The normal changes in bony composition that occur with growth will dictate the radiologic and histologic appearance of the fracture in the age group under review. Capillaries, precursor cells, and strands of collagen must be formed in the damaged tissue before the definitive elements of osteoid and bone are produced. Author information Copyright and License information Disclaimer. Rib fractures produced by birth trauma. Provisional calcification and invasion of cartilage by metaphyseal vessels proceed normally.
Fractures in Abuse
The conversion of cartilage to bone occurs simultaneously with the ossification of fibrous callus. Injuries that are highly specific for the diagnosis of abuse include metaphyseal corner fractures, posteromedial rib fractures, and sternal, scapular, and spinous process fractures. Interdigitation across a linear lucency that ends at a suture, especially when short, is very good evidence that the lucency is indeed a normal accessory suture.
In the former case, the diagnosis is usually known, but rarely an infant may present with a lower extremity fracture related to an undiagnosed diastematomyelia or other myelodysplasia. Rib fractures are usually either nondisplaced or only minimally displaced and can be very difficult to diagnose acutely. Other injuries, which are in themselves nonspecific in terms of their causation, become highly suspicious when the history provided by the caretakers is inconsistent with the type of injury produced. Because of a suspicious injury mechanism and social situation a skeletal survey was performed. Clearly, when there are multiple fractures in an infant without a good history of trauma, infp dating intp a high index of suspicion is necessary.
Level V, diagnostic study. Open in a separate window. Next, the processes of inflammation and resorption of nonviable tissues are initiated.
In these cases, the skeletal survey should consist of a complete depiction of each anatomic region on separate radiographs. Salter noted that fractures of the femoral shaft might serve as an example of this phenomenon. Since the epiphysis is frequently not ossified or only slightly ossified, the displacement may not be apparent to the casual observer. In addition, metabolic bone diseases, e. This search returned citations.
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This amount of callus would not be present in a more recent fracture. Edit article Share article View revision history Report problem with Article. Injuries in these patients require a detailed clinical and social history to differentiate injuries sustained as a result of normal daily care from abuse.
Bone scans have no place in L. On microscopy of biopsied bone, it is indicated by a characteristic mineralization defect in bone. However, each case had at least one rib fracture visible on the two-view series and there were no cases in which the four-view series excluded all rib fractures seen on the two-view series Fig.
Metaphyseal fractures in osteogenesis imperfecta. Normal metaphyseal radiologic variants not to be confused with findings of infant abuse. Spine fractures may be the only indication of skeletal trauma and has an association with intracranial injury Barber et al. Radiologic contributions to the inves- costo-vertebral fractures demonstrated by bone with considerable overlap. Other forms of chest compression and blunt impact may be responsible for rib fractures at other sites.
Features of femoral fractures in nonaccidental injury. As mentioned previously, there are also diseases that may mimic fractures, such as skeletal dysplasias and also more common diseases such as osteomyelitis Fig. Although rib fractures have a high specificity for abuse, they have been described in other scenarios. Mimics of Abuse Rickets Rickets is a very common cause of osteopenia and may be recognized by its effect on the physis. The mechanism for the fractures in infants is usually an indirect force.
The fracture plane has run through the zone of provisional calcification arrowhead of the distal humerus. In the setting of fracture, the periosteum is stripped away from the underlying cortical bone and contained hemorrhage dissects along the bone beneath the osteogenic layer of the periosteum. Since most inflicted skeletal injuries spare the physis, dating purgatory definition this complication is fortunately relatively uncommon in the abusive setting. Radiologists play a vital role in the detection of inflicted injuries. Radiological aspects of non-accidental injury.
- The principles of dating skeletal injuries in this chapter are most applicable to the tubular bones.
- Unsuspected features of bone healing are a continuum, Belanger P.
- Observational study of skeletal surveys in suspected non-accidental injury.
- These fractures are also known as corner or bucket handle fractures.
At this point, the implication of these reports and replies is still unclear, but several points may be made. The physis is frayed and the white line of the zone of provisional calcification is lost. In this article, I will detail the radiographic imaging of the more characteristic highly specific injuries and discuss the major issues that relate to some moderate- or low-specificity injuries.
Osteogenesis imperfecta and other bone disorders in the differential diagnosis of unexplained fractures. In most cases, the fracture line becomes more evident with periosteal reaction. Diagnostic imaging plays an important role in the early diagnosis of abuse. In non-ambulatory infants, however, samples of good online the same fractures are cause for concern. Diffusion- and susceptibility-weighted imaging is very reliable for diagnosing hypoxic-ischemic brain injury and parenchymal hemorrhage Parizel et al.
Healing can usually be judged as early or mature, and when multiple fractures are present, it is often possible to state if the fractures are of similar or different ages. Both of these types manifest severe phenotypes with severe bone fragility. Many variables will affect other earlier elements of histologic healing, such as the production of hemorrhage and inflammatory change at the injury site. Articles Cases Courses Quiz.
In our country, as is the case in many European countries, most hospitals do not have direct access to a paediatric radiologist. Initial radiographs can be normal, with a skeletal survey and follow-up survey being most important. While rib fractures can occur, it is generally in the more severe types.
This addition is supported by the findings of Ingram et al. In all cases abuse was excluded and autopsy showed posterior rib fractures. In the absence of associated osseous or articular injury, these changes are usually not extensive and typically resolve completely within a few days following the injury. In addition, although associated injuries such as solid organ injury and retinal hemorrhages are common, it is by no means the rule.
Thank you for updating your details. When there have been multiple episodes of abuse, secondary abusive trauma to original fracture sites may substantially affect the healing process and complicate dating assessments. Key words can only be determined from their dating. Metaphyseal fractures mimicking abuse during treatment for clubfoot.
They can be very difficult to detect, despite often being multiple. In this situation, speed dating excessive leverage of the ribs over the transverse processes can lead to posterior rib fractures. Attention to proper technique is essential and has been discussed above. The neurologic features and sparseness of the hair are the main clues to the correct diagnosis. Schematic representation of the chest during anterior-posterior compression.
Earliest appearance of periosteal new bone formation. Both studies found a wide range of imaging practices in cases of suspected abuse. Postprocessing functions when used optimally may improve visualization of pathology and bone and soft-tissue detail differentiation.
- Direct communication between the radiologist and the clinician eliciting the clinical history and examining the patient is vital in cases of suspected abuse.
- The ability to date injuries is critical for medicolegal purposes, and thus must be done carefully please refer to specialist text for specific guidelines.
- Application to rickets and other abnormalities.
- Repeated episodes of abusive trauma may not only disrupt whatever repair has taken place, but also provide a stimulus for a new cycle of osseous repair.
- Multiple fractures in different stages of healing, possibly with no bruises or soft tissue injuries.