2023 Friday Quiz 12 Answer | Figure 1

CincyKidsRad

Cincinnati Children's Radiology

2023 Friday Quiz 12 Answer

Radiograph from a skeletal survey shows healing rib fractures (arrows). Distal humeral separation epiphyseal separation injury is associated with non-accidental trauma and birth trauma. Prior research has shown that up to 50% of distal humeral separation epiphyseal separation injuries in children under two years of age are associated with non-accidental trauma. The injury occurs due to rotatory or shear forces in the setting of non-accidental trauma. A skeletal survey should be performed if there is not an otherwise explainable mechanism for the injury.

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AP (image 1) and lateral (image 2) radiograph of the elbow shows radial and anterior displacement of the radius and ulna (arrow on image 1) and an avulsion fracture of the lateral condyle (arrow on image 2). En bloc displacement of the radius and ulna alerts the pediatric radiologist to the presence of distal humeral epiphyseal separation. This fracture is most commonly caused by a fall on an outstretched hand, hyperextensions, and rotation. It is important to recognize due to its strong association with nonaccidental trauma and the need for fixation by orthopedic surgery. On radiography, there is typically ulnar and posterior displacement of the radius and ulna. The images shown in this patient are atypical due to the radial and anterior displacement of the radius and ulna. #MSKMonday #MusculoskeletalMonday

A skeletal survey performed after diagnosing the skull fracture shows additional evidence of non-accidental trauma, including healing rib fractures (yellow arrows), a healing transverse fracture of the proximal ulna (pink arrow), a healing metaphyseal corner fracture of the right femur (orange arrow), and metaphyseal corner fractures of the proximal and distal tibia (arrowheads). Skull fractures in infants are associated with nonaccidental trauma. Specific fractures of nonaccidental trauma include metaphyseal corner fractures, posterior rib fractures, and fractures of different ages.

AP elbow radiograph in a 2-year-old female shows an obliquely oriented irregular lucency through the lateral condyle of the distal humeral metaphysis, consistent with a lateral condylar fracture. There is mild distraction of the fracture fragment. In these cases, the fracture line typically continues distally through the unossified epiphyseal cartilage to the articular surface (i.e., a Salter-Harris IV fracture). #MSKMonday

AP (image 1) and lateral (image 2) radiographs of the right femur in a one-year-old shows extensive periosteal new bone (arrow) and anterior displacement of the distal femoral epiphysis (arrowhead). The extensive new bone formation provides evidence that the fracture is at least 10-14 days of age. In an infant with delayed presentation of a long bone injury and no explanatory history, nonaccidental trauma should be suspected and a skeletal survey performed to identify other findings potentially related to abuse.