MRI diagnosis of suspected atlanto-occipital dissociation in childhood

Objective. To demonstrate the utility of magnetic resonance (MR) imaging in the diagnosis of complete and partial ligamentous injuries in patients with suspected atlanto-occipital dissociation (AOD). Materials and methods. Five patients with suspected AOD had MR imaging performed within an average of 4 days after injury. MR scans were reviewed with specific analysis of craniocervical ligamentous structures. Charts were reviewed to obtain clinical information regarding presentation, treatment, hospital course, and outcome. Results. Two patients demonstrated MR evidence of complete AOD. One had disruption of all visualized major ligamentous structures at the craniocervical junction with anterolisthesis and evidence of cord damage. The second had injuries to the tectorial membrane, superior band of the cruciform ligament, apical ligament, and interspinous ligament at C 1–2. The remaining three patients sustained incomplete severance of the ligamentous structures at the craniocervical junction. All patients demonstrated subtle radiographic findings suggestive of AOD, including soft tissue swelling at the craniocervical junction without fracture. The two patients with complete AOD died. The three patients with partial AOD were treated with stabilization. On follow-up, these three children were asymptomatic following their craniocervical injury. Conclusion. MR imaging of acute AOD provides accurate identification of the craniocervical ligaments injured, classification of full versus partial ligamentous disruption, and analysis of accompanying spinal cord injury. This information is important for early appropriate neurosurgical management and preservation of neurologic function in survivors. Received: 11 February 1998 Accepted: 20 November 1998     

Pediatric chin injury: occult condylar fractures of the mandible

The diagnosis of occult mandibular condylar fractures in children is often missed or delayed on initial examination when children present with a laceration to the chin. A clue to the diagnosis of this type of skeletal injury to the mandible is the knowledge of a commonly occurring pattern of injury associated with chin trauma. Chin laceration, fracture of the parasymphyseal region near the chin, and fracture of the condyles are often concomitant injuries of the mandible. This article reviews three case reports of children who sustained a chin laceration, fracture in the region near the chin, and fracture to the mandibular condyles secondary to chin trauma that were not initially diagnosed on clinical examination.     

Complication of linear skull fracture in young children.

The development of a leptomeningeal cyst following an otherwise uncomplicated linear skull fracture in a young child may result in a sizable cranial defect and irreversible neurological deficit months or years later. This complication most often follows parietal fractures but is also seen after occipital fractures or traumatic suture diastases. An underlying dural tear is a prerequisite to its subsequent development. Neurological deficit may be avoided by early diagnosis, surgical excision, dural closure, and cranioplasty. Early diagnosis depends on obtaining a skull roentgenogram four to six months following the original injury in any child where examination of the scalp and skull suggests and underlying expanding fracture.     

Types and complications of femoral neck fractures in children

This multicenter collaborative study was undertaken to review the types and complications of femoral neck fractures in children. It is a retrospective clinical and radiological review of 108 femoral neck fractures. Cases originated from four different pediatric hospitals. All the patients had plain radiographs. Fractures occurred at all ages (one day to 18 years), and 63% of the patients were boys. Forty-nine fractures were traumatic; 37 were pathologic, 19 were insufficiency fractures; and three were fatique fractures. Unless the underlying bone was abnormal, significant high velocity trauma, fall from a height or other severe violence was required to fracture the femoral neck. A unicameral bone cyst was the underlying lesion in 40% of pathologic femoral neck fractures and malignancy in 35%. Osteoporosis as in myelodysplasia, osteogenesis imperfecta and from other causes was responsible for 52% of insufficiency fractures. Because of the unique osseous and vascular anatomy of the femoral head and neck in the growing child, these fractures have a high incidence of complications. Complications included avascular necrosis 13%, premature closure of the epiphyseal plate 12%, varus deformity 8.3%, and nonunion 3.7%. Unless there is a clear history of significant violence, a cause for a femoral neck fracture should be sought, e. g. an underlying bone lesion or a metabolic bone disease. These fractures are rare, but are serious injuries since their complications may lead to a life-long disability.     

