Differential diagnoses for child not using a limb
- Fracture
- NAI
- Chronic osteomyelitis
- Osteoid osteoma
- Congenital cyst
- Other infection
How do you assess for dislocated hip on x-ray?
Look at whether Shenton line is intact (forms an arc) or broken (=dislocated)
Discuss femoral fractures in NAI
- Proximal femoral fractures are rare
- 2 types of #: shaft, distal metaphysis (classic metaphyseal lesion, bucket-handle fracture - rare but very strongly associated with NAI)
Discuss corner fractures
- Bone is knocked off edge of subperiosteal collar
- Microfractures through primary spongiosa
- Can be difficult to distinguish between metaphyseal fractures and spurs - assess via F/U x-ray 2/52 later
What findings are pathognomonic of child abuse?
There are no findings pathognomonic of child abuse - don’t choose this answer in MCQs
What are the most common fractures found in child abuse <1yr old?
- Skull fractures
- Extremity fractures (esp humerus, femur)
- Rib fractures
Which fractures have the highest specificity for child abuse?
- Rib fractures (usually posterior, paravertebral, transverse processes) and metaphyseal fractures
- Rib fractures usually undisplaced, so don’t see on x-ray until ~day 5 when callous forms. Repeat x-ray 2/52 later if high suspicion of fracture
If suspicious of NAI, what is the risk of finding an abnormality of skeletal survey?
- 20%
- Skeletal survey mandatory in all suspicions <2y/o, optional >2y/o
Why do you get an enlarged zone of calcification in Vitamin D deficiency?
- Phosphate has a role in apoptosis
- Vit D def -> low phosphate -> decr apoptosis -> enlarged zone of calcification
- Vitamin D deficiency doesn’t predispose to fractures unless there are clear radiological changes evident of severe Vit D deficiency
What is the classic pattern of bruising in toddlers?
- Forearm
- Shins
- “T” shaped forehead/face
What is the “Ten 4” rule in NAI?
- Bruising on the torso, ears, neck, soft tissues of face (+ frenulum, angle of jaw, buccal, eyelids, subconjunctival) <4yrs concerning for abuse
- Any bruise <4m age
- Patterned bruising
What are the different shapes of hymen?
- Annular
- Crescentic (most common ~7yo)
- Fimbriated (folded in on itself, due to excess oestrogen)
- Septate
- Sleeve-like
- Can only make comments about abnormalities located from 3-9 o’clock as anterior to this there are too many anatomical variants
What is a hymenal bump?
Intravaginal ridge, normal variant
What percentage of children referred for sexual abuse have an abnormal examination finding?
4% (96% normal exam)
What can cause retinal hemorrhages?
- Late onset hemorrhagic disease of newborn
- Meningococcal meningitis
- Head injury in vWD
- Pertussis?
- NAI
- Should not be seen in SIDS
What are the spinal findings in abusive head trauma?
- Spinal subdural haemorrhage 40-60% (passive gravitation of SDH from brain, not often seen in accidental HT)
- Cervical spinal ligamentous injury 35-75% (due to hyperflexion/extension injury of the neck)
- Bony vertebral injury up to 5%
What is the risk of a subdural hemorrhage following a vaginal delivery?
Up to 50% (uncommon with C-section), resolve by 28 days. Rarely seen in posterior fossa until 90 days, asymptomatic
Widespread brain damage (hyperintensity) seen on diffusion-weighted MRI is suggestive of?
- Hypoxic-ischaemic injury
- Common finding in abusive head trauma, rarely seen in accidental injury
- Changes seen by 5-7 days post injury, then get atrophy and porencephaly (areas of dead brain)
- Due to 1) delay in seeking help 2) apnoea associated with hyperflex/ext of cervicomedullary junction
- Hypoxia doubles mortality and morbidity
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