument of some kind. These assaults most commonly occur in the first six months of life, and frequently involve an unwanted child. The assault is often brought on by loss of sleep, family rows, money worries, alcoholism, marital resentment, further pregnancy, unemployment, excessive crying by the baby and other stressful factors. Child abusers come from every background and may show apparent willingness to co-operate with medical staff.
Fractures - (From the Silenced Angles website at - www.silencedangels.com/index.html
In infants under 12 months of age, fractures are highly suggestive
of abuse. Even infants who crawl or are able to walk do not
produce enough force in their own movements to cause a fracture.
Here are various types of fractures that may be seen in Shaken Baby Syndrome
Avulsion Fractures - These occur when a bone is pulled or torn away from its connecting tissue. One common site of avulsion fractures is within an infant’s spine –due to the intense whiplash movement of shaking, because the vertebrae’s connecting segments are pulled away from their supports. Avulsion fractures can also occur in other bones due to pulling, twisting, or shaking.
Bucket-Handle or Corner Fractures - In any given bone, a mineralized portion can appear on a radiograph to look like a bucket-handle. This appears on the edge of the bone between the metaphysis and epiphysis. This metaphyseal lesion is indicative of abuse. Radiologists originally thought that “corner” fractures occurred in the same area of the bone as “bucket-handle”, but these fractures have been found to be one and the same depending on the angle at which an X-ray is taken.
Clavicular Fractures - The clavicle can break during an episode of shaking if an infant is held by the shoulders and the perpetrator's thumbs press on these bones. The force of shaking combined with the pressure of thumbs can result in clavicular fracture at its midshaft.
Dislocations - A dislocation refers to the abnormal position, or displacement, of a bone from its joint. In child abuse and shaking injuries, it is known as traumatic dislocation
Humerus Fractures - A fracture or ring of calcification around the metaphysis of the humerus, in an infant with a questionable mechanism of injury, should immediately raise suspicion for abuse. The humerus is the segment of the upper arm that is one of the long bones frequently subject to injury. Such injury occurs in several ways: direct impact; shaking; or pulling of the upper arm. Shaking injuries affect the humerus in a variety of ways. The best known is the classic thorax-grasp shake where the long bones (including the humerus) flail violently. It is in this instance that the periosteum or metaphysis of the bone can be displaced.
Impact Fractures - These occur from direct trauma when an infant is slammed onto a hard surface after an incidence of shaking, one end of a fractured bone being driven into another.
Rib Fractures - Infant ribs, as with other growing bones, are supple and tend to compress with elasticity. Hence, rib fractures are rarely seen in minor injuries in children. In the absence of a history of a motor vehicle accident or bone-effecting disease, rib fractures in infants are usually indicative of abuse. During a shaking episode, an infant is usually held around the thorax and shaken. When a perpetrator shakes, their hands can squeeze the child’s rib cage severely. Ribs, during shaking, commonly fracture at the posterior (connected to the spinal column) area, which is structurally their weakest area. They may also fracture at the lateral (side) areas of the ribs. Rib fractures also have been reported not to be a direct result of cardiopulmonary resuscitation (CPR).
Skull Fractures - Skull fractures, while difficult to produce, are one of the more common fractures that occur in child abuse. Significant trauma is needed to cause a simple linear fracture. Skull fractures are difficult to produce in an infant because the cranium is not only pliable, but has three lines of sutures (“soft spots” or fontanelle). Sutures are nature’s way of protecting the infant during the birth process, which widen or compress to protect the brain from direct trauma. Studies have shown that major injuries (including skull fractures) do not occur when there is a fall two to three feet from a bed or couch; especially onto a carpeted floor. Falls down stairs have even been examined in a large group of children, and skull fractures are rarely produced.
Spinal Fractures/Lesions - Spinal cord injury to children occur at a low rate in child abuse, less than 3 percent. Infants have special anatomical features that help protect them from serious injury during serious battery and shaking. An infant’s head and weak neck muscles allow the head to freely “give” during shaking. Perpetrators’ fingers actually may support the spine of an infant when shaking occurs, which can diminish spinal injury as well. The vertebrae within the spinous process (the prominent points of the posterior ends of each vertebra) are wedge-shaped and freely move, and the ligaments within the spinal area are supple. These features prevent the spine from merely snapping during shaking. The trauma of the event is displaced evenly throughout the entire length of the spine.
