Radiology Teaching Files > Case 7759697

Contributed by: John Lichtenberger, Resident, David Grant Medical Center, Travis AFB, California, USA.
Patient: 5 month old male
History: "5 month old male with possible curvature of lower spine."

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Findings: Frontal Chest radiograph: Healing posterior rib fractures (left 8-10, right 6-10). New bone formation about the left proximal humerus and abnormal lucency through the proximal lateral scapula. There is no abnormal periosteal reaction about the jaw.

Lateral Chest radiograph: Mottled abnormal lucencies in the T12/transitional thoracolumbar vertebral body and L1 spinous process posteriorly.  Similar mottled lucency in the superior anterior endplate of L2.

Oblique rib films: Abnormal lucency through the proximal scapula concerning for fracture.  New bone formation about the proximal humerus is concerning for healing injury.  Healing left posterior 10th rib.

Left lower extremity (hip to ankle) in AP projection: Exuberant new bone formation about the expected location of the greater trochanter of the left femur.  There is periosteal new bone in the lateral femoral proximal diaphysis.  Possible epiphyseal separation of the femoral head.  The distal left femoral metphysis is irregular and widened.  Lucencies extend across the entire width of the bone to include the 'corners.'  The left proximal tibial metaphhysis is buckled at both its medial and lateral aspects.  The metaphysis is widened and abnormally lucent.  Probable subperiosteal new bone lateral to the proximal left tibial metadiaphysis.
Diagnosis: Nonaccidental trauma
Discussion: Nonaccidental trauma results in over 5000 children killed each year in the United States.  Suspicion of nonaccidental trauma in children depends heavily on an age-relative understanding of characteristic patterns and distributions of skeletal injury.  While the most common fractures in abused children are of the diaphyses of long bones, the most common skeletal injuries in infants involve the ribs, metaphyses and skull.  Central concepts of long bone skeletal injury in nonaccidental trauma include subperiosteal new bone formation, the classic metaphyseal lesion, epiphyseal separation, and shaft fractures.

-Subperiosteal new bone formation is a response to subperiosteal hemorrhage separating the bony cortex from the osteogenic layer of periosteum, resulting in a hazy cortical margin or thin layer of bone separated from the cortex by a lucent interval.

-The classic metaphyseal lesion is highly specific for inflicted injury resulting from avulsion of the peripheral margin of the metaphysis at the point of insertion of the periosteum by torsional and tractional forces.  Radiolucency in the subphyseal region of the metaphysis may be vague, and the metaphyseal fragment is often disklike.

High specificity skeletal radiologic findings in nonaccidental trauma (Kleinman):
Classic metaphyseal lesions
Posterior rib fractures
Scapular fractures
Spinous process fractures
Sternal fractures

References: Kleinman, Paul K. Diagnostic imaging of child abuse 2nd ed. Mosby, Inc. 1998.

Rogers LF, Poznanski AK. Imaging of epiphyseal injuries. Radiology 191:297-308, 1994.
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Additional Details:

Case Number: 7759697Last Updated: 01-17-2007
Anatomy: Skeletal System   Pathology: Trauma
Modality: Conventional RadiographAccess Level: Readable by all users
Keywords: nonaccidental trauma, child abuse

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