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<h1>Saskia Hilton Child Abuse Expert witness<br><br>
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SASKIA von WALDENBURG HILTON, M.D.<br>
POSITION:¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝClinical Professor of Radiology and Pediatrics Emeritus
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Department of Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý UCSD Medical Center<br><br>
WORK ADDRESS:¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 578 Gage Lane San Diego, California¬Ý 92106<br><br>
TELEPHONE:¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý (619) 224-6259<br><br>
HOME ADDRESS:¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 578 Gage Lane San Diego, California 92106<br><br>
CHILDREN:¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Ian¬Ý¬Ý¬Ý¬Ý¬Ý 10/11/72
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Keith¬Ý¬Ý 10/14/75
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝAvery¬Ý¬Ý 8/18/77
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝMegan 11/27/79<br><br>
MILITARY SERVICE:
July 1976-January 1980¬Ý¬Ý ¬Ý¬Ý Lieutenant Commander, United States Navy
¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Naval Regional Medical Center, San Diego<br><br>
RESERVE STATUS: ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý None<br><br>
EDUCATION:
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1963-1967¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý B.A., French and German Literature
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Hobart and William Smith Colleges
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Geneva, New York
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1967-1971¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý M.D., University of Nebraska
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý College of Medicine
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Omaha, Nebraska
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1971-1972¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Rotating Internship
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of Nebraska
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý College of Medicine
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Omaha, Nebraska
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1972-1975¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Resident, Diagnostic Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of Colorado Medical Center
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Denver, Colorado
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1975-1976¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Fellow, Pediatric Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of Colorado Medical Center
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Denver, Colorado
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý 2001¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Fellowship, Pediatric Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Children’Äôs Hospital of Cincinnati
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý March - April 2001.
PROFESSIONAL EXPERIENCE:
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1976-1980¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Staff Radiologist
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Chief, Division of Pediatric Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Naval Regional Medical Center
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, CA ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1980-1983¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Assistant Clinical Professor of Radiology and Pediatrics
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Department of Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý La Jolla, California
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1983-1989¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Associate Clinical Professor of Radiology and Pediatrics
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Department of Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý La Jolla, California
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1989-2005¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Clinical Professor of Radiology and Pediatrics
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Department of Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý La Jolla, California
EDITORIAL POSITIONS:
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1986-1991¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Associate Editor, American Journal of Roentgenology
LICENSURE AND CERTIFICATION:
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1972¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Diplomate, National Board of Medical Examiners
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1975¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Diplomate, American Board of Radiology ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý Certificate of Additional Qualifications in Pediatric Radiology by the American Board of Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý #G34535¬Ý¬Ý¬Ý¬Ý California Board of Medical Quality Assurance
HONORS, AWARDS:
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝNew York State Academic Honor Society
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝNew York State Regents College Scholarship
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1970¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Best Student of the Year Award in Otorhinolaryngology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1972¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Woman of the Year Award for William Smith College
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1970¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Smith Kline and French Award Fellowship to study tropical medicine in Africa, Ghana, Liberia (Jan 1970 - April 1970)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1987¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Award of Honor presented by San Diego Chief of Police for volunteer assistance to child abuse detectives
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý1998¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Certificate of Appreciation presented by International Relief Teams for commitment and dedication to The People of Latvia.
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý1998¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Certificate of Appreciation presented by International Relief Teams for commitment and dedication to The People of Lithuania.
PROFESSIONAL SOCIETIES:
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Society for Pediatric Radiology
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Pacific Coast Pediatric Radiology Society
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Midwestern Pediatric Radiology Society
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego Radiological Society
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Radiological Society of North America
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý The Society of Breast Imaging
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Council of Biology Editors
PUBLISHED PRESENTATIONS:
November 29, 1975¬Ý¬Ý¬Ý Stables DP, Hilton S, Friedland GW
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"The Radiologic Diagnosis of Perinephric Abscess"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSociety of Uroradiology Annual Scientific Meeting
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝChicago, Illinois
March 1981¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬ÝHilton SvW, Edwards DK
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"The Radiographic Diagnosis of Appendicitis in Neonates and the Premature Infant"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSociety for Pediatric Radiology Annual Meeting
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSan Francisco, California
May 1982¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Epiphyseal Fracture Separation in Child Abuse"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý26th Annual Society for Pediatric Radiology Members Miscellany
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝNew Orleans, Louisiana
April 1983¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"Abberant Right Subclavian Artery Producing Chest Pain and Dysphasia"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý27th Annual Society for Pediatric Radiology Members Miscellany
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝAtlanta, Georgia
October 1983¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Cohen G, O'Connor R, Hilton SvW, Jalowayski A
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝAbstract, Presented to the American Academy of Allergy and
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝImmunology.¬Ý Nasal Cytograms and Sinus Disease.
Nov. 25-30, 1984¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý vanSonnenberg E, Hilton SvW, Coons HG, Edwards DK, Carey PH, Wittich GR, Self TW
¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý "Interventional Radiology in Pediatrics"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝRadiological Society of North America
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝWashington, DC
Nov. 25-30, 1984¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Edwards DK, Merrit TA, Hilton SvW, Gluck L
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"Radiographic Findings in Newborn Infants with Respiratory Distress
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSyndrome Treated with Human Surfactant"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝRadiological Society of North America
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝWashington, DC
April 13-18, 1986¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Writing with Style"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝCategorical Review Course, American Roentgen Ray 1986 Meeting
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝWashington Sheraton Hotel
1986¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý Dowd CF, Edwards DK, Coen RW, Bloom BT, Hilton SvW.
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"Chest Shape in Preterm Newborn Infants"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝRadiological Society of North America
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝChicago, Ilinois
Apr. 26-May 1, 1987¬Ý¬Ý"The Organization of a Scientific Paper"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝCategorical Course of the American Roentgen Ray 1987 Meeting
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝFlorida Fontainbleau Hotel
1987¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬ÝEdwards DK, Berry CC, Hilton SvW
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"Chest Radiographic Diagnosis of Trisomy-21 in Newborn Infants"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý(Vol 165, p 190)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝRadiological Society of North America
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝChicago, Illinois 165(p:190)
May 8-13, 1988¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Designing a Study Which is Scientifically Sound"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝCategorical Course of the American Roentgen Ray 1988 Meeting
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSan Francisco Hilton Hotel
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSan Francisco, California
April 19-22, 1990¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Hilton SvW: Wooton SL, Coley BD, Hilton SvW, Edwards DK, Mattrey R
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"The Relative Efficacy of Barium, Nonionic Contrast Media and
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝBrominated Perfluorocarbons in the Diagnosis of Ileal Obstruction"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSociety for Pediatric Radiology Meeting
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝCincinnati Ohio¬Ý
May 14, 1990¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"Fatal Flaws and How to Avoid Them in Scientific Publications"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý90th Annual Meeting of the American Roentgen Ray Society
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝCategorical Refresher Course
May 8, 1991¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Common Errors in Medical Manuscript Preparation:¬Ý How These
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝDecrease Acceptance Rate"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝAnnual Meeting of the Roentgen Ray Society in Boston, Categorical
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝRefresher Course
NONPUBLISHED PRESENTATIONS:
February 1976¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Interstitial Emphysema in Neonates: Complications and Treatment"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝGive Institute
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝAspen, Colorado
June 1977¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Diagnostic imaging in pediatrics, a summary of the state of the art"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Childrens Hospital Grand Rounds
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSan Diego, California
August 1980¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"Airway Problems in Children" (pp 97-100)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝRadiology for Non-Radiologists
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSyllabus edited
August 1980¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"The radiology of non-accidental trauma"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝChildrens Hospital Grand Rounds
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSan Diego, California
May 4-8, 1981¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Pediatric Gastrointestinal Radiology" (pp 357-366)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSan Diego Pre-Board Radiology Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝEdited by Brahme, Guerra
1981¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý"Non-Accidental Trauma" (pp 307-312)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝSixth Annual San Diego Postgraduate Radiology Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝUniversity of California, San Diego
January 1982¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Non-accidental Trauma - Radiological Aspects"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝDepartment of Pediatrics Grand Rounds
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝUniversity of California, San Diego
March 1982¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Sinusitis in Childhood"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝDepartment of Pediatrics Grand Rounds
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝUniversity of California, San Diego
1982¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Radiographic Evaluation of the Limping Child" (pp 117-122)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Seventh Annual San Diego Postgraduate Radiology Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝUniversity of California, San Diego
April 11-15, 1983¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Pediatric Gastrointestinal Radiology" (pp 205-214)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Radiology Resident's Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
July 22-Aug. 6, 1983¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý1.¬Ý "Approach to Interpretation of the Neonatal Chest X-ray"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Radiographic Evaluation of Urinary Tract Infection in Children"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 3.¬Ý "Radiographic Evaluation of Abdominal Pain in Childhood"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 4.¬Ý "Radiographic Evaluation of Common Skeletal Abnormalities inChildren"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Third Annual Roentgen Revisited
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Germany & Austria
Nov. 9-11, 1983¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Assessment of Normal Physiology by X-ray"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Second Annual Neonatal Symposium
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý The Bahia Hotel, San Diego, California
1983¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý "Urinary Tract Infections" (pp 79-88)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Eighth Annual San Diego Postgraduate Radiology Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
March 15, 1984¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý "Radiologic Diagnosis of Child Abuse"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Mercy Hospital and Medical Center:¬Ý Child Protective Issues
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, California
April 24, 1984¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Presented display on Breast Cancer Diagnosis
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Health Education Day
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Sponsored by the UCSD Medical Center Auxillary
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Intercontinental Hotel, San Diego, California
Apr. 30-May 4, 1984¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1.¬Ý "Pediatric Uroradiology" (pp 285-292)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Pediatric Gastrointestinal Radiology" (pp 345-354)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Presented at the Resident's Radiology Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, California
Apr. 30-May 4, 1984¬Ý¬Ý "Pediatric Skeletal Abnormalities" (pp 469-478)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego Resident's Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, California
May 18, 1984¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Breast Cancer Diagnosis in 1984"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Continuing Medical Education Program, Current Concepts in Cancer:
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Prevention, Early Detection and Treatment. ¬Ý
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, California
Oct. 22-23, 1984¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1.¬Ý "Breast Imaging"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Vomiting in Children"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 9th Annual Postgraduate Radiology Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Hotel Del Coronado, San Diego, California
February 4, 1985¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Hilton SvW, Merritt TA
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Human Surfactant Use in the Treatment of Respiratory Distress Syndrome"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý UCSD Department of Pediatrics Grand Rounds
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, California
Apr. 29-May 3, 1985¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1.¬Ý "Pediatric Gastrointestinal Radiology" (pp 377-384)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Pediatric Uroradiology" (pp 309-316)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 3.¬Ý "Pediatric Osteoradiology" (pp 325-334)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 5th Annual San Diego Resident's Radiology Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Town & Country Hotel, San Diego, California
Apr. 27-May 2, 1986¬Ý¬Ý¬Ý¬Ý¬Ý 1.¬Ý "Pediatric Uroradiology" (pp 309-316)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Pediatric Gastrointestinal Radiology" (pp 293-300)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 3.¬Ý "Pediatric Skeletal Abnormalities" (pp 325-334)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 6th Annual San Diego Radiology Residents' Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Town & Country Hotel, San Diego, California
April 19-24, 1987¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1.¬Ý "Pediatric Gastrointestinal Radiology" (pp 325-332)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Pediatric Uroradiology" (pp 373-380)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 3.¬Ý "Pediatric Osteoradiology" (pp 389-398)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 7th Annual San Diego Residents' Radiology Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý University of California, San Diego
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Town & Country Hotel, San Diego, California
March 17-19, 1988¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1.¬Ý "Pediatric Abdominal Emergencies" (pp 47-59)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý2.¬Ý "Airway Emergencies in Children" (pp 60-67)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Primary Care Medicine-Pediatric Update
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Doubletree Hotel, San Diego, California
April 10-15, 1988¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý¬Ý 1.¬Ý "The Pediatric GI Tract" (pp 589-596)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Bone Diseases in Children" (pp 605-614)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 3.¬Ý "Congenital and Acquired Renal Disease in Children" (pp 625-634)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 8th Annual Residents' Radiology Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Town & Country Hotel, San Diego, California
August 26, 1988¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "The Radiograph as Legal Evidence of Child Abuse"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Course for District Attorneys of San Diego Division of Child Abuse
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý UCSD Medical Center
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, California
April 19, 1989¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Child Abuse and Other Bone Diseases" (pp 580-584)
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 9th Annual Radiology Review Course
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Town & Country Hotel, San Diego, California
April 1994¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1.¬Ý "Designing a Good Scientific Study"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Publication of a Scientific Study"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Society for Pediatric Radiology Meeting
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Colorado Springs, Colorado
January 1995¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ¬Ý¬Ý "Psychologic Approach to the Pediatric Patient for Imaging Studies"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Psychiatry Grand Rounds
March 1995¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 1.¬Ý "Pediatric Imaging Update GI"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý 2.¬Ý "Pediatric Imaging Update GU"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Visiting Professorship University of Alabama
June 1995¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý "Advanced Imaging Techniques of the Pediatric Respiratory Tract"
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Children's Hospital Course for Respiratory Diseases
April 1997¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý’ÄúSocial, Legal, and Diagnostic Issues in Child Abuse’Äù
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego Radiology Society, San Diego, CA.
