Age / Sex : 20 / M

Chief complaint: painful swelling of left thigh (onset: 2 days ago)
                          

Abused child syndrome

Discussion

Findings:

Plain radiograph>

-       Diffuse soft tissue swelling with periostitis in the left thigh and left femoral shaft. Periostitis in the right femoral shaft.

-       Metaphyseal irregularities with corner fractures in the both distal femoral metaphyses.

-       On F/U plain radiography of left femur, dense calcification around left distal femur with periosteal reaction

MRI>

-       On T1WI and T2WI, hematoma calcification and with periostitis is shown around left distal femur.

Differential Diagnosis:

Normal periostitis of infancy

Metaphyseal changes of normal growth

Osteogenesis imperfect

Osteomyelitis

Diagnosis: abused child syndrome

Discussion:

Traumatic insult to the child’s skeleton can produce elevation of the periosteal membrane, which is loosely attached to the diaphysis of tubular bones. Although the resultant periostitis is a delayed radiographic finding, it should be emphasized that firm attachment of the periosteal membrane to the metaphyses of the tubular bones can lead to an immediate radiographic abnormality – single or multiple metaphyseal bone fragments. The resultant fragments consist of a disc of bone and calcified cartilage. Reactive bone formation with sclerosis can be a prominent change associated with periostitis and metaphyseal fracture.

 The proper workup of a child suspected of having been physically abused includes a radiographic survey of all the long bones, the pelvis, the spine, the ribs,and the skull.

 Radiographic findings include single or multiple fractures, especially ribs; other sites, in order of decreasing frequency, include the humerus, femur, tibia, small bones of the hand and foot, and skull.

Subperiosteal bone formation may be apparent between 7 and 14 days after injury. Late skeletal findings include metaphyseal cupping, growth disturbances, subluxation, and diaphyseal widening caused by subperiosteal apposition.

References:

 1. Resnick D.: Bone and joint imaging, 3^rd. Philadelphia: Elsevier-Saunders, 2005:828-829.