ARRS 2022 Abstracts

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E1587. Non-Accidental Trauma in Pediatric Radiology: Need-to-know Basics and Pitfalls
Authors
  1. Baarkullah Awan; Santa Clara Valley Medical Center
  2. Donald Chan; Santa Clara Valley Medical Center
  3. Michelle Lam; Santa Clara Valley Medical Center
  4. Vanessa Starr; Santa Clara Valley Medical Center
Background
There has been an increasing incidence of non-accidental trauma (NAT) during the COVID-19 pandemic. The non-pediatric radiology trained radiologist may not be familiar with all the nuanced aspects of pediatric radiology, but they should be competent in detecting NAT while simultaneously assessing for its mimics. This exhibit focuses on musculoskeletal findings in NAT.

Educational Goals / Teaching Points
To know the imaging techniques and modalities helpful for evaluating NAT; know common musculoskeletal findings associated with NAT; know mimics of musculoskeletal NAT; and how these might be differentiated from true musculoskeletal NAT.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Initial imaging in suspected NAT is usually the skeletal survey, which includes AP views of the humeri, forearms, femurs, lower legs, feet, and hands; AP, lateral, and oblique views of the thorax to include sternum, ribs, thoracic and upper lumbar spine; AP views of the abdomen/pelvis; lateral views of the lumbosacral spine; frontal and lateral views of the skull; and cervical spine if incompletely visualized on lateral skull x-ray. If there are equivocal findings, additional views can be performed, or the survey can be repeated in 2 weeks, although this may expose the patient to 2 more weeks of unsafe living conditions and some fractures (like the classic metaphyseal lesion) may heal by 2 weeks. Additional imaging modalities can help increase sensitivity of fracture detection. Radionuclide scans can help detect rib or spinal fractures but are not helpful for metaphyseal or skull fractures, require intravenous (IV) access, may require sedation, and expose the patient to 10–12x the radiation dose of a skeletal survey. Noncontrast chest CT may help detect fractures of the ribs, scapulae, or thoracic vertebrae, without need for IV access or sedation, and can be performed at a radiation dose less than twice that of a 4-view chest x-ray series. There is increasing interest in utilizing whole body MRI for evaluating NAT, and targeted ultrasound can help assess for transphyseal injuries. Certain fracture types are very suspicious for NAT, including multiple posterior rib fractures (which, if seen, necessitates evaluation for intra-abdominal visceral injury); metaphyseal corner fractures (most common in the distal femur, proximal/distal tibia, and proximal humerus); as well as scapular, spinous process, sternal, and multiple long bone fractures; or fractures of differing ages. Clinical history incompatible with imaging findings can also increase suspicion. However, note that similar fractures can be produced by other processes and conditions including congenital syphilis, cardiopulmonary resuscitation, osteogenesis imperfecta, rickets, vigorous physical therapy, physiologic periostitis, and birth trauma.

Conclusion
The workhorse of NAT imaging remains the skeletal survey, although there is increasing interest in utilizing other modalities such as whole body MRI. It is important to consider classic fractures seen in NAT when evaluating pediatric imaging even with non-concerning clinical history, especially in this period of increased NAT during the COVID-19 pandemic.