January 1998¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý’ÄúRadiographic Diagnosis of Child Abuse’Äù
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý General Review Course for Radiologists
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, California
April 1998¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝVisiting Physician.¬Ý
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Latvia.
April 1998¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬ÝVisiting Physician.¬Ý
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Lithuania
May 1998¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý’ÄúClinical and Radiological Diagnosis of Nonaccidental Trauma’Äù
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Curriculum for Alternate Public Defender’Äôs Office
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Diego, California
April 2000¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ’ÄúThree-dimensional ultrasonographic imaging of the neonatal brain in high-risk neonates: Preliminary Study.’Äù
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Presented at AIUM
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý San Francisco, California
May 2000¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý ’ÄúThree-dimensional ultrasonographic imaging of the neonatal brain in high-risk neonates: Preliminary Study.’Äù
¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý¬Ý Presented at WFUMB, Florence, Italy
PUBLICATIONS:
1.¬Ý¬Ý¬Ý Wesenberg RL, Rossi RP, Hilton SvW, Blumhagen JD, Gilbert JM, Chionis ML.¬Ý Low dose radiography in pediatric radiology.¬Ý AJR 128:1066-1067, 1977.
2.¬Ý¬Ý¬Ý Brooks JG, Bustamante SA, Koops BL, Hilton S, Cooper D, Wesenberg A, Simmons MA.¬Ý Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants.¬Ý J Pediatr 91:648-652, 1977.
3.¬Ý¬Ý¬Ý Hilton SvW, Edwards DK, Young LW.¬Ý Intrathoracic Rib.¬Ý Am J Dis Child 134:1085-1086, 1980 (Case Report).
4.¬Ý¬Ý¬Ý Wesenberg RL, Blumhagen JD, Rossi RP, Hilton SvW, Gilbert JM, Nedeau DJ.¬Ý Low-dose radiology of children.¬Ý Radiologic Tech 1:241-244, 1980.
5.¬Ý¬Ý¬Ý Hilton SvW, Edwards DK, Stapleton FB, Miller KE, Williams R, Wimmer J.¬Ý Genitourinary malformation with calcified intraluminal meconium and pulmonary hypoplasia.¬Ý Urol Radiol¬Ý 1:241-244, 1980 (Case Report).
6.¬Ý¬Ý¬Ý Miller KE, Edwards DK, Hilton S, Collins D, Lynch F, Williams R.¬Ý Acquired lobar emphysema in premature infants with bronchopulmonary dysplasia:¬Ý an iatrogenic disease?¬Ý Radiology 138:589-591, 1981.
7.¬Ý¬Ý¬Ý Stapleton FB, Hilton SvW, Wilcox J, Leopold G.¬Ý Transient nephromegaly simulating infantile polycystic disease of the kidneys.¬Ý Pediatrics 67(4):554-559, 1981 (Case Report).
8.¬Ý¬Ý¬Ý Stapleton FB, Hilton S, Wilcox J, Leopold GR.¬Ý Die Transistorische Nephromegalic mit Simulation einer Infantilen Polyzystischen Nierenerkrankung.¬Ý Extracta Paediatrica Band 6, Heft 2, 152-157, 1982 (Case Report).
9.¬Ý¬Ý¬Ý Scheible W, James HE, Leopold GR, Hilton SvW.¬Ý Occult spinal dysraphism in infants:¬Ý Screening with high resolution real time ultrasound.¬Ý Radiology 146:743-746, 1983.
10.¬Ý¬Ý¬Ý Goscienski P, Spector SA, Hilton SvW, Kleoner B.¬Ý Fever and leukopenia in a two-year old.¬Ý West J Med 138:70-75, 1983 (CPC).
11. ¬Ý¬Ý¬Ý James HE, Scheible W, Kerber C, Hilton SvW.¬Ý Comparison of high resolution real time ultrasonography and high resolution computed tomography in an infant with spinal dysraphism.¬Ý Neurosurgery 13:301-305, 1983.
12. ¬Ý¬Ý¬Ý Nyhan WL, Sawyer M, Kearney T, Spector S, Hilton SvW.¬Ý Lead intoxication in children.¬Ý West J Med 143:357-364, 1985.
13. ¬Ý¬Ý¬Ý Hilton SvW, Edwards DK.¬Ý Radiographic diagnosis of nonaccidental trauma (child abuse). Appl Radiol 14:13-24, 1985.
14. ¬Ý¬Ý¬Ý Edwards DK, Hilton SvW, Merritt TA, Hallman M, Mannino F, Boynton BR.¬Ý Respiratory distress syndrome treated with human surfactant: radiographic findings.¬Ý Radiology 157:329-334, 1985.
15. ¬Ý¬Ý¬Ý Hilton SvW.¬Ý Strengthening maternal, perinatal and family planning services at the provincial and municipal levels.¬Ý The role of pediatric radiology in China.¬Ý World Health Organization Manual, 1986.
16. ¬Ý¬Ý¬Ý Nyhan WL, Wilson N, Powers NG, Zwass M, Hilton SvW.¬Ý Intussusception.¬Ý West J Med 144:722-727, 1986 (CPC).
17.¬Ý¬Ý¬Ý Hilton SvW, Leopold G, Olson L.¬Ý Real-time breast sonography:¬Ý Application in 300 consecutive cases.¬Ý AJR 147:479-486, 1986.
18.¬Ý¬Ý¬Ý vanSonnenberg E, Wittich GR, Edwards DK, Casola G, Hilton SvW, Self TW, Keightley A, Withers C.¬Ý Percutaneous diagnostic and therapeutic interventional radiologic procedures in children:¬Ý Experience in 100 patients.¬Ý Radiology 162:601-605, 1987.
19. ¬Ý¬Ý¬Ý Edwards DK, Hilton SvW.¬Ý Flat chest in chronic bronchopulmonary dysplasia.¬Ý AJR 149:1213-1216, 1987.
20. ¬Ý¬Ý¬Ý Edwards DK, Berry CC, Hilton SvW.¬Ý Trisomy 21 in newborn infants:¬Ý Chest radiographic diagnosis.¬Ý Radiology 167:317-319, 1988.
21.¬Ý¬Ý¬Ý Glockner SM, Holden MG, Hilton SvW, Norcross WA.¬Ý Women's attitudes towards screening mammography.¬Ý Am J Prev Med 8:69-77, 1992.
22.¬Ý¬Ý¬Ý Nyhan WL, Hilton S.¬Ý Histidinuria:¬Ý Defective transport of histidine.¬Ý Am J Med Genetics 44:558-561, 1992.
23.¬Ý¬Ý¬Ý Wootton SL,¬Ý Coley BD, Hilton SvW, Edwards DK, Amberg JR, Mattrey RF.¬Ý Value of brominated fluorocarbons for the radiographic diagnosis of small-bowel obstruction:¬Ý Comparison with other contrast agents in rats.¬Ý AJR 161:409-416, 1993.
24.¬Ý¬Ý¬Ý Salerno CC, Pretorius DH, Hilton SvW, O’ÄôBoyle MK, Hull AD, James GM, Riccabona M, Mannino F, Craft A, Nelson TR.¬Ý Three-dimensional ultrasonographic imaging of the neonatal brain in high-risk neonates: Preliminary study.¬Ý J Ultrasound Med 19:549-555, 2000.¬Ý
25.¬Ý¬Ý¬Ý Szmuilowicz E, Sklansky MS, Kiciman N, Hilton SvW, Rothman A. Evaluation of calibration methods for size estimation in the pediatric cardiac catheterization laboratory.¬Ý Am J Cardiology 86:313-318, 20
BOOK CHAPTERS:
1.¬Ý¬Ý¬Ý Hilton SvW.¬Ý The approach to pediatric patients.¬Ý In:¬Ý Practical Pediatric Radiology.¬Ý SvW Hilton, DK Edwards, JW Hilton, eds.¬Ý W.B. Saunders, Philadelphia, pp. 1-2, 1984.
2.¬Ý¬Ý¬Ý Hilton SvW.¬Ý The child with vomiting.¬Ý In:¬Ý Practical Pediatric Radiology.¬Ý SvW Hilton, DK Edwards, JW Hilton, eds.¬Ý W.B. Saunders, Philadelphia, pp. 229-269, 1984.
3.¬Ý¬Ý¬Ý Hilton SvW.¬Ý The accidentally injured and abused child.¬Ý In:¬Ý Practical Pediatric Radiology.¬Ý SvW Hilton, DK Edwards, JW Hilton, eds.¬Ý W.B. Saunders, Philadelphia, pp. 443-485, 1984.
4.¬Ý¬Ý¬Ý Hilton SvW.¬Ý The child with a urinary tract infection.¬Ý In:¬Ý Practical Pediatric Radiology.¬Ý SvW Hilton, DK Edwards, JW Hilton, eds.¬Ý W.B. Saunders, Philadelphia, pp. 497-535, 1984.
5.¬Ý¬Ý¬Ý Hilton SvW.¬Ý The child with vomiting.¬Ý In:¬Ý Practical Pediatric Radiology, Second Edition.¬Ý SvW Hilton, DC Edwards, eds.¬Ý W.B. Saunders Co., Philadelphia, pp. 297-333, 1994.
6.¬Ý¬Ý¬Ý Hilton SvW.¬Ý Differentiating the accidentally injured from the physically abused child.¬Ý In: Practical Pediatric Radiology, Second Edition.¬Ý SvW Hilton, DC Edwards, eds.¬Ý W.B. Saunders Co., Philadelphia, pp. 389-436, 1994.
7.¬Ý¬Ý¬Ý Hilton SvW.¬Ý The child with a urinary tract infection.¬Ý In: Practical Pediatric Radiology, Second Edition.¬Ý SvW Hilton, DC Edwards, eds.¬Ý W.B. Saunders Co., Philadelphia, pp. 495-531, 1994.
