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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. US Department of Health and Human Services, Administration on Children, Youth, and Families, Child Maltreatment 2009.http://www.acf.hhs.gov/programs/cb/pubs/cm09/cm09.pdf. Review/Other-Dx N/A Present national data about child abuse and neglect known to child protective agencies in the United States during Federal fiscal year 2009. N/A 4
2. Gilbert R, Kemp A, Thoburn J, et al. Recognising and responding to child maltreatment. Lancet. 2009; 373(9658):167-180. Review/Other-Dx N/A Review patterns of recognition and response to child maltreatment and assess ways to improve process. Authors suggest that professionals dealing with children have complementary roles in the recognition and response to child maltreatment. 4
3. Hobbs CJ, Bilo RA. Nonaccidental trauma: clinical aspects and epidemiology of child abuse. Pediatr Radiol. 2009; 39(5):457-460. Review/Other-Dx N/A Review clinical aspects and epidemiology of child abuse in nonaccidental injuries. Knowledge of the differential diagnosis of unexplained or apparent injury is necessary for accurate diagnosis. 4
4. Mok JY. Non-accidental injury in children--an update. Injury. 2008; 39(9):978-985. Review/Other-Dx N/A Review physical abuse of children with emphasis on fractures. Fracture detection rate will be increased by high quality radiographs and interpretation by a skilled pediatric radiologist. 4
5. Dwek JR. The radiographic approach to child abuse. Clin Orthop Relat Res. 2011;469(3):776-789. Review/Other-Dx 44 articles To detail the radiographic imaging of the more characteristic highly specific injuries and discuss the major issues that relate to some moderate- to low-specificity injuries. And to discuss several mimics of abuse with which the orthopaedic surgeon should be familiar and should recognize. Injuries that are highly specific for the diagnosis of abuse include metaphyseal corner fractures, posteromedial rib fractures, and sternal, scapular, and spinous process fractures. Lesions of moderate specificity include, among other injuries, multiple fractures of various ages and epiphyseal separations. Long-bone fractures and clavicular fractures, while common, are of low specificity. In addition to the appropriate accurate diagnosis of these injuries, several diseases and syndromes may mimic abuse due to the similarity in the radiographic picture. 4
6. Merten DF, Carpenter BL. Radiologic imaging of inflicted injury in the child abuse syndrome. Pediatr Clin North Am. 1990; 37(4):815-837. Review/Other-Dx N/A Review radiologic imaging of injuries in child abuse. Awareness of patterns of injuries in abused infants and children may serve to identify potential victims of abuse and stimulate more thorough clinical and radiologic investigation. 4
7. Servaes S, Brown SD, Choudhary AK, et al. The etiology and significance of fractures in infants and young children: a critical multidisciplinary review. [Review]. Pediatric Radiology. 46(5):591-600, 2016 May. Review/Other-Dx N/A To address significant misconceptions regarding the etiology of fractures in infants and young children in cases of suspected child abuse. No abstract available. 4
8. Becker JC, Liersch R, Tautz C, Schlueter B, Andler W. Shaken baby syndrome: report on four pairs of twins. Child Abuse Negl. 1998; 22(9):931-937. Review/Other-Dx 4 pairs of twins To describe incidence of shaken baby syndrome in four pairs of twins. Five children were severely affected and two died. In one family, both of the twins repeatedly suffered injury from being shaken. 4
9. Lindberg DM, Shapiro RA, Laskey AL, Pallin DJ, Blood EA, Berger RP. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012;130(2):193-201. Observational-Dx 134 contacts To determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children. Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5-18.5) <24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0-13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8-69.9). 3
10. Quigley AJ, Stafrace S. Skeletal survey normal variants, artefacts and commonly misinterpreted findings not to be confused with non-accidental injury. Pediatr Radiol. 2014;44(1):82-93; quiz 79-81. Review/Other-Dx N/A To present a pictorial essay to aid the reporting radiologists in the differentiation between normal variants or artefacts and true traumatic injury. N/A 4
11. van Rijn RR, Sieswerda-Hoogendoorn T. Educational paper: imaging child abuse: the bare bones. Eur J Pediatr. 2012;171(2):215-224. Review/Other-Dx N/A To discuss the radiological work-up in case of suspected child abuse and the main radiological findings indicative of child abuse N/A 4
12. Hansen KK, Prince JS, Nixon GW. Oblique chest views as a routine part of skeletal surveys performed for possible physical abuse--is this practice worthwhile? Child Abuse Negl. 2008; 32(1):155-159. Observational-Dx 22 patients Retrospective study to evaluate the value of oblique chest views in the diagnosis of rib fractures when used as a routine part of the skeletal survey performed for possible physical abuse. In 12/22 cases, interpretation of the four-view chest series was different than interpretation of the two-view chest series. Four-view chest series adds information to that obtained from the two-view chest series and increases the accuracy of diagnosing rib fractures in cases of possible physical abuse. Addition of oblique chest views to the routine protocol for skeletal surveys performed for possible physical abuse is recommended. 3
13. Marine MB, Corea D, Steenburg SD, et al. Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified?. AJR. American Journal of Roentgenology. 202(4):868-71, 2014 Apr.AJR Am J Roentgenol. 202(4):868-71, 2014 Apr. Observational-Dx 212 patients To determine whether adding oblique bilateral rib radiography to the skeletal survey for child abuse significantly increases detection of the number of rib fractures. We identified 212 patients (106 with one or more fractures and 106 without). The sensitivity and specificity of the two-view series were 81% and 91%, respectively. Sensitivity and specificity for detection of posterior rib fractures were 74% and 92%, respectively. There was good agreement between observers for detection of rib fractures in both series (average kappa values of 0.70 and 0.78 for two-views and four-views, respectively). Confidence significantly increased for four-views. 3
14. Barsness KA, Cha ES, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003; 54(6):1107-1110. Observational-Dx 78 children (336 fractures) Review medical records and imaging of children over a 6-year period to evaluate rib fractures to determine; the PPV of a rib fracture in defining nonaccidental trauma; and the frequency of rib fractures as the only skeletal manifestation of nonaccidental trauma. For children <3 years, the PPV of a rib fracture as indicator of nonaccidental trauma was 95%. Rib fractures were the only skeletal manifestations of nonaccidental trauma in 29%. 3
15. Cadzow SP, Armstrong KL. Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes. J Paediatr Child Health. 2000;36(4):322-326. Review/Other-Dx 18 infants To examine clinical features, investigation methods and outcomes of infants with rib fractures. Rib fractures were attributed to child abuse in 15 of 18 infants identified. The initial presentation in the abused infants was most often as a result of intracranial pathology and limb fractures. In four cases the rib fractures were incidental findings when abuse had not been suspected. Bone scintigraphy revealed eight previously undetected rib injuries in four cases. In three cases of abuse, the rib fractures were an isolated finding. Three of the infants with inflicted rib injuries were discharged home. In one such infant a significant re-injury occurred. Three returned home with implicated adults no longer in residence, and nine spent a mean period of 12 months in foster care. 4
