1. Nonaccidental Trauma (NAT) and Suspected NAT in the PUCC
Chanda McDaniel, MD
9/29/03

2. 1st Case
R.C. is a 4-month-old male who presented to the PUCC in Sept., 2001 because he was not moving his right leg. At 6pm, the day prior, R.C. was in the living room with his 4- year-old aunt. His aunt carried him to the kitchen where his mom witnessed the 4-year-old dropping the child on his back and head. The aunt grabbed the patient by his leg on his way down to the floor. The patient was seen at TCH that day, where all xrays and a CT of his head were negative according to his PCP. He was seen the following day by his PCP who felt he had decreased movement and pain in his right leg and referred him to the PUCC.

3. 1st Case cont... PMH - no hosp. Meds - Motrin All - none
SHx - lives with mom, dad, grandparents, and 3 aunts. He has no siblings. Mom and gma are his primary caretakers. VS
Alert, interactive, NAD, NCAT
ext - cries with palpation of his R femur, 4x4cm bruise to his R hip, no other bruising, mongolian spots to back
otherwise nl PE

4. 1st Case cont…

5. 1st Case cont...
Right Femur xray - fracture of the distal femoral metaphysis involving the posterior aspect of the metaphysis
What do you do next?
If you don’t know, who can you call to ask?
What is your responsibility, if you suspect NAT?

6. 1st Case cont...
A skeletal survey revealed no other fractures. Ortho casted his leg.
After discussion with the CAP team, a report to the Dept. of Human Services was made with the help of the Social worker. The patient was discharged to home with an appointment at the Family Crisis Center in the am.

7. 2nd Case
B.H. is a 21-month-old who was brought to the PUCC by her aunt in Sept., 2001 for bruising on her chest. The aunt had custody since the day prior when she was called by Social Services to come pick up the child from her disheveled home where she lived only with her mom. The aunt did not notice the bruising until the next day when she brought her into the PUCC.

8. 2nd case cont...
PMH - 1 month ago the mom fell while carrying the baby and the baby sustained lacs to her head requiring sutures
Meds - Tylenol
All - none
ROS - the aunt reports a history of choking when fed by mom, but not by aunt; frequent epistaxis
SHx - She now lives with her aunt, uncle and 4-year-old sibling

9. 2nd case cont...
wt 9.5 kg (5%)
Alert, quiet, allows examiner to examine without fear or crying, nose - crusty dried blood, o/p - left upper lip with 1x1cm ecchymosis, poor dental hygiene, skin - L antecubital area with petechiae, chest with 12, 1x1cm bruises
otherwise PE is unremarkable

10. 2nd Case cont... What do you do next?
Do you suspect NAT? If so, by whom?
Could there be any other explanation for her presentation?
Who do you call to report?

11. 2nd Case cont... Labs WBC 8.8 Hb 14.3 Hct 41.6 Plts 336 PT & PTT - nl
LFTs - nl except Alk phos of 810
Skeletal survey was negative.
The aunt was unable to stay with the child during the evaluation and left her with the DFS worker. DFS felt child was in protective care with the aunt and B.H. stayed with her.

12. NAT Epidemiology
In 2000, child abuse and neglect was responsible for 1200 deaths in the US.
44% of the deaths occurred in children less than 12 months of age.
Head injury is the leading cause of mortality in child abuse.

13. Risk factors for NAT Young or single parents
Parents with lower levels of education
Unstable family situations
Stress (financial/housing)
Domestic violence
Alcohol or drug abuse
Parental depression

14. Risk Factors for NAT (victim)
Multiple birth
Young age
Prematurity
Chronic illness
Difficult temperament

15. Perpetrators of NAT In decreasing order of frequency fathers
stepfather, or male partner of mother
female babysitters
mothers

16. Missed NAT
Mild or moderately injured children may be initially misdiagnosed.
In one study of 173 kids with NAT, 1/3 had been previously evaluated for symptoms that were later attributed to NAT.
Initial diagnoses were -- AGE, influenza, OM, accidental trauma, R/O SBI, seizure disorder, GERD, URIs, UTIs, meningitis.

17. Factors associated with missed NAT
Normal respiratory status on presentation
Two-parent household
Absence of scalp or facial injury
Absence of seizures
Victim less than 6 mos of age
Caucasian
If none of the 1st 4 were present, the probability that NAT was diagnosed was 20%.

