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RADIOLOGY: Suspected Acute Injury

When evaluating the child/adolescent with a suspected acute injury, the history and physical examination determine the use of radiology. The decision-making process is guided by the quality of information that can be obtained. A history is considered reliable when the patient is awake, alert, and appropriately attentive. This implies a person is not under the influence of any intoxicants, has the cognitive development to respond in an appropriate manner, is not so distracted by the injury that information cannot be relied upon, and can indicate areas of pain or injury. When the child/adolescent is too young, has abnormal development, significant trauma, or a co-morbidity that makes the history less reliable, additional sources of a history play an important role. In some cases, an historian may initially be considered reliable and later be considered to be unreliable. If you believe there are conditions that make the history and physical less reliable, use a low threshold for ordering radiological examinations.

Radiological evaluation to detect acute skeletal injuries most commonly involves the use of "plain" X-rays. They are very effective at detecting these types of injuries and are often the only imaging studies needed. In addition to plain films, computed tomography (CT) scanning, and less commonly, ultrasound imaging may be used. Magnetic resonance imaging (MRI) is not commonly used in acute evaluation. Below are the recommended evaluations when injury sites are identified by the history.


Isolated Musculo-Skeletal Injury
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In patients with open growth plates, comparison films of the non-affected side may be necessary for diagnosis. This is especially important if the joints are being evaluated.

CT
The most common reasons for a CT scan is to determine if an injury suspected with plain films actually exists and to better delineate the extent of a fracture seen with plain films. If that information is not needed for acute therapy, this evaluation can be done later.


Head Injury
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A CT scan can determine if there is soft tissue (brain) injury. It is also effective in determining bony injury to the skull or face. Small fractures or fractures aligned in the same plane as the imaging beam can be missed. In these situations plain skull films can supplement the information obtained by the CT.

Plain films
Skull fractures are found in abused infants and young children but more commonly occur as a result of accidental injury. Household injuries from short falls may result in accidental skull fractures. Linear parietal skull fractures may be found in both accidental and non-accidental injuries. However, multiple and bilateral skull fractures and skull fractures that cross suture lines are much more commonly encountered after abuse. Unlike long bone and rib fractures, skull fractures do not show typical radiological signs of healing, such as callus formation. This makes dating of skull fractures difficult.


Chest Injury
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If you believe there is not significant trauma, plain films can be used to image the ribs for fractures and/or the lungs for pneumothorax/pneumomediastinum or evidence of lung injury, such as pulmonary contusion. See the box below for information specific to rib fractures.

CT
If there is a suspicion of potential great vessel injury, a CT scan is very effective at determining if such an injury exists. It is also superior to plain films at determining small pneumothoraces and evaluating the extent of lung injury.

Rib Fractures in Child Abuse
  • The most common type of rib fracture resulting from child abuse is posterior rib fracture, where the rib head articulates with the vertebral body.
  • Rib fractures are commonly asymptomatic with no signs of external trauma, and therefore, may be missed if there is not an index of suspicion or other reason to obtain chest or rib films.
  • Rib fractures generally are not displaced or fragmented, and therefore, may be undetected on plain film until callus formation occurs at 7-10 days after injury.
  • Birth injury rarely, if ever, causes rib fractures.
  • Rib fractures in young infants are very nearly diagnostic of child abuse.

Reference: Reece, R. What the literature tells us about rib fracture in infancy. National Conference on SBS. SBS Quarterly. Fall 2002.

Abdominal Injury
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In addition to evaluating bony elements, a CT scan can determine if there is free fluid/blood from intra-abdominal injury. It also may determine what organ is injured and give an idea of the extent of the injury. It is important to accompany and appropriately monitor the child/adolescent during the scan to rapidly determine and treat any change in condition.

Ultrasound
The role of ultrasound in trauma is largely to determine if there is free fluid in the abdomen of a patient deemed unstable for CT. The advantage of ultrasound imaging is that it can be performed at the bedside and is increasingly being done by emergency medicine practitioners, thus eliminating the need to wait for additional resources.

Plain films
Plain films should not be solely relied upon to make a determination of intra-abdominal injury.

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Radiology: Overview  Radiology: Suspected Acute Injury  Radiology: Suspected Significant Trauma  Radiology: Injuries Associated with Abuse  Radiology: Additional Resources 

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On this page:
Isolated Musculo-Skeletal Injury
Head Injury
Chest Injury
Abdominal Injury