16. American College of Radiology. ACR–SPR Practice Parameter for Skeletal Surveys in Children. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Skeletal_Surveys.pdf. Review/Other-Dx N/A To assist practitioners in providing appropriate radiologic care for patients. No results stated in abstract. 4
17. Karmazyn B, Lewis ME, Jennings SG, Hibbard RA, Hicks RA. The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? AJR Am J Roentgenol. 2011;197(1):W159-163. Review/Other-Dx 930 children To evaluate the prevalence and site of fractures detected on skeletal surveys performed for suspected child abuse at a tertiary children's hospital and to determine whether any survey images may be eliminated without affecting clinical care or the ability to make a diagnosis. Nine hundred thirty children (515 boys and 415 girls) with a median age of 6 months met the entry criteria for the study. Fractures were detected in 317 children (34%), of whom 166 (18%) had multiple fractures. The most common sites for fractures were the long bones (21%), ribs (10%), skull (7%), and clavicle (2%). Ten children (1%) had fractures in the spine (n = 3), pelvis (n = 1), hands (n = 6), and feet (n = 2). All 10 children had other signs of physical abuse. 4
18. Barber I, Perez-Rossello JM, Wilson CR, Silvera MV, Kleinman PK. Prevalence and relevance of pediatric spinal fractures in suspected child abuse. Pediatr Radiol. 43(11):1507-15, 2013 Nov. Review/Other-Dx 751 children To establish the prevalence of spinal fractures detected on skeletal surveys performed for suspected child abuse and their association with intracranial injury (ICI). Fourteen children had a total of 22 definite spinal fractures. This constituted 1.9% (14/751) of the total cohort, and 9.7% (14/145) of children with a positive skeletal survey. Advanced imaging confirmed the fractures in 13 of the 14 children and demonstrated 12 additional spinal fractures. In five cases, spinal fractures were the only positive skeletal findings. In 71% (10/14) of the children, the spinal fractures were accompanied by ICI. Children with spinal fractures were at significantly greater risk for ICI than those without spinal injury (P < 0.05). 4
19. Jha P, Stein-Wexler R, Coulter K, Seibert A, Li CS, Wootton-Gorges SL. Optimizing bone surveys performed for suspected non-accidental trauma with attention to maximizing diagnostic yield while minimizing radiation exposure: utility of pelvic and lateral radiographs. Pediatr Radiol. 2013;43(6):668-672. Review/Other-Dx 530 children To determine whether pelvic and lateral spinal radiographs should routinely be performed during initial bone surveys for suspected non-accidental trauma (NAT). Of the 530 children, 223 (42.1%) had rib and extremity fractures suspicious for NAT. No fractures were identified solely on pelvic radiographs. Only one child (<0.2%) had vertebral compression deformities identified on a lateral spinal radiograph. This infant had rib and extremity fractures and was clinically paraplegic. MR imaging confirmed the vertebral body fractures. 4
20. Kleinman PK, Morris NB, Makris J, Moles RL, Kleinman PL. Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. AJR Am J Roentgenol. 200(3):641-4, 2013 Mar. Observational-Dx 365 studies To assess the prevalence of fractures of the spine, hands, and feet in cases of suspected child abuse on ACR-standardized skeletal surveys acquired near the end of the film-screen era. Twenty of 365 studies (5.5%) yielded fractures involving the spine, hands, or feet. Of all positive skeletal surveys, 8.9% (20/225) had fractures involving the spine, hands, or feet. Of all patients with more than one fracture on skeletal survey, 20.4% (20/98) had fractures involving these regions. 4
21. Phillips KL, Bastin ST, Davies-Payne D, et al. Radiographic skeletal survey for non-accidental injury: systematic review and development of a national New Zealand protocol. Journal of Medical Imaging & Radiation Oncology. 59(1):54-65, 2015 Feb.J Med Imaging Radiat Oncol. 59(1):54-65, 2015 Feb. Review/Other-Dx 30 documents To undertake a systematic review of the evidence supporting skeletal survey protocols to design a protocol that could be implemented across New Zealand. We identified 2 guidelines for skeletal survey, 13 other protocols and 15 articles providing evidence for inclusion of specific images in a skeletal survey. The guidelines scored poorly on critical appraisal of several aspects of their methods. We found no studies that validate any of the protocols or compare their performance. Evidence supporting inclusion in a skeletal survey is limited to ribs, spine, pelvis, hands and feet, and long bone views. Our final protocol is a standardised, two-tiered protocol consisting of between 17 and 22 views. 4
22. Harper NS, Eddleman S, Lindberg DM. The utility of follow-up skeletal surveys in child abuse. Pediatrics. 2013;131(3):e672-678. Observational-Dx 796 children To determine the proportion of FUSS that identified new information in a large, multicenter population of children with concerns of physical abuse. Among 2890 children enrolled in the Examining Siblings To Recognize Abuse research network, 2049 underwent skeletal survey and 796 (38.8%) had FUSS. A total of 174 (21.5%) subjects had new information identified by FUSS, including 124 (15.6%) with at least 1 new fracture and 55 (6.9%) with reassuring findings compared with the initial skeletal survey. Among cases with new fractures, the estimated likelihood of abuse increased in 41 (33%) cases, and 51 cases (41%) remained at the maximum likelihood of abuse. 4
23. Section on Radiology. American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009;123:1430-5. Review/Other-Dx N/A Review role of diagnostic imaging in cases of child abuse. Imaging helps to identify the extent of physical injury when abuse is present and clarifies all imaging findings that point to alternative diagnoses. High-quality technologies, clinical and pathologic alterations that occur in abused children are all important factors in diagnosis. 4
24. Hansen KK, Keeshin BR, Flaherty E, et al. Sensitivity of the limited view follow-up skeletal survey. Pediatrics. 2014;134(2):242-248. Observational-Dx 534 study subjects To determine if a large multicenter study would support the results of our previous single-center study. Our hypothesis was that there would be no clinically significant difference in results from a limited view SS2 protocol that omits the spine and pelvis views (when no spine or pelvis fractures or questioned fractures are present on SS1) compared with a traditional SS2 protocol for radiographic evaluation of suspected physical abuse. We identified 534 study subjects. Five subjects had newly identified spine fractures, and no subjects had newly identified pelvis fractures on traditional SS2 studies. Only 1 subject with a newly identified spine fracture would have been missed with the limited view SS2 protocol used in this study (0.2% [95% confidence interval: <0.005-1.0]). None of the newly identified fractures changed the abuse-related diagnosis. 4
25. Sonik A, Stein-Wexler R, Rogers KK, Coulter KP, Wootton-Gorges SL. Follow-up skeletal surveys for suspected non-accidental trauma: can a more limited survey be performed without compromising diagnostic information? Child Abuse Negl. 2010;34(10):804-806. Observational-Dx 22 cases To evaluate if certain radiographs can be excluded at follow-up skeletal survey without compromising the clinical efficacy. A total of 36 fractures were found on the initial bone survey in 16/22 patients (73%). Six patients had no fractures detected at initial survey. Follow-up bone surveys demonstrated an additional 3 fractures (2 extremities and 1 rib) in 3/22 cases (14%); 1 was in a patient whose initial survey was negative. No additional fractures in the skull, spine, pelvis, feet, or hands were detected in any case. In combination with patients reported in the literature (194 patients total) no new fracture of the skull, spine, pelvis, or hands was detected at follow-up survey. The skull, spine and pelvis radiographs are the highest dose-exposure studies of the skeletal survey. 3
