MRD 510 – MEDICAL IMAGING IVTITLE : SKELETAL SYSTEM SURVEY

ON PEDIATRIC PATIENT

Lecturer: Dr. Hajah Shahridah Binti KassimPresenter:

Nur Syafiqah Binti Jasmin (2012864964)Noor Farahuda Binti Mustafah Maarof (2011236456)

Presentation OverviewO Brief Description

O Common Indications

O Role of Radiographer

O Skeletal Survey’s Protocol

O Recommended Parameters

O Immobilization Techniques

O Radiation Protection

O Summary

O References

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:

To 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)

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 (OsteogenesisImperfecta), syndromes (Bony Dysmorphic Disorder) and metabolic disorder (Paget’s disease)

Neoplasia and related disorder, such as Multiple Myeloma and Metastatic Bone disease.

(Dr. Prashant Mudgal et al, 2014)

3.0 ROLES OF RADIOGRAPHERBefore 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)

Cont.. All the equipment and the room must be prepared before call

the patient, including pre-selecting exposure factor. Make

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)

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)

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)

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 RADIOGRAPH

S

(Royal College of Paediatrics and Child Health, 2008)

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 RADIOGRAPH

S

(Royal College of Paediatrics and Child Health, 2008)

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)

RIB FRACTURES

(Robben, 2006)

Yellow arrow: callus develops

CORNER FRACTURES

(Robben, 2006)

BUCKET HANDLE FRACTURES

(Robben, 2006)

SKULL FRACTURES

(Robben, 2006)

DIAPHYSEAL FRACTURES

(Robben, 2006)

FRACTURE HEALING

(Robben, 2006)

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)

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, 8th and 9th rib fractures

5.0 RECOMMENDED PARAMETERS

As low as reasonably achievable (ALARA)

Optimal high-detail digital imaging system

Sufficient spatial resolution and signal-to-noiseratio characteristics to detect subtle skeletalinjuries

Minimum source image distance is 100 cm (40”)

Precise positioning and collimation over eachanatomic region are essential

Chest imaging should use bone detail techniquefor suspected abuse cases

(The American College of Radiography, 2014)

6.0 IMMOBILIZATION DEVICES

(Freeman, 2012)

7.0 RADIATION PROTECTIONCorrect 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)

8.0 SUMMARY

O There is restrictive definition of positive Skeletal Survey

results for example finding of a fracture that was completely

unsuspected

O 11% to 50% of cases with Skeletal Survey results were

positive.

O In 50% of these cases. the Skeletal Survey results

influenced directly the decision to make a diagnosis of

abuse cases.

O 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),

9.0 REFERENCESDuffy, 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