儿童单纯性膝关节骨软骨骨折的关节镜治疗

目的 探讨小儿单纯性膝关节髌骨、股骨髁骨软骨骨折的关节镜诊断与处理方法.方法 2008～2010年四川大学华西医院经关节镜诊治小儿单纯性膝关节髌骨、股骨髁骨软骨骨折患儿9例,其中男3例,女6例,年龄7～15岁（平均11.3岁）,病程3 d至4周（平均1周）,左膝4例,右膝5例.其中髌骨4例,股骨内髁3例,外髁2例.3例为单纯性软骨骨折,改良Outerbridge分级为Ⅲ级,6例骨折累及软骨下骨,改良Outerbridge分级为Ⅳ级.1例采用可吸收螺钉内固定,2例行微骨折术钻孔处理以刺激软骨生长,6例行单纯关节清理术.结果 伤口均I期愈合,无相关并发症发生.术后5～7 d膝关节肿胀、疼痛基本消失,2周左右重返学校,6周左右拆除膝关节保护支具开始膝关节正常负重工作.随访3～9个月,平均6个月,膝关节lysholms评分均为优,Tegner运动评级4级以上,患儿原有症状消失,膝关节功能恢复正常.结论 对于小儿单纯性膝关节骨软骨骨折,关节镜下早期诊断和治疗是一种有效的治疗方法.     

Pediatric Fractures: Identifying and Managing Physical Abuse

Childhood fractures are a common reason for presentation to the emergency department. Fractures are also an important manifestation of child maltreatment. Therefore, it is critical that healthcare providers understand historical, biomechanical, physical examination, and psychosocial factors that can help differentiate abusive skeletal trauma from accidental injuries and recognize other contributors such as metabolic bone disease. As fractures may not be apparent based on history and examination alone, medical providers with concern for abusive injury in young children should understand when and how to evaluate for occult skeletal and other injuries. While no fracture location is pathognomonic for abuse, certain fracture types have high specificity for abuse and therefore knowledge of their radiologic appearance, mechanism of injury, and association with maltreatment is essential. This article will review current knowledge on the topic of child abuse considerations when children present with fractures.     

Three-dimensional skull models as a problem-solving tool in suspected child abuse

Background

The value of 3-D skull models in evaluation of young children with suspected child abuse is not known.

Objective

The purpose of this study was to assess the value of 3-D skull models as a problem-solving tool in children younger than 2 years.

Materials and methods

We performed a retrospective study on 73 children (ages 0–24 months) seen by a child protection team (CPT) who were undergoing head CT between August 2007 and July 2009.

Results

Of the 73 children, volume-rendered 3-D models were obtained in 26 (35.6%). Three-dimensional models changed initial CT interpretation in nine instances (34.6%). Findings thought to be fractures were confirmed as normal variants in four children. Depressed fractures were correctly shown to be ping-pong fractures in two cases. In one case, an uncertain finding was confirmed as a fracture, and an additional contralateral fracture was identified in one child. A fracture seen on skull radiographs but not seen on axial CT images was identified on the 3-D model in one case. Changes in interpretation led to modification in management in five children.

Conclusion

Use of 3-D skull models can be a problem-solving tool when there is discordance among the CT reading, subsequent radiographic investigations and clinical evaluation.     

儿童长骨骨折不愈合原因分析与治疗

目的 探讨引起儿童长骨骨折不愈合的相关因素,为临床规避相关风险提供借鉴.方法 回顾1996至2006年收治的儿童长骨骨折不愈合病例51例,从损伤原因、骨折部位、治疗方法等方面分析引起骨折不愈合的原因,并采用更换固定方式、植骨等手术方法对骨折不愈合病例进行重新治疗.结果 51例病例经更换内固定为髓内固定或采用外固定架加植骨等治疗方法均获得良好愈合, 在随访期内未发生再骨折.结论 儿童长骨骨折治疗不当是引起骨折不愈合的主要原因,高能量损伤也是引起骨折不愈合的原因之一;在骨折部位方面,本组病例中以股骨干骨折不愈合多见.对于儿童长骨骨折不愈合的治疗应该在诊断明确后尽早更换固定方式, 骨折端重新获得稳定是治疗的关键.     

