Efren Gutierrez, MS III

Gillian Lieberman, MD May 2006

The Skeletal Survey:

Radiographic Evaluation

Efren Gutierrez, Harvard Medical School, Year III

Gillian Lieberman, MD
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Introduction
• The Patient
• Child abuse
• What is a skeletal survey?
• Evaluation of the skeletal survey
– Multiple types of fractures
• Long bones
• Rib fractures
• Bone Scintigraphy
• Differential Diagnosis

2
 Efren Gutierrez, MS III
Gillian Lieberman, MD

The Patient
• 5 wk old infant transferred from OSH for “breathing difficulties”

• PMHx: FT, C/S, no other hx provided

• SH: Lives at home with mother, father (mother’s boyfriend) and 1y/o
brother, mother has an older child in DSS custody

• FH: non-contributory

– At OSH: T:102.3, 86%RA

• Sepsis workup started
• CXR unremarkable
• CT of head found bilateral subarachnoid and R intraparenchymal hemorrhages
– 51A filed
– At Children’s:
• Afebrile, HR:170, BP:121/80, RR:51 O2 sat:100%
• HEENT: PERRL but sluggish
• Neuro: CN II-XII grossly intact, DTRs: Knees, Ankles 2+ bilat; downgoing toes

3
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Child Abuse
• Accounts for approximately 1200 deaths/year in U.S.
– About half occur among children younger than one year of age.
– Incidence ranges from 15-42 per 1000 children

• Radiographically described by Caffey in 1946

– Associated subdural hematomas with certain patterns of skeletal injury

• Kempe and Silverman assign skeletal radiological associations to

describe the term “battered child syndrome” in 1962

• Currently child abuse constitutes multiple entities

– Physical abuse
– Sexual abuse
– Emotional abuse
– Child neglect

Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 4

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Skeletal Survey includes...

• AP and lateral views of the skull and chest

• Lateral views of spine

• AP views of pelvis, long bones of extremities and feet

• Posteroanterior oblique views of hands

• Additional views in at least 2 projects if there are any

findings

American Academy of Pediatrics: Diagnostic imaging of child abuse. Pediatrics 2000; 105:1345-8. 5
Efren Gutierrez, HMS III
Gillian Lieberman, MD

Complete
Skeletal
Babygram
Skeletal
Survey?
Survey
Always do a complete skeletal survey

Not the imaging

useful to evaluate
and document
child abuse

6
Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Indications for Skeletal Survey

• Absolute: Mandatory for all children younger
that two years of age in whom child abuse is
suspected

• Relative:
– Any child younger than 12 months of age with a
fracture
– Any child with severe or extensive fractures
– Any child with a history of having one or more
fractures
– A history in the child or family of “soft” or easily
broken bones
•Ludwig, S. Child Abuse. In Textbook of Pediatric Emergency Medicine, 5th ed. Lippincott Williams and
Wilkins, Philadelphia 2006. p.1761 7
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Specific of Radiologic Findings

High Specificity Moderate Specificity Low Specificity

• Classic metaphyseal • Multiple fractures, • Subperiosteal new bone

lesions (CML) especially bilateral formation

• Rib fractures, especially • Fractures of different

posterior ages • Clavicular fracture

• Fractures of scapula, • Epiphyseal separations • Lone bone shaft fracture

spinous process, and
sternum • Vertebral body fractures
and subluxations • Linear skull fracture

• Digital Fractures

• Complex skull fractures

Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 8

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Common Inflicted Fractures

• Largest study of inflicted fractures (429 fractures in 189
children) with signs of abuse showed on skeletal survey:
– 50% had a single fracture
– 21% two fractures
– 12% three fractures
– 17% >3 fractures

• Among single fractures, common location:

– Femur (35%), humerus (29%), skull (16%)

• Long bone fractures:

– 48% transverse, 26% spiral, 16% avulsion, 10% oblique

King, J et al. Analysis of 429 fractures in 189 battered children. J Pediatric Orthopedics 1988, 8:585 9
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Diaphyseal Fractures
• Most common pattern
– 60-80% of all femoral shaft fractures

