Imaging of Non-accidental Trauma — MCQs

10 questions

Which of the following is not a differential diagnosis of non-accidental injury?

Which of the following is not done in the primary survey of trauma?

A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?

Which of the following is a characteristic feature of Battered Baby Syndrome (Non-Accidental Injury)?

A traumatic injury to an 8-year-old child, with marking of a rickshaw tyre found on the body, is an example of -

An intrauterine scan at the 13th week of pregnancy showed a fetus with multiple long bone fractures. What is commonly associated with this finding?

Investigation of choice for diagnosis of splenic rupture –

Shape of extradural hematoma on NCCT is?

The following X-ray is used to evaluate \qquad sinus?

Q10

What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?

Imaging of Non-accidental Trauma Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is not a differential diagnosis of non-accidental injury?

A. Osteogenesis imperfecta
B. Scurvy
C. Caffey's disease
D. Osteopetrosis (Correct Answer)

Explanation: ***Correct: Osteopetrosis*** - Osteopetrosis is a rare genetic disorder characterized by **increased bone density** due to defective osteoclast function - While it causes bones to be brittle and prone to fracture, it has **distinctive radiological features** including diffuse sclerosis and "bone-within-bone" appearance - The **increased bone density on X-ray** is pathognomonic and readily distinguishes it from NAI, making it **less likely to be confused** with non-accidental injury in clinical practice - Fractures occur but the radiological pattern is diagnostic of the underlying metabolic bone disease *Incorrect: Osteogenesis imperfecta* - This is a **classic differential** for NAI causing **multiple brittle bone fractures** that can be mistaken for abuse - Features include **blue sclera**, **dentinogenesis imperfecta**, **wormian bones**, and **family history** - Often presents with multiple fractures at different stages of healing, mimicking the pattern seen in NAI *Incorrect: Scurvy* - Caused by **vitamin C deficiency**, leads to defective collagen synthesis - Results in **subperiosteal hemorrhages**, **metaphyseal fractures**, and **periosteal elevation** that closely mimic NAI - Additional features include **gingival bleeding**, **petechiae**, **follicular hyperkeratosis**, and **poor wound healing** *Incorrect: Caffey's disease* - Also known as **infantile cortical hyperostosis**, presents in infants under 6 months - Causes **periosteal reactions**, **bone thickening**, and **soft tissue swelling** in long bones, ribs, and mandible - The periosteal new bone formation can be mistaken for healing fractures from NAI, making it an important differential

Question 2: Which of the following is not done in the primary survey of trauma?

A. Intubation
B. NCCT head (Correct Answer)
C. ICD drainage
D. CXR

Explanation: ***NCCT head*** - A **Non-Contrast CT (NCCT) head** is typically performed during the **secondary survey** once the patient is hemodynamically stable and life-threatening conditions have been addressed. - The primary survey focuses on immediate **life-saving interventions** for airway, breathing, circulation, disability, and exposure. *Intubation* - **Intubation** is a critical intervention during the primary survey, specifically under the **'A' (Airway)** component, to establish and secure a patent airway in a compromised patient. - Failure to establish an airway can rapidly lead to **hypoxia** and death. *ICD drainage* - **Intercostal drain (ICD) drainage** is an urgent intervention in the primary survey, falling under **'B' (Breathing)**, to manage conditions like **tension pneumothorax** or massive hemothorax. - These conditions can severely compromise ventilation and circulation, requiring immediate relief. *CXR* - A **Chest X-ray (CXR)** is a rapid and essential diagnostic tool in the primary survey, also under **'B' (Breathing)**, to identify life-threatening thoracic injuries such as pneumothorax, hemothorax, or mediastinal shift. - It provides quick information crucial for immediate management decisions.

Question 3: A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?

A. MRI
B. CECT
C. NCCT (Correct Answer)
D. X-ray

Explanation: ***NCCT*** - **Non-contrast Computed Tomography (NCCT)** of the head is the **investigation of choice** for acute head trauma due to its rapid acquisition, wide availability, and excellent sensitivity for detecting acute hemorrhage, fractures, and mass effects. - It rapidly identifies life-threatening conditions such as **epidural, subdural, and intracerebral hemorrhages**, which require immediate intervention. *MRI* - **MRI** is superior for detecting subtle brain tissue injuries, diffuse axonal injury, and non-hemorrhagic lesions but is generally **not the first-line investigation** in acute trauma due to longer scan times, limited availability in the emergency setting, and inability to detect acute hemorrhage as clearly as CT. - Its use is typically reserved for follow-up studies or when CT findings are inconclusive or specific soft tissue detail is required. *CECT* - **Contrast-enhanced CT (CECT)** of the head is reserved for specific indications like evaluating vascular lesions (e.g., aneurysms, arteriovenous malformations) or tumors, which are generally **not the primary concern** in the initial assessment of acute head trauma. - Administering contrast agents can delay imaging, may pose risks to patients with renal impairment or allergies, and does not significantly improve the detection of acute traumatic hemorrhage compared to NCCT. *X-ray* - **X-rays** of the skull are useful for detecting **skull fractures**, but they provide **limited information** regarding intracranial injuries or soft tissue damage, which are critical in head trauma. - They have largely been superseded by CT scans, which offer a more comprehensive view of both bony structures and intracranial contents.

Question 4: Which of the following is a characteristic feature of Battered Baby Syndrome (Non-Accidental Injury)?

A. Stab injury
B. Firearm injury
C. Bruises of varying ages (Correct Answer)
D. None of the options

Explanation: ***Bruises of varying ages*** - The presence of bruises at **different stages of healing** is a hallmark indicator of **non-accidental trauma** or Battered Baby Syndrome, as it suggests repeated injuries occurring over time rather than a single incident. - **Forensic significance**: Fresh bruises (red/purple) alongside older bruises (yellow/green/brown) indicate multiple episodes of trauma, which is inconsistent with the caregiver's explanation of a single accidental event. - Other classic features include fractures (especially metaphyseal/corner fractures, rib fractures), subdural hematomas, retinal hemorrhages, and injuries in protected body areas. *Stab injury* - While a stab injury represents severe trauma requiring forensic investigation, it is **not characteristic** of the typical presentation pattern of Battered Baby Syndrome. - Stab wounds indicate a specific violent act rather than the pattern of **repeated blunt force trauma** that defines the syndrome. - Battered Baby Syndrome classically involves injuries from shaking, hitting, or blunt trauma rather than penetrating injuries. *Firearm injury* - A firearm injury is a distinct acute traumatic event that does not represent the **chronic, repetitive abuse pattern** seen in Battered Baby Syndrome. - Such injuries are typically isolated incidents rather than part of ongoing physical abuse with varied injury ages. - The syndrome is characterized by multiple injuries at different healing stages from repeated episodes, not single penetrating trauma. *None of the options* - This option is incorrect because "bruises of varying ages" is a **well-established forensic indicator** for diagnosing Battered Baby Syndrome in medical literature and practice. - The presence of injuries at multiple stages of healing is one of the most important diagnostic features that raises suspicion for non-accidental injury in pediatric forensic medicine.

Question 5: A traumatic injury to an 8-year-old child, with marking of a rickshaw tyre found on the body, is an example of -

