UMEM Educational Pearls

Title: What's the Diagnosis? By Dr. Ari Kestler and Dr. Ashley Strobel

Posted: 10/6/2014 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD

Question

7d old child presents with difficulty feeding,vomiting one time, and now with intermittent apneic episodes. What's the diagnosis? (Careful....this one is tricky!)

Answer

Answer: Workup should include an ALTE and sepsis evaluation PLUS evaluation for non-accidental trauma

Non-accidental trauma (NAT)

NAT is most prevalent in children 0-3 months of age.

Classic metaphyseal lesions, rib fractures, and fractures in various stages of healing are most commonly described in children.

How do we know this is not just birth trauma from a shoulder dystocia, large for gestational age, or difficult vaginal delivery?

Key is dating the fracture (see referenced article for more info)
Callus not present prior to 8 days of life and callus thickness decreases inversely with fracture age.
Subperiosteal new bone formation is highly unlikely in fractures less than 7 days old

Subperiosteal new bone formation appears as a:

hazy cortical margin or a thin layer of bone separated from the original cortex by a discrete lucent interval
linear hyperdensity parallel to the cortex of the bone
see referenced article for images

NAT Work-up:

CT head without contrast if 2 yo
Skeletal survey if 2 yo
AST, ALT, amylase, lipase, CBC with manual diff, BMP, urinalysis, urine toxicology
Consults (Ophthalmology, Social Work, Child Protection, etc.)

References

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Walters MM, Forbes PW, Buonomo C, and Kleinman PK. Healing Patterns of Clavicular Birth Injuries as a guide to fracture dating in cases of possible infant abuse. Pediatric Radiology. October 2014; 44: 1224-1229