Imaging in Pediatric Skeletal Trauma: Techniques and Applications

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The child had a right pyeloplasty. It has been noted that the vast majority of PUJ anomalies resolve spontaneously.

Guidance for Paediatric Health Professionals

This results in a stretched renal parenchyma and, in the long term, loss of renal parenchymal function if the condition is left untreated. Preliminary work, which needs further evaluation, has shown that prolonged transit of tracer through the renal parenchyma of the hydronephrotic kidney, in comparison to the normal contralateral kidney, may be a valuable parameter to identify the kidney at risk. Therefore, not all children with a PUJ anomaly need nuclear medicine imaging. It informs the referring clinician on the contribution of the hydronephrotic kidney to total renal parenchymal function and the possible presence of focal areas of reduced or absent parenchymal function.

A renal scintigraphy can be performed in an infant as young as 6 weeks of age.

Skeletal Scintigraphy (Bone Scan)

It is important to be aware that slow drainage on a MAG3 renogram in an asymptomatic child with an ante-natally diagnosed hydronephrosis does not necessarily mean obstruction. It could also be due to a PUJ or VUJ stenosis that is not tight enough to cause significant resistant to urinary outflow and consequent loss of renal parenchymal function. In this condition the pelvi-calyceal system is in equilibrium.

The criteria for surgery are still not well-defined and vary between institutions.

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A renal pelvic dilatation larger than 3 cm, the presence of calyceal dilatation, reduced renal parenchymal function, have been included as surgical criteria. A Tcm-MAG3 dynamic renography can be very helpful in assessing the outcome after surgery, and is usually performed not earlier than 6—9 months post-operatively, to allow the post-surgical oedema and stiffness of the tissues to settle. If the baseline scan was acquired in a very young child, younger than 6 months of age, and with immature kidneys with reduced tracer uptake and raised background activity, or in a child with chronic kidney disease, then the estimation of the split renal function was probably not very precise, and this will have to be taken into account when comparing the following MAG3 renogram.

A dilated ureter, or megaureter, may be dysplastic and flaccid, with loss of peristalsis, or may develop as the result of a stenosis at the level of the VUJ VUJ anomaly. It can be obstructing, refluxing, non-obstructing and non-refluxing. The renal ultrasound examination will show the calibre of the dilated ureter both proximally and distally and the size of the renal pelvis, which is often dilated.

A megaureter may present with UTI or may be detected on an ante-natal ultrasound examination and followed up post-natally. Nuclear medicine imaging informs the referring clinician on the parenchymal function of the hydro-ureteronephrotic kidney and shows if there is urinary stasis at the distal end of the dilated ureter. Sometimes the nuclear medicine study shows urinary stasis in the renal pelvis, with little or no stasis in the dilated ureter; if the ultrasound examination shows a significantly dilated ureter, then a VUJ anomaly is still possible and further evaluation with cystoscopy and a retrograde radiological contrast study, with the view of proceeding to incisor balloon dilatation of the VUJ orifice, may be required.

It is difficult to diagnose this association with a nuclear medicine study; an ultrasound examination is always necessary to demonstrate the size of the renal pelvis and ureter; a radiological contrast study, performed either retro-gradely via cystoscopy or ante-gradely, with percutaneous puncture of the renal pelvis, sometimes may also be required. Nuclear medicine imaging techniques successfully assess renal parenchymal function and drainage in patients with congenital renal anomalies. In a kidney with a duplex renal collecting system, a MAG3 renogram can confirm the diagnosis and show whether the renal parenchyma of the upper and the lower moieties is functional.

The upper moiety of a duplex may be obstructed at the distal end by an ureterocele and, as a result, may drain slowly via a dilated and tortuous ureter. The functional radioisotope study is essential to show the degree of renal parenchymal function. A poorly functional or non-functional upper moiety of a duplex kidney is usually managed surgically with an upper pole heminephrectomy. The lower moiety of a duplex kidney may show VUR, due to the abnormal entry of the lower moiety ureter into the bladder.

If the lower moiety shows very poor or absent parenchymal function, the treatment of choice will be a lower pole heminephrectomy. Nuclear medicine imaging is important to confirm the presence of fused kidneys, which can be difficult to demonstrate on the ultrasound examination due to the presence of bowel gas; it can also show the presence of possible renal cortical scars. Horseshoe kidneys are usually fused at the lower pole and positioned low in the abdomen.

