1. Interesting Case Chris McCrossin R1 Emergency Medicine

2. 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)

3. 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

4. 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

5. 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”.

6. 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)

7. Why do babies grunt? FOUR REASONS: Pain Respiratory infection Neurological injury Sepsis (acid/base disturbance)

8. Our Work-up CT Scan Completely normal Labs No evidence of UTI, CBC and lytes N CXR:

9. Chest Xray

13. 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

14. 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

15. Other fractures

16. Corner Fractures First described by Caffey who noted an association of these fractures with subdural hematomas

17. Bucket Handle Fractures Avulsed bone fragment Common sites: –Tibia –Distal femora –Proximal humeri –Frequently bilateral

18. Diaphyseal Fractures Highly suspect of child abuse in children not yet ambulatory Suspicious in ambulatory children with history inconsistent of child abuse

19. Differential Diagnosis for Multiple/ Unusual Fractures

20. 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

21. 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

22. Metaphyseal Dysplasia Rare genetic disorder Can resemble old corner fractures

23. 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

24. How good are the radiological tests at identifying fractures of child abuse?

25. 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.

26. Skeletal Survey Guidelines

27. 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