Fractures Presumed to Be Low Risk for Abuse in Young Mobile Children: Association With Concomitant Suspicious Injuries.

OBJECTIVES: To evaluate the likelihood of abuse for various fractures, we aimed to compare the prevalence of concomitant suspicious injuries (CSIs) in subjects with fractures presumed to be low risk for abuse to those with non-low-risk fractures (aim 1) and to evaluate the prevalence of low-risk and non-low-risk fractures identified on skeletal survey (SS) (aim 2). METHODS: Subjects included toddlers 9 to 23 months of age presenting to a children's hospital system with a fracture and having an SS completed (aim 1) as well as those who had an SS completed for any concern for abuse (aim 2). For aim 1, we performed a 5-year retrospective case-control study. Low-risk fractures were defined as extremity buckle, clavicle, supracondylar, or toddler's fractures. Controls included moderate- and high-risk fracture groups. Groups were compared for the prevalence of CSIs. For aim 2, we described the frequencies of all fracture types identified by SS completed for any concern for abuse over the same period. RESULTS: For aim 1, there were 58 low-risk, 92 moderate-risk, and 8 high-risk fractures. The rates of CSIs were not significantly different between low- and moderate-risk fractures (odds ratio, 0.9; 95% confidence interval, 0.4-2.5), whereas half of high-risk fractures had CSIs. Forty-five subjects had an occult fracture on SS completed for any abuse concern. All low-risk fractures were identified by SS, most commonly buckle fractures (22.2% of cases). CONCLUSIONS: Fractures presumed to be low risk for abuse in young, mobile children require consideration of abuse as a cause.

Ventricular size measurement methods in fetuses considered for prenatal closure of myelomeningocele.

OBJECTIVE: Prenatal closure of myelomeningocele is associated with a reduced rate of hydrocephalus treatment. This need for hydrocephalus treatment is positively correlated with fetal ventricular width. When ventricular width is 15 mm or greater, the benefits of prenatal closure, as a method to decrease hydrocephalus treatment, are reduced. Thus, fetal ventricular size is an important factor when counseling families who are considering intrauterine surgery with mitigation of hydrocephalus as the primary goal. This study sought to determine whether imaging modality (ultrasound [US] vs MRI) and interobserver variability were factors in any ventricular size disparity seen on imaging studies. METHODS: The imaging studies of 15 consecutive fetuses who underwent prenatal myelomeningocele repair at Children's Mercy Fetal Health Center, Kansas City, Missouri, were reviewed. All fetuses were imaged with US and fetal MRI; on average (range), procedures were performed 3.8 (0-20) days apart. Three comparisons were performed to analyze interobserver and intermodality variability in ventricular width measurements: 1) retrospective comparison of dictated ventricular widths measured with MRI and US by pediatric radiologists (PRs) and maternal-fetal medicine specialists (MFMs), respectively; 2) blinded measurements obtained with US by PRs versus initial US-based measurements by MFMs, and blinded measurements obtained with MRI by PRs versus initial MRI-based measurements by PRs; and 3) blinded measurements obtained with MRI by PRs versus those obtained with US. RESULTS: Retrospective comparison showed that measurements with MRI by PRs were on average 2.06 mm (95% CI 1.43-2.69, p < 0.001) larger than measurements with US by MFMs. Blinded measurements with US by PRs were on average larger than dictated measurements obtained with US by MFMs, but by only 0.6 mm (95% CI 0.31-0.84, p < 0.001). When PRs measured ventricular size in a blinded fashion with both US and MRI, the mean width determined with MRI was significantly larger by 2.0 mm (95% CI 1.26-2.67, p < 0.0001). CONCLUSIONS: The ventricular width of these fetuses was larger when measured with MRI than US by an amount that could impact recommendations for fetal surgery. Every center involved in counseling families about the risks and benefits of fetal intervention for spina bifida needs to be aware of these possible imaging-based disparities.

Occult cranial injuries found with neuroimaging in clinically asymptomatic young children due to abusive compared to accidental head trauma.

OBJECTIVE: To compare occult brain injuries on neuroimaging in clinically asymptomatic children under 20 months due to abusive versus accidental head trauma. SUBJECTS AND METHODS: A retrospective review of 58 children under 20 months who underwent neuroimaging for possible abusive trauma was performed. The data collected were demographics, neurological signs/symptoms, imaging findings, and disposition (abusive or accidental). RESULTS: The disposition of 31 subjects was abusive trauma and 27 were accidental. At presentation, 8/31(25.8%) children with abusive injury and 15/27(55.6%) with accidental injury were neurologically asymptomatic. Neuroimaging was abnormal in 6 of 8 (75.0%) asymptomatic children with abusive injury, and 13/15 (86.7%) children with accidental trauma. No significant (P = 0.59) difference in frequency of abnormal neuroimaging was seen between the asymptomatic abusive and accidental trauma groups. CONCLUSIONS: Although victims of abusive trauma under 20 months of age are less often neurologically asymptomatic compared to accidental trauma victims, neuroimaging revealed a high rate of occult traumatic brain injury in both groups.

Imaging of pediatric pelvic neoplasms.

Pediatric pelvic neoplasms, although relatively uncommon, are often difficult to evaluate and characterize with imaging, due to their overlapping appearances. This article discusses key clinical features and imaging findings that help limit the differential diagnosis of pediatric pelvic neoplasms. Testicular, ovarian, uterine, and bladder masses are included in addition to sacrococcygeal teratoma.

Rare combination of frontonasal and bilateral naso-orbital encephaloceles.

Encephaloceles, while a common entity affecting 1:4000 live births, typically occur in the occipital region. Encephaloceles involving the frontal region comprise only 15% of all cases. Naso-orbital encephaloceles are rarely seen. Our case profiles a child born at term with an atrial septal defect (ASD), micrognathia, cleft lip, and frontonasal as well as bilateral naso-orbital encephaloceles. At birth the encephaloceles were undetected. During the cleft palate pre-operative preparation, the bilateral naso-orbital encephaloceles were diagnosed as dacrocystoceles for which the child underwent surgical repair. Misdiagnosis and loss to follow up lead to delayed surgical treatment until the child was almost two years of age; the right eye was near complete closure due to the increasing size of the encephalocele. This case highlights the importance of meticulous radiologic interpretation of midline nasal masses, as a correct diagnosis impacts clinical management and directs surgical repair.