Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed?

BACKGROUND: Studies have demonstrated the value of the follow-up skeletal survey in identifying additional fractures, clarifying indeterminate findings, and improving dating of skeletal injuries in victims of physical abuse. OBJECTIVE: To determine whether a more limited follow-up survey could yield the same radiologic data as a full follow-up survey. MATERIALS AND METHODS: The study cohort comprised 101 children who had follow-up surveys that met our inclusion criteria. Consensus readings of both original and follow-up surveys were performed by two pediatric radiologists. These results were compared to determine additional findings from the follow-up surveys. Limited skeletal survey protocols were evaluated to determine whether they would detect the same fractures seen with a complete osseous survey. RESULTS: In the 101 children 244 fractures were identified on the initial osseous survey. Follow-up surveys demonstrated new information in 38 children (37.6%). A 15-view limited follow-up survey identified all additional information seen on the complete follow-up survey. CONCLUSION: Our data demonstrate that a 15-view limited follow-up skeletal survey could be performed without missing clinically significant new fractures and still allow proper identification of confirmed fractures or normal findings. A limited survey would decrease radiation dose in children.

Oblique chest views as a routine part of skeletal surveys performed for possible physical abuse--is this practice worthwhile?

OBJECTIVE: To evaluate the utility of oblique chest views in the diagnosis of rib fractures when used as a routine part of the skeletal survey performed for possible physical abuse. METHODS: Oblique chest views have been part of the routine skeletal survey protocol at Primary Children's Medical Center since October 2002. Dictated radiology reports since that time were reviewed, and all cases with rib fractures documented were chosen for study. For each chosen case two pediatric radiologists identified and recorded rib fractures using only the PA and lateral chest radiographs (standard two-view chest series) from the skeletal survey for each case. In a separate session they identified and recorded rib fractures using the PA, lateral, right oblique, and left oblique radiographs (four-view chest series) from the skeletal survey for each case. The results were compared. RESULTS: Twenty-two cases with rib fractures were identified. Interpretation of the four-view chest series was different than interpretation of the two-view chest series in 12 of the 22 cases (54%). Overall, the four-view chest series differed significantly in the number of rib fractures diagnosed compared with the two-view chest series (p=.02, Wilcoxon matched-pairs signed-rank test) adding 19 rib fractures and excluding 6 rib fractures. CONCLUSIONS: The results indicate that use of the four-view chest series adds information to that obtained from the two-view chest series and increases the accuracy of diagnosing rib fractures in cases of possible physical abuse. Addition of oblique chest views to the routine protocol for skeletal surveys performed for possible physical abuse is recommended.

Cerebral aneurysms in a child with acquired immune deficiency syndrome during rapid immune reconstitution.

A 12-year-old boy with perinatally acquired human immunodeficiency virus infection an d Centers for Disease Control and Prevention class C3 disease presented with acute onset of confusion and a right-sided movement disorder 5 months after beginning a new antiretroviral regimen. His CD4 count had been below 50 cells/microL for 4 years but had abruptly risen to more than 250 cells/microL. Computed tomographic and magnetic resonance imaging scans showed cerebral aneurysms and new cerebral lesions consistent with ischemic strokes. The presentation during immune reconstitution suggests that cerebral aneurysms in pediatric patients with acquired immune deficiency syndrome can result from an immune-mediated response to chronic vascular infection.