8.¬Ý¬Ý¬Ý Hilton SvW, Kaplan G.¬Ý Imaging in pediatric urology.¬Ý In:¬Ý Urology Clinics.¬Ý W.B. Saunders, Co., Philadelphia, 1994, in press.
BOOK REVIEWS:
1.¬Ý¬Ý¬Ý Hilton SvW.¬Ý Ultrasound Mammography.¬Ý P Harper (ed).¬Ý J Ultrasound in Med, Feb 1985.
2.¬Ý¬Ý¬Ý Hilton SvW.¬Ý Mammography - A User's Guide.¬Ý Recommendations of the National Council on Radiation Protection and Measurements.¬Ý AJR 143:358, 1987.
3.¬Ý¬Ý¬Ý Hilton SvW.¬Ý Diagnostic Imaging of Child Abuse.¬Ý Williams & Wilkins, Paul Kleinman (ed).¬Ý AJR 149:1212, 1987.
4.¬Ý¬Ý¬Ý Hilton SvW.¬Ý Breast Cancer Detection: Mammography and Other Methods in Breast Imaging. 2nd Edition, LW Bassett, RH Gold (ed).¬Ý Grune & Stratton.¬Ý AJR 151:42, 1988.
5.¬Ý¬Ý¬Ý Hilton SvW.¬Ý Review of Ultrasonography of Infants and Children.¬Ý RL Teele, JC Share, eds.¬Ý AJR 159:824, 1992.
6. ¬Ý¬Ý¬Ý Hilton SvW.¬Ý Review of Diagnostic Imaging of Child Abuse.¬Ý PK Kleinman, ed.¬Ý AJR 172:504, 1999
TEXTBOOKS:
1.¬Ý¬Ý¬Ý Practical Pediatric Radiology.¬Ý Edited by Hilton SvW, Edwards D, Hilton J.¬Ý W.B. Saunders, Philadelphia, 1984.
2.¬Ý¬Ý¬Ý Radiologica Pediatrica.¬Ý (Spanish Translation)¬Ý Edited by Hilton SvW, Edwards DK, Hilton J.¬Ý Editorial, El Manual Moderno, S.A. de C.V., Mexico, D.F., 1987.
3.¬Ý¬Ý¬Ý Practical Pediatric Radiology.¬Ý (Chinese Translation) Yu Wu M.D.¬Ý Chinese Government Press; Beijing, China, 1990.
4.¬Ý¬Ý¬Ý Practical Pediatric Radiology.¬Ý 2nd edition.¬Ý Edited by Hilton SvW.¬Ý W.B. Saunders, Philadelphia, 1994.¬Ý (Translation into Spanish, Portugese)
5. ¬Ý¬Ý¬Ý Practical Pediatric Radiology.¬Ý 3rd edition.¬Ý Edited by Hilton SvW.¬Ý W.B. Saunders, Philadelphia.¬ÝElsevier
MISCELLANEOUS:
1.¬Ý¬Ý¬Ý Marx M, Forrest JV, Hilton SvW:¬Ý Nonchanging Mammograms in Proven Carcinoma of the Breast; Additional Cases Wanted.¬Ý AJR 138:595, 1982 (Letter to the Editor).
2.¬Ý¬Ý¬Ý Review of Current Literature: Introduction of New Concept of Abstracting, Hilton SvW, Assoc Ed, AJR.¬Ý AJR 149:201-205, 1987 (Editorial Announcement).
Dr. Saskia von Waldenburg Hilton MD, Professor Emeritus of Radiology, Professor Emeritus of Pediatrics, University of California at San Diego, School of Medicine, San Diego, CA
Dr. Hilton has been a pediatric radiologist for over 34 years and a physical child abuse expert witness for over 29 years. She has published the definitive text on clinically oriented pediatric radiology which includes a chapter entitled "Differentiating the Accidentally Injured from the Physically Abused Child". Her involvement as an expert witness in cases involving physical child abuse has often provided insight which was the determining factor in the resolution of the case. Her experience as a physician and expert witness provides an uncommonly high level of insight and analysis of the evidence.<p>Court Testify Battered Child Differentiating the Accidentally Injured from the Physically Abused Child SASKIA von Waldenburg HILTON, M.D. </p>
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<p>DIFFERENTIAL DIAGNOSIS OF TRAUMA ACCORDING TO AGE ¬Ý¬Ý¬Ý Nonambulating Children (Birth to 10 Months) ¬Ý¬Ý¬Ý Toddlers (10 Months to 3 Years) ¬Ý¬Ý ¬ÝYoung Children (3 to 5 Years) ACCIDENTAL TRAUMA ¬Ý¬Ý¬Ý Birth Trauma ¬Ý¬Ý¬Ý Common Accidental Trauma NONACCIDENTAL TRAUMA ¬Ý¬Ý¬Ý Diagnosis by Skeletal Radiographs Extremity Trauma Central Skeletal Trauma ¬Ý¬Ý¬Ý Skeletal Scintigraphy in Child Abuse ¬Ý¬Ý¬Ý Injury Dating by Skeletal Radiography 1 to 3 Days 5 to 15 Days 15 Days to 6 Weeks 6 Weeks to 8 Months ¬Ý¬Ý¬Ý Postmortem Radiography ¬Ý¬Ý¬Ý Differential Diagnosis of Skeletal Lesions Normal Variants Metabolic Abnormalities Osteogenesis Imperfecta Hypervitaminosis A Metastatic Malignancies Physiologic Periosteal New Bone Bone Disease of Prematurity Congenital Syphilis Neonatal Osteomyelitis Prostaglandin Inhibitor Therapy Schmid’Äëlike Metaphyseal Chondrodysplasia Menkes' Kinky’ÄëHair Syndrome ¬Ý¬Ý¬Ý Oropharyngeal Injuries ¬Ý¬Ý¬Ý Visceral Injuries Stomach Duodenum Mesentery Liver Spleen Pancreas Summary ¬Ý¬Ý¬Ý Intracranial Injury ¬Ý¬Ý¬Ý Diagnosis of Abuse by Clinical History ¬Ý¬Ý¬Ý Diagnosis of Abuse by Cutaneous Injury ¬Ý¬Ý¬Ý Although significant increases in survival rates have been achieved in premature infants, children with neoplasms, and those with congenital malformations, the incidence of accidental death in childhood remains essentially unchanged from year to year. Approximately one tenth of all emergency department admissions for children younger than 5 years are related to non-accidental trauma. Conservative calculations indicated that approximately one-quarter of a million children are physically abused each year and at least 2000 to 5000 of these die as a result of their injuries. Among survivors, irreversible brain damage of variable degree is common. Distinguishing abuse from accidental trauma is possible most of the time with a relatively high degree of certainty. The distinction can be made by careful analysis of the imaging findings, the clinical picture, and a detailed history of the traumatic event. The intent of this chapter is to facilitate this task for physicians who care for infants and children. Accidental trauma is discussed only when it is likely to be mistaken for abuse. Selected medicolegal aspects of abuse, including physician testimony, are discussed in greater detail in Chapter 15. The imaging of accidental injuries, such as those sustained in motor vehicle accidents or other major nonintentional trauma, is described in Chapter 12. Establishing and documenting the diagnosis of child abuse is important for both medical and legal reasons. Confirmation of the medical diagnosis establishes a cause for the illness and directs appropriate treatment for the child's presenting symptoms, as well as for occult injuries. In addition, the diagnosis of child abuse sometimes dramatically clarifies a constellation of puzzling symptoms, including partial blindness, seizures, hydrocephalus, unusual abdominal injuries, burns, and failure to thrive. Confirmation of abuse also initiates legal proceedings to remove the child and any siblings from a volatile and dangerous home environment until the abuser can be identified and the safety of the child's home guaranteed. The radiologist often plays a major role in diagnosing child abuse. Radiographs with positive findings are legal documents that often reveal uncontestable evidence of battering. Although skeletal radiographs are used most commonly, any imaging modality that reveals lesions typical of abuse can be employed as legal evidence, including such varied studies as computerized tomography (CT) or magnetic resonance (MR) images of typical brain injury, sonography of pancreatic pseudocyst, contrast examination of duodenal hematoma, and bone scans of multiple fractures. Although the exact mechanism of many abuse injuries remains uncertain, a general understanding of the typical forces and methods of injury is helpful to diagnose abuse confidently. The most important factors are the patient's developmental stage and age. Thus, the significance of a spiral tibial fracture is quite different in a 2’Äëmonth’Äëold, nonambulating infant than in a 2’Äëyear’Äëold toddler; in the absence of a convincing history, the infant is probably abused, whereas the 2’Äëyear’Äëold has likely suffered an accidental toddler's fracture. Familiarity with common and typical accidental injuries of childhood is also important to permit distinguishing accidental from nonaccidental trauma. The dictum that high’Äëquality pediatric radiology requires both close cooperation and communication with the pediatrician and detailed clinical information is doubly true when possible child abuse is encountered. Correlating the history of the accident with the severity and type of injury forms the basis for confident diagnosis of nonaccidental trauma. This chapter is divided into three sections. In the first section, common accidental, iatrogenic, and nonaccidental injuries are discussed as they occur in patients of different ages up to 5 years. The second section outlines injuries that are common in childhood and should not suggest abuse; included are brief descriptions of birth injury and automobile trauma. The last section describes the diagnosis of nonaccidental trauma in detail. Although skeletal injury is emphasized, the cranial, abdominal, and cutaneous stigmata of abuse are also included. Neglect, emotional abuse, and sexual abuse, although ultimately much more damaging to the child than physical trauma, are beyond the scope of this textbook. An outstanding textbook by Kleinman9 is highly recommended for readers interested in the subject of physical abuse in greater detail. DIFFERENTIAL DIAGNOSIS OFTRAUMA ACCORDING TO AGE The types of injuries that children incur are closely related to their developmental milestones, which are dependent on age. For simplicity, the relevant ages are divided into three groups: nonambulatory children (birth to 10 months), toddlers (10 months to 3 years), and young children (3 to 5 years). NONAMBULATING CHILDREN (BIRTH TO 10 MONTHS) Statistics from the National Safety Council show that although accidents account for only 2% of all deaths during the first year of life, the total number of accidental deaths during this time is greater than at any other age from 2 through 14 years. Included in this figure and decreasing in frequency are deaths from mechanical suffocation, motor vehicle accidents, fires, drowning, falls, and poisonings.19 Whether some of these accidental deaths represent unrecognized child abuse or the first 12 months are simply a perilous time is uncertain. The common causes of trauma during the first year of life can be grouped into birth trauma, accidental injury in the home, motor vehicle injury, and child abuse. Birth trauma is usually a result of a difficult delivery and is more common in large or neurologically impaired infants. Skull injuries that result from birth trauma include fractures, cephalhematomas, and subdural hematomas from suction extractions. The three bones, other than the skull, that are most commonly fractured as a result of birth trauma are the clavicle, humerus, and femur. Callus formation at these fracture sites is usually visible by 11 days of age; this feature can be used to date the injury if abuse is questioned.4 Accidentally dropping an infant is the most common cause of trauma during infancy. Evaluation of emergency department visits revealed that falls were the leading cause of unintentional injury for children during the first year of life.15 The falls commonly occur when an adult stumbles while carrying the child or when an infant seat falls from a countertop, table, or couch. Sometimes the infant is dropped when an unsupervised sibling attempts to play with or care for an infant. The resulting injuries consist mainly of soft tissue bruises, but occasionally the skull is fractured. In these accidents, there is almost always a plausible clinical history, as well as parental grief, concern, and guilt that are appropriate to the injury. Such injuries are rarely serious. By contrast, motor vehicle trauma involving unrestrained infants is frequently fatal.19 The infant's body tends to accelerate head first, with the brain incurring severe damage on impact. An infant held by a nonrestrained adult in an automobile passenger seat may be crushed between the dashboard and the adult's body. An infant seated on an adult's lap and included in the adult's seat belt may also be crushed by the adult's body. Such accidents are rarely diagnostically difficult, because documentation is readily available. An abused infant is often severely injured because of the small size of the body and the strength and violence of the adult abuser. Multiple metaphyseal fractures are common in this age group, because the abused infant is often severely shaken, and its extremities may be used as "handles" by which to grab the infant's body prior to throwing the child across a bed or room. Fractures of the femur and humerus also occur in child abuse at this age, often reflecting rotatory (twisting) forces applied to the extremities. Thoracic trauma is evident from multiple rib fractures and costochondral separations or costovertebral fracture, which usually result from compression of the thorax during shaking or from direct impact. Often multiple stages of healing are present confirming that multiple assaults occurred. Intracranial injury (hemorrhage, edema, and infarction) may be manifested by signs of increased intracranial pressure or seizures and is the most common cause of death in this age group. TODDLERS (10 MONTHS TO 3 YEARS) As infants learn to ambulate, they may injure themselves by bumping into household furniture such as coffee tables, television sets, and chairs. Soft tissue bruises and facial lacerations constitute most resulting injuries. Climbing becomes another favorite pastime as toddlers explore and expand their domain. Falls from couches, tables, and ladders ensue but rarely cause severe injuries. Some accidents are caused by toddlers ambulating with a walker. If fractures do occur, the midclavicle, distal radius, and skull are the most common sites. It has been my experience that cranial trauma accidentally incurred in a typical household bump or fall is usually clinically benign, even when a skull fracture is present. If a toddler exerts a rotatory force on the tibia when jumping or falling with a foot caught between the bars of a playpen or crib, the resulting spiral fracture of the tibia may be confused with abuse. This typical "toddler's fracture" is described in greater detail in Chapter 16. The leading causes of accidental deaths that occur during the second year of life include motor vehicle accidents (33%), drowning (24%), fires (22%), falls (3%), and airway obstruction (1%).19 An appropriate history is invariably available. Abuse in toddlers occurs through several mechanisms, some of the more common of which are twisting of the extremities, slaps or punches to the head, and direct blows to the midabdomen. The head is often the focal point of parental blows, producing facial bruises and intracranial or ocular damage in the form of retinal hemorrhage and detachment. Superficial lacerations such as those that often result from accidental bumps and falls are uncommon in battered children. Cutaneous burn injuries of the extremities or the buttocks resulting from forceful immersion in hot water become more frequent. YOUNG CHILDREN (3 to 5 YEARS) Normal 3’Äë to 5’Äëyear’Äëold children become increasingly adept at climbing and thus more apt to fall. They learn to run faster and begin to ride "Big Wheels" and tricycles. The ability to ride a bicycle, however, is not usually mastered by a 5’Äëyear’Äëold child; bicycle riding becomes a major source of morbidity and, occasionally, mortality at 6 to 7 years of age. The enforcement of the use of helmets has decreased the injuries. Common accidental fractures in young children include distal radial torus fractures that result from the child attempting to break a fall with an outstretched hand. Clavicular and occasional skull fractures are seen from ordinary accidental falls. The types of fractures produced by abuse are not markedly different in this age group from those in the toddler age group, but their incidence plummets as the child increases in age. In my experience, asymptomatic, unrecognized fractures are rare in patients older than 3 years of age. In a review of our patient population, skeletal surveys performed on children older than 3 years or on asymptomatic older siblings of abused children have yielded no useful clinical or legal information.5 ACCIDENTAL TRAUMA This section discusses the mechanisms of injury and the radiographic findings in birth trauma and common accidental trauma, showing the consistent relationship between the mechanism of injury and the ensuing injury. Contrast between the radiographic findings of accidental and nonaccidental trauma is emphasized when it exists. BIRTH TRAUMA Birth trauma can mimic child abuse and may even be seen with cesarean sections.¬Ý Whenever abuse involves a neonate, the question of obstetric trauma arises, both in daily practice and in court. Skeletal trauma caused by birth injury and that caused by abuse are usually distinguishable by history alone and sometimes by the radiographic age of the injury. Other than the skull, the bones involved in birth injury, in decreasing order of frequency, are the clavicle, humerus, and femur. ¬Ý¬ÝFIG 1¬Ý Rib fractures are rare.23 An isolated midshaft fracture of the clavicle is the most common skeletal birth injury. Affected infants are usually large, and their delivery is often difficult. Usually, the fracture is recognized at or soon after delivery. The parents may seek medical advice when callus formation causes a palpable mass at about 1 month of age . In cases of abuse, the distal portion of the clavicle is fractured more commonly, as opposed to the midshaft fractures seen in obstetric trauma.¬Ý FIG.2¬Ý ¬ÝIn birth fractures, callus formation is visible, depending on the quality of the radiograph, within 7-14 days of delivery and may be quite exuberant. Thus, in an infant older than 2 weeks of age whose fracture has no radiographically visible callus, the injury is clearly not a result of obstetric trauma. Additionally, an isolated clavicular fracture is rarely the sole fracture in abused infants. Birth injury of the humerus may involve the diaphysis (midshaft) or may cause a fracture’Äëseparation of the distal or proximal epiphysis. Although the epiphyseal injury may be undetected, diaphyseal fractures usually are obvious clinically. A history of a difficult delivery and the presence of periosteal new bone is helpful in differentiating birth trauma from abuse. Femoral fractures may occur during difficult breech extraction and may consist of a diaphyseal fracture or a fracture’Äëseparation of the distal epiphysis. ¬Ý( FIGs. 3-6 )¬Ý Proximal epiphyseal separations (i.e., of the unossified capital femoral epiphysis) are uncommon in both birth trauma and child abuse. There is no question that femoral injuries from abuse can mimic those resulting from birth trauma. Furthermore, isolated long’Äëbone fractures may be the sole presenting sign of abuse during this time. A typical history in cases of abuse is "The baby's thigh suddenly became swollen." It is the infant's incessant crying and irritability from the pain of the nonimmobilized fracture that usually brings the family to medical attention.¬Ý¬Ý (fig 7)¬Ý In summary, to distinguish etiologies of femoral fracture, the most helpful factors are a history of a difficult delivery and the presence of periosteal new bone within 7-14 days of age, which indicate birth trauma. The presence of additional fractures indicates abuse. (FIG.8) COMMON ACCIDENTAL TRAUMA Statistics reveal that accidental trauma is the most significant threat to the lives and welfare of children and adolescents. As noted earlier, motor vehicle accidents, burns, poisonings, and drownings are the most common causes of fatal accidents. Falls, minor burns, nonlethal poisonings, and aspiration or ingestion of foreign bodies cause most nonlethal accidents. In healthy children, such accidents result in isolated injuries. There is always an appropriate history of the accident, and appropriate parental concern and grief. Young children sustain injuries that are common and typical for a particular mechanism of trauma. Familiarity with these injuries helps prevent the false diagnosis of abuse. Table 14’Äë1 indicates the developmental capabilities of children at various ages. (FIG.9)¬Ý¬Ý Falls are the most common cause of injury in infants and young children. Children who have experienced accidental falls usually tumble from identifiable heights, such as cribs, kitchen counters, and stairs. Tripping and falling to the ground rarely cause severe injuries in young children because the distance to the ground is short. Falls are usually broken by outstretched hands, preventing or diminishing impact of the face and skull on the ground. However, when a child falls backward from a significant height, moderate or severe cranial injury may occur. The type of surface covering is relevant in these cases. Skull fractures rarely occur when a child falls onto a carpeted surface, but such fractures can result from falling on a concrete or tile floor. In a study of 250 documented falls (severe enough to warrant medical attention) from sofas, beds, and examining tables, superficial bruises and scratches were the only injuries evident in 70% of cases. In 3% of cases, skull or clavicular fractures were present, and one infant had an isolated humeral fracture.18 In such accidents, there is almost always an appropriate, plausible history of the incident, unlike in cases of abuse, in which the history is often absent or bizarre. Parents of infants who are accidentally injured generally exhibit grief and guilt, blaming themselves for inadequately protecting their offspring. Physical and radiographic examinations of genuine accidents reveal the common fractures of the clavicle, distal radius and ulna, skull, tibia, and distal phalanges; these are isolated or all of the same age. The clavicle is the most commonly fractured bone in children. The cause of injury is usually a fall on the shoulder, with the direct impact causing a midshaft fracture with variable displacement. The fall may be from surprisingly low heights, such as from a sofa to the floor. Pain is the most common reason for seeking medical help. An isolated fracture of the midshaft of the clavicle should not arouse suspicion of abuse. Distal radial or ulnar fractures are caused by falling on an outstretched hand. Such fractures present no diagnostic problems, and although they are more common in older age groups, they can occur in any ambulating child. Isolated skull fractures, although rare, occur in young children who have fallen from moderate heights onto their heads. The radiographic appearance of a calvarial injury caused by abuse may be the same as that of such an injury incurred accidentally. However, accidental skull fractures tend to be linear, narrow, and uncomplicated, whereas a larger percentage of fractures caused by abuse are complex, depressed, and diastatic. In accidental skull fractures, the severe intracranial damage seen in battered children is distinctly unusual. Again, accidental cranial injuries are accompanied by an appropriate history, whereas those from abuse are not. ( FIG. 10)¬Ý¬Ý An important accidental injury that may erroneously raise suspicion of abuse is the toddler's fracture. This characteristic spiral or oblique fracture of the distal tibia is considered to be a result of normal trauma and is almost always self’Äëinflicted in young children. The fracture can occur when the foot is immobilized (as between the bars of a playpen or crib) and a rotational force is exerted on the tibia as the child's body falls. Another mechanism for this fracture in young children is a direct lengthwise tibial impact when the child jumps from a considerable height (dresser, bunk bed, piano). The mode of injury is seldom perceived as an accident by either the parents or the child. The usual presenting complaints are refusal to bear weight or walk, or a limp. The onset of symptoms may be delayed, which adds further confusion and accounts for the absence of a history of trauma. ¬Ý¬Ý ( FIG. 11 )¬Ý Persisting limp is sometimes the reason for radiographic evaluation of a toddler's fracture. In these instances, periosteal new bone is present if the fracture occurred more than 12 days previously. The lack of an appropriate history and the presence of periosteal new bone may erroneously raise suspicion of abuse, tumor, or infection. The toddler's fracture is a notable exception to the rule that long’Äëbone fractures are highly suggestive of abuse. Distal phalangeal soft tissue injuries, with or without fractures and soft tissue amputation, constitute most hand injuries in children. The most common mechanism of injury is the fingers being closed in a door. These accidental injuries result in distal phalangeal trauma, as opposed to the metacarpal fractures seen more commonly in abuse. Metacarpal injuries may occur when the hand is accidentally crushed, but in these rare instances, there is usually an appropriate history. ¬Ý ( FIG. 12). In children older than 5 years, significant skeletal trauma is incurred during sports and vehicular accidents. These events are almost always witnessed and clearly defined; confusion with abuse is unlikely. Bicycle accidents, contact sports, and motor vehicle and pedestrian accidents can cause abdominal trauma in older children; however, visceral injuries in children younger ¬Ýthan 5 years of age are very rare. Young children who step on each other, who are stepped on by a dog, or who punch each other rarely have visceral injuries; thus, visceral injury is not included in expected "traumas" of children in this age group. Finally, it should be emphasized that any fracture in a nonambulating child should be viewed with great suspicion. (FIG.13 To summarize, the important nonintentional injuries of children younger than 5 years are as follows: 1.¬Ý Clavicular fractures (usually midshaft), with variable degrees of displacement. 2.¬Ý Skull fractures that are usually narrow, linear, uncomplicated, and seldom associated with neurologic sequelae. 3.¬Ý Toddler's fracture, an oblique, hairline fracture of the tibia, usually best seen on the external oblique view and sometimes invisible on frontal or lateral views. Soft tissue edema may be absent, reflecting a lack of soft tissue injury with only minimal subperiosteal bleeding. 4.¬Ý Torus fractures, or incomplete distal radial and ulnar fractures. 5.¬Ý Complete fractures of both the radius and the ulna, or variations thereof. 6.