Due to their unusual position and the abnormal orientation of their collecting systems, urinary stasis is possible, and one or both moieties may become hydronephrotic. A nuclear medicine imaging study, either a Tcm-DMSA scintigraphy or a Tcm-MAG3 dynamic renography, can confirm the diagnosis, show the possible presence of renal scars and, in the case of a MAG3 renogram, if there is urinary stasis in the renal collecting system. Nuclear medicine imaging provides useful information in crossed-fused renal ectopias. A Tcm-DMSA study is usually preferred to inform on renal parenchymal integrity and on the possible presence of focal renal scars.

There will be no renal parenchymal function in the MCDK. The study will also inform on the parenchymal function of the contralateral kidney. In the hypertensive child a DMSA scan is important to rule out multiple renal scars as a possible cause of hypertension. In the case of renovascular hypertension, due for example to fibro-muscular dysplasia, neurofibromatosis 1, mid aortic syndrome or extrinsic compression on the renal artery by an adjacent mass lesion, a DMSA scan will be helpful to assess renal parenchymal function before and after procedures such as angioplasty, surgical revascularization or resection of the mass lesion.

Dynamic renal scintigraphy has been utilized in the diagnostic work up of renovascular hypertension, especially before and after administration of an angiotensin-converting enzyme ACE inhibitor such as captopril. Dehydrated neonates and those with a traumatic delivery can develop renal vein thrombosis. In these infants, a DMSA scan performed 3—6 months after birth will show the parenchymal function of the kidneys.

Renal vein thrombosis may affect one or both kidneys at varying degree, depending on the degree of venous obstruction.

Imaging Skeletal Trauma

Molecular imaging techniques are increasingly utilized in paediatric oncology. The main questions asked by the referring clinical team are the demonstration of regional or distant metastases, thus contributing to staging the disease, the identification of an appropriate site for biopsy, the evaluation of response to treatment, the differentiation between residual disease and post-therapy changes, the identification of possible recurrent disease.

It is critical to acquire images of the highest possible quality, as the demonstration of a small but definite focus of disease can at times change management significantly. Therefore, the child has to be absolutely still during the acquisition of the images. Sedation or GA is often needed in young children. Meta-iodo-benzyl-guanidine mIBG labelled with either I or I has been clinically available for the last 30 years.

MIBG is an analogue of norepinephrine and is internalized in the pre-synaptic cells of the sympathetic nerve fibres. ImIBG is a cornerstone examination in the management of neuroblastic tumours. Some medications such as labetolol and some decongestant drugs interfere with its uptake and should be withdrawn prior to tracer injection for a variable time up to 1 week.

The radiation dose from the CT component of the study is often well below 1 mSv, if child-friendly CT protocols are used. The distribution of Tcm-MDP depends on blood flow and bone turnover. Tracer uptake is related to osteoblastic activity. The EDE given by a bone scintigraphy in a child varies between 3.

PET is gradually been introduced as a molecular imaging modality in paediatric oncology. A PET study is usually supplemented by a low-dose CT scan for attenuation correction and anatomical localization. Fluorofluorodeoxyglucose FDG , a positron emitter that reflects tumour glucose metabolism, is the main radiotracer currently used. FDG is taken up through a transmembrane glucose transporter but does not enter the energy producing metabolic pathways. Tracer uptake correlates with glucose metabolism. The added radiation dose from the CT component of the study is in the order of 2 mSv.

A dedicated fully diagnostic CT chest is required to demonstrate lung disease. In the adult practice recent studies have shown that a patient with early resolution of disease during chemotherapy has a better prognosis, 33 and radiotherapy at the sites of the original disease is not indicated.

The majority of patients with neuroblastoma present with distant metastases Stage IV or M. Neuroblastoma tends to metastasize predominantly to the skeleton cortical bone and bone marrow ; other sites of metastatic disease include regional and distant lymph nodes, and, less frequently, liver, skin, brain and lung. ImIBG is used in neuroblastoma staging. The bulk of mIBG avid metastatic skeletal disease at diagnosis has prognostic value: the presence of more than three sites of mIBG avid metastatic skeletal disease is associated with a poorer prognosis in comparison to less than three sites Fig.