26. Zimmerman S, Makoroff K, Care M, Thomas A, Shapiro R. Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl 2005; 29(10):1075-1083.. Observational-Dx 48 children Prospective study to evaluate the value of a follow-up skeletal survey in suspected child physical abuse evaluations. Follow-up skeletal survey yielded additional information in 22/48 patients (46%). It identified additional fractures or clarified tentative findings in children who were suspected victims of physical child abuse. The follow-up skeletal survey is recommended. 4
27. Prosser I, Maguire S, Harrison SK, Mann M, Sibert JR, Kemp AM. How old is this fracture? Radiologic dating of fractures in children: a systematic review. AJR Am J Roentgenol. 2005;184(4):1282-1286. Review/Other-Dx 3 articles To conduct a systematic review of the literature to define the evidence for radiologic dating of fractures in children in the context of child protection. Radiologic dating of fractures is an inexact science. Most radiologists date fractures on the basis of their personal clinical experience, and the literature provides little consistent data to act as a resource. There is an urgent need for research to validate the criteria used in the radiologic dating of fractures in children younger than 5 years. 4
28. Bainbridge JK, Huey BM, Harrison SK. Should bone scintigraphy be used as a routine adjunct to skeletal survey in the imaging of non-accidental injury? A 10 year review of reports in a single centre. Clinical Radiology. 70(8):e83-9, 2015 Aug. Observational-Dx 166 patients To retrospectively analyse the bone scintigraphy (BS) and skeletal survey (SS) data to evaluate the role and limitations of BS in the diagnosis of non-accidental injury (NAI). One hundred and sixty-six patients had both SS and BS. The findings were congruent in 74% of cases. BS added confidence to the SS findings in 8% and revealed a new abnormality in 4% of patients. BS demonstrated false-positive and -negative rates of 2% and 13%, respectively. Occult bony injury was detected in 12% of the 237 patients imaged. 3
29. Kemp AM, Butler A, Morris S, et al. Which radiological investigations should be performed to identify fractures in suspected child abuse? Clin Radiol. 2006; 61(9):723-736. Meta-analysis 34 studies;2 reviewers Meta-analysis to determine which radiological investigations should be performed to identify fractures in suspected child abuse. Diagnostic imaging of the skeleton is necessary for children under 2-years old, where physical abuse is suspected. The following options would increase diagnostic yield if evaluated prospectively: Skeletal surveys that includes oblique views, skeletal surveys and bone scintigraphy, a skeletal survey with repeat skeletal survey or selected images 2 weeks later or a bone scintigraphy plus skull radiography and coned views of metaphyses and epiphyses. M
30. Conway JJ, Collins M, Tanz RR, et al. The role of bone scintigraphy in detecting child abuse. Semin Nucl Med. 1993; 23(4):321-333. Review/Other-Dx N/A Review role of bone scan in detecting child abuse. Major advantages of bone scan are increased sensitivity (25% to 50%) in detecting evidence of soft-tissue and bone trauma in child abuse. Radionuclide scintigraphy is a complementary rather than competitive imaging modality to X-ray evaluation in the diagnosis and management of physical child abuse. 4
31. Jaudes PK. Comparison of radiography and radionuclide bone scanning in the detection of child abuse. Pediatrics. 1984;73(2):166-168. Observational-Dx 110 children To compare radiographic surveys or radionuclide bone scans to detect child abuse. One hundred ten children were evaluated with either radiographic surveys or bone scans, and 50 children had both roentgenograms and bone scans. In 40% of the children there was at least one fracture whereas 20% had between two and seven fractures. Among the children who received both skeletal surveys and bone scans, 41 fractures were detected: skeletal survey detected 52% and bone scan detected 88% of those fractures. Children with fractures were more likely to be placed in foster homes than to be returned to the original environment. The presence of single v multiple fractures did not alter the probability of foster placement. 3
32. Mandelstam SA, Cook D, Fitzgerald M, Ditchfield MR. Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child. 2003; 88(5):387-390; discussion 387-390. Observational-Dx 124 bone injuries in 30 children Retrospective review to compare the effectiveness of radiological skeletal survey and bone scintigraphy for the detection of bony injuries in suspected child abuse cases. 64/124 injuries were identified on bone scan and 77 on skeletal survey. Skeletal survey and bone scintigraphy are complementary studies in the evaluation of nonaccidental injury, and should both be performed in cases of suspected child abuse. 3
33. Hedlund GL, Frasier LD. Neuroimaging of abusive head trauma. Forensic Sci Med Pathol. 2009;5(4):280-290. Review/Other-Dx N/A To review pertinent neuroimaging modalities currently utilized in the diagnosis of AHT, describing clinical indications and a collaborative approach to this process. No results stated in abstract. 4
34. Langford S, Panigrahy A, Narayanan S, et al. Multiplanar reconstructed CT images increased depiction of intracranial hemorrhages in pediatric head trauma. Neuroradiology. 57(12):1263-8, 2015 Dec. Observational-Dx 215 cases To evaluate unenhanced head CTs in pediatric trauma patients to investigate the various benefits of multiplanar reconstructed images (MPR) in this age group. MPR improved the detection of hemorrhage in 14 cases (6.5 %, p-value < 0.01) and incidental findings in five cases (2.3 %, p-value < 0.05) as well as helped prove artifacts in five cases (2.3 %, p-value < 0.05). 4
35. Prabhu SP, Newton AW, Perez-Rossello JM, Kleinman PK. Three-dimensional skull models as a problem-solving tool in suspected child abuse. Pediatr Radiol. 2013;43(5):575-581. Review/Other-Dx 73 children To assess the value of 3-D skull models as a problem-solving tool in children younger than 2 years. Of the 73 children, volume-rendered 3-D models were obtained in 26 (35.6%). 3-D models changed initial CT interpretation in 9 instances (34.6%). Findings thought to be fractures were confirmed as normal variants in 4 children. Depressed fractures were correctly shown to be ping-pong fractures in 2 cases. In 1 case, an uncertain finding was confirmed as a fracture, and an additional contralateral fracture was identified in 1 child. A fracture seen on skull radiographs but not seen on axial CT images was identified on the 3-D model in 1 case. Changes in interpretation led to modification in management in 5 children. 4
36. Kemp AM, Rajaram S, Mann M, et al. What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? A systematic review. Clin Radiol. 2009; 64(5):473-483. Review/Other-Dx 18 studies; 367 children Systematic review to examine the optimal neuroradiological investigation strategy to identify inflicted brain injury. Combining MRI with an abnormal early CT revealed additional information in 25% (95% CI: 18.3%-33.16%) of children. Optimal imaging strategy involves initial CT, followed by early MRI and diffusion-weighted imaging if early CT examination is abnormal, or there are ongoing clinical concerns. 4
37. Williams VL, Hogg JP. Magnetic resonance imaging of chronic subdural hematoma. Neurosurg Clin N Am. 2000;11(3):491-498. Review/Other-Dx N/A To highlights the unique ability of magnetic resonance imaging in evaluating the evolution of the subdural hematoma. No results stated in abstract. 4
38. Vezina G. Assessment of the nature and age of subdural collections in nonaccidental head injury with CT and MRI. Pediatr Radiol. 2009;39(6):586-590. Review/Other-Dx N/A No abstract available. No abstract available. 4
