Warkentine Fred H, Horowitz Russ, Pierce Mary Clyde
From the *Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY; and †Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL.
Pediatr Emerg Care. 2014 Jan;30(1):43-6. doi: 10.1097/PEC.0000000000000064.
Occult fractures due to child abuse can be difficult to identify because there is usually no history of trauma, and chief complaints are vague. In addition, the osseous injuries are often subtle, becoming obvious only after healing begins. Missed injuries can lead to inappropriate disposition of a patient and can cause children to be placed at high risk for further injury and death. It is therefore imperative that these children be diagnosed as soon as possible. Ultrasound has some properties that are desirable for detecting fractures, especially in children. Ultrasound waves are almost completely reflected by cortical bone. Thus, fractures easily appear on an ultrasound screen. The cartilaginous nature of pediatric bones makes some fractures difficult to identify on x-ray. The nature of ultrasound waves, however, allows the cartilaginous areas of pediatric bones to be identified. This brief report presents 2 cases of children younger than 1 year presenting with vague complaints (limp, irritability) without a history of trauma. Both children underwent bedside ultrasound by a pediatric emergency medicine physician with training in emergency ultrasound. The bedside ultrasound led to the identification of occult or unsuspected fractures in both children, and state social services were notified. In both cases, the cause of the fracture was determined to be from abuse, and necessary measures were taken to ensure the child's future safety. This report demonstrates that ultrasound may be useful for early identification of some types of occult or unsuspected fractures commonly seen in cases of child abuse.
虐待儿童导致的隐匿性骨折可能难以识别，因为通常没有外伤史，且主要症状模糊。此外，骨质损伤往往很细微，只有在开始愈合后才会变得明显。漏诊会导致对患者的处置不当，并可能使儿童面临进一步受伤和死亡的高风险。因此，必须尽快对这些儿童进行诊断。超声具有一些检测骨折所需的特性，尤其是在儿童中。超声波几乎完全被皮质骨反射。因此，骨折很容易在超声屏幕上显示出来。儿童骨骼的软骨性质使得一些骨折在X光片上难以识别。然而，超声波的特性使儿童骨骼的软骨区域能够被识别。本简要报告介绍了2例1岁以下儿童，他们主诉模糊（跛行、易怒）且无外伤史。两名儿童均由接受过急诊超声培训的儿科急诊医学医生进行床边超声检查。床边超声检查使两名儿童均被发现存在隐匿性或未被怀疑的骨折，并通知了州社会服务部门。在这两例中，骨折原因均被确定为虐待，并采取了必要措施以确保儿童未来的安全。本报告表明，超声可能有助于早期识别虐待儿童案件中常见的某些类型的隐匿性或未被怀疑的骨折。