• Two main types

– Spiral
• Torsional force on the limb
• Worry in a child who is too young to walk

– Transverse
• Direct perpendicular blow to the shaft, most common type
seen in abuse

Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 10

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Metaphyseal Fractures
• 11-18% of all long-bone fractures

• Classic metaphyseal lesion (CML)

– “corner” or “bucket-handle” fracture
– Occurs when the extremity is pulled or twisted forcibly or when shaken due to shearing that undercuts
fragments of the metaphysis
– Usually asymptomatic (pain with severe displacement)
– See disruption as lucency
– Looks “corner” viewed tangentially, looks “bucket-handle” when angulated

• Consists of a series of microfractures occurring in a planar fashion through immature portion of

metaphyseal primary spongiosa (delicate trabeculae/calcified cartilaginous cores).

• Resultant fracture fragment encompasses two adjacent mineralized regions: the distal zone of
hypertrophic chondrocytes of the physis and a thin portion of metaphyseal primary spongiosa

• As injury extends to the periphery of the bone, the fracture line passes toward the cortex away
from the physis to cut across the subperiostal bone collar

• Radiographically see a transverse radiolucency in the subphyseal region of the metaphysis

Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 11

 Efren Gutierrez, HMS III
Gillian Lieberman, MD

Etiology of CML’s
Normal Bone Metaphyseal fracture

Series of microfractures along

metaphyseal spongiosa
E

E=epiphysis
M=metaphysis

M E

Extension to the
subperiostal bone collar
12
Image from Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998
Efren Gutierrez, HMS III
Gillian Lieberman, MD

Our Patient’s Femur

AP Distal Femur X-ray

Corner Fracture

PACS, Children’s Hospital Boston

13
Efren Gutierrez, HMS III
Gillian Lieberman, MD

Our Patient’s knee

AP Knee X-ray Lateral Knee X-ray
Corner Fracture

Bucket Handle
Fracture

Fracture can look like a bucket handle or corner

fracture depending on point of view

PACS, Children’s Hospital Boston 14

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Rib Fractures
• PPV is 95% in age < 3yrs for posterior fractures

• Inflicted rib fractures

– high risk of mortality
– Due to degree of force to produce them
– Produced by direct blows to the chest or during squeezing/shaking
– Force caused by chest compression (CPR) of infants is not great enough
to cause rib fractures

• Multiple sequential ribs (position of abuser’s fingers)

• 36% of rib fractures are visible on skeletal survey

• At times fractures are not apparent . Appear during the stage of

callus formation 10-14 days after injury

Kleinman et al. Mechanical factors associated with posterior rib fractures: laboratory and case studies.
Pediatric Radiology 1998; 27:87-91. 15
 Efren Gutierrez, HMS III
Gillian Lieberman, MD

Mechanism of Rib Injury

Anterior force pushes down causing
Normal rib anatomy
thoracic compression
Sternum depression causes
Costochondral A A fracture force against
junction costochondral junction

Costal
facet

P Rib head P
Transverse
process Lever mechanism causes
loading of force against fixed
point leading to fracture
Image from Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 16
 Efren Gutierrez, HMS III
Gillian Lieberman, MD

Patient’s Chest X-ray

AP Chest X-ray

Costochondral
fracture of 7th
rib

Multiple Posterior
Fractures
4th-7th Ribs

PACS, Children’s Hospital Boston

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Skull Fracture
• Direct force applied to the cranium

• Simple fractures could be accidental

– Single fracture line either straight, jagged or curved

• Complex skull fractures suggestive of inflicted trauma

– More than one fracture line
– May have a branching pattern or stellate configuration

• Most common site of skull fractures whether accidental or inflicted

is the parietal bone and usually it is a linear fracture

• If there is not a skull fracture, it does not rule out intracranial injury
due to abuse. Obtain a CT/MRI to rule out any intracranial injury.

Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 18

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Our patient had a normal skull X-ray, so a

head CT was done to rule out any
hemorrhage.