Treatment:
Even severely injured young babies often show a remarkable and unexpected ability to recover when restored to normal conditions of care. Brain injury can, however, have serious permanent consequences and can lead to learning difficulties, epilepsy and permanent physical disability. The long-term psychological consequences of child abuse may also be severe.
Image 1 Isotope scan showing multiple uptake sites in Non Accidental Injury
Also known as:
Ambroise Tardieu's syndrome
Caffey's syndrome II
Caffey-Kempe syndrome
Silverman syndrome
Definition
The clinical presentation of child abuse: various injuries to the skeleton, soft tissues, or organs of a child sustained as a result of repeated mistreatment or beating, usually by an individual responsible for its care.
Radiographic Appearance
A skeletal survey of the hands, feet, long bones, skull, spine, and ribs should be obtained as soon as the infant's medical condition permits. Skull films complement CT bone windows in detection of skull fractures. In a retrospective series of abused children, skull films were more sensitive and improved the confidence of diagnosis of skull fracture, compared with CT.31 Skull fractures that are multiple, bilateral, diastatic, or that cross suture lines are more likely to be nonaccidental.31 Single or multiple fractures of the midshaft or metaphysis of long bones or rib fractures may be associated findings. Specialized views may be needed to delineate subtle fractures.30 In selected patients, a skeletal survey should be repeated after 2 weeks to better delineate new fractures that may not be apparent until they begin to heal (a process that does not become radiologically apparent for 7-10 days).
CT has the first-line role in the imaging evaluation of a brain-injured child, adequately demonstrating injuries that need urgent intervention. CT often fails to reveal some aspects of the injury, and some false-negative results occur, particularly early in the evolution of cerebral edema.28 The initial CT evaluation should be performed without intravenous contrast and should be assessed using bone and soft-tissue windows. CT is generally the method of choice for demonstrating subarachnoid hemorrhage, mass effect, and large extra-axial hemorrhages.28 CT should be repeated after a time interval or if the neurologic picture changes rapidly.29
MRI is of great value as an adjunct to CT in the evaluation of brain injuries in infants.30 Because of the lack of universal availability of the technology, physical limitations of access to MRI when life support is required for critically ill infants or children, and relative insensitivity to subarachnoid blood and fractures, MRI is considered complementary to CT and should be obtained 2 to 3 days later if possible. Sato et al28 have demonstrated a 50% greater rate of detection of subdural hematomae using MRI, compared with CT. The ability to detect and define intraparenchymal lesions of the brain is substantially improved by use of MRI, yet in the study by Sato et al,28 CT did not miss any surgically treatable injuries. MRI and CT can assist in determining when injuries occurred and substantiating repeated injuries by documenting changes in the chemical states of hemoglobin in affected areas.
Fractures in small children ( Battered Baby Syndrome) - the bone scan is very sensitive for small fractures , and the whole body can be scanned with very little radiation exposure compared with multiple x-rays.
Pathology
Symptoms
The affected child is often undernourished, sometimes grossly, and shows general signs of severe neglect such as dirty skin, nappy rash, dirty and tangled hair, uncut nails, and other signs of lack of care and affection. There may be:
Multiple bruising
Evidence of old injuries
X-ray indication of old or current fractures
Tearing of the central fold behind the upper lip
Cigarette burns
Bite marks
Sometimes indications of bleeding inside the skull or brain
The child may well be withdrawn with a facial appearance of fear called ‘frozen watchfulness’.
Baby battering may involve violent shaking, slapping, punching, throwing or swinging of the baby against a wall, or burning with cigarettes. The child’s head may be struck with an instrument of some kind. These assaults most commonly occur in the first six months of life, and frequently involve an unwanted child. The assault is often brought on by loss of sleep, family rows, money worries, alcoholism, marital resentment, further pregnancy, unemployment, excessive crying by the baby and other stressful factors. Child abusers come from every background and may show apparent willingness to co-operate with medical staff.
Fractures - (From the Silenced Angles website at - www.silencedangels.com/index.html
In infants under 12 months of age, fractures are highly suggestive
of abuse. Even infants who crawl or are able to walk do not
produce enough force in their own movements to cause a fracture.