39. Adamsbaum C, Rambaud C. Abusive head trauma: don't overlook bridging vein thrombosis. Pediatr Radiol. 2012;42(11):1298-1300. Review/Other-Dx N/A No abstract available. No abstract available. 4
40. Choudhary AK, Bradford R, Dias MS, Thamburaj K, Boal DK. Venous injury in abusive head trauma. Pediatric Radiology. 45(12):1803-13, 2015 Nov. Observational-Dx 45 children To define the incidence and characteristics of venous and sinus abnormalities in abusive head trauma. A total of 45 children were included. The median age was 3 months (range 15 days to 31 months) and 28 were boys (62%). Clinical findings included retinal hemorrhage in 71% and extracranial fractures in 55%. CT or MRI demonstrated subdural hemorrhage in 41 (91%); none had subdural effusions. In 31 cases (69%) MR venography demonstrated mass effect on the venous sinuses or cortical draining veins, with either displacement or partial or complete effacement of the venous structures from an adjacent subdural hematoma or brain swelling. We also describe the lollipop sign, which represents direct trauma to the cortical bridging veins and was present in 20/45 (44%) children. 2
41. Beavers AJ, Stagner AM, Allbery SM, Lyden ER, Hejkal TW, Haney SB. MR detection of retinal hemorrhages: correlation with graded ophthalmologic exam. Pediatric Radiology. 45(9):1363-71, 2015 Aug. Observational-Dx 77 children To determine the value of standard brain protocol MRI in detecting retinal hemorrhage and to determine whether there is any correlation with MR detection of retinal hemorrhage and the dilated fundoscopic exam grade of hemorrhage. There was a statistically significant difference in the median grade of retinal hemorrhage examination between children who had retinal hemorrhage detected on MRI and children who did not have retinal hemorrhage detected on MRI (P = 0.02). When examination grade was categorized as low-grade (1-4), moderate-grade (5-8) or high-grade (>8) hemorrhage, there was a statistically significant association between exam grade and diagnosis based on MRI (P = 0.008). For example, only 14% of children with low-grade retinal hemorrhages were identified on MRI compared to 76% of children with high-grade hemorrhages. MR detection of retinal hemorrhage demonstrated a sensitivity of 61%, specificity of 100%, positive predictive value of 100% and negative predictive value of 63%. Retinal hemorrhage was best seen on the gradient recalled echo (GRE) sequences. 3
42. Zuccoli G, Panigrahy A, Haldipur A, et al. Susceptibility weighted imaging depicts retinal hemorrhages in abusive head trauma.[Erratum appears in Neuroradiology. 2014 Dec;56(12):1133]. Neuroradiology. 55(7):889-93, 2013 Jul. Observational-Dx 28 patients To evaluate the capability of magnetic resonance imaging (MRI) susceptibility weighted images (SWI) in depicting retinal hemorrhages (RH) in abusive head trauma (AHT) compared to the gold standard dilated fundus exam (DFE). Of the 21 subjects with RH on DFE, 13 (62%) were identified by using a standard SWI sequence performed as part of brain MRI protocols. Of the 15 patients who also underwent an orbits SWI protocol, 12 (80%) were positive for RH. None of the seven patients without RH on of DFE had RH on either standard or high-resolution SWI. Compared with DFE, the MRI standard protocol showed a sensitivity of 75% which increased to 83% for the orbits SWI protocol. 3
43. Choudhary AK, Bradford RK, Dias MS, Moore GJ, Boal DK. Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology. 2012;262(1):216-223. Review/Other-Dx 252 children To compare the relative incidence, distribution, and radiologic characteristics of spinal subdural hemorrhage after abusive head trauma versus that after accidental trauma in children. In the abusive head trauma cohort, 67 (26.5%) of 252 children had evaluable spinal imaging results. Of these, 38 (56%) of 67 children had undergone thoracolumbar imaging, and 24 (63%) of 38 had thoracolumbar subdural hemorrhage. Spinal imaging was performed in this cohort 0.3-141 hours after injury (mean, 23 hours +/- 27 [standard deviation]), with 65 (97%) of 67 cases having undergone imaging within 52 hours of injury. In the second cohort with accidental injury, only one (1%) of 70 children had spinal subdural hemorrhage at presentation; this patient had displaced occipital fracture. The comparison of incidences of spinal subdural hemorrhage in abusive head trauma versus those in accidental trauma was statistically significant (P < .001). 4
44. Kadom N, Khademian Z, Vezina G, Shalaby-Rana E, Rice A, Hinds T. Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma. Pediatr Radiol. 44(7):839-48, 2014 Jul. Review/Other-Dx 74 children To determine both the incidence and the spectrum of cervical spine and brain injuries in children being evaluated for possible AHT. Article also examined the relationship between cervical and brain MRI findings and selected study outcome categories. Study outcomes were categorized as: n = 26 children with accidental head trauma, n = 38 with AHT (n = 18 presumptive AHT, n = 20 suspicious for AHT), and n = 10 with undefined head trauma. The authors found cervical spine injuries in 27/74 (36%) children. Most cervical spine injuries were ligamentous injuries. One child had intrathecal spinal blood and 2 had spinal cord edema; all 3 of these children had ligamentous injury. MRI signs of cervical injury did not show a statistically significant relationship with a study outcome of AHT or help discriminate between accidental and AHT. Of the 30 children with supratentorial brain injury, 16 (53%) had a bilateral hypoxic-ischemic pattern. There was a statistically significant relationship between bilateral hypoxic-ischemic brain injury pattern and AHT (P<0.05). In addition, the majority (81%) of children with bilateral hypoxic-ischemic brain injuries had cervical injuries. 4
45. Koumellis P, McConachie NS, Jaspan T. Spinal subdural haematomas in children with non-accidental head injury. Arch Dis Child. 2009;94(3):216-219. Review/Other-Dx 18 infants To examine the incidence of spinal pathology in infants with non-accidental head injury. There was a high incidence (8/18 cases, 44%) of subdural collections in the spine. They were all clinically occult and in six cases large. All eight cases were associated with subdural haematomas in the supratentorial and infratentorial compartment. The signal characteristics were analysed and compared with those of the intracranial collections. One had a small epidural haematoma. Other depicted abnormalities and appearances at follow-up were also reviewed. 4
46. Wootton-Gorges SL, Stein-Wexler R, Walton JW, Rosas AJ, Coulter KP, Rogers KK. Comparison of computed tomography and chest radiography in the detection of rib fractures in abused infants. Child Abuse Negl. 2008;32(6):659-663. Observational-Dx 12 abused infants To compare CT and CXR in the evaluation of rib fractures in abused infants. The mean patient age was 2.5 months (1.2-5.6), with seven females and five males. While 131 fractures were visualized by CT, only 79 were seen by CXR (p<.001). One patient had fractures only seen by CT. There were significantly (p<.05) more early subacute (24 vs. 4), subacute (47 vs. 26), and old fractures (4 vs. 0) seen by CT than by CXR. Anterior (42 vs. 11), anterolateral (21 vs. 12), posterolateral (9 vs. 3) and posterior (39 vs. 24) fractures were better seen by CT than by CXR (p<.01). Bilateral fractures were detected more often by CT (11) than by CXR (6). 2