关节囊松解被卡环状韧带下移治疗儿童陈旧性孟氏骨折

目的 探讨关节囊松解被卡环状韧带下移治疗儿童陈旧性孟氏骨折的方法及疗效。方法 2008年3月至2010年2月,采取关节囊松解被卡环状韧带下移桡骨头复位加尺骨延长成角截骨钢板内固定方法治疗Ⅰ、Ⅲ型儿童陈旧性孟氏骨折11例,男8例,女3例;年龄3～7岁7例,年龄8～11岁4例。病程2～3个月4例,4～6个月4例,7～12个月1例,13～30个月2例。结果 术后随访6个月至2年（平均9个月）,随访6～12个月7例,13～24个月4例。按照Mackay[1]功能评定标准进行疗效评价,结果全部为优。X线表现无半脱位或脱位。结论 利用关节囊松解被卡环状韧带下移方法治疗儿童陈旧性孟氏骨折具有：疗效可靠,方法简单,创伤小,重建环状韧带实为环状韧带的再复位,其生物学特性完全符合伤前环状韧带。该方法值得临床医生探讨和推广。     

Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury

Background Abusive head trauma (AHT) in young children usually has a severe outcome when associated with hypoxic-ischemic encephalopathy (HIE), which is best characterized by MRI in the acute or subacute phase utilizing diffusion-weighted imaging (DWI). HIE in this setting has been hypothesized to result from stretching of the spinal cord, brainstem, or vasculature. Objective To provide clinical correlation in patients with unilateral HIE and to postulate a mechanism in the setting of suspected AHT. Materials and methods IRB approval was obtained. Over a 5-year period, the medical records and images were reviewed of the 53 children ≤3 years of age who presented with acute head trauma according to the hospital registry. The children were subselected in order to determine how many suffered either HIE or AHT, and to detect those with unilateral HIE. Results In 11 of the 53 children, the etiology of the head trauma was highly suspicious for abuse. In 38 the head trauma was accidental and in 4 the trauma was of unknown etiology and at the time of this report was unresolved legally. Of the 53, 4 suffered HIE confirmed by CT or MRI. In three of these four with HIE the trauma was considered highly suspicious for AHT. Two of these three were the only patients with unilateral HIE, and both (7 months and 14 months of age) presented with early subacute phase HIE seen on DW MRI (range 4–7 days) and are described in detail with clinical correlation. The third child with AHT and HIE had bilateral findings. In the fourth patient the HIE was bilateral and was considered accidental. The work-up for both patients with unilateral HIE included head CT, craniocervical MRI, and craniocervical MR angiography (MRA). In both, there was mostly unilateral, deep white matter restricted diffusion, with subdural hematomas that were small compared to the extent of hypoxic-ischemic insult, and no skull fracture. Craniocervical MRA and axial thin-section fat-saturation images were negative for dissection, brainstem, or cord injury. Legal authorities obtained a confession of inflicted injury in one and a partial confession in the second (which did not fit the extent of injury). Five other children with HIE (based on DWI) were found during this period who had not suffered head trauma; all were bilateral insults. Conclusion HIE associated with AHT might present with largely unilateral white matter injury on DWI following extensive cortical infarction. We propose that unilateral HIE in a young child might be a sign of AHT and might result from cervical vascular compression, whether from kinking during hyperflexion/hyperextension or from direct strangulation.     

