Child Abuse



10.1055/b-0034-87949

Child Abuse















































Table 5.98 Child abuse: conditions that masquerade as child abuse and simulate the classic metaphyseal lesion (see Table 5.44)

Diagnosis


Comments


Birth trauma


After low segment cesarean sections.


Iatrogenic


After orthopedic manipulations.


Osteomyelitis


Osteomyelitis has a predilection for the metaphysis in infants. Although systemic signs and symptoms of infection may be lacking in infants and multiple sites of osteomyelitis and different stages of healing may simulate child abuse, the metaphyseal erosions in osteomyelitis tend to be less well-defined than classic metaphyseal lesions (CMLs; see Table 5.43 ).


Rickets and metabolic bone disease


Fig. 5.180


Controversy exists as to whether or not osseous fragments resembling CMLs are always accompanied by more obvious changes of rickets such as metaphyseal irregularity and physeal widening.70,71 Laboratory findings may also help support a diagnosis of rickets.


Bone dysplasias


Skeletal survey will reveal other abnormalities associated with the given skeletal dysplasia. DD: osteogenesis imperfecta, metaphyseal chondrodysplasia (Schmid type), and spondylometaphyseal dysplasia (corner fracture type).


Leukemia


Bone demineralization, osteolytic lesions, and subperiosteal new bone formation. Radiolucent bands at the metaphyses. Imaging findings may be due to a combination of nutritional disturbance and leukemic invasion (see Table 5.43 ).


Scurvy


Subperiosteal hemorrhage and metaphyseal and epiphyseal changes. Characteristic findings of scurvy may help to distinguish from child abuse (see Table 5.43 ).


Vitamin A intoxication


Subperiosteal new bone formation predominantly in the tubular bones.


Lower extremity paralysis


Routine handling of infants with paralysis may cause fractures.


Infantile cortical hyperostosis (Caffey disease)


Subperiosteal new bone formation and cortical thickening. Preference for the mandible, clavicle, and ulna.


Menkes syndrome (kinky hair disease)


Rare genetic disorder resulting in defective gastrointestinal absorption of copper. Metaphysis of the long bones have spurs ± fractures. Subperiosteal new bone formation and bone demineralization. Tortuous and irregular cerebral and abdominal arteries.


Congenital indifference/insensitivity to pain


Lack of sensation of pain may lead to a delay in diagnosis of both minor and major trauma. Imaging may show metaphyseal injuries, subperiosteal hemorrhage, fractures, and epiphyseal separations in various stages of healing during infancy. Charcot-type joints manifest later in childhood.

Fig. 5.180 Rickets and metabolic bone disease. Metaphyseal irregularity simulating a metaphyseal corner fracture (arrow) in a 3-year-old girl with resorptive metabolic bone disease of unclear etiology.






















Table 5.99 Child abuse: specificity of fracture locations

Specificity


Fracture


High


Classic metaphyseal lesion


Fig. 5.74, p. 545


Fig. 5.75, p. 545


Rib fractures


Fig. 5.181


Scapular fractures


Spinous process fractures


Sternal fractures


Moderate


Multiple fractures (especially bilateral)


Fractures of different ages


Epiphyseal separation


Vertebral body fractures and subluxations


Digital fractures


Complex skull fractures


Low


Subperiosteal new bone formation


Clavicular fractures


Long bone shaft fractures Linear skull fractures


Table 5.99 reproduced with permission from Kleinman PK. Diagnostic imaging of child abuse. 2nd ed. St. Louis: Mosby, 1989.

Fig. 5.181 Healing posterior rib fractures (arrow) in child abuse.



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