A. Pattern bruises (Correct Answer)
B. Imprint abrasion
C. Percolated bruise
D. Contusion

Explanation: ***Pattern bruises*** - This scenario describes **pattern bruising**, where the **shape of the injuring object** (rickshaw tyre) is clearly visible on the body. - Pattern bruises are indicative of severe trauma and provide crucial **forensic evidence** about the **weapon or mechanism of injury**. - This is the **specific forensic medicine term** for bruises that retain the characteristic pattern of the causative object. *Imprint abrasion* - An imprint abrasion occurs when the **surface features of an object are scraped onto the skin**, leaving a superficial injury with disruption of the epidermis. - This typically involves **scraping or rubbing** of the skin surface, whereas the question describes **marking** on the body, which in forensic context refers to a bruise (subcutaneous hemorrhage) rather than a superficial abrasion. *Percolated bruise* - A percolated bruise refers to a bruise where the **blood has spread extensively** through the tissue planes, often making its initial impact site difficult to discern. - The pattern becomes **diffuse and indistinct**, which is the opposite of the clear tyre marking described in the question. *Contusion* - A contusion is the **general medical term** for a bruise - any blunt force injury causing damaged capillaries and blood vessels with subcutaneous bleeding. - While the injury IS technically a contusion, **"pattern bruise" is the more specific and correct forensic medicine terminology** that describes a contusion with the distinctive shape of the causative object. - In forensic medicine, specificity matters - we use "pattern bruise" to immediately convey that the injury has evidential value showing the weapon's characteristics.

Question 6: An intrauterine scan at the 13th week of pregnancy showed a fetus with multiple long bone fractures. What is commonly associated with this finding?

A. Osteogenesis imperfecta (Correct Answer)
B. Marfan syndrome
C. Achondroplasia
D. Cretinism

Explanation: ***Osteogenesis imperfecta*** - **Multiple long bone fractures** detected early in pregnancy are a classic presentation of **osteogenesis imperfecta (OI)**, a genetic disorder characterized by **bone fragility**. - OI is primarily caused by mutations in genes encoding **type I collagen**, leading to defective bone formation. *Achondroplasia* - This condition is a form of **dwarfism** characterized by disproportionately short limbs and a normal-sized trunk, resulting from a mutation in the **FGFR3 gene**. - While it affects bone growth, it typically does not cause **multiple fractures** prenatally. *Marfan syndrome* - This is a connective tissue disorder affecting the skeletal, ocular, and cardiovascular systems, characterized by **tall stature**, **long limbs and fingers**, and **aortic root dilation**. - It results from a mutation in the **fibrillin-1 gene** and is not primarily associated with prenatal long bone fractures. *Cretinism* - This is a historical term for **congenital hypothyroidism**, which results from severely deficient thyroid hormone production in a newborn. - It leads to developmental delays, growth retardation, and intellectual disability, but not to **multiple bone fractures**.

Question 7: Investigation of choice for diagnosis of splenic rupture –

A. MRI
B. Peritoneal lavage
C. Ultrasound
D. CT scan (Correct Answer)

Explanation: **CT scan** - A **CT scan** with intravenous contrast is the investigation of choice for splenic rupture due to its high sensitivity and specificity in detecting **splenic injury**, **hematomas**, and **free intraperitoneal fluid**. - It provides detailed anatomical information, crucial for grading the injury and guiding management decisions, especially in hemodynamically stable patients. *MRI* - **MRI** offers excellent soft tissue contrast, but it is **time-consuming** and often **not readily available** in emergency settings for acute trauma. - It is typically reserved for more chronic or complex cases where detailed soft tissue characterization is not immediately needed in acute trauma. *Peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** is an **invasive procedure** that is less specific than imaging for diagnosing splenic rupture. - It detects the presence of **intraperitoneal bleeding** but does not localize the injury or provide information about the extent of organ damage. *Ultrasound* - **Ultrasound (FAST exam)** is a rapid, non-invasive tool for detecting **free fluid** in the abdomen but has limited sensitivity for directly visualizing the spleen or accurately grading splenic injuries. - While useful for rapid assessment of **hemodynamically unstable** patients, a **negative FAST exam does not rule out splenic injury**, especially in stable patients.

Question 8: Shape of extradural hematoma on NCCT is?