Magnetic resonance imaging of intracranial injuries from child abuse

Magnetic resonance imaging (MRI) and computed tomography (CT) were compared in four children who had evidence of intracranial injury caused by shaking. All children had intracranial bleeding, neurologic impairment, and history or physical examination findings suggestive of child abuse. Three had bilateral retinal hemorrhages, and three had visual impairment. MRI revealed bilateral subdural hematomas in all four children, but CT showed this in only one. Skull fractures in one patient were visualized by CT alone. MRI alone demonstrated posterior fossa bleeding in one patient and intraparenchymal bleeding in another; an additional patient in whom CT showed relatively diffuse atrophy also had defined areas of focal atrophy apparent on MRI. Subarachnoid hemorrhages were equally well detected using CT or MRI. Overall, MRI was superior to CT for detection of intracranial injury caused by shaking, and may help to document milder instances of this form of child abuse.     

儿童创伤性骺板及骨骺损伤的多排螺旋CT诊断分析

目的探讨儿童骺板及骨骺损伤的多排螺旋CT影像学表现。方法收集首都医科大学附属北京儿童医院2009年1月至2011年3月收治的X线平片或CT检查可疑骨骺损伤的33例患儿临床资料,年龄1d至14岁,中位年龄7岁,男14例,女19例,病史为1h至3个月。分别行x线平片及CT检查,分析其多排螺旋CT表现。结果33例患儿共29处骺板受累,其中2例为双骨干骺端骨折,6例经多排螺旋CT证实排除骺板骨折,9例X线平片未发现骨骺损伤而多排螺旋CT发现骺板骨折。骨折位于肱骨远端8例,肱骨近端1例,桡骨近端2例,桡骨远端3例,股骨远端2例,胫骨近端1例,胫骨远端8例,腓骨远端1例,指骨2例,趾骨1例。按Salter—Harris分型,Ⅰ型2例（6．9％）,Ⅱ型19例（65．5％）,Ⅲ型4例（13．8％）,Ⅳ型4例（13．8％）。结论多排螺旋CT可以了解骨骺受累情况,直观观察骨骺移位以及关节内情况,及时提示临床进行相应处理,对病变的预后起着重要的作用。     

Long bone fractures in children under 3 years of age: Is abuse being missed in Emergency Department presentations?

OBJECTIVE: Distinguishing injuries due to accidents from those due to child abuse in young children is important to prevent further abuse. We aimed to study the presenting features, mechanism of injury, type of fracture and indicators of possible abuse in children under 3 years of age, presenting to the Emergency Department (ED) of a tertiary referral Children's Hospital, to see whether those injuries that were more likely abusive were distinguished from those that were more likely accidental. METHODS: We analysed the medical records from the Emergency Department Information System of all children below 3 years of age, who were treated for a long bone fracture at the Sydney Children's Hospital, Randwick, NSW, over a 1-year period. Demographic details, presenting complaint, mechanism of injury, type of fracture, other historical and examination data and action taken were noted. Nine indicators that raise suspicion of abuse were developed from the literature. Using these indicators, patients' ED notes were reviewed to establish whether long bone fractures suspicious for abuse had been referred for further evaluation. RESULTS: One hundred patients with a total of 103 fractures presented during the study period. No child had multiple fractures at a single visit. The fractures included 36 radius/ulna, 27 tibia/fibula, 20 humeral, 17 clavicular and three femoral. The mean age of patients was 21.6 months (range 13 days - 35 months). Fourteen patients were younger than 12 months. Review of the notes revealed 31 children with indicators suspicious for abuse, of whom 17 children had one indicator, 11 children had two indicators, and three children had three indicators. Only one child was referred for further evaluation to child protection. CONCLUSION: Abuse cannot usually be determined by fracture type alone. Doctors in the ED miss indicators for abuse because they do not look for these indicators in the history and examination. Knowledge of indicators that raise suspicion of abuse is needed for a further forensic assessment to occur. The development of specific referral guidelines, ongoing education and a comprehensive injury form may improve referral of children from the ED to child protection.     

