婴儿损伤的影像学诊断

Deborah Doroshow, HMS III Gillian Lieberman, MD Trauma X in the Infant Deborah Doroshow, HMS III Gillian Lieberman, MD 2 Deborah Doroshow, HMS III Gillian Lieberman, MD Infant Abuse • In 2004, approximately 872,000 children were victims of child abuse or neglect. • Children under 1 year of age accounted for 45% of these victims. 3 Deborah Doroshow, HMS III Gillian Lieberman, MD An Incidental Finding • 2 month old boy with 2 days of bilious vomiting immediately after feedings • KUB done at OSH to r/o SBO; possible dilated loop of small bowel and question of healing posterior R 6th rib fracture • Transferred to CHB for further evaluation of emesis and possible nonaccidental trauma 4 Deborah Doroshow, HMS III Gillian Lieberman, MD Initial Evaluation at CHB • Repeat KUB showed paucity of gas, but a normal UGI study ruled out volvulus • However, KUB also demonstrated multiple rib fractures 5 Deborah Doroshow, HMS III Gillian Lieberman, MD Our pt: Multiple rib fractures on KUB Healing fracture on lateral rib with soft tissue swelling Image courtesy of Dr. Velez and Dr. Hines-Peralta, Children’s Hospital Boston 6 Deborah Doroshow, HMS III Gillian Lieberman, MD Our pt: Multiple rib fractures on KUB Image courtesy of Dr. Velez and Dr. Hines-Peralta, Children’s Hospital Boston Healing posterior rib fracture with large callus 7 Deborah Doroshow, HMS III Gillian Lieberman, MD Concern for Child Abuse High specificity: •Classic metaphyseal lesions •Rib fractures, especially posterior •Scapular fractures •Spinous process fractures •Sternal fractures Moderate specificity: •Multiple fractures, especially bilateral •Fractures of different ages •Epiphyseal separations •Vertebral body fractures and subluxations •Digital fractures •Complex skull fractures Common but low specificity: •Subperiosteal new bone formation •Clavicular fractures •Long bone shaft fractures •Linear skull fractures Kleinman, PK (ed). Diagnostic Imaging of Child Abuse, ed 2, Boston, Mosby, 1998. 8 Deborah Doroshow, HMS III Gillian Lieberman, MD Injuries Characteristic of Infant Abuse • Rib fractures, especially posterior • Classic metaphyseal lesions • Subdural hemorrhage • Any fracture in a non-ambulating infant is concerning to some degree 9 Deborah Doroshow, HMS III Gillian Lieberman, MD Full Trauma X Workup Begun • Child Protection Services contacted • Patient admitted overnight • Guard stationed outside room to prevent flight • Mother denies abuse; says no one else in house has abused the child 10 Deborah Doroshow, HMS III Gillian Lieberman, MD What tests to order? • Skeletal survey: – ACR/AAP recommendations: 19 plain films covering entire body – all abnormal areas should be viewed in 2 projections – Oblique views of thorax if rib fractures suspected – Four views of skull if fractures suspected (frontal, 2 lateral, Towne’s for occipital injury) – Role of scintigraphy: not part of routine survey but helpful for identifying otherwise overlooked rib fractures • Neuroimaging: – CT to evaluate acute hemorrhage – MRI if CT positive or if CT negative but strong suspicion of intracranial injury 11 Deborah Doroshow, HMS III Gillian Lieberman, MD Our pt: Formal Skeletal Survey Image courtesy of Dr. Velez and Dr. Hines-Peralta, Children’s Hospital Boston • Posterior fractures of ribs 5 and 6 • Lateral fracture of rib 5 • Right clavicular fracture 12 Deborah Doroshow, HMS III Gillian Lieberman, MD Rib fractures in infant abuse • Typically result from two hand anteroposterior compression of the rib cage • Common fracture patterns: – Bilateral – located at the same position on adjacent ribs – multiple fractures in one rib 13 Deborah Doroshow, HMS III Gillian Lieberman, MD Rib fractures in infant abuse • Posterior: lever effect, ventral surface first • Lateral: buckling effect, medial to lateral • Anterior: costochondral junction Lonergan G, Baker A, Morey M, and Boos S. From the Archives of the AFIP: Child Abuse: Radiologic-Pathologic Correlation. Radiographics 2003; 23: 811-845. 14 Deborah Doroshow, HMS III Gillian Lieberman, MD Identifying rib fractures • Acute rib fractures can be very difficult to see, especially if they are incomplete, nondisplaced, or oblique to the x-ray beam – Importance of oblique views and perhaps bone scintigraphy • Role of callus formation – E.g. lateral rib fractures appearing outside pleural margin – Costochondral junction fractures are probably more common than we think because there is little new bone formation afterwards 15 Deborah Doroshow, HMS III Gillian Lieberman, MD Rib fractures and CPR • Extremely rare in otherwise healthy babies • Posterior rib fractures do not occur with CPR, making them pathognomonic for child abuse 16 Deborah Doroshow, HMS III Gillian Lieberman, MD The Classic Metaphyseal Lesion • A classic injury in child abuse, especially in infants • Occurs when the child is twisted or pulled by an extremity or shaken entirely, causing shearing injury • A series of microfractures through the most immature part of the metaphysis, the primary spongiosa, curving upward at the end to undercut the subperiosteal bony collar Lonergan G, Baker A, Morey M, and Boos S. From the Archives of the AFIP: Child Abuse: Radiologic-Pathologic Correlation. Radiographics 2003; 23: 811-845. 