Here are various types of fractures that may be seen in Shaken Baby Syndrome
Avulsion Fractures - These occur when a bone is pulled or torn away from its connecting tissue. One common site of avulsion fractures is within an infant’s spine –due to the intense whiplash movement of shaking, because the vertebrae’s connecting segments are pulled away from their supports. Avulsion fractures can also occur in other bones due to pulling, twisting, or shaking.
Bucket-Handle or Corner Fractures - In any given bone, a mineralized portion can appear on a radiograph to look like a bucket-handle. This appears on the edge of the bone between the metaphysis and epiphysis. This metaphyseal lesion is indicative of abuse. Radiologists originally thought that “corner” fractures occurred in the same area of the bone as “bucket-handle”, but these fractures have been found to be one and the same depending on the angle at which an X-ray is taken.
Clavicular Fractures - The clavicle can break during an episode of shaking if an infant is held by the shoulders and the perpetrator's thumbs press on these bones. The force of shaking combined with the pressure of thumbs can result in clavicular fracture at its midshaft.
Dislocations - A dislocation refers to the abnormal position, or displacement, of a bone from its joint. In child abuse and shaking injuries, it is known as traumatic dislocation
Humerus Fractures - A fracture or ring of calcification around the metaphysis of the humerus, in an infant with a questionable mechanism of injury, should immediately raise suspicion for abuse. The humerus is the segment of the upper arm that is one of the long bones frequently subject to injury. Such injury occurs in several ways: direct impact; shaking; or pulling of the upper arm. Shaking injuries affect the humerus in a variety of ways. The best known is the classic thorax-grasp shake where the long bones (including the humerus) flail violently. It is in this instance that the periosteum or metaphysis of the bone can be displaced.
Impact Fractures - These occur from direct trauma when an infant is slammed onto a hard surface after an incidence of shaking, one end of a fractured bone being driven into another.
Rib Fractures - Infant ribs, as with other growing bones, are supple and tend to compress with elasticity. Hence, rib fractures are rarely seen in minor injuries in children. In the absence of a history of a motor vehicle accident or bone-effecting disease, rib fractures in infants are usually indicative of abuse. During a shaking episode, an infant is usually held around the thorax and shaken. When a perpetrator shakes, their hands can squeeze the child’s rib cage severely. Ribs, during shaking, commonly fracture at the posterior (connected to the spinal column) area, which is structurally their weakest area. They may also fracture at the lateral (side) areas of the ribs. Rib fractures also have been reported not to be a direct result of cardiopulmonary resuscitation (CPR).
Skull Fractures - Skull fractures, while difficult to produce, are one of the more common fractures that occur in child abuse. Significant trauma is needed to cause a simple linear fracture. Skull fractures are difficult to produce in an infant because the cranium is not only pliable, but has three lines of sutures (“soft spots” or fontanelle). Sutures are nature’s way of protecting the infant during the birth process, which widen or compress to protect the brain from direct trauma. Studies have shown that major injuries (including skull fractures) do not occur when there is a fall two to three feet from a bed or couch; especially onto a carpeted floor. Falls down stairs have even been examined in a large group of children, and skull fractures are rarely produced.
Spinal Fractures/Lesions - Spinal cord injury to children occur at a low rate in child abuse, less than 3 percent. Infants have special anatomical features that help protect them from serious injury during serious battery and shaking. An infant’s head and weak neck muscles allow the head to freely “give” during shaking. Perpetrators’ fingers actually may support the spine of an infant when shaking occurs, which can diminish spinal injury as well. The vertebrae within the spinous process (the prominent points of the posterior ends of each vertebra) are wedge-shaped and freely move, and the ligaments within the spinal area are supple. These features prevent the spine from merely snapping during shaking. The trauma of the event is displaced evenly throughout the entire length of the spine.
Treatment:
Even severely injured young babies often show a remarkable and unexpected ability to recover when restored to normal conditions of care. Brain injury can, however, have serious permanent consequences and can lead to learning difficulties, epilepsy and permanent physical disability. The long-term psychological consequences of child abuse may also be severe.
Image 1 Isotope scan showing multiple uptake sites in Non Accidental Injury