Skeletal survey on pediatric patient

A review of skeletal system survey's protocol on suspected child abused / non-accidental injury (NAI)

1. MRD 510 – MEDICAL IMAGING IV TITLE : SKELETAL SYSTEM SURVEY ON PEDIATRIC PATIENT Lecturer: Dr. Hajah Shahridah B inti Kassim Presenter: Nur Syafiqah Binti Jasmin (2012864964) Noor Farahuda Binti Mustafah Maarof (2011236456)

2. Presentation Overview Brief Description Common Indications Role of Radiographer Skeletal Survey’s Protocol Recommended Parameters Immobilization Techniques Radiation Protection Summary References

3. 1.0 - SKELETAL SURVEY Definition: “A systematically performed series of radiographic images that encompasses the entire skeleton or those anatomic regions appropriate for the clinical indications. “ What it is about??? Purposes: T o allow the detection of occult bony injuries in children with suspected non-accidental injury (NAI) - Obtain further information about a clinical injury, - Aid in the dating of bone injury Help in diagnosing the unknown abnormalities from the normal developmental changes and other anatomic variants Help in detection of any underlying skeletal disorder that may mimic the fractures (The American College of Radiography, 2014)

4. 2.0 COMMON INDICATIONS Known or suspected child abuse, in which the children’s physical, emotional or sexual assaulted a.k.a Non-accidental Injury (NAI) Skeletal dysplasia ( Osteogenesis Imperfecta ), syndromes (Bony Dysmorphic Disorder) and metabolic disorder (Paget’s disease) Neoplasia and related disorder, such as Multiple M yeloma and Metastatic B one disease. (Dr. Prashant Mudgal et al, 2014)

5. 3.0 ROLES OF RADIOGRAPHER Before examination: The request form of the skeletal survey examination should be reviewed the examination must be requested by a physician or other appropriately licensed health care provider it must be provided with sufficient medical information, which are: 1) signs and symptoms, and/or 2) relevant history, and 3 ) specific reason for undergoing the examination At least two radiographers are available for the examination one is available for handling the patient, while the other one is available for preparing the machine and equipment, including for selecting the exposure factor and processing the images. Another professional who is responsible for the child’s safety on radiology department should be available. (Royal College of Paediatrics and Child Health, 2008)

6. Cont.. All the equipment and the room must be prepared before call the patient, including pre-selecting exposure factor. M ake sure the immobilization devices are available and the room is tidy. Clearly identify the patient identification. Give a brief explanation to the patient and guidance, including a careful and accurate presentation clinical concerns, a description of imaging procedures that are being planned, explanation of the reasons for procedure and the risk and benefit of procedure. Informed consent must be obtained by referring pediatrician. Make sure all the metal or any object-inducing artefact are removed. (Royal College of Paediatrics and Child Health, 2008)

7. Cont.. During examination: The guidance is allowed to be within the examination room if; Patient is uncooperative The guidance is not pregnant (if women) All the radiographs should have the correct patient name, side marker, date and time of examination. The radiographers’ name who are performing the procedure should be recorded Further radiographic projections may be required, according to the supervising radiologist’s instruction. (Royal College of Paediatrics and Child Health, 2008)

8. Cont.. After examination: The patient should be returned for ongoing care to referring clinician after the examination is completed. An official interpretation (the final report) of examination made by radiologist should be included in the patient’s medical record. A concise description of all area of definite and suspected abnormalities should be provided on the report. (Royal College of Paediatrics and Child Health, 2008)

9. 4.0 - PROTOCOLS SKULL Anterior posterior (AP), lateral, and Townes view (if clinically indicated) CHEST AP including the clavicles Oblique views of both of the sides of the chest to show ribs (left and right oblique) ABDOMEN AP of abdomen including the pelvis and hips PROJECTIONS RADIOGRAPHS (Royal College of Paediatrics and Child Health, 2008)

10. cont.. SPINE Lateral: may require separate exposures of the cervical, thoracic and thoracolumbar regions / separate radiograph LIMBS PA of both hands AP of both radius-ulna AP of both humerus AP of both feet AP of both tibia-fibula AP of both femur # If clinical signs suggest a focal injury, such as soft tissue swelling or tenderness, two projections at 90°should be performed. PROJECTIONS RADIOGRAPHS (Royal College of Paediatrics and Child Health, 2008)

11. Brain bounce back and forth: Intracranial injuries Compressive Force at Thorax: Rib Fractures Leg Flailing Back-Forth : Corner Fracture of Metaphyseal Bucket Handle Fractures Shaken Baby Syndrome ( Robben , 2006)

