The infant whiplash-shake injury syndrome: a clinical and pathological study

Nonaccidental pediatric head injury: diffusion-weighted imaging findings

OBJECTIVE

Diffusion-weighted imaging (DWI) reveals nonhemorrhagic posttraumatic infarction hours to days before conventional computed tomographic scanning or magnetic resonance imaging (MRI). We evaluated the diagnostic utility of DWI in children with nonaccidental head trauma.

METHODS

The medical records and imaging examinations obtained between January 1998 and May 2000 for all children less than 2 years of age with presumed or suspected nonaccidental head injury were reviewed retrospectively. Twenty children who had undergone DWI within 5 days of presentation were included in the study. Computed tomographic scans, conventional MRI sequences, and DWI combined with apparent diffusion coefficient (ADC) maps were evaluated.

RESULTS

Eleven girls and nine boys (median age, 5 mo) were studied. Eighteen children had presumed nonaccidental head trauma, and two children had suspected nonaccidental head trauma. Of the 18 children with presumed nonaccidental trauma, 16 (89%) demonstrated abnormalities on DWI/ADC, as compared with neither of the two children with suspected nonaccidental trauma. In 13 (81%) of 16 positive cases, DWI revealed more extensive brain injury than was demonstrated on conventional MRI sequences or showed injuries not observed on conventional MRI. DWI combined with ADC maps allowed better delineation of the extent of white matter injury. DWI/ADC abnormalities in the nonaccidental head-injured children were likely to involve posterior aspects of the cerebral hemispheres, with relative sparing of the frontal and temporal poles. Severity on DWI correlated significantly with poor outcome (P < 0.005).

CONCLUSION

DWI has broad applications in the early detection of infarction in children with nonaccidental head injury and enhances the sensitivity of conventional MRI. In the patients in this study, early DWI provided an indicator of severity that was more complete than any other imaging modality. The use of DWI may help to identify children at high risk for poor outcome and to guide management decisions.

Shaken baby syndrome: rotational cranial injuries-technical report

Shaken baby syndrome is a serious and clearly definable form of child abuse. It results from extreme rotational cranial acceleration induced by violent shaking or shaking/impact, which would be easily recognizable by others as dangerous. More resources should be devoted to prevention of this and other forms of child abuse.

MR imaging of shaken baby syndrome manifested as chronic subdural hematoma

Shaken baby syndrome (SBS) is a form of child abuse that can cause significant head injuries, of which subdural hematoma (SDH) is the most common manifestation. We report the MRI findings of chronic SDH in three cases of SBS, involving two-, three- and eight-month-old babies. The SDH signal was mostly low on T1-weighted images and high on T2-weighted images, suggesting chronic SDH. In chronic SDH, a focal high signal on T1-weighted images was also noted, suggesting rebleeding. Contrast-enhanced MRI revealed diffuse dural enhancement.

Pharmacologic Treatment of Cognitive Deficits and Hypersexuality Due to “Shaken-Baby Syndrome”

Objective:

To describe the clinical effects of amantadine and propranolol in an agitated pediatric patient with cognitive deficits, hyperactivity, and hypersexualism secondary to “shaken-baby syndrome.”

Background:

Patients with shaken-baby syndrome can present with cognitive and behavioral impairments.

Case:

A 9-year-old girl presented with cognitive impairments secondary to shaken-baby syndrome at 3 weeks of age. She was receiving many medications, including dextroamphetamine, methylphenidate, and clonidine, that were not effective in improving her cognitive status or decreasing her hypersexuality. She was weaned from stimulants and clonidine and prescribed amantadine 100 mg bid with improvement of attention, concentration, and cognition, although hypersexuality remained. She was then started on propranolol 10 mg tid and a gradual increase to 40 mg tid with amelioration of hypersexuality and hyperactivity and no unwanted effects noted. Self-weaning of propranolol was associated with the return of hypersexuality. The combination of amantadine and propranolol led to improvement of cognition and behavior, especially intellectual functioning and appropriate socialization with peers, respectively.

Conclusion:

Cognitive deficits and hypersexuality with hyperactive features due to shaken-baby syndrome may respond to the drug regimen of amantadine and propranolol.

The acute reversal sign: comparison of medical and non-accidental injury patients

OBJECTIVES

(1) To compare the intracranial computed tomography (CT) appearances of patients admitted with various causes of hypoxic ischaemic encephalopathy. Children with known documented accidental trauma were excluded. (2) To compare our results with those in the published literature.

MATERIALS AND METHODS

Seventy-three patients aged between 1 day and 15 years were admitted with clinical features of brain injury and underwent cranial CT. A retrospective review of their medical records and radiology was undertaken. Clinical and radiological data were collected.

RESULTS

On the basis of the combination of the presenting clinical history, progress, outcome, long term follow up and radiology, two groups of patients were identified. Forty-seven children had been the victims of non-accidental injury (NAI). No child in this group had any associated medical condition or any other medical cause for brain injury. All 47 children demonstrated hypoxic ischaemic encephalopathy and had CT signs of cerebral oedema and 'Reversal Sign'. Intracranial haemorrhage was a highly associated feature. Subdural blood was demonstrated in all 47, acute interhemispheric fissure subdural in 42, intracerebral blood in 16 and intraventricular blood in nine. The remaining 26 children were found to have an identifiable 'medical' cause for brain injury. Acute reversal was demonstrated in 21 of this group. Intracranial haemorrhage was uncommon, found in only five and all five had an underlying predisposition to bleeding. No patient in this group demonstrated subdural blood.

CONCLUSION

Non-accidental injury is strongly associated with the finding on CT of intracranial blood, particularly subdural haematoma and interhemispheric fissure bleeding in the presence of hypoxic ischaemic brain injury. The outlook is extremely poor whatever the underlying cause for hypoxic ischaemic brain injury.

Subdural haemorrhages in infants: population based study

OBJECTIVES

To identify the incidence, clinical outcome, and associated factors of subdural haemorrhage in children under 2 years of age, and to determine how such cases were investigated and how many were due to child abuse.

DESIGN

Population based case series.

SETTING

South Wales and south west England.

SUBJECTS

Children under 2 years of age who had a subdural haemorrhage. We excluded neonates who developed subdural haemorrhage during their stay on a neonatal unit and infants who developed a subdural haemorrhage after infection or neurosurgical intervention.

MAIN OUTCOME MEASURES

Incidence and clinical outcome of subdural haemorrhage in infants, the number of cases caused by child abuse, the investigations such children received, and associated risk factors.

RESULTS

Thirty three children (23 boys and 10 girls) were haemorrhage. The incidence was 12.8/100 000 children/year (95% confidence interval 5.4 to 20.2). Twenty eight cases (85%) were under 1 year of age. The incidence of subdural haemorrhage in children under 1 year of age was 21.0/100 000 children/year and was therefore higher than in the older children. The clinical outcome was poor: nine infants died and 15 had profound disability. Only 22 infants had the basic investigations of a full blood count, coagulation screen, computed tomography or magnetic resonance imaging, skeletal survey or bone scan, and ophthalmological examination. In retrospect, 27 cases (82%) were highly suggestive of abuse.

CONCLUSION

Subdural haemorrhage is common in infancy and carries a poor prognosis; three quarters of such infants die or have profound disability. Most cases are due to child abuse, but in a few the cause is unknown. Some children with subdural haemorrhage do not undergo appropriate investigations. We believe the clinical investigation of such children should include a full multidisciplinary social assessment, an ophthalmic examination, a skeletal survey supplemented with a bone scan or a skeletal survey repeated at around 10 days, a coagulation screen, and computed tomography or magentic resonance imaging. Previous physical abuse in an infant is a significant risk factor for subdural haemorrhage and must be taken seriously by child protection agencies.

Bruising in non-accidental head injured children; a retrospective study of the prevalence, distribution and pathological associations in 24 cases

Non-accidental head injury, be it shaking, impact(s) or a combination of the two, is characterised by subdural and/or subarachnoid haemorrhages with retinal haemorrhages, but minimal or absent external cranio-facial trauma. The classical assault scenario depicts the infant being gripped around the head, face, chest and abdomen and shaken or being gripped by a limb and swung. This gripping might be expected to leave physical evidence in the form of bruising. A study was undertaken to establish the prevalence, distribution and pathological association of external bruising in 24 cases of fatal non-accidental head injury in children. At autopsy, 17 cases had new external bruises, 15 old external bruises and 13, a combination of both. However, seven (29%) cases showed no fresh external bruising and five (21%) showed no external bruising at all. Thus, external bruising may be absent in children with fatal intracranial injury. The face was shown to be the commonest site of bruising followed by the forehead and buttocks. Limb, chest and abdominal bruising were found to be uncommon. Retinal haemorrhages were confirmed in 23 (96%) cases. It is hypothesised that bruising, when present, may be a result of abuse in the form of punches and slaps rather than due to gripping during the assault. We discuss why gripping does not necessarily result in external bruising.

Cerebral complications of nonaccidental head injury in childhood

Patterns of cerebral parenchymal injury and their relationship to outcome morbidity are evaluated in this retrospective study of 14 children with confirmed nonaccidental head injury (NAHI). The mean age at time of injury was 12 months 6 days, mean Children's Coma Score was 5.36, and mean postinjury follow-up was 17 months 12 days. All patients had acute subdural hematoma (interhemispheric or convexity) on initial CT imaging. Two major groups of children were identified from initial CT scans; those with diffuse cerebral hypoattenuation (n = 7) and those with focal cerebral hypoattenuation (n = 7). The two groups differed significantly by age (diffuse group, mean age 5 months 9 days +/- 36 days; focal group, mean age 19 months 3 days +/- 6 months 9 days; P < 0.01) and ultimate type and extent of parenchymal damage. Outcome was generally poor in both groups (mean Children's Outcome Score of III/IV). Cerebral infarction developed in all survivors. Most common were hemispheric necrosis after hemispheric swelling subjacent to an ipsilateral convexity acute subdural hematoma (n = 5); distribution of the posterior cerebral artery (n = 4) or callosomarginal branch of the anterior cerebral artery (n = 4); and borderzone infarctions (n = 4). Of 14 children, 11 (79%) had early posttraumatic seizures (EPTS). Clinical progression of symptoms was confirmed in nine patients (mean Childrens Coma Score was 4.0 +/- 0.33). None had a lucid interval. This is the first study using strict inclusion criteria that documents the range of infarction patterns and potential age-dependent differences in postinjury response cascades after nonaccidental head injury.

Outcome after severe non-accidental head injury

Over the past three years 15 children have been admitted to the paediatric intensive care unit (PICU) at Addenbrooke's hospital suspected of having non-accidental injuries; presentation was diverse and often mild and out of proportion to the degree of morbidity seen at discharge and follow up. When compared with a group of similar aged children admitted to the PICU with severe head injury caused by accidental impact trauma, the differences in morbidity were profound. It is suggested that these differences are explained in part by the predominant repetitive rotational forces experienced during severe shaking compared with the translocational forces that the head experiences during impact injuries. This anecdotal evidence supports the theory that shaking alone may cause severe intracranial injury. Thus campaigns should continue to increase public and doctors' awareness that shaking may be dangerous.

Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study

OBJECTIVE

Child abuse occurs in 1% of children in the United States every year; 10% of the traumatic injuries suffered by children under 5 years old are nonaccidental, and 5% to 20% of these nonaccidental injuries are lethal. Rapid characterization of the injury as nonaccidental is of considerable benefit to child protection workers and police investigators seeking to safeguard the child care environment and apprehend and prosecute those who have committed the crime of child abuse. Physically abused children present with a variety of well-described injuries that are usually easily identifiable. In some cases, however, particularly those involving children with the shaken baby syndrome, obvious signs of physical injury may not exist. Although external signs of such an injury are infrequent, the rapid acceleration-deceleration forces involved often cause subdural hematomas and retinal hemorrhages, hallmarks of the syndrome. Frequently, retinal hemorrhages may be the only presenting sign that child abuse has occurred. Complicating the interpretation of the finding of retinal hemorrhages is the belief by some physicians that retinal hemorrhages may be the result of chest compressions given during resuscitative efforts. The objective of this study is to determine the prevalence of retinal hemorrhages after inpatient cardiopulmonary resuscitation (CPR) in pediatric patients hospitalized for nontraumatic illnesses in an intensive care unit.

DESIGN

Prospective clinical study.

SETTING

Pediatric intensive care unit.

PATIENTS

Forty-three pediatric patients receiving at least 1 minute of chest compressions as inpatients and surviving long enough for a retinal examination. Patients were excluded if they were admitted with evidence of trauma, documented retinal hemorrhages before the arrest, suspicion of child abuse, or diagnosis of near-drowning or seizures. All of the precipitating events leading to cardiopulmonary arrest occurred in our intensive care unit, eliminating the possibility of physical abuse as an etiology.

INTERVENTIONS

None.

MEASUREMENTS

Examination of the retina was performed by one of two pediatric ophthalmologists within 96 hours of CPR. The chart was reviewed for pertinent demographic information; the platelet count, prothrombin time, and partial thromboplastin time proximate to the CPR were recorded if they had been determined.

RESULTS

A total of 43 pediatric patients hospitalized with nontraumatic illnesses survived 45 episodes of inpatient CPR. The mean age was 23 months (range, 1 month to 15.8 years), and 84% of the patients were under 2 years old. The majority of the patients (44%) were admitted to the intensive care unit after surgery for congenital heart disease, and another 21% were admitted for respiratory failure. The mean duration of chest compressions was 16.4 minutes +/- 17 minutes with 58% lasting between 1 and 10 minutes. Five patients had chest compressions lasting >40 minutes, and two patients had open chest cardiac massage. All patients survived their resuscitative efforts. Ninety-three percent of patients had an elevated prothrombin time and/or partial thromboplastin time while 49% were thrombocytopenic. Sixty-two percent of the patients had low platelet counts and an elevated prothrombin time and/or partial thromboplastin time. Small punctate retinal hemorrhages were found in only one patient.

CONCLUSIONS

Retinal hemorrhages are rarely found after chest compressions in pediatric patients with nontraumatic illnesses, and those retinal hemorrhages that are found appear to be different from the hemorrhages found in the shaken baby syndrome. Despite the small number of patients in this prospective study, we believe that these data support the idea that chest compressions do not result in retinal hemorrhages in children with a normal coagulation profile and platelet count. A larger number of patients should be evaluated in a prospective multi-institutional study to achieve statistical significance

The pathology of fatal child abuse

It is a sad indictment of human society that the abuse of children is such a prevalent and widespread problem. The acknowledgement that physical, emotional and sexual injury as well as intentional neglect can be inflicted upon the young by any person but especially by caregivers has been increasingly realised by the community. As a result, many professionals, especially in the medical sciences, are involved in the study and management of such cases with the ultimate goals of recognising children at risk, diagnosing those cases that have occurred, preventing initial or subsequent injury and bringing perpetrators to justice. The aim of this paper is to review recent published work on the pathology of abuse leading to death of the child. Particular reference is made to the patterns of observed physical damage as well as to the interpretation of those observations. Clearly many more children are abused than die directly as a result of that abuse, but pathologists are infrequently involved in the management of clinical abuse cases. Exceptions to this rule, of course, include assessment of biochemical changes in cases of Munchausen syndrome by proxy, diagnosis of infective lesions resulting from sexual assault as well as the interpretation of unexplained cutaneous lesions subsequently shown to be caused by physical assault (such as burns and bite marks). Cases of physical abuse are usually managed by pediatric specialists with assistance from radiologists, neurosurgeons and ophthalmologists, and it is important that effective communication be maintained by pathologists with these practitioners when investigating a case that has unfortunately culminated in death.

Cervical spine MRI in abused infants

OBJECTIVE

To determine clinical utility of screening with cervical spine MRI to detect unsuspected cord injury in children with head injury from child abuse.

DESIGN

Prospectively collected case series. Setting-Tertiary care children's hospital and county medical examiner's office.

PATIENTS

Twelve children with intracranial injury secondary to child abuse. None was clinically suspected to have cord injury. Includes all eligible children whose attending felt: (a) needed follow-up cranial imaging: (b) could be safely imaged; and (c) whose caretakers consented between November, 1991 and September, 1994.

INTERVENTIONS

MRI scans of the cervical spine were obtained either more than 3 days after clinical presentation or postmortem.

MAIN OUTCOME MEASURES

Clinical observations by neurologist, child protection team pediatrician and medicinal examiners by prospective protocol. MRI scans evaluated by prospective radiology protocol with emphasis on cervical cord injury.

RESULTS

Four of the five autopsied children had small subdural or subarachnoid hemorrhages at the level of the cervical spine; MRI scan did not identify them. MRI did not identify cord injury in any child studied.

CONCLUSION

Routine cervical spine MRI scans are probably not warranted in children with head injury secondary to child abuse without clinical symptoms of cervical cord injury.

Evidence from proton magnetic resonance spectroscopy for a metabolic cascade of neuronal damage in shaken baby syndrome

OBJECTIVE

The purpose of this study was to use proton magnetic resonance spectroscopy (MRS) as a metabolic assay to describe biochemical changes during the evolution of neuronal injury in infants after shaken baby syndrome (SBS), that explain the disparity between apparent physical injury and the neurological deficit after SBS.

METHODOLOGY

Three infants [6 months (A), 5 weeks (B), 7 months (C)] with SBS were examined repeatedly using localized quantitative proton MRS. Examinations were performed on days 7 and 13 (A), on days 1, 3, 5, and 12 (B), and on days 7 and 19 (C) posttrauma. Long-term follow-up examinations were performed 5 months posttrauma (A) and 4.6 months posttrauma (B). Data were compared to control data from 52 neurologically normal infants presented in a previous study.

RESULTS

Spectra from parietal white matter obtained at approximately the same time after injury (5 to 7 days) showed markedly different patterns of abnormality. Infant A shows near normal levels of the neuronal marker N-acetyl aspartate, creatine, and phosphocreatine, although infant C shows absent N-acetyl aspartate, almost absent creatine and phosphocreatine, and a great excess of lactate/lipid and lipid. Analysis of the time course in infant B appears to connect these variations as markers of the severity of head injury suffered in the abuse, indicating a progression of biochemical abnormality. The principal cerebral metabolites detected by MRS that remain normal up to 24 hours fall precipitately to approximately 40% of normal within 5 to 12 days, with lactate/lipid and lipid levels more than doubling concentration between days 5 and 12.

CONCLUSIONS

A strong impression is gained of MRS as a prognostic marker because infant A recovered although infants B and C remained in a state consistent with compromised neurological capacity. Loss of integrity of the proton MR spectrum appears to signal irreversible neurological damage and occurs at a time when clinical and neurological status gives no indication of long-term outcome. These results suggest the value of sequential MRS in the management of SBS.

Ocular and cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for paediatric practice

AIMS

To determine the sites, mechanisms, and clinical significance of injuries to the eyes and brains of children with non-accidental injuries in relation to differing levels of trauma.

METHODS

A forensic pathological study of injuries in the eyes and brains of 23 consecutive children dying of non-accidental injuries over a 4 year period (1988-92) under the jurisdiction of Yorkshire and Humberside coroners.

RESULTS

Sixteen children died from cerebral injuries and seven died from non-cerebral causes. There were high incidences of retinal detachment (63%) and subhyaloid (75%), intraretinal (75%), and perineural (68%) haemorrhages in CNS deaths. Local subhyaloid haemorrhages and retinal detachment were more common at the periphery and optic disc than at the equator. There was a strong correlation between CNS and eye trauma scores in all 23 children (r = 0.7551, p < 0.0001). Ranking of injuries by severity suggests progressively more trauma required for (a) subdural haemorrhage, (b) subhyaloid, intraretinal, perineural haemorrhages, and (c) retinal detachment. At highest trauma levels choroidal and vitreous haemorrhages were associated with additional cerebral lacerations, intracerebral and subarachnoid haemorrhages.

CONCLUSIONS

In non-accidental (and probably accidental) infantile head injury the earliest eye injuries (coinciding with subdural haemorrhage) could be missed if indirect ophthalmoscopy is not performed. Retinal detachment and multiple (particularly choroidal/vitreous) haemorrhages may indicate additional cerebral lacerations and/or intracerebral haemorrhage. Vitreous traction is the likely cause of intraocular pathology.

Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome

A morphometrical analysis of retinal hemorrhages was performed in cases of physical child abuse including the shaken baby syndrome and in controls (severe head injury, intravital brain death, non-traumatic intracranial hemorrhage, SIDS including cardiopulmonary resuscitation). The extent of the retinal hemorrhages was significantly different between both groups. In all cases of physical child abuse, massive retinal hemorrhages in at least one eye could be found ranging between a maximum value of 19.2 and 73.2% of the entire retinal area. In contrast, only two cases of the control group (severe head injury with skull fractures and intracranial bleeding following traffic accident or fall) showed slight hemorrhages of 3.33 or 1.18% of the retinal area but only in one eye. Therefore, the results provide evidence that massive intraretinal hemorrhages indicate violent shaking -- in particular in association with other signs of physical child abuse.

Understanding fatal child abuse

Medical, social service and coroner reports were reviewed for 14 cases of fatal child abuse and neglect identified at a children's hospital from 1988-1992. Twelve cases involved physical abuse and two neglect. The median age was 6.5 months (range 24 days to 3 years). Six families (43%) had prior protective service involvement; however, four of the referrals involved a sibling. Only two of 12 physical abuse victims had a history of a prior suspicious injury. Clinical and postmortem findings are presented. The cause of death in all physically abused patients was blunt impact head injury; one also had contributing intraabdominal injuries. Ten cases were ruled due to homicide; 12 have come to legal closure resulting in nine felony convictions. These findings emphasize the role of blunt impact brain injury in fatal child abuse cases. Two findings have significant implications for prevention: (a) the paucity of injuries recognized prior to the fatal event, and (b) among families known to child protection agencies the focus was not the fatally injured child.

Retinal hemorrhage in the young child: a review of etiology, predisposed conditions, and clinical implications

Retinal hemorrhage is a frequent finding in child abuse, but may also be associated with cardiopulmonary resuscitation, accidental trauma, and a variety of illnesses such as blood dyscrasias and infections. Although it is imperative that child abuse be considered in all children who present with retinal hemorrhages, whether retinal hemorrhages can be attributed to cardiopulmonary resuscitation in suspected cases of abuse poses a dilemma. The etiologies of retinal hemorrhage as well as the literature presently available to support or refute the various diagnoses are discussed. Guidelines for funduscopic examination in the Emergency Department as well as a clinical classification of retinal hemorrhage are provided. In addition, guidelines are suggested for the appropriate clinical investigations in children with retinal hemorrhages.

Shaken baby syndrome: identification and prevention for nurse practitioners

Shaken baby syndrome is a less widely recognized form of physical child abuse. It is defined as vigorous manual shaking of an infant who is being held by the extremities or shoulders, leading to whiplash-induced intracranial and intraocular bleeding and no external signs of head trauma; often identifying shaken baby syndrome is difficult because of the lack of obvious external signs. Shaken baby syndrome should be considered in infants with seizures, failure to thrive, vomiting associated with lethargy or drowsiness, respiratory irregularities, coma, or death. With the increased awareness of child abuse, more attention has been focused on morbidity and death caused by the violent shaking of infants. This article describes the clinical findings of shaken baby syndrome, explores the characteristics of families at risk for abuse, and discusses implications for nurse practitioners.

Ocular and optic nerve hemorrhages in abused infants with intracranial injuries

PURPOSE

To ascertain whether the pathology of the eye and optic nerve might be useful in determining the manner of death in infants who died after sustaining apparent nonaccidental intracranial injury.

METHODS

Complete autopsies were performed on 13 infants who died of acute intracranial injuries after nonaccidental trauma. The infants were divided into two groups: nine with physical evidence of blunt trauma to the head, and four without detectable scalp or skull injury whose intracranial injuries were attributed to violent shaking (shaken baby syndrome). Six infants with no intracranial injuries who died suddenly from unidentifiable causes (the so-called sudden infant death syndrome) served as controls.

RESULTS

Optic nerve sheath hemorrhage, most prominent in the subdural space, was present in all 13 infants with nonaccidental intracranial injury. Multilayered retinal hemorrhage was present in at least one eye of 11 of these 13 infants. The location and quantity of the intraocular and optic nerve sheath hemorrhages did not differ in those with external head trauma and those without scalp or skull lesions. A single control infant had a few erythrocytes in the nerve fiber layer of the anterior optic nerve of one eye. The remainder of the control infants did not have evidence of hemorrhage in the eye or optic nerve sheath.

CONCLUSION

Histopathologic analysis of optic nerve sheath and intraocular hemorrhages may be helpful in distinguishing traumatic from non-traumatic causes of death in infants.

The role of bone scintigraphy in detecting child abuse

This review of diagnostic imaging in cases of suspected child abuse characterizes the significant differences between bone scintigraphy and x-ray evaluation, describes the advantages and disadvantages of each modality, postulates on the specific mechanisms of injury that produce the characteristic scintigraphic findings, and emphasizes the influences that scintigraphic studies have on the medical, social, and legal aspects of child abuse. The major advantages of bone scintigraphy are its increased sensitivity (25% to 50%) in detecting evidence of soft tissue as well as bone trauma in child abuse. Furthermore, it is postulated that the specific mechanisms of inflicting the trauma relate to the patient's size and are characterized by bone scintigraphy. During fits of anger or frustration, the perpetrator of child abuse grasps the small infant or child by the thorax during the shaking activity. This produces characteristic rib injuries. The older and heavier child is more likely to be grabbed by the extremities, which produces periosteal injuries manifested as characteristic abnormal localizations in the diaphyses of the extremities. The roentgenograms of these injuries are frequently normal. The importance of bone scintigraphy is its complementary nature in defining and characterizing the extent and severity of trauma from child abuse. Such findings have direct bearing on the medical, social, and legal outcomes for the abused child. The quality of scintigraphic imaging is important, requiring the use of magnification techniques in the infant. The interpretation of the scintigraphic images depends on an understanding of the mechanisms by which the radionuclide localizes in bone. The same traumatic incident can lead to decreased, normal, or increased localization at the trauma site. Radionuclide scintigraphy is a complementary rather than competitive imaging modality to X-ray evaluation in the diagnosis and management of physical child abuse.

Vitreoretinal traction and perimacular retinal folds in the eyes of deliberately traumatized children

The pathophysiology of perimacular folds in eyes of deliberately traumatized children is disputed. The authors reviewed the clinical and forensic records and systemic and ocular findings at autopsy of three children with perimacular retinal folds who died after being violently shaken. Two of the children suffered direct head trauma in addition to being shaken; one patient was violently shaken without any physical or forensic evidence of direct head trauma. No direct ocular trauma was detected. In each case, the vitreous had partially separated from the retina but remained attached to the internal limiting membrane at the apices of the folds and the vitreous base, implicating traction in the pathogenesis of these folds. Although some intraocular findings in deliberately traumatized children may be explained by direct head injury, the possibility of both direct head trauma and shaking must be considered. Perimacular folds may develop without direct ocular or head trauma and may constitute evidence supporting violent shaking.