Cardiopulmonary resuscitation and rib fractures in infants. A postmortem radiologic-pathologic study.

OBJECTIVE: To determine the incidence of rib fractures visible at autopsy or with postmortem radiographs after cardiopulmonary resuscitation (CPR) in infants younger than 1 year. DESIGN: Retrospective review. SETTING: Medical examiner's office in a county consisting of a medium-sized city, towns, and rural areas. PATIENTS: Ninety-one infants (56 males, 35 females; mean age, 2.4 months; age range, 26 hours to 8.5 months) without evidence of child abuse who had undergone CPR before death. METHODS: Medical records, skeletal surveys, and autopsy results were reviewed. RESULTS: No patient had rib fractures. CONCLUSIONS: Cardiopulmonary resuscitation is unlikely to cause rib fractures in infants.

Extension of growth-plate cartilage into the metaphysis: a sign of healing fracture in abused infants.

The present study was carried out to determine if healing metaphyseal injury in abused infants is accompanied by an increase in the thickness of the growth-plate zone of hypertrophic cartilage and if a radiolucent extension from the growth plate into the metaphysis correlates with this histologic indicator of healing fracture. The radiologic studies of 13 infants who died with evidence of inflicted injury were reviewed. Thirteen distal metaphyseal fractures were identified. Histologically, nine of these fractures were noted to be healing and four showed no evidence of healing. The nine healing injuries were accompanied by statistically significant thickening of the zone of hypertrophic cartilage. Seven of these demonstrated localized areas of hypertrophic cartilage extension; in six of these, corresponding radiolucent extensions of the growth plate into the metaphysis were seen. The extensions tended to be single and focal with minimal osseous injury and broad and multiple with extensive injury. No similar extension was visible in the four acute injuries. Because metaphyseal injuries are notoriously difficult to date, the presence of a reliable radiologic indicator of healing metaphyseal fracture can be important in the evaluation of infant abuse. Because the radiologic findings reflect the histologic alterations, extension of the growth-plate cartilage into the metaphysis may have implications for estimating fracture age.

Normal metaphyseal radiologic variants not to be confused with findings of infant abuse.

Postmortem high-detail skeletal radiography of 78 infants who died of the sudden infant death syndrome was performed during a 3-year period. Review of the studies reveals a variety of distinct radiologic variants that should not be confused with the metaphyseal injuries caused by infant abuse.

Atretic esophagus: transgastric balloon-assisted hydrostatic dilation.

Esophageal atresia may be associated with a long interval or gap between the upper and lower pouches. Despite a variety of procedures to elongate the esophagus, surgeons have been unable to achieve esophageal continuity in many patients. Three infants with esophageal atresia and long gaps recently underwent hydrostatic dilation of the distal esophageal pouch followed by primary anastomosis. The technique entailed passing a balloon-tipped catheter through a gastrostomy site to the distal esophageal pouch. The balloon was inflated to a diameter sufficient to occlude the distal esophagus. Dilute contrast material was then infused under fluoroscopic visualization to a maximal pressure of 145 cm H2O. Dilations were performed daily over a 2-week period, followed by surgery. Primary anastomosis was accomplished in all patients. The promising results in these patients should stimulate other investigators to assess this technique in infants with this challenging surgical problem.

Radiologic contributions to the investigation and prosecution of cases of fatal infant abuse.

In 1984 we started a two-year program in Worcester (Mass.) and Boston to provide additional radiologic data for the medical investigation of suspected fatal infant abuse. During that period the investigation of 12 cases of unexplained infant death included the review of complete radiographic skeletal surveys by a pediatric radiologist. Autopsies were supplemented with resection, high-detail radiography, and histologic study of all non-cranial sites of suspected osseous injury. Thirty-four bony injuries were noted, including 12 acute and 16 healing fractures of the long-bone metaphyses and posterior-rib arcs in patterns indicative of infant abuse. The investigations determined that there were eight cases of abuse, two accidental deaths, and two natural deaths (sudden infant death syndrome). At this writing, the radiologic and osseous histologic studies appear to have influenced the determination of the manner of death in six of the eight cases of abuse and the criminal prosecution in four of the five convictions. These findings suggest that a thorough postmortem radiologic evaluation followed by selected histologic studies can have an impact on the investigation and prosecution of cases of fatal infant abuse.