This tracer is also valuable in the evaluation of response to chemo- and radiotherapy. The bulk of residual disease following chemotherapy has prognostic significance. Four year old girl with a right suprarenal mass lesion, raised urinary catecholamines and a diagnosis of poorly differentiated neuroblastoma on biopsy.

The ImIBG scan at staging planar images shows avid tracer uptake within the primary tumour in the left suprarenal region and widespread skeletal metastatic infiltration. The patient was treated with an aggressive chemotherapy regimen and achieved complete remission of the metastatic deposits. The primary neuroblastoma was completely excised. Bone scintigraphy has currently no role to play in children with neuroblastoma. It fails to identify bone marrow disease, very frequent in neuroblastoma.

Cortical bone metastases can be visualized; however, as skeletal uptake of the bone scan tracer reflects an on-going osteoblastic activity, abnormal cortical uptake may persist as a false positive finding even when the metastatic lesions have resolved. Imaging of the central nervous system CNS tumours is mainly based on magnetic resonance imaging MRI as the cornerstone imaging modality.

Imaging in pediatric skeletal trauma : techniques and applications

Although MRI provides good sensitivity and specificity, this technique presents some pitfalls. The borders of tumour mass not always coincide with the MRI findings. Some brain tumours tend to have a heterogeneous cell population, with highly malignant cells alternating to cells with less pronounced cellular atypias. A significant problem often encountered in the evaluation of response to surgery and radiotherapy is the difficulty in distinguishing between recurrent tumour and post-radiotherapy fibrosis. This assumes that changes seen on imaging represent the biological activity of the tumour itself.

However, this is not always the case. Molecular imaging in CNS tumours with PET can be used to analyse physiologic and metabolic changes in healthy and pathologic tissue, monitoring treatment effect and detection of recurrence. FDG is not an ideal tracer for brain tumours, due to the physiological high uptake within the normal brain.

However, high-grade brain tumours show highly increased FDG uptake, often higher than the normal brain.

MDCT of the Musculoskeletal System: Skeletal Trauma: A New Look at a Classic Application

FDG uptake is a predictor of prognosis and is particularly useful for distinction of brain lymphoma from non-malignant lesions. The best studied amino acid tracer is Cmethionine. Because of the short half-life of C 20 min , Flabelled aromatic amino acids have been developed for tumour imaging. The distinction between radiotherapy induced necrosis and recurrent tumour is a persistent challenge in the management of brain tumours. All available tracers have demonstrated potential to assist with this distinction but the results from various studies show considerable variation in sensitivity and specificity.

PET imaging techniques are also increasingly being used to improve the accuracy of histologic diagnosis by targeted biopsies and for radiotherapy planning. The histology of RMS varies, with two main subtypes alveolar and embryonal found in children. The primary tumour is usually best imaged by MRI, including draining lymph nodes. CT of the chest, bone scintigraphy and bone marrow aspirate and trephine biopsy are routine part of the staging. Osteosarcoma accounts for 2. Imaging tests at diagnosis include plain radiographs and MRI of the primary tumour, CT of the primary tumour and lungs frequent site of metastases , bone scintigraphy to show metastatic bone disease.

Ewing's sarcoma classically occurs in the second decade of life, affecting fewer than three in every 1 million children under 15 years of age. Plain radiographs may reveal the moth-eaten bone with raised periosteum. MRI defines the extent of soft tissue involvement. Metastatic disease should be sought in the lungs chest CT , bones bone scan and bone marrow aspirates. In inflammatory bowel disease IBD the Tcm-labelled white cell scan has been used to differentiate between active inflammation, which may respond to medical therapy, and scarring, which may require surgery.

Bone scintigraphy with Tcm-labelled diphosphonates has been successfully used in musculo-skeletal MSK conditions for many years. Bone scintigraphy in children can be performed in the following conditions: osteomyelitis, chronic recurrent multifocal osteomyelitis CRMO , inflammatory arthropathies, sports injuries, back pain, avulsion fractures, localization of the source of pain, non-accidental trauma, avascular necrosis of the bone, benign bone tumours, fibrous dysplasia, hyperostosis, oncological disorders osteosarcoma, Ewing's sarcoma, rhabdomyosarcoma with unfavourable prognosis.

