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Interesting Case
Chris McCrossin R1
Emergency Medicine
Initial Presentation• Friday Night: 4 month old girl Referred from
family physician because of a 3 day history of persistent vomiting and grunting
• The story: Dad was coming back from grocery shopping and put baby and car seat on the kitchen table. Turned around to start putting groceries away when baby rolled out of the car seat and hit head on the hardwood floor (fall of about 3.5 feet)
More History• Since the fall:
» Not sleeping well
» Persistently irritable with only short intervals where she wasn’t crying. Not sleeping well
» Persistent vomiting (had seven episodes in a 1/2 hour time span prior to me seeing her)
» Persistent grunting respirations
» Not taking to the breast (only taking small amounts of formula)
» Ros: No fevers, No diarrhea, No cough, No signs of respiratory distress, No cyanosis
• PMHx: 1 prior ear infection
Physical Examination• Vitals: 36.8, P 164, RR 56, 107/63, SaO2 100% r/a
• HEENT:» TM’s N, Throat N, no lymphadenopathy, no conjunctivitis, no
external signs of head trauma• CVS:
» S1, S2, no murmur, regular rhythm• Resp:
» Persistent grunting with respirations when not crying, high pitched cry, no cyanosis, no adventitious sounds
• Abd:» Difficult to assess because crying every time she is laid down
• Neuro:» Alert, easily irritated, crying throughout most of the
assessment, moving all 4 extremities equally, pupils reactive but intermittently asymmetrical, full fontanelle (but crying), reflexes symmetric, fundi appeared normal
• Derm:» No rash, no bruises
Prior Work-up• Had been seen by doc in their home
town. Skeletal survey had been done and was reported as normal. Sent to ACH for further assessment of “grunting, vomiting, irritability, and decreased feeding”.
Differential Diagnosis for this upset baby
• Infection (pneumonia, UTI, Meningitis)
• Head Trauma• Child Abuse• Political turmoil south of
the border?• Other (hair tourniquet,
corneal abrasion)
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Why do babies grunt?• FOUR REASONS:
• Pain• Respiratory infection• Neurological injury• Sepsis (acid/base disturbance)
Our Work-up• CT Scan
• Completely normal
• Labs• No evidence of UTI, CBC and lytes N
• CXR:
Chest Xray
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Fractures Associated with Child Abuse
• High Specificity– Posterior Rib Fractures– Metaphyseal lesions
• bucket handle• Corner fracture
– Spinous process fractures
– Sternal fractures– Multiple fractures in
stages of healing– Occipital Impression
fractures
• Low Specificity– Epipheseal
Separations– Vertebral body
fractures– Complex skull
fractures– Digit fractures
Specificity of Rib Fractures• Rib fractures and their
association with child abuse is inversely proportional to age
• In Children < 3 they are highly specific for abuse
• Numerical value for specificity is a very difficult number to find in the literature
• Paper by Williams and Connolly in Arch Dis Child 2004 May: 89(5) reviews all studies relevant to answering this question
Other fractures
Corner Fractures• First described by
Caffey who noted an association of these fractures with subdural hematomas
Bucket Handle Fractures• Avulsed bone
fragment• Common sites:
– Tibia– Distal femora– Proximal humeri– Frequently bilateral
Diaphyseal Fractures• Highly suspect of
child abuse in children not yet ambulatory
• Suspicious in ambulatory children with history inconsistent of child abuse
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Differential Diagnosis for Multiple/ Unusual Fractures
Osteogenesis Imperfecta• May present with multiple
fractures and bruising• Collagen disorder• Although genetic, wide
phenotypic variability and mosaicism, spontaneous mutations common
• Signs/Symptoms– Poor growth– Blue Sclera– Easy Bruising– Limb Deformities/scoliosis– Demineralized Bones– Hearing impairment
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are needed to see this picture.
Preterm Birth• Bone Density may not normalize until first year
of life• Osteopenia common complication • Often presents between 6-12 weeks of age• Complicated because preterm infants at
increased risk of abuse
Metaphyseal Dysplasia• Rare genetic
disorder• Can resemble old
corner fractures
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are needed to see this picture.
Osteomyelitis• Infants can present with multiple lesions at the
metaphyses of long bones
• May initially resemble the classical metaphyseal lesions found in abused children
• Expect fever, increased WBC, increased ESR
How good are the radiological tests at identifying fractures of child abuse?
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Radiographic Studies in Suspected Child Abuse Cases
• Systematic Review of literature on radiographic techniques used to diagnose child abuse
• Kemp et al; Clinical Radiology (2006) 61, 723-736.
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
Skeletal Survey Guidelines
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References• Kemp et al. Which radiological investigations should
be performed to identify fractures in suspected child abuse? Clinical Radiology. 2006; 61:723-736.
• Jenny et al. Evaluating infants and young children with multiple fractures. Pediatrics. 2006; 118:1299-1303.
• William et al. In children undergoing chest radiography what is the specificity of rib fractures for non-accidental injury? Archives of Diseases in Childhood. 2004; 89(5): 490-492
• Nelson Textbook of Pediatrics (online at MD Consult)• The Radiology Assistant.
http://www.radiologyassistant.nl/en/42023a885587e
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.