A. Bean shaped
B. Crescent shaped
C. Lens shaped (Correct Answer)
D. Medially concave

Explanation: ***Lens shaped*** - An **extradural hematoma** (EDH) appears **biconvex** or **lens-shaped** because it is limited by the cranial sutures, where the dura mater is tightly attached to the inner table of the skull. - This characteristic shape helps differentiate it from other intracranial hemorrhages on **non-contrast CT (NCCT)** scans. *Bean shaped* - While descriptive, "bean-shaped" is not the standard or most accurate descriptor for an EDH, which is typically more organized and sharply delineated due to its confinement. - This term might be loosely applied to other lesions but lacks the precision needed for a confident diagnosis of EDH. *Crescent shaped* - A **crescent shape** is characteristic of a **subdural hematoma (SDH)**, which spreads more freely over the brain surface as it is located between the dura and arachnoid mater, not limited by sutures. - This shape indicates bleeding across suture lines, a key differentiator from EDH. *Medially concave* - This describes the typical appearance of a **subdural hematoma** (SDH), where the collection of blood conforms to the curvature of the brain surface and can extend across suture lines. - An EDH is typically **convex** towards the brain parenchyma because of the dura's adherence to the skull at the sutures.

Question 9: The following X-ray is used to evaluate \qquad sinus?

A. Frontal
B. Maxillary (Correct Answer)
C. Ethmoidal
D. Sphenoidal

Explanation: ***Maxillary*** - The image provided is a **Waters' view** (occipitomental view) X-ray of the paranasal sinuses, which is primarily used to visualize the **maxillary sinuses**. - In a Waters' view, the **petrous ridges** (dense bone at the base of the skull) are projected below the maxillary sinuses, allowing for a clear view of these sinuses. *Frontal* - While the **frontal sinuses** are visible in a Waters' view, they are generally better visualized in a **Caldwell view** (occipitofrontal view) or lateral view. - In this projection, their visualization can be obscured by other bony structures, and they are not the primary focus. *Ethmoidal* - The **ethmoidal sinuses** are typically comprised of multiple small air cells located between the orbits and are best seen on a **Caldwell view** or specialized oblique views. - In a Waters' view, their evaluation is limited due to superimposition of other facial bones. *Sphenoidal* - The **sphenoidal sinuses** are located deep within the skull, inferior to the sella turcica, and are quite difficult to visualize on standard plain radiographs like the Waters' view. - They are best assessed using a **lateral view of the skull** or advanced imaging like **CT scans**.

Question 10: What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?

A. Contrast enhanced computed tomography (Correct Answer)
B. Retrograde urogram
C. Intravenous urogram
D. Ultrasonography of abdomen

Explanation: ***Contrast enhanced computed tomography (CECT)*** - **CECT** is the **investigation of choice** for evaluating solid organ injuries, including renal trauma, in hemodynamically stable patients with blunt abdominal trauma and hematuria. - It provides detailed imaging of the kidneys, urinary tract, and surrounding structures, allowing for the classification of injury severity and identification of associated injuries. *Retrograde urogram* - A retrograde urogram is primarily used to evaluate the **lower urinary tract** (urethra and bladder) for strictures or injuries, specifically when there is a suspicion of urethral injury. - It is not the primary imaging modality for assessing renal parenchymal or collecting system injuries from blunt trauma. *Intravenous urogram (IVU)* - While an IVU can assess the upper urinary tract, it has largely been replaced by **CECT** in the acute trauma setting due to CECT's superior resolution and ability to evaluate renal parenchyma and other abdominal organs. - IVU exposes the patient to radiation and requires contrast administration, and it may not adequately visualize subtle renal injuries or hematomas as effectively as CECT. *Ultrasonography of abdomen* - **Ultrasound** is useful for rapidly detecting free fluid (suggesting hemorrhage) or gross hydronephrosis in trauma, but it has limited sensitivity for diagnosing specific renal parenchymal injuries or urinary extravasation. - Its role in blunt abdominal trauma with hematuria is often as an initial screening tool, but it is not sufficient for definitive diagnosis or grading of renal injuries.

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