However, and especially in the presence of localizing symptoms and following an X-ray radiograph, MRI tends to be favoured as the first-choice investigation in some of these conditions. If MRI is not readily available or the child needs sedation or GA, and this is difficult to organize, bone scintigraphy is usually the next choice. Osteomyelitis is a common problem in paediatrics; it may be haematogenous or the result of penetrating trauma.

When the spread of infection is haematogenous, the metaphysis of long bones is most likely to be involved owing to the slow blood flow, although flat bones may also be affected. In a suspected osteomyelitis with symptoms localizing to a particular skeletal segment, the first imaging test is a plain X-ray, usually followed by MRI. If a focus is identified, no further imaging is necessary. If there are no localizing symptoms, or MRI is not readily accessible, a three-phase bone scan is justified.

High quality bone scanning is highly sensitive for osteomyelitis, with hyperaemia and highly increased tracer uptake demonstrated at the focus of infection. Bone scintigraphy can be helpful in inflammatory conditions such as juvenile rheumatoid arthritis, IBD, psoriasis and connective tissue disease such as systemic lupus erythematous, especially where access to MRI is more difficult. Bone scintigraphy is more sensitive than radiography and clinical examination for detecting inflammatory joint disease of wrists, hands, ankles and feet.

In addition, a negative bone scintigraphy accurately excludes active arthritis in patients with persistent polyarthralgia. In these conditions MRI is often negative or equivocal, and a CT scan fails to differentiate between areas of sclerosis, due to an old inactive process, and on-going active mechanical stress. Also, recent spondylolysis with increased tracer uptake on bone scan could be managed with surgical fixation, while old spondylolysis with no tracer uptake needs bone grafting as well to facilitate union of the two ends of the fracture. Recurrent right sided low back pain. The planar images of the bone scintigraphy a show a focal area of mildly increased tracer uptake in the right side of L5; however, no precise anatomical localization is possible to guide further treatment.

This finding prompted steroid injection at this site. Nuclear medicine can be successfully utilized in the evaluation of gastro-intestinal GI motility. Gastric emptying scintigraphy is sensitive, physiological, non-invasive and safe in patients presenting with symptoms suggestive of abnormal gastric emptying. An anatomical obstruction, due for example to intestinal malrotation, must be excluded with a radiological contrast study prior to the scintigraphic study. In infants and new-born children, gastric emptying is assessed scintigraphically using milk or formula radiolabelled with Tcm-sulphur colloid.

In older children a radiolabelled solid meal based on eggs, cheese or other feed can be used. The EDE given by a gastric emptying study in a child is between 0. Some state that eighty percent of deaths of children under 2 years of age result from nonaccidental head trauma. A baby's neck muscles are very weak and its head is large and heavy in proportion to the rest of its body. The infant brain is poorly myelinated and is surrounded by larger subarachnoid spaces than the brain in older children and adults. When a baby is shaken, the neck snaps back and forth, much like in a whiplash injury, causing the brain to hit the front and back of the skull.

This can damage the brain and cause it to bruise, bleed and swell. Imaging studies of the head may show subdural or subarachnoid bleeding, diffuse axonal injury and associated cerebral edema or older injuries such as subdural effusions. The case on the left shows an ultrasound examination that demonstrates an old and a new subdural hematoma in an abused child. Subdural hematomas arise from disruption of delicate bridging veins extending from the cortex to the dural sinuses. Although bleeding can occur at any site, the tendency is for blood to extend into the posterior interhemispheric fissure.

MR examination is even more sensitive in detecting subdural hematomas. The case on the left shows chronic bilateral subdural hematomas and new subdural hematomas in the right frontal and posterior interhemispheric region. The bright signal is a result of methemoglobin indicating subacute hematoma about one week old.

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Visceral injury Visceral injury is seen at autopsy of young infants, but it is rarely documented radiologically in living victims less than 1 year of age. The mean age of these children is about 2 years, which is older than the cases we have discussed before. It is more common in boys than girls. These children are brought to the hospital days after the injury, when a perforation already has resulted in peritonitis and sepsis. The history given by the abusers usually does not correlate with the symptoms, which makes these cases very difficult to evaluate for the clinician.

The most common non-accidental abdominal injuries are: - visceral perforation or hematoma - liver- and pancreatic laceration - adrenal bleeding Suprisingly the most common abdominal accidental injuries, which are laceration or subcapsular bleeding of the spleen and the kidney, are unusual in these children. The figure on the left shows a case of pancreatic laceration in child abuse.

The figure on the left shows a case of liver laceration in child abuse. These abdominal injuries are non specific and could also be attributed to accidental injury. However in most of these cases of child abuse, there is a history that does not correlate well with the injuries, that are found. So you have to look for other more specific skeletal injuries in these children. Retinal hemorrhage Retinal hemorrhage is seen in nearly all cases of infant abuse in which shaking is documented.

Cervical spine compression Cervical spine compression results as shaking or impact injury damages the spinal cord. Infants are vulnerable to spinal cord injury because of their large head and weak underdeveloped paraspinous and neck musculature. Spinal cord injury may be difficult to document. These infants may exhibit apnea or vasomotor collapse similar to spinal shock. Radiographic skeletal survey is necessary in all children less than 2 years old suspected of abuse.

It consists of individual AP X-rays of chest, skull also lateral and extremities. In children 12 months or younger, also perform a lateral thoracolumbar spine film. Head CT scan shoud be performed on all suspected abuse victims 1 year of age or younger and in all children with neurological symptoms. Expert attention to technique and detail is necessary to get quality radiographs that show some of the very subtle injuries of abuse.

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  • Do not perform a 'babygram'. Remember that these are the radiographs that will go to court. Repeated skeletal imaging in days may provide evidence of a healing injury, that was inapparent on the initial study. Nuclear bone scan is usually not necessary. Perform this if there are equivocal findings on the skeletal survey or if there is a high clinical suspicion of skeletal injury but the skeletal survey is normal.

    Plain X-rays of the skeleton in the areas of abnormality identified at bone scan, are still needed to evaluate for the exact nature of the abnormality. Abusive head trauma AHT is a major cause of morbidity and mortality in children subjected to abuse, accounting for nearly one-third of all deaths caused by child abuse.

    Recent studies suggest healthcare providers had previously seen nearly one-third of children who subsequently died from AHT in the time leading up to their death. Efforts continue to be made to understand the underlying pathogenesis and mechanisms of AHT. However, the exact mechanisms of injury are often unknown and may result from a combination of forces. Parenchymal damage further can be multifactorial; for example, intracranial hemorrhage, hypoxic-ischemic injury and axonal disruption may all result in cytotoxic edema.

    In addition to evaluating brain injury, increasing emphasis has been placed on imaging of the orbits, olfactory tracts, and cervical spine. We outline current imaging techniques appropriate for the evaluation of AHT, highlighting their unique contribution to obtaining an accurate and timely diagnosis, as well as common radiologic findings.

    Noncontrast head CT is considered the appropriate primary study for children who present with signs and symptoms of head trauma including loss of consciousness, confusion, vomiting, irritability, seizures, or respiratory difficulties.

    Techniques and Applications

    CT is rapid, cost effective, widely available, and able to reveal injuries that may need rapid surgical intervention, including hemorrhage, midline shift, and herniation. Contrast should generally be avoided, as it can obscure high-density acute hemorrhage often found in AHT. Although the risk of ionizing radiation associated with CT should always be a consideration, it is widely accepted that the benefits of obtaining a CT in substantial trauma far outweigh the risks. Furthermore, in cases of suspected trauma when clinical evaluation may be difficult or indeterminate, or in cases when abuse is strongly suspected even without major neurological symptoms, head CT should be obtained, as studies have shown CT can detect occult head trauma even in cases of children with normal exams.

    Thus, facial or skull radiographs are often not necessary and may only serve as a source of supplemental information. In particular, interhemispheric, convexity, and posterior fossa hematomas are individually associated with AHT 17 and significantly elevated in AHT versus accidental trauma 27 Figure 1A. Noncontrast CT is also useful for detecting the reversal sign, a phenomenon in which there is an inversion of the normal attenuation relationship between gray and white matter where gray matter has lower attenuation than white matter and there is an increased attenuation of the thalami, brainstem, and cerebellum.

    Positive cases of acute trauma on CT should be evaluated in conjunction with head MRI within hours to better define extent of injury. Additionally, if the head CT is negative but trauma is strongly suspected by clinical evaluation, MRI should be obtained, as CT is often negative in the acute setting.

