Henry M Katherine,  White Ammie,  Servaes Sabah,  Wood Joanne

Final Pr. ID: Poster #: EDU-031

Infants are at risk for fatal physical abuse yet may present to care multiple times with inflicted trauma before abuse is diagnosed and the infant is protected. Prompt identification of at-risk infants is essential to protection from ongoing abuse. Sentinel injuries are unexplained minor injuries in young infants that are appreciable on physical exam. Examples of sentinel injuries include bruising, subconjunctival hemorrhages, and intra-oral trauma. These injuries can be a subtle external sign of concurrent clinically occult internal injuries (e.g., skeletal, abdominal, intracranial injuries) in a well-appearing infant or may be an early warning that foretells more significant trauma in the future. Identification and evaluation of these infants with appropriate imaging has been highlighted as one approach to ensure that abuse is promptly detected, injuries are addressed, and the infant is protected.

In this multidisciplinary educational presentation made in collaboration with child abuse pediatricians and pediatric radiologists, we will: (1) review different types of sentinel injuries; (2) discuss current evidence and guidance for performance of imaging (skeletal survey, abdominal CT, neuroimaging with MRI or CT) when a sentinel injury is identified; (3) discuss the interpretation and significance of imaging findings; (4) provide imaging examples of these injuries; and (5) discuss gaps in the literature while highlighting opportunities for collaboration between child abuse pediatricians and pediatric radiologists to improve the care of these infants.

Following completion of this educational module, our goals are that the participant will better understand the clinical context of sentinel injuries and have a baseline knowledge to make an appropriate imaging plan for these infants. Read More

Authors:  Henry M Katherine , White Ammie , Servaes Sabah , Wood Joanne

Keywords:  Child Abuse, Sentinel Injuries, Skeletal Survey

Henry M Katherine,  Bennett Colleen,  Servaes Sabah

Final Pr. ID: Poster #: EDU-032

Intra-abdominal injuries are a less common manifestation of child abuse, but can be associated with high mortality. These injuries may be difficult to detect on physical exam alone, as many children do not have external cutaneous signs of abdominal injury, and symptomatology may be non-specific. Once detected, no specific intra-abdominal injury is pathognomonic for abuse, though some are more common in physical abuse. Determination of the likelihood of abuse as a mechanism relies on the plausibility of the history provided in the context of the constellation of identified injuries.

In this multidisciplinary educational presentation made in collaboration with pediatric radiologists and child abuse pediatricians, we will: (1) review physical exam and laboratory indicators to obtain abdominal imaging; (2) review imaging examples of intra-abdominal solid organ injuries; (3) review imaging examples of hollow viscus injuries; (4) discuss the types of trauma that causes solid organ and hollow viscus injuries; (5) review imaging modalities available, and (6) briefly discuss medical management. Read More

Authors:  Henry M Katherine , Bennett Colleen , Servaes Sabah

Keywords:  Child Abuse, Trauma, Abdominal

Warner Christopher,  Maguire Sabine,  Miller Angie,  Trefan Laszlo,  Fadell Michael

Final Pr. ID: Poster #: SCI-057

Fractures are a common manifestation of physical child abuse, and when present can have considerable bearing on the legal process. Although the timing of skeletal injury and healing is of great importance in forensic cases, the dating of fractures in the age group in which fractures from physical abuse most frequently occur is largely based on the radiologist’s personal experience as opposed to primary research. A full understanding of the radiological features of healing in infant fractures will enhance the assessment of fracture dating in cases where the time of injury is unknown, such as suspected abuse. The objective of this study was to describe the timing of fracture healing in infants using previously defined radiographic signs of fracture healing. Read More

Authors:  Warner Christopher , Maguire Sabine , Miller Angie , Trefan Laszlo , Fadell Michael

Keywords:  Healing Fracture, Fracture Healing, Non Accidental Trauma, Abuse, Long Bone

Mousa Abeer,  Ray Alyxandra,  Halderman Kelly,  Pfeifer Cory

Final Pr. ID: Poster #: EDU-088

Differentiation of sutural variants from fractures can be a challenging topic for radiology trainees. Genetic disorders and vascular channels can create the appearance of traumatic injury and potentially suggest the diagnosis of abusive head trauma to the untrained radiologist. Likewise, expert witnesses may use alternate diagnoses to explain findings in which the current evidence basis favors a traumatic mechanism. This exhibit describes the pediatric skull with attention to the differentiation between fractures and mimics as an aid to the trainee. Read More

Authors:  Mousa Abeer , Ray Alyxandra , Halderman Kelly , Pfeifer Cory

Keywords:  Child Abuse, Cranial Sutures, Wormian Bones

Garg Vasant,  Partovi Sasan,  Vasavada Pauravi,  Weinert Dayna,  Berlin Sheila,  Mcdavid Lolita,  Sivit Carlos