19
Efren Gutierrez, HMS III
Gillian Lieberman, MD

CT of Patient’s Head
Axial Head CT Axial Head CT

Occipital
fracture was
found

PACS, Children’s Hospital Boston 20

 Efren Gutierrez, HMS III
Gillian Lieberman, MD

CT of Patient’s Head
Axial Head CT

Subarachnoid
Hemorrhage

PACS, Children’s Hospital Boston 21

 Efren Gutierrez, MS III
Gillian Lieberman, MD

To further characterize the bleeding and to

look for other signs of injury, a head MRI
was performed

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Efren Gutierrez, HMS III
Gillian Lieberman, MD

MRI of Patient’s Head Subdural

T1 Axial MRI T1 Axial MRI hemorrhage

Subdural
hemorrhage

Subarachnoid
hemorrhage

Intraventricular
PACS, Children’s Hospital Boston 23
collection
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Other Fractures
• Sternum, Scapula, and Pelvis fractures are
suspicious for child abuse if they occur in the
absence of a plausible history of high-energy
injury

• Spinal
– Most common is asymptomatic compression fracture
due to forceful sitting
– Hyperflextion or hyperextension during violent
shaking produce a variety of fractures
Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 24
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Bone Scintigraphy
• Alternative to skeletal survey for the initial evaluation of possible fractures

• Advantages
– More sensitive than plain radiography (25-50% more)
– Can detect rib and costovertebral fractures
– Recent non-displaced fractures
– Early periosteal elevation

• Disadvantages
– Less specific that plain films, with more false positives
– Cannot detect skull fractures
– Symmetrically located bilateral fractures may be overlooked
– Cannot estimate age of fractures
– Injuries near physis difficult to assess
– Difficult to obtain on an emergency basis
– Cost is about 300% higher
– Requires sedation

• Currently used as an adjunct to the skeletal survey

Mandelstram et al. Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony 25
injuries in suspected child abuse. Arch Dis Child 2003; 88: 387-390
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Repeat Skeletal Survey

• Repeat skeletal survey two weeks after
initial evaluation
– Increases the diagnostic yield
– Recommended in highly suspicious cases.
• Detects additional fractures
• Differentiates fractures from normal
developmental variants
• Date injuries

26
 Efren Gutierrez, HMS III
Gillian Lieberman, MD

Repeat Skeletal Survey two weeks later

AP X-ray Lateral X-ray

Fractures
of 4th-7th
rib still
evident,
Show
signs of
healing

27
PACS, Children’s Hospital Boston
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Fracture age
I. Soft tissue changes (obliteration of the normal fat planes and
muscle boundaries) secondary to hemorrhage or inflammation
last for few days

II. Periosoteal new bone formation detectable on plain film

radiographs only after it becomes calcified (usually 7-14 days)

III. Necrotic bone is reabsorbed, margins of the fractures lines

become blurred and the fracture gap widens at 2-3 weeks after
injury and is the only means of dating metaphyseal fractures

IV. Soft callus from production and calcification of osteoid follows

V. Hard callus (lamellar bone that bridges the fracture site, filling the
fracture line) appears approximately 1 week after soft callus,
completes at 3-6 wks after injury

Cramer K. Orthopedic aspects of child abuse. Pediatr Clin North Am 1996; 43:1035-1051 28
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Fractures in children
• Osteogenesis Imperfecta • Prostaglandin E1 therapy
• Congenital indifference • Methotrexate Therapy
to pain • Menkes’ syndrome
• Myelodysplasia • Copper deficiency
• Osteomyelitis • Metaphyseal and
• Congenital syphilis spondylometaphyseal
• Rickets dysplasia
• Scurvy • Accidental injury
• Vitamin A intoxication • Obstetric injury
• Caffey’s disease
• Leukemia

Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 29

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Osteogenesis Imperfecta (OI)

• Generalized disorder of connective tissue involving bone, skin, ligaments,
fascia, sclera, and the auditory system