47. Sanchez TR, Lee JS, Coulter KP, Seibert JA, Stein-Wexler R. CT of the chest in suspected child abuse using submillisievert radiation dose. Pediatric Radiology. 45(7):1072-6, 2015 Jul.Pediatr Radiol. 45(7):1072-6, 2015 Jul. Observational-Dx 4 children To determine if CT of the chest in suspected child abuse using nsubmillisievert radiation dose is more useful in the evaluation of high specificity fractures of non-accidental trauma when the four-view chest radiographs are negative. We retrospectively identified four children (three boys, one girl; age range 1-4 months) admitted between January 2013 and February 2014 with high suspicion for non-accidental trauma from unexplained fractures of the long bones; these children all had CT of the chest when no rib fractures were evident on the skeletal survey. The absorbed radiation dose estimates for organs and tissue from the four-view chest radiographs and subsequent CT were determined using Monte Carlo photon transport software, and the effective dose was calculated using published tissue-weighting factors. In two children, CT showed multiple fractures of the ribs, scapula and vertebral body that were not evident on the initial skeletal survey. The average effective dose for a four-view chest radiograph across the four children was 0.29 mSv and the average effective dose for the chest CT was 0.56 mSv. Therefore the effective dose of a chest CT is on average less than twice that of a four-view chest radiograph. 4
48. Alkadhi H, Wildermuth S, Marincek B, Boehm T. Accuracy and time efficiency for the detection of thoracic cage fractures: volume rendering compared with transverse computed tomography images. J Comput Assist Tomogr. 2004;28(3):378-385. Observational-Dx 50 patients To compare accuracy and time efficiency of volume rendering compared to transverse images on MDCT to identify thoracic cage fractures. Patients with acute blunt chest trauma. 30/50 patients had 178 rib fractures. Mean sensitivity, specificity and accuracy for their detection were similar for transverse (96%, 100% and 99%) and volume rendering (98%, 100% and 100%) images. The time to read volume rendering images (106 seconds) was significantly reduced compared to the time needed for transverse image reading (167 seconds). 2
49. Sheybani EF, Gonzalez-Araiza G, Kousari YM, Hulett RL, Menias CO. Pediatric nonaccidental abdominal trauma: what the radiologist should know. Radiographics. 2014;34(1):139-153. Review/Other-Dx N/A To review injury patters and their imaging appearances, especially abdominal injury in nonaccidental trauma. No results stated in abstract. 4
50. Harper NS, Feldman KW, Sugar NF, Anderst JD, Lindberg DM. Additional injuries in young infants with concern for abuse and apparently isolated bruises. J Pediatr. 2014;165(2):383-388 e381. Review/Other-Dx 2890 children To determine the prevalence of additional injuries or bleeding disorders in a large population of young infants evaluated for abuse because of apparently isolated bruising. Among 2890 children, 33.9% (980/2890) were <6 months old, and 25.9% (254/980) of these had bruises identified. Within this group, 57.5% (146/254) had apparently isolated bruises at presentation. Skeletal surveys identified new injury in 23.3% (34/146), neuroimaging identified new injury in 27.4% (40/146), and abdominal injury was identified in 2.7% (4/146). Overall, 50% (73/146) had at least one additional serious injury. Although testing for bleeding disorders was performed in 70.5% (103/146), no bleeding disorders were identified. Ultimately, 50% (73/146) had a high perceived likelihood of abuse. 4
51. Lindberg DM, Berger RP, Reynolds MS, Alwan RM, Harper NS. Yield of skeletal survey by age in children referred to abuse specialists. J Pediatr. 2014;164(6):1268-1273 e1261. Observational-Dx 2609 children To determine rates of skeletal survey completion and injury identification as a function of age among children who underwent subspecialty evaluation for concerns of physical abuse. Among 2609 subjects, 2036 (78%) had skeletal survey and 458 (18%) had at least one new fracture identified. For all age groups up to 36 months, skeletal survey was obtained in >50% of subjects, but rates decreased to less than 35% for subjects >36 months. New fracture identification rates for skeletal survey were similar between children 24-36 months of age (10.3%, 95% CI 7.2-14.2) and children 12-24 months of age (12.0%, 95% CI 9.2-15.3) 3
52. Wood JN, Fakeye O, Feudtner C, Mondestin V, Localio R, Rubin DM. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 2014;134(1):45-53. Review/Other-Dx N/A To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties. Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type. 4
53. Barber I, Perez-Rossello JM, Wilson CR, Kleinman PK. The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatric Radiology. 45(1):69-80, 2015 Jan. Observational-Dx 567 infants To determine the diagnostic yield of high-detail radiographic skeletal surveys in suspected infant abuse. In 313 of 567 infants (55%), 1,029 definite fractures were found. Twenty-one percent (119/567) of the patients had a positive skeletal survey with a total of 789 (77%) unsuspected fractures. Long-bone fractures were the most common injuries, present in 145 children (26%). The skull was the site of fracture in 138 infants (24%); rib cage in 77 (14%), clavicle in 24 (4.2%) and uncommon fractures (including spine, scapula, hands and feet and pelvis) were noted in 26 infants (4.6%). Of the 425 infants with neuroimaging, 154 (36%) had intracranial injury. No significant correlation between positive skeletal survey and associated intracranial injury was found. Scapular fractures and complex skull fractures showed a statistically significant correlation with intracranial injury (P = 0.029, P = 0.007, respectively). 4
54. Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics. 2011;127(1):e47-52. Observational-Dx 703 skeletal survey To assess the use of the skeletal survey (SS) to evaluate for physical abuse in a large consecutive sample, to identify characteristics of children most likely to have unsuspected fractures, and to determine how often SS results influenced directly the decision to make a diagnosis of abuse. Of the 703 SSs, 10.8% yielded positive results. Children <6 months of age, children with an apparent life-threatening event or seizure, and children with suspected abusive head trauma had the highest rates of positive SS results. Of children with positive SS results, 79% had >/=1 healing fracture. 4
55. Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinman PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol 2011;197:1005-8. Review/Other-Dx 42 infants To determine the relative likelihood of encountering a classic metaphyseal lesion in infants at low and high risk for abuse There were 42 low-risk infants (age range, 0.4-12 months; mean age, 4.4 months) and 18 high-risk infants (age range, 0.8-10.3 months; mean age, 4.6 months). At least one classic metaphyseal lesion was identified in nine infants (50%) in the high-risk category. No classic metaphyseal lesions were identified in the low-risk group. The relative prevalence of classic metaphyseal lesions in the low-risk group (0/42) versus that in the high-risk group (9/18) was statistically significant (p < 0.0001; 95% CI, 0-8% to 29-76%). 4
56. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child. 1993; 147(1):87-92. Review/Other-Dx 215 children 253 fractures Case series to determine features of fractures in young children that are useful in distinguishing child abuse from unintentional injuries. Fractures considered likely due to abuse were: 1) Fractures in children whose caretakers reported either a change in the child’s behavior, but no accidental event, or a minor fall, but the injury was more severe than expected; 2) Fractures of the radius/ulna, tibia/fibula, or femur in children <1 year of age; 3)Midshaft or metaphysical fractures of the humerus. 4
57. Shrader MW, Bernat NM, Segal LS. Suspected nonaccidental trauma and femoral shaft fractures in children. Orthopedics. 2011;34(5):360. Review/Other-Dx 137 patients To analyze femoral shaft fractures at a major pediatric level I trauma center in a large metropolitan area over a 5-year period to determine the incidence of suspected nonaccidental trauma and the risk factors associated with that diagnosis. Over the 5-year study period, 137 patients presented to our institution with a femoral shaft fracture. Mean patient age at the time of injury was 2.2 years (range, 1 month to 4 years). Overall, 43 patients with a mean age of 1.8 years were determined to have injuries suspicious of nonaccidental trauma and were referred to Child Protective Services, giving an overall incidence of 31%. Age younger than 1 year was a highly significant risk factor for suspected nonaccidental trauma. Of the 20 children younger than 1 year, 18 (90%) were referred to Child Protective Services, comprising 42% of those children suspicious of nonaccidental trauma. 4