Final Pr. ID: Poster #: CR-040

We present a rare Case Report Exhibit of a 4-year child with myositis ossificans secondary to non-accidental trauma. The child presented to the ER complaining of a headache. Head CT was unremarkable. However, initial physical examination revealed numerous bruises over the lower abdomen and thighs including belt marks. The patient also demonstrated restricted range of motion. A skeletal survey showed multiple remote fracture deformities and myositis ossificans extending the length of both femurs. Although myositis ossificans frequently occurs in athletes who sustain blunt injury, this unfortunate case occurred secondary to non-accidental trauma and specifically the caregiver intentionally standing on the patient’s legs. Pediatric radiologists should be mindful of non-accidental trauma as a potential cause of myositis ossificans, especially in very young children and when multifocal. Read More

Authors:  Garg Vasant , Partovi Sasan , Vasavada Pauravi , Weinert Dayna , Berlin Sheila , Mcdavid Lolita , Sivit Carlos

Keywords:  myositis ossificans, non-accidental trauma, child abuse

Osman Radya,  Ahmed Ilham,  Yagoub Shima,  Bakeit Mohamed Salih,  Mustafa Elrayah,  Gabir Abdalla,  Marine Megan,  Karmazyn Boaz,  Gunderman Richard,  Heitkamp Darel,  Hibbard Roberta,  Miller Aaron,  Mohammed Alaaeldeen,  Satti Satti

Final Pr. ID: Poster #: EDU-053

To assess the awareness and knowledge of Radiologists, Pediatricians, Orthopedists and Emergency Physicians regarding child abuse incidence, imaging, and management in Sudan, Africa. Read More

Authors:  Osman Radya , Ahmed Ilham , Yagoub Shima , Bakeit Mohamed Salih , Mustafa Elrayah , Gabir Abdalla , Marine Megan , Karmazyn Boaz , Gunderman Richard , Heitkamp Darel , Hibbard Roberta , Miller Aaron , Mohammed Alaaeldeen , Satti Satti

Keywords:  Child Abuse, Africa, Imaging

Tsai Andy,  Kleinman Paul

Final Pr. ID: Paper #: 061

Radiologic diagnosis of rib fractures in suspected infant abuse is often challenging, and costochondral junction (CCJ) rib fractures can be particularly problematic. In an effort to enhance diagnostic accuracy and dating, we studied the dynamic radiologic spectrum of CCJ rib fractures on serial skeletal surveys (SSs). Read More

Authors:  Tsai Andy , Kleinman Paul

Keywords:  Abuse, Fractures, Radiography

Messer Diana,  Adler Brent,  Ruess Lynne,  Brink Farah,  Xiang Henry,  Agnew Amanda

Final Pr. ID: Paper #: 055

Healing fractures are a common radiographic finding in cases of child physical abuse. Accurate time since injury estimation of healing fractures may provide an opportunity for identification and characterization of physical abuse, especially in young children unable to verbalize. This study examines patterns of long bone fracture healing in a modern sample of young children. Read More

Authors:  Messer Diana , Adler Brent , Ruess Lynne , Brink Farah , Xiang Henry , Agnew Amanda

Keywords:  Child Abuse, Fracture Healing, Radiography

Gibbs Liliane,  Keyak Joyce

Final Pr. ID: Poster #: SCI-041

Determining the underlying etiology of bone fracture in children is an essential part of patient care. Very young patients who may be victims of child abuse, but who may not be able to express themselves, must be distinguished from those who have low bone mineralization due to disease. Quantitative computed tomography (QCT) has been used to evaluate volumetric bone mineral density (BMD) in children, but there is little information on BMD in very young subjects.^1,2 The goal of this study was to demonstrate the feasibility of using QCT to evaluate BMD and volume (Vol) of lumbar vertebral bodies in children and to establish the need for a separate comparative database to evaluate these parameters in subjects less than 6 years. Read More

Authors:  Gibbs Liliane , Keyak Joyce

Keywords:  QCT, BMD, Abuse

Noda Sakura,  Otjen Jeffrey,  Koti Ajay,  Schlatter Adrienne,  Blessing Matthew,  Feldman Ken,  Menashe Sarah

