|
Year |
2005 |
|---|---|
|
Question Number |
37. |
|
Category |
Pediatric Orthopaedics |
Question
Examination findings of a 9-month-old boy are suspicious for child abuse. Which of the following studies should be ordered to screen for possible fractures?
1- Bone scan
2- Total body CT
3- Skeletal survey
4- Single AP radiograph of the entire body on one cassette
5- Radiographs only of areas found to be suspicious on examination
Figures
Answer (click for answer)
PREFERRED RESPONSE: 3
Fractures are the second most common presentation of physical abuse, after soft-tissue bruising and burns. Approximately one third of physically abused children will require orthopaedic treatment. The incidence of fractures in child abuse ranges from 9 to 55%, depending on the type of abuse and the methods of detecting fractures.
Fractures from abuse are more common in younger children. Long bone fractures in in preambulatory infants in the absence of metabolic bone disease are more often inflicted than accidental. In several studies, 50-69% of all fractures in abused children occurred in those less than 1 year of age and 78 to 85% occurred in children less than 3 years of age.
Multiple fractures in various stages of healing are found in more than 70% of abused children less than 1 year of age and more than 50% of all abused children.
In addition to imaging of acute injuries, a skeletal survey is often used to detect the presence of additional fractures in physically abused children. Multiple images are preferable to a single AP x-ray of the entire infant because of obliquity and lack of detail. Skeletal surveys are more useful in children less than 5 years of age who have clinical evidence of physical abuse. The American Academy of Pediatrics has recommended a mandatory survey in all cases of suspected child abuse in children younger than 2 years of age and individualized use of a survey in children aged 2 to 5 years based on clinical indicators.
The use of bone scan as a screening procedure in physical abuse is controversial. Bone scans are more sensitive than skeletal surveys in screening for abuse, but the disadvantages include cost, lack of specificity, radionuclide exposure, and limited availability. In addition it may be difficult to detect epiphyseal-metaphyseal abnormalities and to date fractures with bone scans. Thus, many recomment bone scan when skeletal surveys are negative or questionable despite a clinical suspicion of abuse.
Reference: RECOMMENDED READINGS: Akbarnia BA, Campbell RM: The role of the orthopaedic surgeon in child abuse, in Morrissy RT, Weinstein SL (eds): Lovell & Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 1423-1445.
Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10-20.