Spinal trauma in children

Evaluation of the child with suspected spinal injury can be a difficult task for the radiologist. Added to the problems posed by lack of familiarity with the normal appearances of the paediatric spine is anxiety about missing a potentially significant injury resulting in neurological damage. Due to differences in anatomy and function, the pattern of injury in the paediatric spine is different from that in the adolescent or adult. Lack of appreciation of these differences may lead to over investigation and inappropriate treatment. This review attempts to clarify some of the problems frequently encountered. It is based on a review of the literature as well as personal experience. The normal appearances and variants of the spine in children, the mechanisms and patterns of injury are reviewed highlighting the differences between children and adults. Specific fractures, a practical scheme for the assessment of spinal radiographs in children, and the role of cross sectional imaging are discussed. Received: 13 January 2000 Revised: 21 September 2000 Accepted: 6 March 2001     

Traumatic pelvic fractures in children and adolescents

Although traumatic pelvic fractures in children are relatively rare, these injuries are identified in about 5% of children admitted to level 1 trauma centers after blunt trauma.1, 2, 3, 4 Such injuries differ from adult pelvic fractures in important ways and require distinct strategies for management. While the associated mortality rate for children with pelvic fractures is much lower than that for adults, the patient may require urgent surgical intervention for associated life-threatening injuries such as head trauma and abdominal injury. Unstable pelvic ring fractures should be acutely managed using an initial approach similar to that used in adult orthopedic traumatology. Although very few pediatric pelvic fractures will ultimately need surgical treatment, patients with these injuries must be followed over time to confirm proper healing, ensure normal pelvic growth, and address any potential complications. The trauma team suspecting a pelvic fracture in a child must understand the implication of such a finding, identify fracture patterns that increase suspicion of associated injuries, and involve pediatric or adult orthopedic specialists as appropriate during the management of the patient.     

Giant intradiploic pseudomeningocele of occipital bone

The management of intradiploic CSF collection is controversial. Although it is a benign lesion, even then delay in diagnosis and treatment may lead to significant morbidity. The authors report a very rare case of giant posttraumatic intradiploic pseudomeningocele involving the occipital bone, occipital condyles, and clivus. The pathogenesis and management of intradiploic CSF collection are discussed. This 16-year-old boy presented with a history of enlarging swelling in the suboccipital region associated with headache, lower cranial nerve palsy, and features of high cervical compressive myelopathy. Investigations revealed a giant intradiploic lesion involving the occipital bone, condyles, and clivus associated with secondary basilar invagination, hydrocephalus, and syringomyelia. Intrathecal contrast administration did not reveal communication of intradiploic space with the subarachnoid space. A large occipital craniotomy was performed. A linear fracture and dural defect in the midline was identified, which was closed with fascial graft after removing the inner table of the skull. Cranioplasty was performed using the expanded calvarial bone. Ventriculoperitoneal shunt insertion was performed for hydrocephalus, and the patient improved remarkably. Posttraumatic intradiploic CSF collection, although a benign condition, may present with severe complications if treatment is delayed. Early diagnosis and treatment is essential. The authors suggest that this condition should be treated early, as for growing skull fractures.     

Facial fractures in children.

