NonAccidental Trauma
Answer: C
This child presents to you with multiple high-risk features: young child, return visit, vague and unclear symptoms, now with isolated vomiting without diarrhea. Any return visit is an opportunity to broaden the differential diagnosis and incorporate new information that time has provided. The potential systems involved here include neurologic, gastrointestinal, infectious/hematologic, metabolic, and traumatic.
Before we narrow the differential diagnosis, a brief note of three common diagnostic errors: preconception bias (information perceived or interpreted differently due to preconceived notions/judgements of the disease process, patient, or family, leading to skewed interpretation of the evidence or incomplete data collection); fixation errors (other information is not considered due to foregone conclusion, leading to ignoring facts or clues that do not fit the early conclusion well); and knowledge errors (incomplete data collection result in incorrect conclusions or diagnoses).
This radiograph shows a metaphyseal fracture, also known as a “bucket handle fracture” or “corner fracture”. Classically this fracture occurs in children less than one year of age and is highly specific for abuse. A metaphyseal fracture requires high shearing forces and is not a consequence of a toddler’s fall; this fracture has no consistent relationship with overlying bruising or swelling. Metaphyseal fractures are the most frequently found long bone fractures in infants who die with evidence of abuse.
It should be noted that there is no particular fracture of the extremities that is conclusive of abuse in isolation. However, some (such as metaphyseal fractures in a child younger than 2 years old) are very suggestive. In any case of possible abuse, the clinician must consider the patient, the injury, the caregivers, the explanation, and the context.
This young non-ambulatory child with prolonged vomiting, fussiness, otherwise vague history, and evidence of a fracture associated with abuse warrants a total body check, skeletal survey, and laboratory investigation for occult trauma (UA > 25 RBCs/hpf, low Hct, metabolic acidosis, and/or AST or ALT > 80 IU/dL; AST > 200 IU/dL is more specific). As abuse is now highly suspected, a CT non-contrast of the head is done to investigate her vomiting and inconsolability (C):
This child presents to you with multiple high-risk features: young child, return visit, vague and unclear symptoms, now with isolated vomiting without diarrhea. Any return visit is an opportunity to broaden the differential diagnosis and incorporate new information that time has provided. The potential systems involved here include neurologic, gastrointestinal, infectious/hematologic, metabolic, and traumatic.
Before we narrow the differential diagnosis, a brief note of three common diagnostic errors: preconception bias (information perceived or interpreted differently due to preconceived notions/judgements of the disease process, patient, or family, leading to skewed interpretation of the evidence or incomplete data collection); fixation errors (other information is not considered due to foregone conclusion, leading to ignoring facts or clues that do not fit the early conclusion well); and knowledge errors (incomplete data collection result in incorrect conclusions or diagnoses).
This radiograph shows a metaphyseal fracture, also known as a “bucket handle fracture” or “corner fracture”. Classically this fracture occurs in children less than one year of age and is highly specific for abuse. A metaphyseal fracture requires high shearing forces and is not a consequence of a toddler’s fall; this fracture has no consistent relationship with overlying bruising or swelling. Metaphyseal fractures are the most frequently found long bone fractures in infants who die with evidence of abuse.
It should be noted that there is no particular fracture of the extremities that is conclusive of abuse in isolation. However, some (such as metaphyseal fractures in a child younger than 2 years old) are very suggestive. In any case of possible abuse, the clinician must consider the patient, the injury, the caregivers, the explanation, and the context.
This young non-ambulatory child with prolonged vomiting, fussiness, otherwise vague history, and evidence of a fracture associated with abuse warrants a total body check, skeletal survey, and laboratory investigation for occult trauma (UA > 25 RBCs/hpf, low Hct, metabolic acidosis, and/or AST or ALT > 80 IU/dL; AST > 200 IU/dL is more specific). As abuse is now highly suspected, a CT non-contrast of the head is done to investigate her vomiting and inconsolability (C):
This infant girl’s CT shows bilateral mixed-density subdural collections with an area of acute hemorrhage in the left temporal area.
Abusive head trauma (AHT) in infants can be a challenging diagnosis, and may present in subtle ways. In one study, up to 31% of cases of AHT were missed initially in an academic children’s hospital. Children with AHT were more likely to present with seizure, altered mental status, and/or palsy without the caregiver’s reporting a history of trauma.
Although this child will likely need IV access and further workup, her vital signs are normal and she does not require emergent resuscitation. Furthermore, an afebrile child with the above history, physical exam, and (nearly pathognomonic) fracture does not have a septic joint or osteomyelitis (A, B). If either of these were suspected and the child were ill appearing, the possibility of bacteremia (hematogenous spread of organism) should be considered (D).
Remember that when considering non-accidental trauma or abuse, the question is not “is this (explanation) possible?” Possibility is much too low of a standard. The question should be “is this (explanation) plausible?” which considers specific details of the child, the injury, radiographic findings, and the account of events before the trauma. In other words, the question is not “could this make sense?”, rather it is “does this make sense?” – always give the benefit of the doubt to the child. In this case, the child is not able to get herself into any position that would cause these injuries and the caregiver gave no inkling as to a history of trauma, both very worrisome features.
References
Ford CR, Chiesa A, Sirotnak A. Pearls and Pitfalls for the Pediatric Emergency Medical Provider in the Evaluation of Abusive Head Trauma. Clin Pediatr Emerg Med. 2012; 13:3.
Pierce MC, Kaczor K, Lohr D, Richter K, Starling SP. A Practical Guide to Differentiating Abusive From Accidental Fractures: An Injury Plausibility Approach. Clin Pediatr Emerg Med. 2012; 13:3.
Abusive head trauma (AHT) in infants can be a challenging diagnosis, and may present in subtle ways. In one study, up to 31% of cases of AHT were missed initially in an academic children’s hospital. Children with AHT were more likely to present with seizure, altered mental status, and/or palsy without the caregiver’s reporting a history of trauma.
Although this child will likely need IV access and further workup, her vital signs are normal and she does not require emergent resuscitation. Furthermore, an afebrile child with the above history, physical exam, and (nearly pathognomonic) fracture does not have a septic joint or osteomyelitis (A, B). If either of these were suspected and the child were ill appearing, the possibility of bacteremia (hematogenous spread of organism) should be considered (D).
Remember that when considering non-accidental trauma or abuse, the question is not “is this (explanation) possible?” Possibility is much too low of a standard. The question should be “is this (explanation) plausible?” which considers specific details of the child, the injury, radiographic findings, and the account of events before the trauma. In other words, the question is not “could this make sense?”, rather it is “does this make sense?” – always give the benefit of the doubt to the child. In this case, the child is not able to get herself into any position that would cause these injuries and the caregiver gave no inkling as to a history of trauma, both very worrisome features.
References
Ford CR, Chiesa A, Sirotnak A. Pearls and Pitfalls for the Pediatric Emergency Medical Provider in the Evaluation of Abusive Head Trauma. Clin Pediatr Emerg Med. 2012; 13:3.
Pierce MC, Kaczor K, Lohr D, Richter K, Starling SP. A Practical Guide to Differentiating Abusive From Accidental Fractures: An Injury Plausibility Approach. Clin Pediatr Emerg Med. 2012; 13:3.