• Large phenotypic range

– Four different subtypes

• Consider OI if skeletal survey or physical exam show the following

– Significant or equivocal osteoporosis
– Wormian bones
– Blue sclerae
– Abnormal skin texture
– Hearing loss
– Dentinogenesis imperfecta
– Joint laxity

• Diffucult to ascertain if abuse is also involved

– Look for nonskeletal findings, CMLs, or multiphasic rib fractures to rule in abuse

Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 30

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Accidental Trauma
• Radiologically difficult to rule out
– Necessary for a detailed description of events surrounding
fracture
• Fall is usually the most common event offered to explain
fracture
– Fractures from crib/bed falls are unusual
• Except for clavicle/skull fractures
• Certain fractures are noted to be accidents
– Toddler’s fracture
• Spiral fracture of tibia usually associated with the toddler
“cruising” or walking
– Midshaft humeral fracture
• Rolling of infant from prone to supine by placing had under axilla
leads to contralateral midshaft humeral fracture. Hear loud “snap”

Kleinman et al. Diagnostic Imaging of Child Abuse 2nd Edition, 1998 31

 Efren Gutierrez, MS III
Gillian Lieberman, MD

Conclusions
• Skeletal survey is currently the diagnostic modality for
documenting child abuse and should be done if there is a high
clinical suspicion

• Certain fractures are hallmarks for abuse (CMLs, posterior rib

fractures)

• Bone scintigraphy is currently adjunct radiographic image that can

find fractures before evident on skeletal survey

• Other radiological modalities (CT/MRI) add more information

especially for head and visceral trauma

• Differential diagnosis for fractures in children is extensive; history

and physical exam are useful tools for initial evaluation

32
 Efren Gutierrez, MS III
Gillian Lieberman, MD

Our Patient
• The patient had multiple subdural, subarachnoid
hemorrhages, and intrathecal bleeds and developed
seizures which were controlled with phenobarbital

• Found to have a duodenal hematoma w/pancreatitis

• Developed central diabetes insipidus

• Father admitted to abuse of the child. Child was placed

into DSS custody. At time of discharge, mother was
considering giving up child for adoption.

33
 Efren Gutierrez, MS III
Gillian Lieberman, MD

References
• Kleinman et al. Diagnostic Imaging of Child Abuse 2nd ed. Mosby, Boston 1998
• Mandelstram et al. Complementary use of radiological skeletal survey and bone scintigraphy in
detection of bony injuries in suspected child abuse. Arch Dis Child 2003; 88: 387-390
• American Academy of Pediatrics: Diagnostic imaging of child abuse. Pediatrics 2000; 105:1345-8.
• Kleinman et al. Mechanical factors associated with posterior rib fractures: laboratory and case
studies. Pediatric Radiology 1998; 27:87-91
• Ludwig, S. Child Abuse. In Textbook of Pediatric Emergency Medicine, 5th ed. Lippincott Williams
and Wilkins, Philadelphia 2006. p.1761
• Belfer et al. Use of the skeletal survey in the evaluation of child maltratment. Am J Emerg Med
2001; 19:122
• Kleinman et al. The metaphyseal lesion in abused infants: a radiologic-histopathologic study.
American Journal of Roentgenology 1986; 146: 895
• Cramer K. Orthopedic aspects of child abuse. Pediatr Clin North Am 1996; 43:1035-1051
• Kleinman et al. Normal metaphyseal radiologic variants not to be confused with finding of infant
abuse. American Journal of Roentgenology 1991; 156:781-783
• Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural
hematoma. American Journal of Roentgenology 1946; 56:163-173
• Kempe et al. The battered-child syndrome. Journal of American Medical Association 1962; 181:105-
112

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 Efren Gutierrez, MS III
Gillian Lieberman, MD

Acknowledgements
• Larry Barbaras, webmaster
• Gillian Lieberman, MD
• Pamela Plekowksi
• Katherine Krajewski, MD

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Efren Gutierrez, MS III
Gillian Lieberman, MD

Questions?

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