A 5 week old girl presents to the pediatric emergency department with failure to thrive. The following chest and abdomen x-ray is obtained:
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A mildly displaced fracture of the left posterior 5th rib is seen. This raises the suspicion for non-accidental trauma. A full skeletal survey should be obtained (or actually already was in this case, as clinical suspicion was high).
A skeletal survey is obtained:
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Multiple additional left posterior rib fractures are seen with dedicated rib films. These fractures are at multiple stages of healing (some show callus formation around them), which suggests the fractures occurred during separate incidents rather than a single injury, further supporting non-accidental trauma.
A CT of the head was then obtained to further evaluate the skull fractures and brain:
The skull fractures noted on the skeletal survey are better characterized with CT. We also see further signs of trauma, including encephalomalacia of the bilateral frontal lobes, likely due to a previous brain trauma. There is also prominence of the extra-axial spaces overlying both frontal lobes, which could represent chronic subdural hematomas as a result of non-accidental trauma, or coincidental benign enlargement of the subarachnoid space (BESS).
There are many findings of non-accidental trauma in this case. Certain fractures are much more specific for non-accidental trauma, including:
- posterior rib fractures
- metaphyseal corner fractures or bucket handle fractures (also called "Classic metaphyseal lesion")
- sternal fractures
- scapular fractures
- spinous process fractures
Subdural hematomas are also very concerning for abuse, particularly when there is blood of differing ages indicating multiple separate insults. In this case, the fluid in the frontal extra-axial (outside the brain tissue) spaces was quite low in density, meaning close to simple fluid. No obvious blood products are seen, however given the multiple other findings of abuse, this could still represent old blood which has broken down into simple fluid, now indistiguishable from CSF.
Not all fractures in children are concerning for abuse. For instance, the "toddler fracture", a spiral long bone fracture in an ambulatory (walking) child is common and not generally associated with abuse. Likewise, there are reasons other than abuse for a child to have skull fractures.
For more reading about non-accidental trauma, see this Radiopedia article