Final Pr. ID: Poster #: EDU-013

Faulty fetal packing is a concave depression of the skull caused in utero by external pressure (such as by the maternal pelvic bone, a fetal limb, or uterine fibroid). It has an incidence of approximately 1 in 10,000 births. Its main differential diagnosis is acquired ping-pong-type fracture of the malleable neonatal skull, which can raise suspicion for nonaccidental trauma if there is no history of accidental trauma. Most recent literature on faulty fetal packing describes only single case reports. This educational exhibit reviews a series of faulty fetal packing and neonatal calvarial fracture cases. After reviewing this educational exhibit, readers will be able to 1) describe the mechanism of faulty fetal packing, 2) describe the appearance of faulty fetal packing on multiple modalities including radiographs and CT, and 3) distinguish between prenatal faulty fetal packing, perinatal skull trauma, and neonatal accidental and non-accidental trauma. Read More

Authors:  Noda Sakura , Otjen Jeffrey , Koti Ajay , Schlatter Adrienne , Blessing Matthew , Feldman Ken , Menashe Sarah

Keywords:  nonaccidental trauma, Skull, child abuse

Hwang Misun,  Servaes Sabah

Final Pr. ID: Poster #: EDU-088

Many normal variants in the skeletal survey can be misconceived as signs of child abuse. Accurate differentiation between the two is crucial in subjecting only the perpetrators to trial. The present exhibit educates on the radiographic signs and techniques that can help differentiate between normal variants and child abuse on the skeletal survey. Read More

Authors:  Hwang Misun , Servaes Sabah

Keywords:  Child abuse, Skeletal Survey, Normal variants

Marine Megan,  Smith Jessica,  Wanner Matthew,  Jennings Samuel,  Hibbard Roberta,  Karmazyn Boaz

Final Pr. ID: Poster #: SCI-030

The purpose is to evaluate how well hospitals comply with ACR-SPR guidelines for skeletal surveys in the cases of possible child abuse. Read More

Authors:  Marine Megan , Smith Jessica , Wanner Matthew , Jennings Samuel , Hibbard Roberta , Karmazyn Boaz

Keywords:  Skeletal Survey, Child Abuse, Nonaccidental Trauma

Annapragada Akshaya,  Donaruma-kwoh Marcella,  Annapragada Ananth,  Starosolski Zbigniew

Final Pr. ID: Paper #: 028

Child abuse is the principal cause of traumatic injury and death in children 0-36 months old. Radiologic findings are a critically important piece of evidence necessary for assessment by a Child Protection Team to assess possible abuse. Current algorithmic strategies for the detection of abuse are sensitive, but compromise specificity. The purpose of this study was to determine the performance of deep learning to diagnose child abuse using Natural Language Processing of the unstructured free-text from Electronic Health Records (EHR), including essential information from Radiology Reports. Read More

Authors:  Annapragada Akshaya , Donaruma-kwoh Marcella , Annapragada Ananth , Starosolski Zbigniew

Keywords:  Child Abuse, decision support, Convolutional Neural Network

Paddock Michael,  Offiah Amaka,  Sprigg Alan

Final Pr. ID: Poster #: EDU-004

Recognising the skeletal manifestations of inflicted injury (II) in infants and young children is of crucial importance. There are specific fracture patterns that are highly suspicious of II and common differential diagnoses with which radiologists should be familiar. Read More

Authors:  Paddock Michael , Offiah Amaka , Sprigg Alan

Keywords:  Inflicted injury, Non-accidental injury, Physical abuse, Skeletal survey, Child abuse

Steinhardt Nicole,  Marine Megan,  Supakol Nucharin,  Radhakrishnan Rupa,  Lahiri Niloy,  Jennings Greg,  Thompson Shannon,  Karmazyn Boaz

Final Pr. ID: Poster #: SCI-023

The purpose of this poster is to review the imaging findings of spinal fractures in children evaluated for child abuse on radiography, CT, and MRI, and differentiate fractures from vertebral body variations. Read More

Authors:  Steinhardt Nicole , Marine Megan , Supakol Nucharin , Radhakrishnan Rupa , Lahiri Niloy , Jennings Greg , Thompson Shannon , Karmazyn Boaz

Keywords:  Child abuse, spinal fractures, Vertebral variations

Brennan Brian,  Henry M Katherine,  Altaffer Ana,  Wood Joanne

Final Pr. ID: Paper #: 113

Prior research describing risk of physical abuse in children with rib fractures has included children whose rib fractures were incidentally identified in the context of an abuse evaluation. In our practice, the child in whom a rib fracture is the first presenting injury can be a diagnostic challenge, and less is known about this population. Our objectives were to determine the prevalence of 1) additional injuries concerning for abuse, 2) diagnosis of abuse and 3) a report to Child Protective Services (CPS) among children <60 months presenting with rib fractures or with rib fractures identified incidentally during evaluation of a chief complaint unrelated to abuse. Read More

