Clinical Presentation

Lethargy in a 6-month-old with a history of ventriculoperitoneal shunt placement.

(A) A lateral radiograph of the skull demonstrates no disruption of the shunt catheter. (B) An abdominal radiograph obtained as part of the shunt series demonstrates the tip of the shunt catheter in the pelvis, with no evidence of disruption. However, there are bilateral rib fractures of varying ages, both old (with ample callus, arrows) and new (without evidence of healing, arrowhead).

Differential Diagnosis

• Child abuse: Except in rare settings of an underlying disease such as osteogenesis imperfecta or multiple episodes of accidental trauma, fractures of varying ages are essentially diagnostic of child abuse.

• Osteogenesis imperfecta: