| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Commentary |
1 Department of Radiology, Section of Musculoskeletal Imaging, Children's Hospital Boston and Harvard Medical School, 300 Longwood Ave., Boston, MA 02115.
Received September 26, 2007; accepted after revision September 27, 2007.
Address correspondence to P. K. Kleinman
(paul.kleinman{at}childrens.harvard.edu).
Keywords: bone • bone injuries • child abuse • fractures • history of 20th century medicine • infant • radiography • radionuclide imaging
It is not often appreciated that many individuals responsible for the care of infants and children (who cannot give their own history) may permit trauma and be unaware of it, may recognize trauma but forget or be reluctant to admit it, or may deliberately injure the child and deny it [1].
This passage appears in the introduction of Frederic N. Silverman's [1] classic article detailing the radiographic findings in infants with "unrecognized skeletal trauma." His report appeared 8 years after John Caffey's [2] groundbreaking AJR article describing infantile subdural hematoma and long-bone fractures. Like his mentor, Caffey, Silverman was trained in clinical pediatrics and then turned his interests to diagnostic radiology, first as a special assistant and then as junior associate to Caffey. He had been working with Caffey for just 9 months, a time he described as a "glorious gestational period," when the Caffey article was published. The cases described in Silverman's 1953 article were first shared with Caffey to be certain that the master agreed with his protégée [3].
The Silverman [1] article described the clinical, laboratory, and radiographic findings in three infants (age range, 2–7 months). Thematically, these cases were grouped not because of any explicit indication that the infants were abused but because their skeletal trauma was "unrecognized." In a relatively lengthy manuscript, Silverman artfully described in painful detail how the skeletal injuries in these three infants were unrecognized despite multiple interactions with health care providers. In contrast to the nonspecific long-bone shaft injuries emphasized by Caffey [2], Silverman described and illustrated the two most important and specific injuries highly associated with infant abuse.
In a 4.5-month-old infant, Silverman [1] described a healing fracture of the posteromedial aspect of the left 10th rib. This type of fracture occurs with severe anteroposteri- or thoracic compression and is often seen in infants dying of inflicted head injury [4]. In all three cases, he noted metaphyseal lesions, curious injuries that Caffey [5] latter classified as "corner" and "bucket-handle" fractures. These classic metaphyseal lesions have distinctive radiologic and histopathologic features and in otherwise normal infants are strong indicators of inflicted injury [6].
Silverman's [1] description in case one of a proximal femoral epiphyseal separation illustrates how this injury can easily be confused with a dislocated hip when the femoral head is not yet ossified—without the aid of sonography or MRI! He stressed the importance of followup radiography to document injuries that are inapparent or confusing on initial radiographs. Subsequent studies have shown the utility of follow-up skeletal surveys in suspected infant abuse, and this approach is now recommended by the American College of Radiology and the American Academy of Pediatrics [7, 8].
Despite a rigorous clinical approach to his subject, one cannot mistake the deep personal interest shown by Silverman [1] in these three injured infants. In case two, he noted, "The roentgen diagnosis of traumatic lesions in the skeleton was strongly resisted by pediatricians and orthopedists interested in the child." This led him to a personal interview with the parents, during which a "long series of episodes of trauma was discovered." These seminal observations were followed by Silverman's collaboration with the noted pediatrician, Henry Kempe, and their work culminated with the landmark article, "The Battered Child Syndrome" published in 1962 in the Journal of the American Medical Association [9].
Always the scholar, Silverman [1] placed his important work in a historical context, drawing attention to the studies of Ambroise Tardieu [10], professor of legal medicine at the University of Paris, who in 1860 published an article on the maltreatment of children. Accordingly, Silverman suggested the term "the syndrome of Ambroise Tardieu" to characterize the disorder [11]. It is notable that despite the earlier work of Tardieu, some of Silverman's French colleagues preferred the term "Le syndrome de Silverman" [12].
On first reading, one might be inclined to criticize Silverman [1] for his use of the term "unrecognized skeletal trauma" in describing the findings in these infants rather than explicitly indicating that these infants suffered maltreatment. Silverman made it quite clear that he chose his language carefully and made reference to similar concerns held by Caffey [2, 3] during the preparation of his earlier articles. In describing these injuries as unrecognized rather than inflicted, Silverman focuses on the failure of providers to detect or properly interpret the findings rather than the specific factors responsible for the injuries.
Although an immense body of literature now exists detailing an extraordinary variety of inflicted injuries and the psychological and societal factors influencing child maltreatment, it should be stressed that the first role of the radiologist is to ensure that the appropriate imaging studies are acquired and interpreted in a rigorous fashion. Only then should a determination be made as to whether the findings reflect inflicted injury or one of its mimickers. Frederic Silverman's [1] work reflects this meticulous analytic method and deserves a careful reading by those newly initiated into the field and seasoned radiologists like myself who may have failed to recognize or have forgotten the fine points of this important original scientific contribution.
References
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  R. J. Stanley Reflections on This Month's Wealth of Content Am. J. Roentgenol., March 1, 2008; 190(3): 555 - 555. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
