RadioGraphics -- eLetters for Lonergan et al., 23 (4) 811-845

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AFIP Archives:
Gael J. Lonergan, Andrew M. Baker, Mitchel K. Morey, and Steven C. Boos
From the Archives of the AFIP: Child Abuse: Radiologic-Pathologic Correlation
Radiographics 2003; 23: 811-845 [Abstract] [Full text] [PDF]

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Electronic letters published:

Bone scintigraphy as the primary investigation in cases of suspected child abuse: Siroos Mirzaei, MD, Peter Knoll, MD (19 November 2003)

Bone scintigraphy as the primary investigation in cases of suspected child abuse 19 November 2003

Siroos Mirzaei, MD,
Physician for Nuclear Medicine
Wilhleminenspital, Institute of Nuclear Medicine,
Peter Knoll, MD
Send letter to journal:
Re: Bone scintigraphy as the primary investigation in cases of suspected child abuse

siroos.mizaei{at}wienkav.at Siroos Mirzaei, MD, et al.

Lonergan et al (1) emphasize in their recent publication the diagnostic value of radiologic modalities for detection of fractures in cases of child abuse. Bone scintigraphy with technetium-99m-labeled diphosphonates has been described as highly sensitive for depicting bone lesions, even for lesions that are not clearly seen on anatomic images (2,3). Most fractures are scintigraphically detectable within 24 hours; other skeletal pathologies besides acute fractures are stress fractures, shin splints, and spondylolysis, for which radiography may be nondiagnostic (3). Therefore, in agreement with other publications, we suggest the primary use of bone scintigraphy in cases of suspected child abuse to screen the skeleton for possible injuries in a single examination (4). Performing additional spot radiologic investigations should be limited to verification of the morphologic nature of the scintigraphic abnormalities and/or other symptomatic sites.
References
1. Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP: child abuse--radiologic-pathologic correlation. RadioGraphics 2003; 23:811-845.
2. Mirzaei S, Knoll P, Lipp RW, Wenzel T, Koriska K, Kohn H. Bone scintigraphy in screening of torture survivors. Lancet 1998; 352:949-951.
3. Love C, Din AS, Tomas MB, Kalapparambath TP, Palestro CJ. Radionuclide bone imaging: an illustrative review. RadioGraphics 2003; 23:341-358.
4. Cadzow SP, Armstrong KL. Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes. J Paediatr Child Health 2000; 36:322-326.
Dr Lonergan responds:
We appreciate Dr Mirzaei’s comments regarding the use of skeletal scintigraphy as the primary diagnostic method for detection of skeletal injuries in abused children. As he correctly points out, scintigraphy is very sensitive for detection of skeletal injury, especially rib fracture (1-3). Because rib fracture is a highly specific indicator of inflicted injury in infants, scintigraphy is useful for detection of these important injuries. Thus, for the infant with suspicious injury whose skeletal survey reveals no specific injuries, skeletal scintigraphy should be considered a useful adjunct.
Scintigraphy has several disadvantages, however, that relegate it to complementary status for the majority of suspected abuse cases. Classic metaphyseal lesions (CMLs) may be difficult to detect scintigraphically, even when the technique is performed with exquisite care (4,5). Because CML is highly specific for abuse, this is a considerable drawback. Also, dating of injury is not possible with scintigraphy; thus, scintigraphically detected skeletal injury typically requires plain radiography to determine evidence of healing (4-6). Because abused children are often abused multiple times, and because confabulated histories are common, the discovery of “older” injuries has critical medicolegal import. Finally, skull fracture, a common inflicted injury, is typically occult at scintigraphy (5).
Although scintigraphy is unquestionably a sensitive imaging modality for skeletal injury in general and rib fracture in particular, its limitations for the detection of some highly abuse-specific injuries (CML and skull fracture) and its inability to accurately demonstrate evidence of healing suggest that it is a supplementary, though important, modality for imaging the possibly abused child.
References
1. Sty JR, Starshak RJ. The role of bone scintigraphy in the evaluation of the suspected abused child. Radiology 1983; 146:369-375.
2. Smith FW, Gilday DL, Ash JM, Green MD. Unsuspected costo-vertebral fractures demonstrated by bone scanning in the child abuse syndrome. Pediatr Radiol 1980; 10:103-106.
3. Haase GM, Ortiz VN, Sfakianakis GN, Morse TS. The value of radionuclide bone scanning in the early recognition of deliberate child abuse. J Trauma 1980; 20:873-875.
4. Merten DF, Radkowski MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology 1983; 146:377-381.
5. Conway JJ, Collins M, Tanz RR, et al. The role of bone scintigraphy in detecting child abuse. Semin Nucl Med 1993; 23:321-333.
6. American Academy of Pediatrics, Section on Radiology. Diagnostic imaging of child abuse. Pediatrics 2000; 105:1345-1348.