¬Ý Distal phalanx injury, a soft tissue injury, with or without a fracture of the distal phalanx. NONACCIDENTAL TRAUMA The concept of physical abuse of children is best understood in the context of family violence.9 Society has become aware of the plight of battered wives, physical abuse of the elderly, and even physical abuse of parents by teenagers. In many dysfunctional families, verbal and physical abuse is common toward family members who are unable or unwilling to defend themselves. Low self’Äëesteem is frequent among battered wives, and beatings may continue for years. Similarly, abused children erroneously assume responsibility for their plight. Children of abusive parents often believe that they "deserved" the beatings because they were "naughty" or "bad." The child's ready acceptance of guilt makes it more comprehensible that abused children continue to love their dangerous parents and often wish to return to them. Few problems in pediatrics evoke more emotional response than that of parents who mutilate or kill their children. Disbelief, disgust, anger, and an intense desire for punitive action are common responses of health professionals who encounter child abuse. Unfortunately, excessively emotional responses are seldom appropriate or effective. It is important to remember that the radiologist's sole function is to establish or refute the diagnosis of abuse. Two issues that the radiologist and pediatrician should consciously avoid are establishing the identity of the perpetrator (the function of the police) and ensuring that justice is carried out (the function of the courts). Competent, unbiased diagnosis is more effective when the radiologist allows other professionals to deal with interrogation, confrontation, and prosecution. In this setting, most experienced pediatric radiologists deliberately avoid any interaction with the parents, because such interaction serves little purpose and may complicate an already difficult situation. The approach to giving accurate and effective testimony in court is discussed in Chapter 15, which addresses selected legal aspects of child abuse. Some physicians are reluctant to diagnose abuse because of potential legal involvement. In addition, these cases tend to be very time consuming and are seldom rewarded by either positive interactions or financial compensation. To ensure the reporting of cases of potential abuse, all states have passed laws that hold the physician liable for overlooking or not reporting abuse, and most states have adopted laws that protect physicians in cases of false’Äëpositive abuse diagnosis. As early as 1976, the State Supreme Court of California ruled that a physician who fails to identify or report a case in which there is physical, historical, or radiographic evidence of abuse is guilty of professional negligence. Thus, knowledge of the radiographic findings of child abuse, much like malpractice insurance, cannot be considered optional for radiologists. "Reporting" means notifying the social services department responsible for child protection. The referring physician is usually the one to send the official notice of potential abuse; however, if nonaccidental trauma is a rare diagnosis, it is advisable for the radiologist to verify that such a report has been sent. California laws have expanded the obligation to report abuse to in clude all professionals who work with children, such as nurses, school teachers, and guidance counselors. The official radiology dictation should be thoughtfully and carefully dictated without errors and equivocation. Although an unequivocal diagnosis can be made from the radiographs alone, it is important to fully understand the proposed mechanism of injury and to include in the report that the findings seen on imaging could not have resulted from the described mechanism of injury. DIAGNOSIS BY SKELETAL RADIOGRAPHS Skeletal radiographs can provide irrefutable evidence that abuse has occurred; therefore, the films should be considered a legal document. In Table 14’Äë2, the standard radiographic views obtained for child abuse at the University of California at San Diego are listed. Close monitoring of the examination is helpful, including looking briefly at the patient as well as at the films, because in court, the radiologist is often asked to verify that the films presented as evidence were actually taken of the child in question and not of some other child. The radiographs should be of good quality and correctly labeled. Additional views should be obtained of any areas with questionable findings so that equivocation on the final radiographic report is minimized or eliminated. Occasionally, the fractures seen on trauma surveys are virtually pathognomonic for abuse (e.g., metaphyseal corner fractures, acromial fractures, and multiple rib fractures). More commonly, it is the type of fracture, together with the clinical history and the age of the patient, that permits diagnosis of abuse (e.g., femoral or humeral fractures, fracture’Äëseparation of the distal humeral epiphysis, and tibial fractures in a nonambulating child). Evidence of multiple fractures in different stages of healing helps verify the diagnosis and documents the fact that multiple episodes of abuse have occurred. However, a child does not need to be abused on multiple occasions before a competent radiologist can make a firm diagnosis of such abuse. The bones of children younger than 5 years differ from the bones of adults in several respects. These differences warrant brief emphasis, because they improve understanding of skeletal injuries in children. In young children, the strongest parts of the skeleton are the ligaments, and the weakest parts are the cartilaginous growth plates (epiphyses); the bones are of intermediate strength. Thus, sprains or ligamentous tears, which are common in adults and adolescents, are rare in young children. Instead of ligamentous tears, young children suffer disruption of the epiphyses (Salter type I injuries) and fractures of the underlying bones, especially the most immature portions of the metaphyseal primary spongiosa. Another notable skeletal difference in young children is the presence of considerable woven bone. Woven bone is weaker in structure than the haversian bone that eventually replaces it, and it tends to wrinkle or bend rather than shatter when subjected to stress. As a result, torus and bowing fractures are common in young children. During childhood, the periosteal membrane is loosely attached to most of the underlying cortex except at the cartilaginous physis and epiphyses. This contrasts with the uniform, tight, periosteal adherence present in adults. Thus, subperiosteal elevation from bleeding occurs readily in children and is manifested radiographically by calcification of the subperiosteal hematoma in 5 to 15 days. The volume of subperiosteal bleeding is greatest at the diaphysis and least at the physis, producing a gently, outward, diaphyseal ballooning. Although loosely adherent, the periosteum is much stronger and thicker in children than in adults, functioning as a strong envelope to protect the growth plate and bone. This membrane is rarely torn in children, although it is easily and frequently displaced. Thus, it functions as a splint by protecting the delicate growth plate and minimizing the displacement of fracture fragments. In young children, the healing of fractures occurs rapidly and completely; anatomic remodeling is the rule. The rate of remodeling depends on the rate of bone growth; thus, complete remodeling of a fracture takes less time in a 2’Äëmonth’Äëold infant than in a 5’Äëyear’Äëold child. Healing is facilitated by proper immobilization and optimal nutrition, both of which may be lacking in an abused child. In the following section, the mechanisms and typical appearances of skeletal trauma resulting from nonaccidental injury are discussed; such trauma includes metaphyseal corner fractures, long’Äëbone fractures, thoracic injuries, fracture’Äëseparation of the distal humeral epiphysis, vertebral fractures, and other miscellaneous fractures. The validity of this discussion assumes the presence of normal underlying bone. If the skeleton is globally or focally abnormal (e.g., as a result of metabolic bone disease, infection, genetic abnormalities, or tumor), the radiographic features of abuse as presented here may be unreliable indicators. Extremity Trauma Metaphyseal Injuries or CML: Classic Metaphyseal Lesions.¬Ý Metaphyseal injuries are seen commonly in physically abused infants and are virtually pathognomonic of nonaccidental trauma. The most common names for these are corner fracture and bucket’Äëhandle fractures, although the terms avulsion fracture or metaphyseal infraction are sometimes used. Periosteal new bone is usually not seen with small corner fractures because subperiosteal bleeding rarely occurs; bleeding and elevation of the periosteum are requisites for the formation of periosteal new bone.¬Ý FIG¬Ý 14 Histopathologic analysis of the anatomy of metaphyseal injuries, performed by Kleinman in the mid’Äë1980s, revealed that this lesion is not an isolated fragment of bone, but instead a complete or partial disc of metaphyseal bone that has fractured and separated from the primary spongiosa of the metaphysis.13 The periphery of this disc is thicker than the thin center and therefore appears as two isolated triangles of bone when radiographed in tangent. It is the thickness of the changes in orientation of the bony disc that may result in different radiographic appearances, varying from the usual corner fracture to a bucket’Äëhandle appearance as the crescentic portion of the disc is imaged. Variations in appearance are influenced by the configuration of the metaphysis and the x’Äëray beam angulation. Other factors that may give an atypical appearance to metaphyseal injuries are incomplete circumferential fractures and superimposed healing. Repeated trauma at the same site can also produce an atypical appearance. Additional studies by Kleinman14 have indicated that metaphyseal trauma frequently causes vascular injury and disruption. Vascular insufficiency results in an abnormal persistence of epiphyseal cartilage instead of the orderly transformation of such cartilage to bone. Persistent vertical cartilaginous columns extend into the metaphysis and become visible radiographically as zones of lucency that are contiguous with the growth plate.¬Ý FIG.¬Ý 15. The precise etiology of metaphyseal fractures remains uncertain. It is theorized that the extremities of small infants may be used by the abuser as "handles" to grab the child's body prior to throwing or violently moving it. Shaking the infant's body violently while holding the thorax produces deceleration and acceleration forces that can cause metaphyseal injuries of the extremities. It appears reasonable that symmetric metaphyseal injuries result from shaking, whereas focal or unilateral metaphyseal damage is probably related to using the extremities as "handles." A second study, which has verified the predominance (60%) of left’Äësided fractures,5 makes a plausible case for the scenario in which a right’Äëhanded abuser faces the child and uses the left extremity to hold the infant during episodes of abuse.¬Ý ¬Ý¬Ý¬Ý¬ÝFIG¬Ý 16. Metaphyseal lesions are most commonly seen in nonambulatory abused infants, and in this age group they are highly specific for abuse. These metaphyseal lesions are not the result of the child's own actions, nor are they seen in accidental trauma. The most common locations for metaphyseal fractures of abuse are the knee, ankle, and distal humerus. Although these injuries are most often seen in association with other fractures, they can occur in isolation. It is important to understand that normal handling of an infant (such as bathing and diapering), rough play with siblings or parent, and accidental falls from any height may produce other injuries, but not the metaphyseal lesions of abuse. ¬Ý FIG¬Ý 17.¬Ý In the presence of normal bones, even a single metaphyseal lesion in an infant is virtually pathognomonic of abuse. Unfortunately, it is sometimes difficult to convince the referring clinician that this benign’Äëappearing lesion signifies such an ominous etiology. I once encountered a solitary corner fracture that was the sole skeletal abnormality in a child who subsequently died of visceral injuries; it was also the sole fracture in another 18’Äëmonth’Äëold girl who returned to the hospital 2 weeks later with a femoral fracture, a depressed skull fracture, and severe neurologic damage. Spiral Long’ÄëBone Fracture. In my experience, an isolated, usually oblique, long’Äëbone fracture has been the initial presentation in 15% of children radiographed for suspected abuse. In the absence of trauma, an oblique fracture of the femur or humerus is highly suggestive, but not invariably diagnostic,24 of abuse. Certainly, there should be no doubt about the cause of this injury in a nonambulating infant. The most common history given in these cases is "sudden swelling of the thigh or arm. Medical help ¬Ýhelp is usually sought because the child cries incessantly, as a nonimmobilized fracture of this magnitude is very painful .These infants and children will also exhibit refusal to bear weight on the afflicted side Extensive periosteal new bone is sometimes seen in cases in which medical help is delayed and the extremity is not immobilized. Although femoral fractures in ambulating children are highly suggestive of abuse, they can be incurred accidentally An appropriate, plausible history must be obtained and carefully analyzed in these unusual cases. We once encountered a 2’Äëyear’Äëold boy who fell from the top of a bunk bed and broke his femur. FIGS¬Ý 18,19,20¬Ý ¬Ý¬ÝA possible mechanism of femoral injury in abuse is a rotatory force applied to the leg. The resulting fracture is often spiral, and most such fractures are diaphyseal. If the extremity is grasped above the knee, a more proximal spiral femoral fracture results. External signs of bruising are often absent, as is disruption of the fat muscle interface, because the fracture results from a rotational stress on the femoral diaphysis instead of a blow that injures the soft tissues. Many femoral fractures are incurred while changing diapers, and they most often happen when no other person is in the room.¬Ý The perpetrators describe not only an audible ’Äúpop’Äù when the bone breaks, but some also describe feeling the bone break. FIGS.¬Ý 21-29¬Ý A similar mechanism may cause spiral fractures of the humerus. Again noteworthy is the increased frequency of left’Äësided diaphyseal fractures, reflecting the preponderance of right’Äëhandedness (87%) in the general population. The majority of abuse is apparently carried out with the abuser facing the child. Although the mechanism just described is probably the most common way by which a humerus or femur is fractured, there are many ways a bone can be broken during abuse. For example, I have encountered a transverse femoral fracture in which the abuser subsequently admitted to stepping on the child's thigh. Falls from a bed, couch, or highchair seldom fracture long bones. In considering the clinical history of the accident, the physician must remember that children younger than 3 years of age rarely climb trees or roof tops. When such injuries occur accidentally, there is almost always a caregiver to witness the event and give an appropriate history. By contrast, an abuser often initially denies any trauma, specifying that swelling of the extremity and evidence of pain were the first untoward events noted. Conspicuously absent is a plausible explanation of how the injury occurred. Epiphyseal Displacement. It is fortunate that irreversible disruption of the growth plate as seen in a Salter type V injury is rare in child abuse, as such lesions create considerable growth disturbances. Epiphyseal displacement, or a Salter type I injury of the distal humeral epiphysis, has become increasingly recognized as an injury suggestive of abuse. The entire epiphysis is likely to slip when subjected to a rotatory shearing force. Such forces most frequently result from abuse but are also seen in accidental injury or birth trauma. FIG¬Ý 30¬Ý The mechanism of injury is external rotation, usually of the left forearm. This rotatory force causes posteromedial displacement of the entire distal humeral epiphysis. The ossification centers of the elbow remain intact and maintain their normal relationship to each other. Thus, the capitellum, if visibly ossified, retains its normal anatomic alignment with the long axis of the radial shaft. In injuries that result from such abuse, the forearm is displaced medially, whereas in accidental elbow dislocations, displacement is lateral. FIG¬Ý 31¬Ý The most significant physical finding acutely is a markedly swollen, painful elbow. Clinically, children with such injuries usually are suspected of having a dislocated elbow, and the true diagnosis of fracture’Äëseparation often is made solely by the characteristic radiographic appearance. The possibility of nonaccidental trauma should be entertained if a fracture’Äëdislocation of the distal humeral epiphysis is noted and a plausible history is lacking. In such instances, a trauma survey is indicated and can be conclusive if it reveals occult fractures. FIG¬Ý 32,33,34¬Ý During the healing of this injury, the medial periosteum of the humerus is more markedly elevated. The extensive periosteal ossification may produce a hard mass that is palpable around the elbow. This late’Äëonset physical finding may be the first abnormality that prompts the parents to seek medical attention. Typically, referral is made to "rule out bone tumor." Prognosis for normal elbow function is excellent, and no treatment is indicated in injuries that are not acute. In most cases, the distal radius remodels without residual deformities. The same type of epiphyseal dislocation can occur at the proximal femoral head, but this is far less common in cases of abuse. Injuries of Hands and Feet. Accidental injuries to the hands usually involve the phalanges. These injuries often result from fingers getting slammed in doors. Almost all accidental hand injuries are accompanied by an appropriate trauma history from the parent and, often, the patient. Child abuse more commonly results in fractures of the metacarpals or metatarsals but may include injury to the digits as well. Many of these injuries are clinically unsuspected. The significance of documenting these lesions lies not in their specificity for abuse, but in their ability to serve as additional evidence of child abuse in children with suspicious skeletal trauma. A single anteroposterior view of both hands and feet is a routine part of my radiographic skeletal survey, and these regions are also included in skeletal scintigraphy for abuse. Central Skeletal Trauma FIG ¬Ý35 Thoracic Injuries.¬Ý The bony thorax as seen on routine chest radiography is a high’Äëyield examination for documenting, and often for first suspecting, the presence of child abuse. The chest film includes the ribs, proximal humeri, acromion, scapula, sternum, and upper spine. Fractures of any of these structures are highly suggestive of abuse; rib fractures are especially common in nonaccidental trauma. Thus, a "routine" chest radiograph in a subgroup of children at risk for abuse should be carefully scrutinized for these fractures. A high index of suspicion is indicated under the following circumstances: shunt tube placement for idiopathic hydrocephalus ¬Ý¬Ý FIG 36¬Ý¬Ý¬Ý¬Ý While giving careful scrutiny to the bony thorax, it is important to recognize the limitations of conventional frontal chest radiography. This examination rarely demonstrates acute, nondisplais indied fractures in the medial half of the posterior rib arc. The fractures that do occur here cause subsequent callus formation along the inner aspect of the rib, with the outer cortex often remaining intact.13 Such fractures become easily visible when periosteal new bone has formed. Equally difficult to visualize are injuries close to the costochondral junction and fractures of the lower ribs, if the lower portion of the thorax is underexposed. Coned and oblique views can be used in infants in whom there is a high degree of suspicion for abuse. The presence of focal pleural thickening should alert the radiologist to the high likelihood of a recent rib fracture in a child suspected of being abused. Meticulously performed scintigraphy reveals more fractures of the thorax than conventional radiography and is often helpful in selected cases.¬Ý Fig¬Ý 37,38,39 Fractured ribs are highly suggestive of abuse because they are rare in normal children subjected to the daily trauma of childhood and most minor accidents. The normal pediatric thorax is highly resilient, and minor trauma almost never results in fractures. In addition, although rib fractures from birth trauma can simulate child abuse in the axial skeleton, rib fractures are only very rarely incurred during delivery. By contrast, premature infants with bronchopulmonary dysplasia and diffuse osteopenia may develop multiple rib fractures during pulmonary toilet. FIG¬Ý 40,41,42 Sometimes the legal question arises as to whether closed chest massage during cardiopulmonary resuscitation (CPR) was the cause of rib fractures. Studies by Kleinman and others6 revealed that despite prolonged resuscitation performed by people with variable degrees of skill, no fractures could be attributed to CPR in children with normal bones. FIGS¬Ý 43,44¬Ý¬Ý The major postulated mechanism for thoracic trauma is anteroposterior compression of the chest caused by shaking an infant. The typical posterior rib fracture, located on the inner surface of the rib opposite the costotransverse articulation, is most likely caused by anteroposterior compression. ¬ÝSuffice it to say to date much remains to be learned about the precise mechanisms of injury. Clavicular Injuries. The clavicle is the bone most commonly fractured during delivery, and clavicular fractures are quite common in accidental childhood injuries. By contrast, the clavicle is relatively rarely injured in child abuse (2% to 6%).9 Although medial and lateral clavicular injuries are more likely to be seen with abuse than are midshaft fractures, the specificity of an isolated occult clavicular fracture for abuse is so low as to be almost useless in an ambulating child. Falling on the shoulder or breaking a fall with an outstretched hand may not be perceived by the child or parent as forceful enough to cause a fracture. Thus, these fractures may be truly accidental but unsuspected. When these patients are radiographed for persistent pain or a clavicular mass, the radiologist's discovery of a healing clavicular fracture should not cause concern for abuse unless there is clinical suspicion. FIG¬Ý 45,46¬Ý¬Ý¬Ý Distinguishing abuse from birth trauma is seldom a problem in the case of a fractured clavicle. A clavicular fracture incurred during delivery invariably constitutes an isolated injury; documentation is usually available, and periosteal new bone is seen as early as 11 days.4 By 1 month of age, mature callus is evident around the fracture site. Conversely, any clavicular fracture without periosteal new bone in an infant older than 2 weeks of age did not result from birth trauma. It must be noted that an acute, isolated clavicular fracture in an in an infant is very worrisome. Acromial Injuries. An ¬Ýimportant and ¬Ýinjury of the scapula in child abuse involves the acromion, a curved protrusion of bone arising from the scapular spine that serves as the tendinous insertion for several shoulder girdle muscles. This lesion is easily identified when specifically sought and is virtually pathognomonic for abuse. As mentioned previously, the shoulder girdle is often injured when an upper extremity is used as a lever or handle to manipulate the child's body. FIG 47,48¬Ý Partial avulsion of bony fragments or complete fracture of the acromial process may occur. Although an acute injury may be invisible, periosteal new bone soon renders this lesion obvious on the frontal chest film or shoulder view. An easy method of identification is to compare both acromial processes. In my experience, the lesion is usually unilateral and more often left sided.The asymmetry caused by periosteal new bone or residual deformity is easily discernible. Confident diagnosis requires careful scrutiny and familiarity with this highly specific lesion. Normal variants may cause confusion and must be differentiated from true fractures.16 Other Scapular Injuries. Less common but equally specific for abuse are other fractures to the scapula. A sudden force exerted on a ligamentous insertion may avulse portions of the coracoid, the inferior angle of the scapula, or portions of the glenoid. Sternal Injuries. Sternal fractures or sternomanubrial dislocations are rarely documented lesions that are nonetheless highly specific for abuse. These lesions are easily seen on scintigraphy but are invisible on a frontal view of the chest. Identification is often possible when the sternum is included on the lateral view of the thoracic spine; and this projection should be carefully scrutinized. Injuries to the Spine. Vertebral trauma is thought to be relatively rare in child abuse, although it is also possible that subtle abnormalities remain undetected. The lateral view of the spine is optimal for detecting such abnormalities and is therefore included in a routine trauma survey. Injuries to the thoracic spine fall into three categories: FIG¬Ý 49,50¬Ý¬Ý 1.¬Ý Compression fractures of the vertebral body. Findings can range from severe compression of the anterior portion of the vertebral body to a subtle decrease in height that may be difficult to appreciate. Sometimes the compression extends uniformly across the vertebral body, producing variable degrees of platyspondyly. Variations include a¬Ý burst fracture of the thoracolumbar spine and a "hangman's fracture" in the cervical region. The relative instability of the thoracolumbar junction makes this location a common site for vertebral body abnormalities caused by forceful flexion of an abused infant. 2.¬Ý Disk herniation. Herniation of the nucleus pulposus usually occurs into the anterosuperior portion of the vertebral body with concomitant loss of intervertebral disk height. The resulting abnormality has a characteristic appearance, with variable degrees of notching of the anterosuperior part of the vertebral body. This may be due to a growth disturbance secondary to involvement of the growth plate of the ring apophysis. 3.¬Ý Avulsion of the posterior elements. Avulsion of cartilaginous and bony fragments of the spinous process can be identified on the lateral view of the spine. However, cartilaginous avulsions and paraspinal hematomas are not seen unless periostitis has formed. Vertebral compression fractures and disk herniation are caused by an axial force exerted through the length of the spine. FIG¬Ý 51¬Ý¬Ý Most children in the 18’Äë to 24’Äëmonth age range who have spinal injuries are ambulatory. The resulting radiographic changes, when not recognized as indications of abuse, are sometimes mistaken for infection, leukemic infiltration, or eosinophilic granuloma. No neurologic symptoms occur unless there is dislocation or the spinal cord or nerve roots have been injured by transection, contusion, or hemorrhage. MR imaging is the modality of choice for these cases. The most common physical finding in vertebral trauma is unexplained kyphosis at or near the thoracolumbar junction. Rarely are these injuries seen in isolation, and a trauma survey usually documents additional fractures, thereby establishing the true diagnosis.¬Ý FIG¬Ý 52 SKELETAL SCINTIGRAPHY IN CHILD ABUSE Some authorities have advocated skeletal scintigraphy as the primary method of investigation in questionable cases of abuse. They recommend that only scintigraphically questionable or abnormal areas be further evaluated radiographically. When supervised and interpreted by personnel who have a high level of experience and expertise, there is no doubt that the bone scan is more sensitive than the radiographic trauma survey.22 A drawback to the use of skeletal scintigraphy in young children is that adequate studies are technically very demanding. High’Äëquality images are obtained consistently only under the following conditions: 1.¬Ý Adequate patient immobilization, sedation, or both, is needed. (Heavy sedation is usually required in young children.) 2.¬Ý Positioning is done without patient rotation. 3.¬Ý Homologous joints that cannot be positioned neutrally must be imaged with the same degree of joint rotation, flexion’Äëextension, and abduction’Äëadduction. 4.¬Ý A high’Äëresolution technique must be employed (i.e., 3’Äëmm pinhole collimator views). 5.¬Ý Adequate densities (i.e., counts per square centimeter) are obtained. 6.¬Ý Separate images of the diaphysis and the metaphysis are obtained to exclude the presence of metaphyseal corner fractures. The primary theoretical problem with scintigraphic examination is that metaphyseal fractures located at the ends of actively growing bone lie in regions of maximal normal radionuclide uptake. Despite these problems, if high’Äëquality images can be obtained consistently, the accuracy of bone scans should supersede or at least equal that of radiographs in the diagnosis of child abuse.22 FIG¬Ý 53¬Ý The bone scan often detects many more fractures in the central skeleton, as acute rib fractures and chondral injuries may be invisible on plain films. A+ negative result on a technically poor bone scan is not acceptable, because on such a scan, pathognomonic metaphyseal injuries may be missed. ¬Ý Radiography is used as a primary imaging modality. Scintigraphic examination is used as a supplemental procedure (1) if the sole radiographic finding is focal pleural thickening, suggesting that acute but occult rib fractures (scintigraphically demonstrable) have caused pleural bleeding; (2) if only a single fracture, which is very suggestive of abuse, is present and if the presence of additional unrecognized skeletal trauma would simplify testimony; and (3) on very rare occasions when clinical suspicion is exceedingly high but all test results, including those on radiographs, are negative, and a positive bone scan would permit the child to be removed from a presumptively dangerous home. FIG¬Ý 54¬Ý¬Ý¬Ý The choice of plain films or skeletal scintigraphy as the primary method of examination is a matter of personal preference, expertise, and technical capability. INJURY DATING BY SKELETAL RADIOGRAPHY Precise dating of bony injury based on radiographic appearance can be important for establishing evidence that multiple episodes of skeletal trauma have occurred and for temporally defining a single or multiple assaults. Multiple fractures that occurred at different times have long been considered the most significant indication of child abuse. In the absence of some of the more pathognomonic injuries, the identification of multiple episodes of trauma is indeed very helpful in verifying the diagnosis of abuse. Such identification requires determination of the ages of the fractures. Dating the injury is sometimes crucial in eliminating the possibility of abuse or identifying potential abusers. For instance, it is necessary if the child was temporarily in the care of someone other than the parents or, more commonly, if a man has joined the household of a previously single or divorced mother.¬Ý¬Ý¬Ý¬Ý¬Ý FIGS¬Ý 55-63 Accurate radiographic dating is possible in acute or relatively new fractures, but such dating is less specific with old injuries. It is important that the radiologist date the injuries as accurately as possible, but it is equally important for all involved to understand the limitations of this procedure. The following discussion is a general guide to the sequence of radiographic findings in skeletal healing. 1 to 3 Days With the initial injury, there is disruption of the normal sharp interface of muscle and subcutaneous fat planes, caused by diffuse edema of soft tissues. Frequently, the soft tissue abnormalities will not be obvious or even detectable by physical examination. If subperiosteal bleeding has occurred without distinct fracture, the soft tissue abnormalities will be the sole radiographic finding of abuse. If a fracture has occurred, its edges will be sharp. In fact, the sharpness of the fracture line is similar to that of the edge of a piece of shattered glass. 5 to 15 Days Resorption around fracture lines makes the edge of the fracture less crisp and more indistinct. Hyperemia and associated osteoclastic activity will sometimes resorb enough bone to enable the radiologist to conclude with moderate certainty that the fracture is not acute but several days old. The indistinctness of a fracture line, however, is a subjective assessment that usually cannot be made with great confidence. An unequivocal sign during this time period is calcification of subperiosteal hemorrhage, which appears as periosteal new bone. Subtle but definite periosteal new bone may be seen as early as 5 days in young infants. Generally, in older children, periosteal new bone is commonly seen by 1 week and should be present by 15 days after the injury. Rib fractures usually take slightly longer (15 to 20 days) to clearly show callus formation. Definite presence of slight callus formation accurately indicates that the fracture is not acute and is probably between 1 and 2 weeks old. 15 Days to 6 Weeks During this period, the callus formation becomes more mature and the fracture begins to remodel. Usually, it is impossible to date the fracture precisely during this period. 6 Weeks to 8 Months During this period, remodeling of bone and incorporation of periosteal new bone into the growing skeleton takes place. Slightly asymmetric bone contour persists for several months, but this may not be obvious unless side’Äëto’Äëside comparisons are made. The rapidity with which bone remodeling occurs is dependent on the following factors: 1.¬Ý Age of the patient. The younger the child, the more rapid the healing and remodeling. 2.¬Ý Nutritional status of the patient. Suboptimal nutrition, which may be a factor in some abused infants and children, retards bone healing and remodeling. 3.¬Ý Lack of proper immobilization. Most central and some extremity fractures that are incurred in child abuse are diagnosed retrospectively and therefore have not been treated with immobilization. Thus, residual deformity and exuberant callus formation are more common in untreated fractures than in properly casted injuries. Skull fractures are notoriously difficult to date accurately because there is no periosteal new bone. The only criteria that are used are sharpness of the fracture edge and visibility of the fracture. Most fractures will be visible for a minimum of 6 weeks, and many can still be seen at 12 to 16 weeks, after which they may be invisible or persist for a variable time. Precise determination of the age of skull fractures is seldom possible. The following rules are helpful in determining the age of fractures: ¬Ý¬Ý¬Ý FIG¬Ý 64 1.¬Ý A fracture without periosteal new bone is less than 7 to 12 days old depeding on the qulitiy of the film. 2.¬Ý A fracture with definite but slight periosteal new bone is more than 10 to days old. 3.¬Ý A fracture with a large amount of periosteal new bone is more than 2 weeks old. In conclusion , the dating of fractures not a science and as such be used to pinpoint the precise date of injury. POSTMORTEM RADIOGRAPHY It has been our practice to obtain postmortem radiographs on any child whose cause of death is unknown or uncertain. Cases from the coroner's office of San Diego are transported to the radiology department of the University of California Medical Center at San Diego, where postmortem radiographs are performed under the direct supervision of a pediatric radiologist. High’Äëdetail technique and multiple views are used to obtain maximal information. Any abnormalities found on this examination are further evaluated by the pathologist during the autopsy. High’Äëyield areas in infants under 1 year of age include the metaphyses around the shoulder, knee, and ankle. ¬ÝOn several occasions, exhumation of a child's body has revealed unequivocal evidence of child abuse. If the diagnosis of abuse remains in question a forensic pathologist well versed in child abuse can confirm the diagnosis.¬Ý¬Ý FIGS¬Ý 65-66 DIFFERENTIAL DIAGNOSIS OF SKELETAL LESIONS In the medical practice of pediatric radiology, the most common differential diagnosis for skeletal abuse is accidental injury. In related legal proceedings, however, the question of abnormal bones is an issue that is often raised. If the skeleton is radiographically abnormal (i.e., severe osteoporosis, rachitic changes, superimposed infection or tumor, skeletal dysplasia, or osteopetrosis), child abuse cannot be diagnosed radiographically with certainty. In those rare cases of possible abuse in children who have skeletal abnormalities that produce fragile bones, the diagnosis of abuse is preferably established clinically. Conditions that can cause confusion with abuse include normal variants, metabolic abnormalities, infections, neoplasms, and miscellaneous entities; these are discussed in this section. Knowledge of these diseases is essential in the legal arena and occasionally useful in daily practice. Normal Variants Normal variants are described by Kleinman et al,12 (based on postmortem high’Äëdetail radiography) and fall into four categories: spurring, beaking, metaphyseal step’Äëoff, and proximal tibial cortical irregularity. A normal spur is a continuous metaphyseal projection of bone that may be seen in the lateral aspect of the distal femur or in the radius, ulna, or metacarpals. This contour variation is not a separated fractured fragment as is seen in child abuse. A beak is a well’Äëdefined, dense projection from the medial aspects of the humerus. Beaking of the proximal tibia is less well defined. The typical location, appearance, lack of cortical separation, and bilaterality (77%) differentiate beaking from corner fractures. A metaphyseal step’Äëoff is an almost horizontal extension of cortical bone. The margins may be indistinct; involvement can be seen in the distal portion of the femur, radius, and ulna or proximal tibia. Bilaterality was seen in 44% of patients in Kleinman's study. The tibia may demonstrate a focal, cortical irregularity medially and proximally. Metabolic Abnormalities ( FIG. 67). Of all the metabolic diseases, rickets is the most frequently encountered, usually secondary to renal or, occasionally, biliary disease. Rickets causes extensive osteoporosis, splaying of the metaphyses, and widening of the growth plate or physis. Invariably the renal or biliary disease is evident clinically. Osteogenesis Imperfecta ( FIGS.68-70) Osteogenesis imperfecta is an inherited disorder of connective tissue characterized by abnormal bone fragility with osteoporosis, defective dentition, presenile hearing impairment, and blue sclera. Less common clinical features include easy bruising, fragile skin, hyperplastic healing, ligamentous laxity, short stature, wormian bones, progressive scoliosis, and premature vascular calcification.1 ¬Ý¬ÝOsteogenesis imperfecta types I and II should be clinically apparent by the presence of blue sclera. Although the sclera are normal in type III Osteogenesis imperfecta, there is severe osteoporosis and progressive deformity of long bones and spine. Wormian bones and typical clinical features help differentiate the milder forms of type III from injuries caused by abuse. Type IV osteogenesis imperfecta, an autosomal dominant subtype, is very rare, and radiologic evaluation of the disease is limited.1 Most patients demonstrate radiographic abnormalities, and those mild cases in which radiographs are normal can usually be identified by clinical findings (dentinogenesis imperfecta and hearing loss) or a positive family history. Problems can arise if the patient has a new dominant mutation of type IV osteogenesis imperfecta without clinical findings and with normal radiographs. This combination is highly unlikely, because the incidence of new mutations in type IV is between 1 and 3 per 1 million births. These statistics translate into a single case of autosomal dominant mutation being born in a city with a population of 