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Chest CT in the evaluation of child abuse - When is it useful?
Boaz Karmazyn1, Megan B Marine1, Matthew R Wanner1
1Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN 46202, United States of America.
Insights
Chest CT identifies more rib fractures in child abuse cases than X-rays, especially when initial surveys are negative or indeterminate. Consider CT for high-suspicion children to improve fracture diagnosis.
Area of Science:
- Pediatric Radiology
- Medical Imaging
- Child Abuse Forensics
Background:
- Indications for using chest computed tomography (CT) in evaluating child abuse are not well-established.
- Identifying optimal imaging strategies is crucial for accurate diagnosis and patient care.
Purpose of the Study:
- To determine which groups of children under three years old can benefit most from chest CT scans.
- To compare the diagnostic yield of chest CT versus skeletal surveys for detecting rib fractures in young children suspected of abuse.
Main Methods:
- A 10-year retrospective study analyzed children under three years who underwent chest CT within three days of an initial skeletal survey.
- Two pediatric radiologists independently reviewed anonymized rib X-rays and chest CT scans, with disagreements resolved by a third radiologist.
- Statistical analyses included kappa statistics for inter-rater agreement and negative binomial models/chi-square tests for fracture counts.
Main Results:
- Chest CT detected significantly more fractures than X-rays (112 vs. 42 initially, 93 vs. 49 on follow-up).
- Additional fractures were identified in 84.6% of patients with positive initial surveys and 18.9% of those with negative initial surveys via CT.
- Chest CT identified fractures in four of ten cases with indeterminate fractures on initial X-rays.
Conclusions:
- Chest CT is valuable for evaluating young children with suspected child abuse, particularly when skeletal surveys are negative or findings are indeterminate.
- The study supports considering chest CT in specific pediatric populations to enhance the detection of rib fractures indicative of abuse.
Background:
Indications for chest CT in evaluation of child abuse are unknown.
Objective:
Determine which groups of children can best benefit from chest CT.
Participants And Setting:
10-year (1/2010 to 12/2019) retrospective study of children <3 years who had chest CT within 3 days of the initial skeletal survey.
Methods:
Demographic and clinical information were obtained from medical records. Two pediatric radiologists reviewed, independently and blinded to clinical information, anonymized rib X-rays (initial and follow up when available) and chest CT. Disagreements were resolved by a third pediatric radiologist. Agreement was evaluated using kappa statistics. Number and percentage of fractures were analyzed by negative binomial models and chi-square tests, respectively.
Results:
50 children (21 females) with average age of 9.7 months, 27 of whom had follow-up radiography. Agreement on initial and follow-up X-rays was substantial (k = 0.72) and perfect (k = 1.00), respectively, and almost perfect (k = 0.82) for CT scans. Chest CT demonstrated more fractures than X-ray, both initially (112 vs. 42, p < 0.0001) and at follow-up (93 vs. 49, p < 0.0001). Significantly more additional fractures were found at CT (11/13, 84.6 %) in patients with positive than in those with negative initial surveys (7/37, 18.9 %, p < 0.001). Ten initial surveys had only indeterminate fractures; four of them had fractures and six had no fractures on CT. Chest CT missed one patient (1/27, 3.7 %) with acute nondisplaced anterior rib fractures.
Conclusion:
Chest CT can be considered in children with negative skeletal survey and high clinical suspicion for child abuse, and when the diagnosis of rib fractures is indeterminate.
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