17 Deborah Doroshow, HMS III Gillian Lieberman, MD Corner or Bucket Handle Fracture? Lonergan G, Baker A, Morey M, and Boos S. From the Archives of the AFIP: Child Abuse: Radiologic-Pathologic Correlation. Radiographics 2003; 23: 811-845. 18 Deborah Doroshow, HMS III Gillian Lieberman, MD How to spot a healing CML: Companion patient #1 • Most reliable sign: extension of physeal lucency into the metaphysis (hypertrophic chondrocyte activity due to vascular disruption at chondro-osseous junction) • +/- fracture line, sclerosis MedPix Medical Image Database, http://rad.usuhs.edu/medpix/medpix_home.html 19 Deborah Doroshow, HMS III Gillian Lieberman, MD The Great Imitators • Rickets: metaphyseal fractures, subperiosteal new bone formation • Metabolic bone disease of prematurity: ribs, long bones • Osteogenesis imperfecta: diaphyseal fractures most common; metaphyseal fractures occur, but don’t look like CMLs – typically have diffuse osteopenia and bowing deformities; blue sclerae in type I 20 Deborah Doroshow, HMS III Gillian Lieberman, MD The Great Imitators • Congenital syphilis: lesions may look identical to CMLs • Accidental trauma: especially long bone fractures – Important to consider child’s age in the context of the history provided • Obstetric trauma: most commonly clavicle fractures – Callus formation is rapid and extensive; if child is >11 days old without callus formation, injury is not birth-related 21 Deborah Doroshow, HMS III Gillian Lieberman, MD Intracranial injury • The most common and specific form of intracranial injury in infant abuse is the subdural hematoma • “Shaken baby” theory of shear injury • Typically crescentic or parafalcine 22 Deborah Doroshow, HMS III Gillian Lieberman, MD Radiologic Imaging of SDHs • Acute SDHs are best evaluated on noncontrast CT – Hyper Æ hypoattenuated over weeks – For acute SDHs in the parafalcine area, coronal reformation CT images or ultrasound are often necessary • MRI is excellent for subacute or chronic SDHs – Especially iso- or hypodense lesions 23 Deborah Doroshow, HMS III Gillian Lieberman, MD Head CT shows new and old hemorrhage Acute focal parenchymal hemorrhages Two old, layered subdural hemorrhages Images courtesy of Dr. Velez and Dr. Hines-Peralta, Children’s Hospital Boston 24 Deborah Doroshow, HMS III Gillian Lieberman, MD Other Etiologies of Infant SDH • Severe force from a household fall • Vacuum assisted delivery – Symptoms usually apparent within 36 hours of life 25 Deborah Doroshow, HMS III Gillian Lieberman, MD What happened next? • Foster care the next morning • Grandmother’s care several months later • Developing well • Parents never admitted to intentionally harming him 26 Deborah Doroshow, HMS III Gillian Lieberman, MD References Child Welfare and Information Gateway. Child Abuse and Neglect Fatalities: Statistics and Interventions. http://www.childwelfare.gov/pubs/factsheets/fatality.cfm Duhaime, AC, Christian CW, Rorke LB, and Zimmerman RA. Nonaccidental head injury in infants – the “shaken-baby syndrome.” New England Journal of Medicine 1998; 338(25): 1822-9. Kemp, AM et al. Which radiological investigations should be performed to identify fractures in suspected child abuse? Clinical Radiology 2006; 61:723-736. Kleinman, PK (ed). Diagnostic Imaging of Child Abuse, ed 2, Boston, Mosby, 1998. Lonergan G, Baker A, Morey M, and Boos S. From the Archives of the AFIP: Child Abuse: Radiologic-Pathologic Correlation. Radiographics 2003; 23: 811-845. Nimkin, K and Kleinman P. Imaging of Child Abuse. Radiology Clinics of North America 2001; 39(4): 843-864. U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2004 (Washington, DC: U.S. Government Printing Office, 2006). http://www.acf.hhs.gov/programs/cb/pubs/cm04/summary.htm 27 Deborah Doroshow, HMS III Gillian Lieberman, MD Acknowledgments Andrew Hines-Peralta, MD Jeff Velez, MD Gillian Lieberman, MD Pamela Lepkowski Larry Barbaras, BIDMC webmaster Trauma X in the Infant Infant Abuse An Incidental Finding Initial Evaluation at CHB Our pt: Multiple rib fractures on KUB Our pt: Multiple rib fractures on KUB Concern for Child Abuse Injuries Characteristic of Infant Abuse Full Trauma X Workup Begun What tests to order? Our pt: Formal Skeletal Survey Rib fractures in infant abuse Rib fractures in infant abuse Identifying rib fractures Rib fractures and CPR The Classic Metaphyseal Lesion Corner or Bucket Handle Fracture? How to spot a healing CML: Companion patient #1 The Great Imitators The Great Imitators Intracranial injury Radiologic Imaging of SDHs Head CT shows new and old hemorrhage Other Etiologies of Infant SDH What happened next? References Acknowledgments