= CAFFEY-KEMPE SYNDROME = CHILD ABUSE = PARENT -INFANT TRAUMATIC STRESS SYNDROME = NON-ACCIDENTAL TRAUMA

• Most common cause of serious intracranial injuries in children <1 year of age; 3^rd most common cause of death in children after sudden infant death syndrome + true accidents

Prevalence: 1.7 million cases reported + 833,000 substantiated in USA in 1990 (45% neglected, 25% physically abused, 16% sexually abused children); resulting in 2,500–5,000 deaths per year; 5–10% of children seen in emergency rooms

Age: usually <2 years

• skin burns, bruising, lacerations, hematomas (SNAT = suspected nonaccidental trauma)

• Skeletal trauma (50–80%)
  • Site: multiple ribs, costochondral / costovertebral separation, acromion, skull, anterior-superior wedging of vertebra, tibia, metacarpus
  • Unusual sites: transverse fracture of sternum, lateral end of clavicles, scapula, vertebral compression, vertebral fracture dislocation, disk space narrowing, spinous processes
  • Other clues: bilateral acute fractures, fractures of lower extremities in children not yet walking
  • multiple asymmetric fractures in different stages of healing (repeated injury = HALLMARK)
  • exuberant callus formation at fracture sites
  • avulsion fracture of ligamentous insertion; frequently seen without periosteal reaction
  • Epiphysis
    • separation of distal epiphysis
  • Metaphysis
    • marked irregularity + fragmentation of metaphyses (DDx: osteochondritis stage of congenital syphilis; infractions of scurvy)
    • “corner” fracture (11%) = “bucket-handle” fracture = avulsion of an arcuate metaphyseal fragment overlying the lucent epiphyseal cartilage
    • Cause: sudden twisting motion of extremity (periosteum easily pulled away from diaphysis but tightly attached to metaphysis)
    • Location: knee, elbow, distal tibia, fibula, radius, ulna
  • Diaphysis
    • isolated spiral fracture (15%) of diaphysis ← external rotatory force applied to femur / humerus
    • extensive periosteal reaction from large subperiosteal hematoma apparent after 7–14 days following injury (DDx: scurvy, copper deficiency)
    • cortical hyperostosis extending to epiphyseal plate (DDx: not in infantile cortical hyperostosis)
• Head trauma (13–25%)
  • Most common cause of death + physical disability!
  1. Impact injury with translational force: skull fracture (flexible calvaria + meninges decrease likelihood of skull fractures), subdural hematoma, brain contusion, cerebral hemorrhage, infarction, generalized edema
  2. Whiplash injury with rotational force: shearing injuries + associated subarachnoid hemorrhage
  • bulging fontanels, convulsions
  • ocular lesions, retinal detachment
  
  Skull film (associated fracture in 1%):
  • linear fracture >comminuted fracture >diastases (conspicuously absent)
  
  CT:
  • subdural hemorrhage (most common): interhemispheric location most common
  • subarachnoid hemorrhage
  • epidural hemorrhage (uncommon)
  • cerebral edema: focal, multifocal, diffuse
  • acute cerebral contusion as ovoid collection of intraparenchymal blood with surrounding edema
  
  MR:
  • More sensitive in identifying hematomas of differing ages
  • white matter shearing injuries as areas of prolonged T1 + T2 at corticomedullary junction, centrum semiovale, corpus callosum
• Visceral trauma (3%)
  • Second leading cause of death in child abuse
  
  Cause: crushing blow to abdomen (punch, kick)
  Age: often >2 years
  • small bowel / gastric rupture
  • hematoma of duodenum / jejunum
  • contusion / laceration of lung, pancreas, liver, spleen, kidneys
  • traumatic pancreatic pseudocyst

Cx:

1. Brain atrophy (up to 100%)
2. Infarction (50%)
3. Subdural hygroma
4. Encephalomalacia
5. Porencephaly

DDx: normal periostitis of infancy, long-term ventilator therapy in prematurity, osteogenesis imperfecta, congenital insensitivity to pain, infantile cortical hyperostosis, Menkes kinky hair syndrome, Schmid-type chondrometaphyseal dysplasia, scurvy, congenital syphilitic metaphysitis