W6 ADI

What 4 other names is Battered Child Syndrome also known as?

• Child abuse

• Non-accidental injury

• Parent- Infant Traumatic Stress Syndrome

• Caffey-Kempe Syndrome

What is the general description given to a child suffering from Battered Child Syndrome?

A child with multiple fractures of long tubular bones and subdural haematoma

What are genuine accidental injuries that are NOT findings of Battered Child Syndrome?

• Torus fracture (distal radius)

• Spiral fracture of tibia (toddler’s fracture)

• Clavicle fracture

• Skull fracture

What is the hallmark feature of Battered Child Syndrome?

Repeated episodes of multiple fractures

What clinical features make up Battered Child Syndrome?

• Children usually less than 6 years old (between 1-4)

• Often less than 2 years old when exposed to trauma

• After age 4, children can escape abuser or talk about what is happening

• Evidence of repeated trauma such as bruising or burns

• Repeated episodes of multiple fractures

What radiographic features make up Battered Child Syndrome?

• Hallmark feature of multiple fractures (especially ribs) at different stages of healing

• Fractures at the corner of metaphyses (especially medial side of distal femoral metaphysis) or exuberant callus in diaphyses or metadiaphyses of long tubular bones

• Periosteum loosely attached to shaft of a tubular bone, but more firmly attached to metaphysis

• Trauma leads to lifting of periosteum along the shaft (exuberant callus) and avulsion of bone at metaphysis (corner fractures)

• Periostitis seen within 1-2 weeks of injury

What sites are often involved in Battered Child Syndrome?

• Ribs

• Humerus

• Tibia

• Small bones of hand, foot and skull

• Unusual fractures include sternum, lateral clavicle, scapula, spine (spinouses)

• Be suss with bilateral acute fractures and lower limb fractures in children who are not walking

• Bilateral humeral fractures from severe shaking are seen because the child is held by upper arms

What can severe shaking of children cause?

• Brain damage (Cerebral haematoma) (intracranial and subdural haematoma)

• Retinal detachment

• SP fractures of thoracic and lumbar spine

• Rib fractures

• Humeral fractures

What is seen in this image? What syndrome could be the cause?

• Posterior rib fractures

• Battered Child Syndrome

What syndrome is this? What sign can be seen?

Battered Child Syndrome

Metaphyseal corner fractures

What syndrome is this? What sign can be seen?

Battered Child Syndrome

Tibia fractures (can see periosteal response)

What syndrome is this? What sign can be seen?

Battered Child Syndrome

Massive periosteal reaction in humerus

What is the most common cause of death in Battered Child Syndrome? What signs may you see with it?

Head trauma

• Skull fracture

• subarachnoid haemorrhage

• retinal detachment

• cerebral oedema

What is the second leading cause of death in Battered Child Syndrome? What signs may you see with it?

Visceral trauma

• Crushing blow to abdomen

• Bowel/stomach rupture

• Lacerated internal organs

What can be seen on the skin in Battered Child Syndrome?

• Burns

• Bruises

• Lacerations

What are possible internal injuries in Battered Child Syndrome?

• Liver fracture (separation)

• Pancreas rupture

• Bowel contusions

What are typical features of accidental injuries?

What are typical features of non-accidental injuries?

What possible conditions may be mistaken for Battered Child Syndrome?

Infantile cortical hyperostosis

• Changes evident in first 5 months, symmetrical, fever, elevated ESR, resolves within few months

Scurvy

• Changes after 4 months old, generalised osteopaenia, symmetrical

Congenital syphilis

• Symmetrical and diffuse

Osteogenesis imperfecta

• Generalised osteoporosis

Congenital insensitivity to pain

• Neuropathic joint changes, soft tissue ulcerations, scarred tongue and fingers from burns

What syndrome is this, what sign can be seen?

Battered Child Syndrome

Metaphyseal corner fractures

The image provided is of a 3 month old female. What syndrome could explain the fracture? Provide reasoning.

Battered Child Syndrome

Lower limb fracture in a child who is not walking

What syndrome is depicted in this image?

Battered Child Syndrome

What syndrome is shown here? What hallmark feature helps you to determine this?

Battered Child Syndrome

• Hallmark feature of multiple fractures (especially ribs) at different stages of healing

What is shown in this image from a child suffering Battered Child Syndrome?

Left Subdural haematoma

What signs are shown in this image of a child suffering from Battered Child?

• Left lateral rib fractures (blue)

• Left sided pleural effusion (yellow)

What signs are shown in this image of a child suffering from Battered Child?

Distal radius and ulna fracture

What signs are shown in this image of a child suffering from Battered Child?

Multiple parietal fractures

What signs are shown in this image of a child suffering from Battered Child Syndrome?

Bilateral distal femur fractures

I don’t really know what to say for this one so here’s an image describing soft tissue calcification (myositis ossificans).

I think its just saying how prevalent it is.

What is most radiographically visible calcification due to?

Dystrophic calcification

• Tissue damage leads to non-specific inflammatory response

• Response can include calcification

What is another name for myositis ossificans?

Heterotopic ossification

What is heterotopic ossification?

Bone formation outside it’s usual location

Where does the process of heterotopic ossification occur?

Muscle and connective tissue

What are the most common sites for heterotopic ossification?

• Elbow→ Brachialis anterior

• Thigh→ Quadriceps femoris and adductor muscles

• Knee→ Medial collateral ligament of the knee (Pellegrini-Stieda disease)

• Shoulder→ Coracoclavicular ligament rupture

What can be observed in this image and what structure is being affected? What is this indicative of?

Ossification of the medial collateral ligament
Heterotopic ossification

What can be seen in this image and what is this indicative of?

Calcification

Heterotopic calcification

What can be observed in this image and what structure is being affected? What is this indicative of?

Calcification of the ulnar collateral ligament

Indicative of Heterotopic ossification

What can be observed in this image? What is this indicative of?

Calcification (almost ossification) of soft tissue structures around the bone

Indicative of Heterotopic ossification

What key sign of Heterotopic ossification can be seen in this image? (Hint: shown by right arrow)

Cleavage sign

What can be seen in this example of Heterotopic ossification and what structure is affected?

Ossification of the gluteal muscle

What structure/s has been affected in this case of Heterotopic ossification?

Distal calf and achilles tendon

What is shown in this example of a post traumatic femur?

Heterotopic ossification

What are possible differential diagnoses of dystrophic soft tissue calcifications? (Hint: think of examples that may cause calcification using VINDICATE)

Vascular

• Venous insufficiency

Infection

• Parasitic infestation

• Cysticercosis

• Dracunculiasis

• Armillifer armillatus

Neoplasm

• Osteoma

• Osteosarcoma

• Tumour

Drugs

• Vitamin D

Autoimmune

• Dermatomyositis

• Scleroderma

Trauma

• Heterotopic calcification

• Injection granulomas

• Necrosis