A 4-week-old girl was brought to the ED with right thigh swelling after reportedly getting caught up in the restraints of her car seat. Lower extremity radiographs revealed a healing right femur fracture, as well as multiple fractures of the left lower extremity. In light of these findings, a complete skeletal survey was performed. Look at the chest radiograph below. Other than the striking number of fractures that you see, what else do you notice about them?
The various posterior rib fractures are in different stages of healing. For example, the left 3rd through 5th posterior rib fractures (red, below) appear most acute, while the left 7th-9th ribs (blue) show some degree of healing. The rib fractures on the right side (yellow) show more substantial callous formation (2nd through 9th, and 11th).
Unfortunately, these findings strongly suggest that this patient was the victim of non-accidental trauma (NAT). There are many radiographic findings suggestive of NAT, but some of them are more specific than others.
Highly specific findings include:
- Rib fractures (especially posterior)
- Metaphyseal lesions – “bucket handle” or “corner” fractures
- Scapular fractures
- Spinous process fractures
- Sternal fractures
Now, let’s take a closer look at the lower extremity fractures that were initially discovered.
These are classic metaphyseal fractures, which we just learned were some of the most highly specific findings for NAT. The child has a healing metaphyseal fracture of the right distal femur. There is also a metaphyseal fracture at the right proximal tibia.
The left distal femur shows an acute transverse metaphyseal fracture. Metaphyseal fractures are also seen involving the left distal tibia. Finally, notice the periosteal reaction along the shafts of the left tibia and fibula, right lateral distal femur, and right fibula.
It should be noted that it is very important to rule out other potential causes of such fractures, like Vitamin D deficiency or osteogenesis imperfecta, since a diagnosis or even the suggestion of NAT will bring about a wide range of social, economic, and legal consequences.
The images and fracture patterns above are not all-inclusive for NAT as many fractures can occur. It is imperative that physicians utilize their clinical index of suspicion along with radiologic imaging in search of NAT.
What should be included in a typical skeletal survey when NAT is suspected? The American College of Radiology suggests the following protocol:
- Chest (AP, lateral and bilateral obliques to include the thoracic and upper lumbar spine)
- Pelvis (AP, to include the mid-lumbar spine)
- Lumbosacral spine (lateral)
- Cervical spine (AP and lateral)
- Skull (Fontal and lateral, oblique view as needed)
- Humeri (AP)
- Forearms (AP)
- Femurs (AP)
- Lower legs (AP)
- Hands and Feet (AP)
Images courtesy of Dr. Thomas Sanchez
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Author: Mitchell Datlow
Filed under: Student Corner Tagged: Non-Accidental Trauma, Pediatrics