OBJECTIVE: To determine the pattern of injury of facial fractures in children, the relative contribution of plain radiography and CT scanning in the diagnosis of these injuries, and factors leading to delayed diagnosis. DESIGN: Retrospective case note review. PARTICIPANTS: All children with facial fractures identified using the trauma and medical record databases at our institution. RESULTS: Forty-six children with 59 facial fractures presented over a 4-year, 2-month period from November 1995 to December 1999. The median age was 10 years, with a range from 1 to 14. There was a 2-to-1 male-to-female sex ratio. A motor vehicle accident (MVA) involving a child as passenger, pedestrian, or cyclist accounted for 63% of cases. In seven of these, the child was either a front seat passenger or inappropriately restrained for their age and size. In all but one case, the presence of a fracture was associated with an overlying laceration, abrasion, or significant soft tissue edema. Initial examination and plain radiologic assessment by a pediatric clinician led to diagnostic delay in nine children. Facial CT was performed in 38 children, and all results were positive. Twenty-six patients required operative intervention for their facial fracture. Associated injuries, particularly of the head and limbs, were present in all but six patients. CONCLUSIONS: Facial fractures were uncommon overall but occurred more frequently in children with major trauma. Plain facial radiographs provided limited additional diagnostic information to careful clinical examination and often fail to detect or clearly define a facial fracture in children. In the correct clinical setting, a facial CT scan allows accurate diagnosis of the injury and can reveal previously unsuspected additional fractures.     

Jefferson fracture in a child--illustrative case report

In adults, atlas burst fractures (Jefferson fractures) are not uncommon. In the pediatric population, they are extremely rare, and only few cases have been reported so far. They all showed a highly consistent clinical presentation with rare neurological deficits as well as recovery with full function without any surgical intervention. We describe a case of a Jefferson fracture in a 7.5-year-old-boy after falling onto the top of his head, presenting solely with slight neck pain. The initial radiological characteristics are presented on magnetic resonance imaging (MRI) and computer tomography (CT); the bony bridging and fusion of the fracture sites are demonstrated on CT during the course of the healing. The patient was placed in a rigid cervical collar, and his physical examination results remained normal according to age. Complete fusion of both fracture sites was seen on the third follow-up 6.5 months after presentation. In this rare case of a Jefferson fracture in a child monitored by radiological imaging techniques, important aspects of conservatively treated atlas burst fractures are illustrated. It underlines their benign character and favorable outcome with full functional recovery without any surgical intervention.     

Head and neck lymph nodes in children: the spectrum from normal to abnormal

Lymphadenopathy of the head and neck region is a common finding in children and a very common reason to image the craniocervical region. Enlarged lymph nodes are commonly palpated by the pediatrician in the office and commonly imaged by the pediatric radiologist. The difficult task of the clinician is to determine whether the adenopathy is acute (<3 weeks) or chronic (>6 weeks) and when imaging is indicated. In children, radiation is always a consideration when choosing an imaging modality; thus, US is usually the first imaging study at our institution, and CT the second option, usually reserved for the very ill child or for when there is a high index of suspicion for malignancy. We present the normal anatomy of head and neck lymph nodes and the US, CT, and MRI appearances in normal and pathologic states to help clinicians generate a reasonable differential diagnosis and prevent unnecessary procedures.     

儿童移位≤2mm肱骨外髁骨折手术与保守治疗的多中心回顾性研究

目的 比较移位≤2mm肱骨外髁骨折早期经皮固定手术和保守治疗的效果分析.方法 回顾性分析5个研究单位2010年1月至2015年12月收治的初诊在受伤1周内、移位≤2mm的114例肱骨外髁骨折患儿.其中,使用石膏固定于旋转中立位及屈肘90度41例(A组),使用经皮克氏针或者可吸收骨棒固定73例(B组).结果 114例均获随访,随访时间5个月～4年,平均1.2年.A组41例中11例出现骨折再移位,B组73例均未出现骨折移位.11例骨折再移位者(C组)均接受了切开复位克氏针或空心加压螺钉固定.根据Dhillon评分,A组30例保守治疗成功者和B组73例评分均优良,C组11例评分一般.C组关节活动度评分(1.82±0.4)与A、B组(2.93±0.25和2.89±0.31)比较,差异有统计学意义(P＜0.05).C组出现骨骺早闭1例,皮肤激惹反应1例,无感染和皮肤坏死等并发症.结论 移位≤2mm肱骨外髁骨折保守治疗易发生再移位;早期经皮固定手术是一种安全、微创有效的治疗方式,可避免骨折再移位导致的切开复位手术、功能不佳、骨骺早闭等并发症.