58. Lloyd DA, Carty H, Patterson M, Butcher CK, Roe D. Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet. 1997; 349(9055):821-824. Observational-Dx 883 children; CT done in 156 children Prospectively study head-injured children to assess the value of skull radiography. Radiographs showed 162 fractures. 107/156 children had a skull fracture. 23 children had intracranial injuries on CT. The presence of neurological abnormalities had sensitivity of 91% (21/23) and NPV of 97%. The corresponding values for skull fracture on radiography were 65% (15/23) and 83%. Skull x-ray not reliable to detect intracranial injury. A neurological abnormality is predictor of intracranial injury. 3
59. Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Pediatrics. 1997; 99(5):E11. Observational-Dx 322 children Prospective cohort study to provide information relevant to the choice of imaging modalities in children with acute head trauma. Intracranial injury occurred in 27 children (8%), while 50 (16%) had skull fractures. Intracranial injury may occur with few or subtle signs and symptoms in children <1 year. 3
60. Laskey AL, Holsti M, Runyan DK, Socolar RR. Occult head trauma in young suspected victims of physical abuse. J Pediatr. 2004;144(6):719-722. Review/Other-Dx 51 patients To determine the frequency of neuroimaging and ophthalmology consults in children evaluated for physical abuse without neurologic symptoms and the diagnostic yield of these studies. 51 patients had a skeletal survey and no clinical signs of ICI. 75% of patients had CT or MRI; 69% had formal evaluation for retinal hemorrhages. 29% had evidence of ICI without neurologic symptoms. Age less than 12 months was the only factor significantly associated with neuroimaging (90% vs 55%, P=.004). Sex, race, insurance, and having an unrelated male caretaker were not significantly associated with performance of neuroimaging or findings of ICI. 4
61. Rubin DM, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR. Occult head injury in high-risk abused children. Pediatrics. 2003;111(6 Pt 1):1382-1386. Review/Other-Dx 65 patients To estimate the prevalence of occult head injury in a high-risk sample of abused children with normal neurologic examinations and to describe characteristics of this population. Of the 65 patients, 51 (78.5%) had a head CT or MRI in addition to skeletal survey. Of these 51 patients, 19 (37.3%, 95% CI, 24.2%-50.4%) had an occult head injury. Injuries included scalp swelling (74%), skull fracture (74%), and ICI (53%). All except 3 of the head-injured patients had at least a skull fracture or ICI. Skeletal survey alone missed 26% (5/19) of the cases. Head-injured children were younger than non-head-injured children (median age 2.5 vs 5.1 months); all but 1 head-injured child was <1 year of age. Among the head-injured children, 72% came from single parent households, 37% had mothers whose age was <21 years, and 26% had a history of prior child welfare involvement in their families. Ophthalmologic examination was performed in 14/19 cases; no retinal hemorrhages were noted. 4
62. Wilson PM, Chua M, Care M, Greiner MV, Keeshin B, Bennett B. Utility of head computed tomography in children with a single extremity fracture. J Pediatr. 2014;164(6):1274-1279. Observational-Dx 320 children To determine the clinical and forensic utility of head computed tomography (CT) in children younger than 2 years of age with an acute isolated extremity fracture and an otherwise-negative skeletal survey. Of the 320 children evaluated, 37% received neuroimaging, 95.7% of which had no signs of skull fracture or intracranial trauma. Five children (4.3%) with head imaging had traumatic findings but no children in the study had clinically significant head injury. Three of these children had previous concerns for nonaccidental trauma and findings on head CT that were forensically significant. There was a greater rate of head imaging in children in the younger age groups and those with proximal extremity fractures (P < .05). 4
63. Rennie L, Court-Brown CM, Mok JY, Beattie TF. The epidemiology of fractures in children. Injury. 2007;38(8):913-922. Review/Other-Dx 108,987 children To analyse all paediatric fractures presenting to hospital in Edinburgh, Scotland in 2000 to ascertain their incidence, demonstrate which fractures were most common and investigate the causes of fracture in different age groups. And to examine the fracture distribution curves of all fractures to see if there was a reproducible set of curves, which would encompass all fractures. Analysis of paediatric fractures shows that there are six basic fracture distribution curves with six fractures showing a bimodal distribution but most having a unimodal distribution affecting younger or older children. The incidence of fractures increases with age with falls from below bed height (<1m) being the commonest cause of fracture. The majority of fractures in children involve the upper limb. Lower limb fractures are mainly caused by twisting injuries and road traffic accidents. 4
64. Kellogg ND. Evaluation of suspected child physical abuse. Pediatrics. 2007; 119(6):1232-1241. Review/Other-Dx N/A Review clinical guidance in the evaluation of suspected physical abuse in children. Medical assessment is outlined with respect to obtaining a history, physical examination, and appropriate ancillary testing. Role of physicians include reporting suspected abuse; assessing the consistency of the explanation, the child’s developmental capabilities, and the characteristics of the injury or injuries. Accurate and timely diagnosis can ensure appropriate evaluation, investigation, and outcomes. 4
65. Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH. A population-based study of inflicted traumatic brain injury in young children. JAMA. 2003;290(5):621-626. Review/Other-Dx 152 cases To determine the incidence of serious or fatal inflicted TBI in a defined US population of approximately 230 000 children aged 2 years or younger. A total of 152 cases of serious or fatal TBI were identified, with 80 (53%) incurring inflicted TBI. The incidence of inflicted traumatic brain injury in the first 2 years of life was 17.0 (95% confidence interval [CI], 13.3-20.7) per 100 000 person-years. Infants had a higher incidence than children in the second year of life (29.7 [95% CI, 22.9-36.7] vs 3.8 [95% CI, 1.3-6.4] per 100 000 person-years). Boys had a higher incidence than girls (21.0 [95% CI, 15.1-26.6] vs 13.0 [95% CI, 8.4-17.7] per 100 000 person-years). Relative to the general population, children who incurred an increased risk of inflicted injury were born to young mothers (< or =21 years), non-European American, or products of multiple births. 4
66. Kemp AM, Jaspan T, Griffiths J, et al. Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Arch Dis Child. 2011;96(12):1103-1112. Review/Other-Dx 18 studies To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury. Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with inflicted brain injury and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI, 18.3%-33.16%) of children. The additional findings included further subdural hematoma, subarachnoid hemorrhage, shearing injury, ischemia, and infarction; it also contributed to dating of injuries. DWI further enhanced the delineation of ischemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI. 4