    Conventional sequences in particular are better able to demonstrate recurrent episodes and evolution of injury by helping to date subacute and chronic hematomas, combating one of the challenges of CT Figure 1C. T1-weighted imaging will often demonstrate hyperintensity of the cortical ribbon, identifying hemorrhagic cortical contusions or laminar necrosis.

    Identifying ischemia on T2-weighted imaging is challenging in infants and young children due to the high water content of unmyelinated white matter; however, loss of gray-white distinction along cortex and in deep nuclei can be a clue.

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    Conventional MRI sequences have also been shown to detect additional injuries not initially detected by CT including SDH, shearing injuries, ischemia, and parenchymal hemorrhages. In order to avoid the use of anesthesia, as well as potentially eliminate the need for an initial CT, the use of rapid MRI sequences has gained recent attention in evaluation of intracranial pathology in the pediatric population; however, a recent study suggests ultrafast MRI, even in combination with noncontract CT, has lower sensitivity compared to conventional MRI in patients with suspected AHT 33 and therefore is not generally used in this setting.

    DWI often reveals more extensive injury than conventional sequences Figure 1D. Diffuse supratentorial or posterior cerebral are the most frequently reported patterns Figure 4A. DTI is currently considered a useful technique in the evaluation of microstructural white matter abnormalities, as it is a direct measure of injury to axonal fibers. These findings suggest that DTI is able to detect additional white matter changes that may be helpful in predicting long-term outcomes; however, it is also important to note that a negative DTI does not exclude AHT.

    Susceptibility-weighted imaging —SWI is a 3D high-resolution MRI technique that accentuates the paramagnetic properties of blood products. Examples of better visualized abnormalities include hemorrhagic foci associated with DAI, 52,53 clot formation within injured bridging veins, and hemosiderin deposition in superficial siderosis 32,54,55 Figure 3D. Bridging vein thrombosis, in particular, is considered a sign of traumatic SDH in the context of AHT, as evidenced by blooming within bridging veins on SWI and often without signs of venous infarction.

    MR Spectroscopy— MRS is a noninvasive imaging technique that acquires concentration levels of various metabolites that are indicative of underlying neuronal dysfunction. Lactate elevation is widely known to result from hypoxic-ischemic damage as neurons switch to anaerobic metabolism. Confirming diffuse brain injury with spectroscopy, if available, can aid in early management and intervention. Instead of contrast, ASL uses magnetically labeled water molecules in arterial blood as an endogenous tracer, making ASL a noninvasive technique for quantifying cerebral blood flow.

    An investigation of perfusion using ASL in patients with AHT found children with AHT had more perfusion abnormalities compared to those without AHT and children with the most significant hypoperfusion had the poorest clinical outcomes. When AHT is suspected, special attention should be paid to the retina and other orbital structures. As noted above, retinal hemorrhages are considered highly specific for AHT. They are often bilateral, extensive and multilayered in this context, and their presence indicates an acceleration-deceleration type mechanism. High-resolution imaging of the orbits, olfactory bulbs, and other cisternal structures can be readily performed with balanced coherent steady-state free precession bSSFP imaging.

    This sequence provides superior contrast for fine structures that are profiled by fluid or fat, making it ideal for delineating the small anatomic structures of the orbits, skull base, and exiting craniospinal nerves. The evaluation of pediatric AHT is an ongoing diagnostic challenge as there are currently no standard criteria for differentiating AHT from accidental trauma. Clinical presentation and histories are often nonspecific, and thus investigations always warrant a thorough, multi-disciplinary approach including skeletal surveys and ophthalmologic exam.

    Neuroradiologic imaging is vital in the evaluation of suspected cases, potentially offering insight into the mechanisms of injury and long-term prognosis. Nguyen D, de Kanztow L. Neuroimaging of pediatric abusive head trauma. Appl Radiol. Section Neuroimaging of pediatric abusive head trauma. Imaging modalities Computerized tomography Noncontrast head CT is considered the appropriate primary study for children who present with signs and symptoms of head trauma including loss of consciousness, confusion, vomiting, irritability, seizures, or respiratory difficulties.

    Other imaging considerations When AHT is suspected, special attention should be paid to the retina and other orbital structures. Child maltreatment deaths in the U. Child Abuse Negl. Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma. Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury.

    A comparison of accidental and nonaccidental trauma: It is worse than you think.