Occult head injury is common in children with concern for physical abuse

Boehnke, Mitchell; Mirsky, David M.; Stence, Nicholas; Stanley, Rachel; Lindberg, Daniel M.

doi:10.1007/s00247-018-4128-6

Cited by 23 publications

(16 citation statements)

References 26 publications

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“…In determining occult injuries, our study classified patients with any skull fracture seen on X-ray as having a sign of head injury, regardless of whether the CT head scan or skeletal survey were carried out first. However, other published studies [7][8][9][10][11][12] variably include skull fractures as occult head injuries, and If an intracranial injury is associated with the skull fracture, this would be counted as an occult intracranial injury. In addition, our study did not attempt to ascertain extracranial injuries, as their clinical and forensic value can be difficult to determine.…”

Section: Discussionmentioning

confidence: 99%

“…[6] Studies reporting frequency of occult head injuries in infants with suspected physical abuse differ in their definition of occult and in populations studied, with reported yields ranging from 4% to 38%. [7][8][9][10][11][12] Information about yield is important in balancing risks and benefits of medical investigations. The Royal College of Paediatrics and Child Health calls for 'further research… to determine the positive diagnostic yield of head CT in children less than one year of age'.…”

Section: Introductionmentioning

confidence: 99%

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Intracranial injuries on computed tomography head scans in infants investigated for suspected physical abuse: a retrospective review

et al. 2020

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BackgroundUK national guidelines recommend that investigation of infants (aged <12 months) with suspected physical abuse should always include CT head scans. Such imaging carries small but recognised risks from radiation exposure. Studies report a range of yields for occult intracranial injuries in suspected physical abuse.AimsTo report the yield of intracranial injuries on CT head scans carried out for suspected physical abuse in infants, compare yields for those presenting with or without signs of head injury and to describe selected clinical and radiological features.MethodsA retrospective cross-sectional review of case records of infants undergoing skeletal survey for suspected physical abuse in Wessex, England. The main outcome measure was yield of intracranial injuries on CT head scan.ResultsIn total, n=363 CT head scans were included (n=275 aged <6 months). The overall yield of intracranial injury was 37 (10%). Among 68 infants presenting with neurological signs or skull fractures, yield was 36 (53%) compared with just 1 (0.34%) of 295 without neurological signs or skull fractures. This one intracranial injury was found to be consistent with an accidental fall. Scalp injury was the only additional clinical feature associated with intracranial injury.ConclusionIn suspected physical abuse, CT head scans should be carried out in infants who present with neurological signs, skull fractures or scalp injuries. However, in balancing potential risks and benefits, we question the value of performing a CT head scan in every infant investigated for suspected physical abuse.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Intracranial injuries on computed tomography head scans in infants investigated for suspected physical abuse: a retrospective review

et al. 2020

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“…Rarely, radionuclide imaging (‘bone scan’) may be indicated although this is now usually replaced by a second skeletal survey 1 2 4. Because of the risk of intracranial injuries, it is recommended best practice routinely to include a non-contrast CT scan of the head in children under 1 year1 5 and to have a low threshold for neuroimaging in children under 2 years where abuse is suspected 2 6…”

Section: Introductionmentioning

confidence: 99%

Radiation doses in diagnostic imaging for suspected physical abuse

et al. 2019

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ObjectiveTo measure the actual radiation dose delivered by imaging techniques commonly used in the radiography of suspected physical abuse and to make this information available to health professionals and families.MethodsData were collected retrospectively on children under 3 years referred for skeletal surveys for suspected physical abuse, non-contrast CT head scan or radionuclide imaging of the bones in Starship Children’s Hospital, Auckland, New Zealand from January to December 2015. Patient size-specific conversion coefficients were derived from International Commission on Radiologic Protection tissue weighting factors and used to calculate effective dose.ResultsSeventy-one patients underwent an initial skeletal survey, receiving a mean effective dose of 0.20 mSv (95% CI 0.18 to 0.22). Sixteen patients had a follow-up survey with a mean effective dose of 0.10 mSv (95% CI 0.08 to 0.11). Eighty patients underwent CT head which delivered a mean effective dose of 2.49 mSv (95% CI 2.37 to 2.60). Thirty-nine patients underwent radionuclide bone imaging which delivered a mean effective dose of 2.27 mSv (95% CI 2.11 to 2.43).ConclusionsIn a paediatric centre, skeletal surveys deliver a relatively low effective radiation dose, equivalent to approximately 1 month of background radiation. Non-contrast CT head scan and radionuclide bone imaging deliver similar doses, equivalent to approximately 1 year of background radiation. This information should be considered when gaining informed consent and incorporated in patient education handouts.

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“…Despite the fact that both the incidences of ICI and abuse-related fracture are highest in very young children, few studies have examined the co-occurrence of ICI and abuse-related LBF (13,(16)(17)(18). Maguire et al estimated the probability of ICI in hospitalized children with head trauma and reported that LBF alone has a 35% positive predictive value for ICI (19).…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Intracranial Injury Among Children with Abuse-Related Long Bone Fractures

Chahla

Ortega

2020

The Journal of Emergency Medicine

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Background: Intracranial injury (ICI) from abusive head trauma is the leading cause of death among young abused children but is difficult to detect. Long bone fracture (LBF) may lead to the recognition of abuse in young abused children. Objectives: This study is the first to report the incidence and features of ICI in children with abuse and LBFs. Methods: This is a retrospective study of children younger than 3 years with the diagnosis of LBF in the National Trauma Data Bank from 2009 to 2014. LBF, abuse, and clinical features were identified using International Classification of Diseases, Ninth Revision codes. Abuserelated LBF with and without ICI were compared to identify risk factors for ICI. Results: There were 4345 encounters for abuse-related LBF in kids ages < 3 years; 970 (22%) had ICI. Infants < 1 year of age were more likely to have ICI compared with older children (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.38-2.33). After adjusting for age, fracture of the ulna, radius, tibia, or fibula were associated with greater odds of ICI (OR 3.35, 95% CI 2.81-4.00). Abuse-related LBF with additional findings of skull fracture, rib fracture, or head/neck bruising had an increased odds of ICI (OR 8.27, 95% CI 6.85-9.98; OR 2.67, 95% CI 2.28-3.14; OR 2.41, 95% CI 1.99-2.92, respectively). Conclusions: ICI occurred in nearly 1 in 4 children under 3 years old with abuse-related LBF. Abuse-related LBF with skull fracture, rib fracture, head/neck bruising, or patient age < 1 year should prompt consideration for ICI with head imaging.

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Occult head injury is common in children with concern for physical abuse

Abstract: Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.

Cited by 23 publications

References 26 publications

Intracranial injuries on computed tomography head scans in infants investigated for suspected physical abuse: a retrospective review

Intracranial injuries on computed tomography head scans in infants investigated for suspected physical abuse: a retrospective review

Radiation doses in diagnostic imaging for suspected physical abuse

Intracranial Injury Among Children with Abuse-Related Long Bone Fractures

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