18. “Whiplash Shaken-Baby Syndrome”
A term coined by John Caffey, MD and peds radiologist, in the ‘70s.
The constellation of:
infantile subdural and subarach. hemorrhages
traction-type metaphyseal fractures
retinal hemorrhages

19. Shaken Baby Syndrome Usually occurs in children less than 1 yr
During shaking, the infant’s head rotates rapidly on the neck, abruptly accelerating and decelerating as the neck hyperflexes and extends. This causes differential movement of the skull, dura and intracranial contents, and can result in subdural hemorrhages and diffuse axonal injury.

20. Symptoms of Shaken Baby
May be mild:
vomiting
poor feeding
irritability or lethargy
Or severe:
apnea
coma
seizures

21. PE findings in Shaken Babies
Apnea or bradycardia
Hypothermia
Full fontanel
HC > 90%
Seizures
Retinal hemorrhages
Bruises

22. Injuries sustained in falls <4ft
One retrospective study evaluated the injuries sustained in 167 infants < 10 months who fell < 4 feet.
85% had no or minor injuries
7% had skull fractures (isolated and linear)
2 had intracranial bleeding, that were later confirmed to have inflicted injuries

23. Skull fractures in NAT
In studies of skull fractures in children < 2 yrs, fractures that are associated with NAT:
cross suture lines
are multiple
bilateral
depressed or complex
diastasis greater than 3mm

24. Noncontrast Head CT

25. Epidural Hematoma
This is a NC head CT of a 2-year old male who fell from a couch to the tile floor. There was no history of LOC. The CT shows a Rt parietal epidural hematoma. The hematoma is biconvex or lens-shape in appearance and there is a midline shift to the Lt.
An EH, can occur following a short vertical fall and is less likely to occur with NAT than SDH.

26. Noncontrast Head CT

27. Subdural Hematoma
This is a NC head CT of a 4-month-old with suspected shaken baby syndrome. The CT shows frontal subacute (or chronic) subdural effusions with an acute Rt temporo-parietal subdural hematoma. There is a small amount of blood in the interhemispheric fissure posteriorly. The posterior interhemispheric subdural hematoma is felt to be indicative of shaken baby syndrome unless other explanations of severe trauma can account for the findings.
SDH is an unusual accidental injury except when severe forces (MVA) are involved.

28. Noncontrast Head CT

29. Subdural Hematoma
This is a NC head CT of a 21-month-old female admitted to the PICU. A skeletal survey also revealed a Lt clavicle fracture and greenstick fracture of the distal portion of the shaft of the Lt radius and ulna. The CT shows an acute subdural hematoma in the right fronto-temporal region. There is compression of the Rt lateral ventricle with shift of the midline structures from Rt to Lt.
SDH often appears as a crescentic convexity or interhemispheric (parafalcine) collection.

30. Noncontrast Head CT

31. Cerebral Edema
This is a NC head CT of 14-month-old male with history of a CHI, who is bradycardic and has dilated pupils. These CT cuts demonstrate:
hypodensity of the cerebral hemispheres with loss of white-gray matter differentiation suggesting cerebral edema
slit-like ventricles and obliteration of the subarachnoid spaces
blood in the interhemispheric regions, posteriorly and anteriorly
subarachnoid hemorrhage in the basal cisterns (suprasellar cistern and quadrigeminal cistern), posterior fossa, and interhemispheric fissure
the suprasellar cistern and the quadrigeminal cisterns are obliterated, indicating severe intracranial hypertension

32. Skeletal Survey
The skeletal survey should be done in all cases of suspected NAT in kids < 2 yrs.
It has little value in kids > 5 yrs.
Patients in the 2-5 yr age group should be handled individually.
A “body gram” or abbreviated skeletal survey is not acceptable.

33. Skeletal Survey
Should be performed with the same level of technical excellence routinely used to evaluate accidental injuries.
A follow-up skeletal survey in 1-2 weeks can increase the diagnostic yield.
A radionuclide bone scan may be used as an adjunct in selected cases, usually in children less than 1 year. It is insensitive for the detection of skull fractures.

34. Skeletal Fractures in NAT
Metaphyseal fractures are thought to be the result of torsion, traction, or shearing when an extremity is twisted, pulled, or when a baby is shaken.
Rib fractures
Fractures in different stages of healing
The history is inconsistent with the physical exam findings or fractures on x-rays.

