Child Abuse Musculoskeletal Injury

  • Etiology: trauma – shaken or shaken and slammed
  • Imaging: specificity of fracture for abuse
    — High – classic metaphyseal lesions (bucket-handle fracture on AP view / corner fracture on lateral view), rib fractures (especially posteromedial), scapular fractures, spinous process fractures, sternal fractures
    — Moderate – multiple fractures (especially bilateral), fractures of different ages, epiphyseal separations, vertebral body fractures and subluxations, digital fractures, complex skull fractures
    — Low – subperiosteal new bone formation, clavicular fractures, long-bone shaft fractures, linear skull fractures
  • Note: skeletal survey should be repeated at 2 weeks, rib fractures are easy to miss acutely, classic metaphyseal lesions are often bilateral and symmetrical and often heal without callus and may be inconspicuous initially
  • DDX:
    — Normal variants – skull vascular groove, wormian bone, accessory suture can mimic skull fracture
    — Accidents – < 3 yo with femur fracture without good history suspect abuse
    — Birth trauma
    — CPR – can cause anterior rib fracture
    — Copper deficiency
    — Menke’s disease
    — Skeletal dysplasia – metaphyseal chondrodysplasia type Schmid, spondylometaphyseal dysplasia corner fracture type
    — Osteogenesis imperfecta
    — Scurvy
    — Rickets
    — Osteomyelitis – causing periostitis
    — Caffey’s disease
    — Congenital syphilis
    — Leukemia – causing periostitis
    — Medications (prostaglandin) – causing periostitis
  • DDX of classic metaphyseal lesion
    — Metaphyseal step-off
    — Metaphyseal beak
    — Proximal tibia cortical irregularity
    — Metaphyseal spur
    — Distal femoral + proximal tibial metaphyseal fragmentation with physiologic bowing in > 15 month old
  • Clinical: incidence is 1 million abused / neglected children in United States / year resulting in 1,500 – 3,000 deaths / year, suspect in children with multiple instances of unexplained trauma, recent unreported physical trauma, history of mild trauma non consistent with severity of injury

Cases of Child Abuse Musculoskeletal Injury

CXR of posterior rib fractures in child abuse
CXR AP shows poorly expanded but grossly clear lungs bilaterally. There is dense periosteal reaction / callus formation around the posterior aspect of the left 8th and 9th ribs.
CXR of posterior rib fractures in child abuse
CXR AP shows lucent lines without surrounding periosteal reaction through the right 6th-8th and left 6th-11th ribs posteriorly.
3D CT construction of anterior rib fractures in child abuse
3D CT reconstruction with contrast of the chest shows callus formation around the right 4th-8th ribs and left 4th-9th ribs anteriorly.
CXR of posterior rib fractures which were initially missed in child abuse
CXR AP (above) from initial skeletal survey was unremarkable. Repeat CXR AP (below) from follow-up skeletal survey 2 weeks later shows interval development of periosteal reaction around the left 8th-9th ribs posteriorly.
Radiograph of classic metaphyseal lesion / bucket handle fracture of the femur and tibia in child abuse
AP radiograph of the lower extremities shows bucket handle irregularities of the metaphyses of the bilateral distal femurs and bilateral proximal tibiae. There is also periosteal reaction of the distal left femur and bilateral tibiae.
Radiograph of classic metaphyseal lesion / bucket handle fracture / corner fracture of the tibia in child abuse
AP radiograph of the right tibia and fibula (left) shows a faint bucket handle irregularity of the distal tibial metaphysis. Lateral radiograph of the right tibia and fibula (right) shows anterior and posterior corner irregularities of the distal tibia metaphysis.
Radiograph of metaphyseal spur
AP and lateral radiographs of the right knee shows a spur along the lateral aspect of the metaphysis which was proven at autopsy to be a spur and not a fracture.
Radiograph of femur fracture in child abuse
AP and lateral radiographs of the right femur (above) show a linear lucency through the diaphysis of the right femur with no associated periosteal reaction. CXR AP shows callus formation around the lateral aspect of the right 5th-6th ribs.
Radiograph of femur fracture in child abuse
AP radiograph of the right femur shows a lucency through the diaphysis of the right femur with no associated periosteal reaction. CXR AP shows callus formation around the right 7th and 9th ribs laterally, the right 7th-9th ribs posteriorly, the left 3rd-7th ribs laterally and the left 8th rib posteriorly.
AXR of chylous ascites in child abuse
CXR AP (left) shows the lungs to be poorly expanded and clear but there are dense areas of callus along the lateral aspect of the right 3rd-5th ribs. Centralization of the loops of bowel were also incidentally noted and confirmed on a subsequent AXR AP (right).
Gross pathological image of posterior rib fractures in child abuse
CXR (above) and complete skeletal survey showed no evidence of rib fractures. Gross pathological image (below) shows callus formation along the posterior aspect of the left 4th-8th ribs.