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E1308. Nonaccidental Trauma: Understanding the Bone Survey
Authors
  1. Eleanor Yu; John H. Stroger Jr. Hospital of Cook County
  2. Gaurav Rana; John H. Stroger Jr. Hospital of Cook County
  3. Anupum Basu; John H. Stroger Jr. Hospital of Cook County
Background
Non accidental trauma (NAT) or physical abuse, is a leading cause of pediatric mortality in the United States, with younger children more likely and susceptible to abuse. In 2010, approximately 2.07 per 100,000 children died as a result of child abuse or neglect. Of these deaths, the vast majority, 80%, occurred due to accidental head trauma (AHT), commonly referred to as “shaken baby syndrome.” Because the presentation of AHT is often vague and non-specific (vomiting, irritability, lethargy), clinicians must maintain a high index of suspicion, especially when evaluating infants. Although NAT typically involves superficial structures like the skin and soft tissues, fractures can be found in approximately a third of cases of NAT. The skeletal or bone survey, therefore, constitutes one of the workhorse studies in instances of suspected abuse. Positive findings have medicolegal ramifications and play an important role in not only removing children from situations of abuse, but also in prosecuting abusers. However, while radiologists must remain vigilant for cases of abuse, there are additional differentials to consider such as osteogenesis imperfecta, prolonged glucocorticoid use, preterm birth, or rickets.

Educational Goals / Teaching Points
This educational exhibit aims to emphasize the role of imaging in detecting pediatric non-accidental trauma as well as describing the indications and proper technique on a skeletal survey, reviewing key imaging findings and pitfalls, and presenting differentials diagnoses to consider.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
A complete skeletal survey protocol includes multiple radiographs of each anatomic area, including AP/lateral skull, AP views of the extremities, AP view of the chest and abdomen/pelvis, oblique views of the chest, and lateral views of the spine. A single radiograph or babygram is technically inadequate and insufficient to evaluate fine bony detail. The classic imaging finding in NAT is a metaphyseal corner or bucket-handle fracture at the growth plate of the proximal humerus, distal femur, or tibia. Pediatric bones are weakest at the metaphyseal-physeal junction and yanking forces on the limbs can produce these types of fracture. Additional fracture patterns that are suspicious for abuse include multiple healing fractures of different ages, posterior rib fractures, compression fractures of the thoracolumbar spine, and finger/thumb fractures. When a fracture is not seen in the settting of abuse, additional follow-up studies may be ordered in 10-14 days to search for healing fractures. In addition to the bone survey, a CT head or nuclear medicine bone scan may also be used to evaluate for child abuse.

Conclusion
Non-accidental trauma is an unfortunate cause of pediatric mortality. In establishing a case of abuse, bone surveys are typically ordered and can reveal multiple fractures, uncovering cycles of abuse. By understanding the proper technique in obtaining a bone survey and common imaging findings, radiologists can identify victims of non-accidental trauma to help break these cycles of abuse.