35. Metaphyseal Fracture

36. Metaphyseal Fracture
Radiographically, a MF is a lucent area within the subphyseal metaphysis, extending completely or partially across the metaphysis, perpendicular to the long axis of the bone.

37. Metaphyseal Fractures
Occur most often in:
distal femur
proximal tibia
distal tibia
proximal humerus

38. What is a bucket handle fx?
A classic metaphyseal lesion where the fx fragment is separated by a prominent fracture lucency and the thick rim may be visible as a curvilinear structure resembling a bucket handle.

39. What is a metaphyseal corner fx?
When the fracture fragment has a very thin center, it may be radiographically occult. The thicker peripheral rim is more radiopaque and appears as a triangular fragment.

40. Rib Fractures

41. Rib Fractures

42. Rib Fractures

43. Rib Fractures
1st rib fractures are considered diagnostic of NAT since they require considerable force to occur.
AP compression of the chest causes fractures laterally, posteriorly, and anteriorly usually in the distribution of hands and are often bilateral and in multiple adjacent ribs.
Oblique CXRs and bone scans can improve detection of rib fractures.
CPR has caused ant. rib fxs, but has never been documented to cause post. rib fxs.

44. Rib Fractures

45. Retinal Hemorrhages
During shaking, the vitreous humor slides along the surface of the retina, disrupting the vessels between the layers of the retina causing RH.
A dilated fundoscopic exam is recommended in children less than 3 years in whom NAT is suspected.
RH increases the suspicion for NAT, but does not confirm it. Lack of RH, does not exclude NAT.

46. Retinal Hemorrhages
Normal Retina
Hemorrhages

47. Toddler’s Fractures
Once a child is walking, a spiral fracture of the tibia or a TF is common and often has no memorable antecedent trauma and by itself is not suggestive of NAT.
A spiral fracture in a non-ambulatory child is suggestive of an inflicted injury -- especially without a good accidental explanation.

48. Toddler’s Fracture

49. Visceral injury in NAT
Abdominal injury is not the most common form of abuse-related injury, but it is highly lethal.
The most commonly injured abdominal organ is the small bowel (duodenum and proximal jejunum).
Kids with small bowel hematomas present with pain and vomiting from obstruction.

50. CAP Team
Child Advocacy and Protection Team at the Children’s Hospital, Denver.
The CAP team is a multidisciplinary (SW, RN, Psychologists, Psychiatrists, attorneys) group that consults on cases of suspected child abuse and neglect.
The team is led by pediatricians whose clinical focus is child abuse.

51. CAP Team
A member of the team is on call every night and can be reached via TCH’s operator.
The team routinely reviews difficult cases of suspected NAT and can help you decide what diagnostic studies you should obtain or whether an injury could have occurred accidentally or not.

52. Reporting NAT
If abuse is suspected, the law requires that the appropriate child-welfare and law-enforcement agencies be notified.
Caretakers should be informed, in a nonaccusatory manner, that the diagnosis is suspected and that investigative procedures will be necessary for the welfare of the child.

53. Reporting NAT
The Colorado Children’s Code requires that all reports of suspected child abuse or neglect telephoned to the county Dept. of Human Services be followed promptly with a written report.
The attached form should be completed and faxed to the appropriate county DHS and the Denver Health Clinical SW admin. office. See numbers attached.

54. References
1) Endom, E. Overview of nonaccidental head injury in infants and children. Sept
2) Greenbaum, V. Ophthalmologic aspects of nonaccidental head injury in infants (the shaken baby syndrome). Sept
3) Listman, D. Accidental and abusive head injury in young children. Current Opinion in Pediatrics, June 2003:Vol 15(3), pg
4) Carole, J. Analysis of missed cases of abusive head trauma. JAMA, Feb. 1999:Vol 281(7), pg
5) Duhaime, C. Nonaccidental head injury in infants -- the “Shaken Baby Syndrome.” NEJM, June 1998:Vol 338, pg
6) Sane, S. Diagnostic imaging of child abuse. Pediatrics, June 2000:vol 105(6).
7) Images obtained from via Brahm Goldstein, MD, Chief, PICU, OHSU, Portland, Oregon.
8) Lonergan, G. Child Abuse: Radiologic-Pathologic Correlation. AFIP Archives, Vol. 23(4), 2003, pg
9) Images obtained from