67. Cramer JA, Rassner UA, Hedlund GL. Limitations of T2*-Gradient Recalled-Echo and Susceptibility-Weighted Imaging in Characterizing Chronic Subdural Hemorrhage in Infant Survivors of Abusive Head Trauma. Ajnr: American Journal of Neuroradiology. 37(9):1752-6, 2016 Sep. Review/Other-Dx N/A To present 5 cases of chronic subdural hemorrhages in infants, demonstrating intensity near or greater than that of CSF with variable amounts of hemosiderin staining along the neomembranes. To review the physiology and MR imaging physics behind the appearance of a chronic subdural hemorrhage, highlighting that the absence of a BBB can allow hemosiderin to be completely removed from the subdural compartment. To stress the importance of reviewing all multiplanar sequences for the presence of neomembranes, which can be quite subtle in the absence of hemosiderin staining and are critical for making the diagnosis of chronic subdural hemorrhage. No results stated in abstract. 4
68. Sieswerda-Hoogendoorn T, Postema FA, Verbaan D, Majoie CB, van Rijn RR. Age determination of subdural hematomas with CT and MRI: a systematic review. Eur J Radiol. 2014;83(7):1257-1268. Review/Other-Dx 22 studies To systematically review the literature on dating subdural hematomas (SDHs) on CT and MRI scans. We included 22 studies describing 973 SDHs on CT and 4 studies describing 83 SDHs on MRI. Data from 17 studies (413 SDHs) could be pooled. There were significant differences between time intervals for the different densities on CT (p<0.001). Time interval differed significantly between children and adults for iso- and hypodensity (p=0.000) and hyperdensity (p=0.046). Time interval did not differ significantly between abused and non-abused children. On MRI, time intervals for different signal intensities on T1 and T2 did not differ significantly (p=0.108 and p=0.194, respectively). 4
69. Larimer EL, Fallon SC, Westfall J, Frost M, Wesson DE, Naik-Mathuria BJ. The importance of surgeon involvement in the evaluation of non-accidental trauma patients. J Pediatr Surg. 2013;48(6):1357-1362. Review/Other-Dx 267 patients To evaluate the necessity of primary surgical evaluation and admission to the trauma service for children presenting with non-accidental trauma (NAT). We identified 267 NAT patients presenting with 473 acute injuries. Injuries in NAT patients were more severe than in AT patients, and Injury Severity Scores, ICU admission rates, and mortality were all significantly (p<0.001) higher. The majority suffered from polytrauma. Multiple areas of injury were seen in patients with closed head injuries (72%), extremity fractures (51%), rib fractures (82%), and abdominal/thoracic trauma (80%). Despite these complex injury patterns, only 56% received surgical consults, resulting in potential delays in diagnosis, as 24% of abdominal CT scans were obtained >12 hours after hospitalization. 4
70. Trokel M, DiScala C, Terrin NC, Sege RD. Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes. Child Maltreat. 2004; 9(1):111-117. Review/Other-Dx 927 children Extract cases from National Pediatric Trauma Registry to evaluate injury causes and patient outcomes in young children (0-4 years) with abdominal injuries. Three most common mechanisms of abdominal injury were motor vehicles (61.27%), child abuse (15.75%), and falls (13.59%). Patient outcomes were more severe in abused children. Child abuse, compared to falls, is independently associated with a 6-fold increase in in-hospital mortality. 4
71. Trokel M, Discala C, Terrin NC, Sege RD. Patient and injury characteristics in abusive abdominal injuries. Pediatr Emerg Care. 2006;22(10):700-704. Review/Other-Dx 664 cases To identify patient and injury characteristics associated with suspected child abuse in the setting of blunt abdominal trauma. Six hundred sixty-four cases were analyzed. The median age of patients was 2.6 years; 11.4% were undernourished. The 3 most common mechanisms of injury were suspected child abuse (40.5%), fall (36.6%), and struck-not child abuse (9.7%). Hepatic injury (46.1%) was the most common intra-abdominal injury, followed by splenic (26%), hollow viscous (17.9%), and pancreatic (8.6%) injuries. Eighty-four percent of deaths were related to suspected child abuse. There was a greater proportion of children with suspected child abuse in every patient and injury characteristics studied than all other mechanisms combined. In a regression model including age, undernourishment, pancreatic injury, hollow viscous injury, traumatic brain injury, and mortality, all variables were significantly associated with suspected abuse. Hollow viscous injury had the highest odds ratio (OR, 9.5; confidence limits, 5.7, 15.8), whereas traumatic brain injury had the lowest (OR, 3.6; confidence limits, 2.4, 5.6). 4
72. Ledbetter DJ, Hatch EI, Jr., Feldman KW, Fligner CL, Tapper D. Diagnostic and surgical implications of child abuse. Arch Surg. 1988; 123(9):1101-1105. Review/Other-Dx 156 children To review children <13 years with blunt abdominal injuries, and compare those injured in accidents (89%) with those injured by child abuse (11%). Abused children were younger (mean age, 2 1/2 years) and all presented late to medical attention with a history that was inconsistent with their physical findings. Only 65% of abused children had physical or roentgenographic signs of prior abuse, while 35% had no signs of prior abuse. Physicians should suspect child abuse when children have unexplained injuries (especially young children with hollow viscus injuries). 4
73. Hilmes MA, Hernanz-Schulman M, Greeley CS, Piercey LM, Yu C, Kan JH. CT identification of abdominal injuries in abused pre-school-age children. Pediatr Radiol. 2011; 41(5):643-651. Review/Other-Dx 84 children Retrospective review of a child abuse registry was performed to describe abdominopelvic injuries in abused pre-school-age children as identified on CT. Of 84 children, 35 (41.7%) had abdominal injuries. Abdominal injuries included liver (15), bowel (13), mesentery (4), spleen (6), kidneys (7), pancreas (4) and adrenal glands (3). Of these children, 26% (9/35) required surgical intervention for bowel, mesenteric and pancreatic injuries. Another 9/35 children died, not as a result of abdominal injuries but as a direct result of inflicted intracranial injuries. Data indicate that abdominal injuries in abused children present in a pattern similar to that of children with accidental abdominal trauma, underscoring the need for vigilance and correlative historical and clinical data to identify victims of abuse. Mortality in abused children with intra-abdominal injury was frequently related to concomitant head injury. 4
74. Lindberg D, Makoroff K, Harper N, et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009; 124(2):509-516. Observational-Dx 1,272 patients with transaminase testing; 54 identified with abdominal injuries To determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either aspartate aminotransferase or alanine aminotransferase yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity. In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the aspartate aminotransferase or alanine aminotransferase level is >80 IU/L or with abdominal bruising, distention, or tenderness. 3
75. Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD. Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use? Pediatr Radiol. 2011; 41(1):92-98. Observational-Dx 68 children Retrospective review was performed to identify clinical or laboratory criteria that may predict intra-abdominal injury and guide the use of abdominal and pelvic CT in this population. CTs were positive in 16% of patients (11/68). Hypoactive/absent bowel sounds (P=0.01, specificity?=?94.7%) and aspartate aminotransferase/alanine aminotransferase values greater than twice normal (P=0.004 and P=0.003 respectively, NPV?=?93.6%) were significantly associated with positive CTs. Multiple abnormal physical exam or laboratory findings were also significantly associated with positive CTs (P=0.03 and P=0.002 respectively, specificity?=?91.3% and NPV?=?93.6% respectively). CTs of the abdomen and pelvis are infrequently positive in cases of suspected abuse. To reduce radiation exposure, CTs should only be ordered if there are findings indicating that they may be positive. 3
