Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Pediatrics 2014;133:e477-e489 INTRODUCTIONFractures are the second most common injury caused by child physical abuse; bruises are the most common injury. 1 Failure to identify an injury caused by child abuse and to intervene appropriately may place a child at risk for further abuse, with potentially permanent consequences for the child. 2-4 Physical abuse may not be considered in the physician' s differential diagnosis of childhood injury because the caregiver may have intentionally altered the history to conceal the abuse. 5 As a result, when fractures are initially evaluated, a diagnosis of child abuse may be missed. 3 In children younger than 3 years, as many as 20% of fractures caused by abuse may be misdiagnosed initially as noninflicted or as attributable to other causes. 3 In addition, fractures may be missed because radiography is performed before changes are obvious or the radiographic images are misread or misinterpreted. 2 However, incorrectly diagnosing physical abuse in a child with noninflicted fractures has serious consequences for the child and family. To identify child abuse as the cause of fractures, the physician must take into consideration the history, the age of the child, the location and type of fracture, the mechanism that causes the particular type of fracture, and the presence of other injuries while also considering other possible causes. DIFFERENTIAL DIAGNOSIS OF FRACTURES Trauma: Child Abuse Versus Noninflicted InjuriesFractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries. [6][7][8] In infants and toddlers, physical FROM THE AMERICAN ACADEMY OF PEDIATRICSGuidance for the Clinician in Rendering Pediatric Care by guest on May 11, 2018 http://pediatrics.aappublications.org/ Downloaded from abuse is the cause of 12% to 20% of fractures. 9 Although unintentional fractures are much more common than fractures caused by child abuse, the physician needs to remain aware of the possibility of inflicted injury. Although some fracture types are highly suggestive of physical abuse, no pattern can exclude child abuse. 10,11 Specifically, it is important to recognize that any fracture, even fractures that are commonly noninflicted injuries, can be caused by child abuse. Certain details that can help the physician determine whether a fracture was caused by abuse rather than unintentional injury include the hist...
Objective: To determine the validity of existing imaging-derived formulas for predicting the fetal lung volume (FLV). Methods: In a consecutive series of postmortem lungs without pulmonary anomalies, the observed FLV (FLVobs) after inflation was correlated with individual fetal variables used in imaging-derived formulas. In addition, FLVobs was correlated with the predicted FLV calculated according to these same formulas. Results: Postmortem FLVobs showed a strong correlation with estimated fetal body weight, biparietal diameter, and head circumference (r > 0.9). The correlation of FLVobs with gestational age, femur length, and liver weight was less strong (0.8 < r < 0.9). The correlation was strongest for midgestation fetuses (between 22 and 32 weeks’ gestation). The predicted FLV calculated using formulas based on fetal body weight, biparietal diameter, and head circumference showed the strongest correlation with the actual FLVobs (r > 0.9). Conclusions: Postmortem FLVobs strongly correlates with fetal body weight, biparietal diameter, and head circumference, especially in midgestation fetuses. Regression formulas based on these fetal variables provide the most accurate prediction of FLV.
In recent years radiation risk from CT scanning has become an important area of investigation. Many authors have suggested that radiation dose can be decreased without loss of diagnostic information. This dose reduction has primarily been achieved through a decrease in tube current. An area that has received little attention has been variations in dose from different CT scanners. To evaluate this aspect of radiation exposure, we measured the radiation dose of 4 different CT scanners. We found that the radiation dose for the same CT technique can vary by as much as a factor of 3 when 1 mm slices are used. CT dose variation was greatest for thin slices, making these observations particularly important for high-resolution CT. Our measurement technique used standard quality assurance equipment available in most radiology departments. Use of these measurements to assess the radiation dose from different CT scanners is an easily performed technique that may allow a decrease in radiation exposure in departments by choosing the most appropriate intra departmental CT scanner for specific indications.
Abusive head trauma (AHT) is a significant cause of morbidity and mortality for infants. Determining when to pursue a complete physical abuse evaluation can be difficult, especially for nonspecific findings or when a child appears clinically well. This retrospective study of 7 cases sought to describe the presentation, evaluation, and diagnoses for infants with abnormal subdural collections identified on cranial ultrasound for macrocephaly, and to determine how frequently AHT is diagnosed. The results of this study showed that while each patient presented due to asymptomatic macrocephaly, the extent of the workup varied greatly. In addition, no infants had suspicious injuries for abuse during the initial evaluation or the year following. In summary, among the 7 patients seen for asymptomatic macrocephaly with possible subdural hemorrhage, there were very inconsistent child abuse workups. There needs to be a standardized clinical guideline for this specific patient population involving a child abuse pediatric evaluation.
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