12. RIB FRACTURES ( Robben , 2006) Yellow arrow: callus develops

13. CORNER FRACTURES ( Robben , 2006)

14. BUCKET HANDLE FRACTURES ( Robben , 2006)

15. SKULL FRACTURES ( Robben , 2006)

16. DIAPHYSEAL FRACTURES ( Robben , 2006)

17. FRACTURE HEALING ( Robben , 2006)

18. Follow-Up Procedure Skeletal survey is recommended to be repeated in approximately 2 weeks from the initial skeletal survey in cases of suspected physical abuse in children less than 1 year of age. Follow up or repeat skeletal survey has shown positive result in finding additional information in 46-61% of cases. Additional information detected are usually rib fractures and metaphyseal lesions ( Giardino , Lyn, & Giardino , 2014)

19. Follow-Up Procedure ( Offiah , Rijn, Perez- Roseelo , & Kleiman , 2009) a Initial chest radiograph shows an acute left 7th rib fracture (arrow). b Initial oblique images of the chest better demonstrate the left 7th rib fracture and a possible left 8th rib fracture (arrows). c Follow-up oblique images of the chest obtained 2 weeks later show healing left 7th, 8 th and 9th rib fractures

20. 5.0 RECOMMENDED PARAMETERS As low as reasonably achievable (ALARA) Optimal high-detail digital imaging system Sufficient spatial resolution and signal-to-noise ratio characteristics to detect subtle skeletal injuries Minimum source image distance is 100 cm (40”) Precise positioning and collimation over each anatomic region are essential Chest imaging should use bone detail technique for suspected abuse cases (The American College of Radiography, 2014)

21. 6.0 IMMOBILIZATION DEVICES (Freeman, 2012)

22. 7.0 RADIATION PROTECTION Correct Patient Correct procedures Ensure that the image taken has not yet been taken in the emergency department, to avoid repetitive procedure that can increase dose received by the child Appropriate collimation Patient’s shielding in area not in the region of interest As low as reasonably achievable (ALARA) Skeletal survey should not consist of a single image of the patient’s skeleton (known as baby-gram) because the detail is not sufficient to recognize subtle injuries. Grids are not routinely used to image spine, pelvis, skull and abdomen on children under 6 months (The American College of Radiography, 2014)

23. 8.0 SUMMARY There is restrictive definition of positive Skeletal Survey results for example finding of a fracture that was completely unsuspected 11% to 50% of cases with Skeletal Survey results were positive. In 50% of these cases. the Skeletal Survey results influenced directly the decision to make a diagnosis of abuse cases. Children 6 months of age has the highest rate of positive Skeletal Survey results and it is recommended that a Skeletal Survey should be completed for them with suspected abuse cases. (Duffy , Squires, Fromkin & Berger, 2011 ),

24. 9.0 REFERENCES Duffy , S.O., Squires, J., Fromkin , J.B., & Berger, R.P. (2010). Use of skeletal surveys to evaluate for physical abuse: Analysis of 703 consecutive skeletal surveys . Retrieved September 28, 2014, from http://pediatrics.aappublications.org/content/ 127/1/e47.full.html Freeman, C. (2012). Imaging children; immobilisation , distraction techniques and use of sedation. Society of Radiographers. Retrieved September 27, 2014, from http://www.sor.org Giardino,A.P ., Lyn.M.A , & Giardino,E.R . (2010). A practical guide to the evaluation of child physical abuse and neglect. Springer Science & Business Media: London. Offiah , A., Rijn, R.R.V., Perez- Rosello , J.M., & Kleinman , P.K. (2009). Skeletal imaging of child abuse (non- accidental injury). Radiopedia . (2014). Skeletal Survey . Retrieved September 25, 2014, from http://radiopaedia.org/articles/skeletal-survey Robben , S. (2006). Diagnostic imaging in child abuse non accidental trauma . Retrieved September 28 , 2014, from http:// www.radiologyassistant.nl/en/p43c63c41ef792/diagnostic- imaging-in-child-abuse.html Royal College of Paediatrics and Child Health. (2008). Standards for radiological investigations of suspected non-accidental injury . Retrieved September 23, 2014, from https ://www.rcr.ac.uk/docs/radiology/pdf/RCPCH_RCR_final.pdf The American College of Radiography. (2014). ACR-SPR practice parameter for skeletal surveys in children . Retrieved September 24, 2014 from http://www.acr.org/QualitySafety/Standards-Guidelines/Practice-Guidelines-by-Modal ity /Pediatric The Royal College of Radiologists. (2011). Imaging for non-accidental injury (NAI): use of anatomical markers . Retrieved September 28, 2014, from https :// www.rcr.ac.uk/docs/radiology/pdf/BFCR(11)5_RCR_COR_NAI.pdf