Authors:  Brennan Brian , Henry M Katherine , Altaffer Ana , Wood Joanne

Keywords:  Child Abuse, Fracture, Rib Fracture

Gensel Anna,  Karmazyn Boaz,  Forbes-amrhein Monica

Final Pr. ID: Paper #: 115

This study aimed to elucidate the imaging appearance of costochondral junction (CCJ) fractures in young children, determine the association with nonaccidental trauma (NAT), and suggest a mechanism for injury. Read More

Authors:  Gensel Anna , Karmazyn Boaz , Forbes-amrhein Monica

Keywords:  Child Abuse, CCJ fracture, NAT

Birkemeier Krista,  Ward Erica,  Salman Sehar,  Blazovic Sarah,  Mallett Lea

Final Pr. ID: Paper #: 065

Imaging during the evaluation of suspected child abuse victims may be requested 24 hours a day, however, pediatric radiologists may not always be available to interpret these studies. Timely reporting is important for treatment and disposition in this vulnerable population. In addition, the accuracy of detection of subtle injuries is critical for patient safety. The current protocol at our institution consists of an immediate preliminary interpretation by an adult radiologist when a skeletal survey is obtained after hours, and final interpretation by one of three pediatric radiologists during normal business hours. Read More

Authors:  Birkemeier Krista , Ward Erica , Salman Sehar , Blazovic Sarah , Mallett Lea

Keywords:  Skeletal Survey, Discrepancy, Child Abuse

Marine Megan,  Smith Jessica,  Wanner Matthew,  Jennings Samuel,  Hibbard Roberta,  Karmazyn Boaz

Final Pr. ID: Poster #: SCI-029

The purpose is to evaluate how well non-pediatric radiologists interpret skeletal surveys in the cases of possible child abuse. Read More

Authors:  Marine Megan , Smith Jessica , Wanner Matthew , Jennings Samuel , Hibbard Roberta , Karmazyn Boaz

Keywords:  Skeletal Survey, Child Abuse, Nonaccidental Trauma

Messer Diana,  Adler Brent H.,  Brink Farah,  Xiang Henry,  Agnew Amanda

Final Pr. ID: Poster #: SCI-038

Skeletal fractures may go undetected and untreated in physically abused children for significant periods of time. When discovered later through radiographic survey, the time since injury (TSI) may be important for the medical diagnosis of physical abuse and have implications for child protection. Prior research suggests that clinical and biological variables, such as fracture location and age, may influence pediatric fracture healing. However, radiographic determination of TSI has been poorly studied until recently. It has been commonly understood that in general younger patients heal faster and lower extremity fractures heal slower than upper extremity fractures. However, the influence of patient age and fracture location on fracture healing has only been explored on a limited scale and not between pediatric age groups. This study examines the effect of age on specific features of pediatric fracture healing through radiographic analysis. Read More

Authors:  Messer Diana , Adler Brent H. , Brink Farah , Xiang Henry , Agnew Amanda

Keywords:  Fracture, Healing, Abuse

Shields Jared,  Marine Megan,  Karmazyn Boaz

Final Pr. ID: Poster #: EDU-063

The Classic Metaphyseal Lesion (CML) is one of the most specific findings on skeletal surveys indicating child abuse. While there have been multiple studies to show the prevalence and specificity of the CML, very little has been published on the characteristic healing patterns.

The child protective team in our tertiary children’s hospital reviews approximately 6,000 cases from all over the state every year. Many children with a positive skeletal survey will undergo a 14-day follow up survey.

The purpose of this study is to share our experience on patterns of CML healing by comparing the primary survey with its follow up. We have identified a few distinct patterns: Bone formation and sclerosis along the proximal metaphyseal zone, angular deformity of the metaphyseal corner, and subchondral metaphyseal lucencies. These patterns are represented by the accompanying supplemental figures and are described below.

Figure 1 is the 14-day follow up radiograph of an acute distal tibial CML diagnosed on the primary skeletal survey. This radiograph reveals increased sclerosis along the entire length of the metaphyseal zone, a common pattern of CML healing.

Figure 2 is 14-day follow up of a different patient who sustained a CML of the distal tibia. Healing in this case is denoted by the angular deformity and periosteal reaction along the metaphyseal corner.

Figure 3 is a radiograph of the left wrist from a patient’s primary skeletal survey. The subchondral lucency identified along the lateral metaphysis is another common pattern indicative of a healing CML. Interestingly, the 14-day follow up skeletal survey of this patient demonstrated complete resolution of this finding with no signs of prior injury. In several other cases, the metaphysis on follow up exam appeared completely normal.

In summary, knowledge of the radiographic patterns of CML healing can help to identify these lesions as their classic imaging characteristics change. It is also important to recognize that if the first radiograph demonstrates CML, a normal 14-day follow up radiograph does not exclude the diagnosis. Read More

Authors:  Shields Jared , Marine Megan , Karmazyn Boaz

Keywords:  CML, Child Abuse