76. Roaten JB, Partrick DA, Bensard DD, et al. Visceral injuries in nonaccidental trauma: spectrum of injury and outcomes. Am J Surg. 2005;190(6):827-829. Review/Other-Dx 3705 patients To characterize visceral injuries associated with nonaccidendal trauma (NAT) and the management and outcomes of children with these injuries. NAT accounted for 7% (n = 265 of 3705) of all trauma admissions during the period of study. Visceral injuries were diagnosed in 9% (n = 24 of 265) of NAT patients. Compared with the remaining NAT population, children with visceral injuries were similar in age and sex but had higher injury severity scores (21 vs. 17, P < .05). There was a high coincidence of thoracic trauma and nonburn integumental injuries in abdominally injured NAT patients. Children with visceral injuries were more likely to undergo emergent operations (46% [11 of 24] vs. 5% [15 of 241], P < .0001) than those without. However, there was no difference in Intensive Care Unit stay, hospital stay, or overall mortality for children with visceral injuries compared with those without. 4
77. Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 2003; 23(4):811-845. Review/Other-Dx N/A Review injury patterns and imaging features in abused children. For skull injuries, radiography is best for detecting fractures, but CT and MRI best depict intracranial injury. 4
78. Maguire SA, Upadhyaya M, Evans A, et al. A systematic review of abusive visceral injuries in childhood--their range and recognition. Child Abuse Negl. 2013;37(7):430-445. Review/Other-Dx 88 studies To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children. Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger(2.5–3.7 years vs. 7.6–10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation.Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries(53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations,in particular those with ‘negative’ screening tests were not consistently investigated. 4
79. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007;42(9):1588-1594. Meta-analysis 25 articles To obtain the best estimates of the test performance of abdominal ultrasonography (US) for identifying children with intraabdominal injuries (IAIs). Twenty-five articles met the inclusion criteria, and 3838 children evaluated with abdominal US were included. Abdominal US had the following test characteristics for identifying children with hemoperitoneum: sensitivity, 80% (95% confidence interval [CI] 76%-84%); specificity, 96% (95% CI 95%-97%); positive likelihood ratio, 22.9 (95% CI 17.2-30.5); and negative likelihood ratio, 0.2 (95% CI 0.16-0.25). Using the most methodologically rigorous studies, however, yielded the following test characteristics of abdominal US for identifying children with hemoperitoneum: sensitivity, 66% (95% CI 56%-75%); specificity, 95% (95% CI 93%-97%); positive likelihood ratio, 14.5 (95% CI 9.5-22.1); and negative likelihood ratio, 0.36 (95% CI 0.27-0.47). M
80. Menichini G, Sessa B, Trinci M, Galluzzo M, Miele V. Accuracy of contrast-enhanced ultrasound (CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CE-MDCT. Radiol Med. 2015;120(11):989-1001. Observational-Dx 73 children To assess the sensibility and feasibility of CEUS in the assessment of low-energy abdominal trauma compared to baseline US in pediatric patients, using contrast-enhanced MDCT as the reference standard. 6/73 patients were negative at US, CEUS, and MDCT for the presence of organ injuries. In the remaining 67 patients, US depicted 26/67 parenchymal lesions. CEUS identified 67/67 patients (67/67) with parenchymal lesions: 21 lesions of the liver (28.8 %), 26 lesions of the spleen (35.6 %), 7 lesions of right kidney (9.6 %), 13 lesions of left kidney. MDCT confirmed all parenchymal lesions (67/67). Thus, the diagnostic performance of CEUS was better than that of US, as sensitivity, specificity, PPV, NPV, and accuracy were 100, 100, 100, 100, and 100 % for CEUS and 38.8, 100, 100, 12.8, and 44 % for US. In some patients CEUS identified also prognostic factors as parenchymal active bleeding in 8 cases, partial devascularization in 1 case; no cases of vascular bleeding, no cases of urinoma. MDCT confirmed all parenchymal lesions. Parenchymal active bleeding was identified in 16 cases, vascular bleeding in 2 cases, urinoma in 2 cases, partial devascularization in 1 case. 3
81. Anderst JD. Chylothorax and child abuse. Pediatr Crit Care Med. 2007;8(4):394-396. Review/Other-Dx 1 To report an unusual presentation of child abuse in a critical care setting. Child abuse can present with unusual findings, and the diagnosis is not always apparent. In this and previous case reports of child abuse presenting as chylothorax, the diagnosis of abusive injury was not initially made by the managing clinicians. When abusive injury is in the differential diagnosis of a child's condition, a thorough and complete investigation-including skeletal survey, eye exam by an ophthalmologist, cranial neuroimaging, and consultation with child abuse physicians and child protective services-may be indicated. 4
82. Bennett BL, Chua MS, Care M, Kachelmeyer A, Mahabee-Gittens M. Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal. BMC Res Notes. 2011;4:354. Observational-Dx 47 children To evaluate the utility of a follow-up skeletal survey in suspected child physical abuse evaluations when the initial skeletal survey is normal. Forty-seven children had a negative initial skeletal survey and were included for analysis. The mean age was 6.9 months (SD 5.7); the mean number of days between skeletal surveys was 18.7 (SD 10.1)Four children (8.5%) had signs of healing bone trauma on a follow-up skeletal survey. Three of these children (75%) had healing rib fractures and one child had a healing proximal humerus fracture. The findings on the follow-up skeletal survey yielded forensically important information in all 4 cases and strengthened the diagnosis of non-accidental trauma. 3
83. Kleinman PK, Nimkin K, Spevak MR, et al. Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol. 1996; 167(4):893-896. Observational-Dx 23 infants and toddlers To assess the additional yield of a repeat skeletal survey in identifying and dating skeletal injury for cases in which child abuse was strongly suspected. Follow-up skeletal survey yielded additional information regarding skeletal injury in 14 (61%) of 23 cases. Follow-up study increased the number of definite fractures detected from 70 to 89 (27%) (P=.005). In 13/70 fractures previously detected, the follow-up skeletal survey also provided important information about the age of those injuries. 3
84. Harlan SR, Nixon GW, Campbell KA, Hansen K, Prince JS. Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed? Pediatr Radiol. 2009;39(9):962-968. Observational-Dx 101 children To determine whether a more limited follow-up survey could yield the same radiologic data as a full follow-up survey. In the 101 children 244 fractures were identified on the initial osseous survey. Follow-up surveys demonstrated new information in 38 children (37.6%). A 15-view limited follow-up survey identified all additional information seen on the complete follow-up survey. 3
85. Islam O, Soboleski D, Symons S, Davidson LK, Ashworth MA, Babyn P. Development and duration of radiographic signs of bone healing in children. AJR Am J Roentgenol. 2000;175(1):75-78. Review/Other-Dx 141 patients To establish a timetable for expected radiographic changes visible during bone healing in otherwise healthy children. Sclerosis at the fracture margins was evident in 85% of fractures 5 weeks after injury. Widening of the fracture gap was observed in 62% of fractures at 6 weeks. Periosteal reaction was evident on all images by 4 weeks, and after 7 weeks, periosteal reaction was separable from cortex in only 10% of fractures. Fracture callus had a density equal to or greater than that of adjacent cortex 10 weeks after injury in 90% of fractures. 4
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