500,000 every 100 to 300 years.10 Although these rare sporadic cases with normal bone density may be relatively susceptible to fracture, it is uncertain whether any resulting injuries mimic the typical fractures of child abuse and even whether fractures in osteogenesis imperfecta type IV occur in the absence of recognizable trauma. Hypervitaminosis A Toxic doses of vitamin A in childhood are usually administered orally as dietary supplements by well’Äëmeaning, misguided parents. Clinical symptoms include anorexia, pruritus, soft tissue swelling, coarse and sparse hair, hepatosplenomegaly, and digital clubbing. Periosteal new bone is present in a unique, characteristic, and symmetric distribution: the medial aspect of the ulnar diaphysis, the metatarsal diaphysis, and, less commonly, the clavicles, tibia, and fibula. An acute and chronic increase in cerebrospinal fluid results in splitting of cranial sutures. The split sutures and periosteal new bone may be mistaken either for cranial and osseous trauma in abuse or for systemic disease such as metastatic neuroblastoma or leukemia. Symmetric involvement, characteristic predilection for the ulna, and verification of excess vitamin intake differentiate hypervitaminosis A from other diseases. Metastatic Malignancies Metastatic neuroblastoma, or leukemia, can cause painful focal or diffuse destructive skeletal changes. There may be associated reactive new bone with a mixed lytic and blastic appearance. These changes result in abnormal bones whose etiology is easily distinguished from abuse. Isolated periosteal new bone may be seen in such malignancies, and when present, the major differential diagnostic considerations are osteomyelitis and trauma. Rarely, pancreatitis from pancreatic trauma in abuse may produce mixed lytic and blastic bony lesions that mimic neuroblastoma or leukemia. Physiologic Periosteal New Bone (FIG.71a,b.) Physiologic periosteal new bone is a normal phenomenon seen in approximately one third of neonates younger than 3 months. The tibia, femur, and humerus are most commonly involved. Kleinman21 performed a postmortem comparison between a group of 79 infants who died from sudden infant death syndrome and 20 infants who suffered fatal abuse. In the normal infants, the thickness of the periosteal reaction was usually 1 mm; a thickness of 1.8 mm was never seen. He concluded that normal infants older than 3 months did not demonstrate physiologic¬Ý periosteal new bone and that periosteal reaction greater than 1 mm in thickness was unlikely to represent a physiologic phenomenon.21 In addition, it is important to note that normal periosteal new bone is bilaterally perfectly symmetric, while traumatic injuries almost never have this characteristic. ( FIGS. 72-74.) Bone Disease of Prematurity Metabolic bone disease in premature infants results in moderate to severe demineralization and mild rachitic changes. Affected premature infants often require intubation because of respiratory distress syndrome or prolonged apnea. Segmental atelectasis is a common problem when these infants are weaned from the respirator or after extubation. Chest physiotherapy to relieve the atelectasis may cause multiple rib fractures that simulate those caused by abuse. Another group of infants at risks for metabolic bone disease¬Ý Complete healing of rib fractures usually occurs within 2 to 4 months after cessation of physical therapy. A history of prematurity, pulmonary disease, and chest physical therapy distinguish iatrogenic rib fractures from those of abuse. Congenital Syphilis Congenital syphilis may produce trophic changes of the entire skeleton, most commonly involving the metaphyseal regions. Symmetric involvement of the proximal humeri and distal femurs is common. The changes seen are metaphyseal irregularities, fragmentation, and periosteal new bone. Clinical signs include splenomegaly, rhinorrhea, rash, and anemia. Radiographic abnormalities can be present at birth but may not develop until 2 months after delivery, depending on the time of intrauterine infection. The symmetric skeletal involvement of congenital syphilis usually is not confused with abuse. Neonatal Osteomyelitis Neonatal osteomyelitis produces moderate to severe destructive changes with exuberant callus formation. Usually there is a single focus, but hematogenous infection may result in multiple lesions. The "moth’Äëeaten" lytic lesions of osteomyelitis are almost always metaphyseal and can be distinguished from fractures by their lytic component. Abundant periosteal new bone may cause some confusion, but clinical differentiation between abuse and osteomyelitis is usually not a problem. Prostaglandin Inhibitor Therapy Prostaglandin inhibitors may be used in neonates with congenital heart disease that requires a patent ductus arteriosus for survival; prostaglandin E1 prevents closure of the ductus arteriosus until palliative shunting or surgical correction is possible. The use of this drug frequently causes diffuse periosteal new bone formation along the ribs and long bones. The uniform, symmetric involvement of the skeleton and the clinical history make confusion with child abuse unlikely. Schmid’Äëlike Metaphyseal Chondrodysplasia ( FIG.75) Schmid’Äëlike metaphyseal chondrodysplasia is a hereditary disorder which frequently produces short stature, metaphyseal flaring and irregularity.11 The metaphyseal abnormalities are most marked in the femur and tibia. The spine in these patients is normal. To the unwary, the metaphyseal irregularity and spurring may be confused with child abuse, especially when viewing isolated films of the knee. The diagnosis is not clinically obvious during infancy. A family history of this disorder is helpful diagnostically, as is a complete trauma survey demonstrating the typical findings and their symmetry. Menkes' Kinky’ÄëHair Syndrome (FIG.76.) Menkes' kinky’Äëhair syndrome is a rare disease of copper metabolism ¬Ýdefisency that results in severe retardation, seizures, hypotonia, failure to survive, and coarse hair (e.g., affected sheep produce an unacceptably poor grade of wool). Radiographic findings include metaphyseal spurring and wormian bones. The spurring may be confused with a corner fracture, but the spur is not separated from the metaphysis. The presence of wormian bones and the clinical features of Menkes' kinky’Äëhair syndrome make the distinction from child abuse apparent. OROPHARYNGEAL INJURIES Oropharyngeal injuries are common in abused children, although they rarely come to the attention of the radiologist. Feeding a child is sometimes a volatile event as is dealing with¬Ý the childs stools. The soft tissues of this region are bruised or torn by forceful insertion of foreign bodies, and occasionally, pharyngeal or esophageal perforations occur. Although spoons are commonly used during "forced feedings," I have seen a child whose esophagus was injured by a coat hanger and a 4’Äëweek’Äëold girl who had the base of her tongue torn during a sexual assault by her father. Kleinman17 reported a 5’Äëweek’Äëold boy with an esophageal perforation who initially presented with stridor resulting from airway obstruction. VISCERAL INJURIES Most children with visceral injuries present with strange symptoms, and frequently the diagnosis of abuse is made only with great difficulty. Although precise data are lacking, visceral injury is a common cause of death in child abuse. In children younger than 5 years, significant abdominal trauma related to accidents is extremely rare, except when children are struck by motor vehicles (a setting in which documentation is virtually always available). Thus, in the absence of such an accident, the finding of visceral trauma in a child younger than 5 years is highly suggestive of abuse. The average age of fatal visceral injury is 2 years, but children older than 5 years can be affected. It has been my experience that although abuse of boys is more common, injuries are fatal more often in girls. The precise mechanism of abdominal injury is often unknown, but it appears that most cases of visceral trauma result from a direct blow to the abdomen. This blow is most commonly delivered to the center of the abdomen, compressing the viscera against the spine. At greatest risk are the underlying duodenum, pancreas, mesentery, and left lobe of the liver. The most significant problem in visceral injuries caused by abuse is that their magnitude is seldom appreciated. Absence of any external signs of abuse and the lack of a history of trauma can mislead the physician into believing that the child's vomiting, abdominal distention, and pain result from gastroenteritis, a urinary tract infection, or other medical disorder. The extent, and often the presence, of severe visceral damage are frequently appreciated only after hypotension, caused by blood loss or septic shock secondary to peritonitis, supervenes. Commonly a child with vague abdominal symptoms and no history of trauma presents at the emergency department. Abdominal disease requiring surgery may be unsuspected, because a variable period of well’Äëbeing may precede the onset of circulatory collapse. Thus, the child may be sent home, only to return later in a moribund state. A revealing accidental model for abdominal injury is the child with seat belt ecchymosis sustained during vehicular accidents.20 The single lap belt is intended to immobilize the iliac crest of adult passengers. On a child, this belt usually crosses the midabdomen. A sudden blow to the abdomen is delivered as the child is catapulted forward against the fixed belt. The most common injuries in a group of 59 children with seat belt ecchymoses resulting from immobilization with an adult lap belt involved the jejunum and duodenum. Some patients had partial or total small bowel transection and intramural hematoma formation. Mesenteric injury, when present, consisted of contusion and laceration. Solid organ injury was most common in the liver, spleen, and pancreas. Bowel strictures, presumably owing to mesenteric injury, were noted 2 to 3 weeks following the accident.20 A series of 21 intestinal perforations¬Ý in abused¬Ý children demonstrated the following distritribution: Duodenum 30%,jejunum 60% just distal to the ligament of Treitz and 10% in the ilium. The average age of the of these children was 2 years. Stomach Perforation of the stomach is the most serious complication of gastric trauma in abuse. When the injury occurs after a meal, gastric distention makes the organ more vulnerable to rupture. The most common site of perforation is the anterior gastric wall. Radiographic recognition is rarely a problem, as there is usually massive pneumoperitoneum. Contrast studies to define the site of perforation are not indicated, because immediate surgery is required to prevent hypovolemic or septic shock. ( FIG. 77-79.)¬Ý Another important entity, which is seen in child neglect rather than physical abuse, is acute gastric dilatation. This complication follows ingestion of a large meal in children who are chronically starved. If abundant food is made available, the child eats voraciously and then becomes severely ill, with abdominal distention, pain, and vomiting.7 Early recognition of this complication and exclusion of gastric outlet obstruction ensure the institution of correct therapy: suction to decompress the atonic stomach and gradual resumption of small quantities of food thereafter; intravenous fluids may be needed to counteract systemic circulatory collapse. In many of these children, neglect may already be known to be an underlying problem, but sometimes acute gastric dilatation may be the first indication of chronic abuse by starvation. Duodenum An intramural hematoma is the most frequently documented small bowel injury in nonlethal cases of child abuse with abdominal trauma. Most commonly involved is the duodenum or proximal jejunum. Maximal damage occurs at the sites of small bowel fixation, the retroperitoneal duodenum, and the jejunum proximal to the ligament of Treitz. The immobilized bowel is compressed between the anterior abdominal wall and the spine, typically resulting in a hematoma at the junction of the first and second portions of the duodenum. The usual clinical symptoms are abdominal pain and vomiting; variable degrees of mechanical obstruction also occur.(FIG. 80.)¬Ý Upper intestinal examination is helpful to diagnose and document this injury. In the absence of accidental trauma, this finding is highly suggestive of abuse, and the injury should be documented for legal purposes. Occasionally, the importance of legal evidence is overlooked when the patient is improving and clinical management would not be altered by imaging the gastrointestinal findings. Plain films of the abdomen may be normal and show varying degrees of obstruction. Contrast examination of the duodenum reveals an intramural mass of variable size and extent that is typically located in the outer aspects of the curvature of the duodenum. Conservative treatment and exclusion of pancreatic injury constitute the current management of choice. Mesentery Mesenteric tears are a frequent postmortem finding in fatal cases of abuse. Avulsion of arteries and veins causes severe and usually fatal hemorrhage. Mesenteric contusion and thrombosis may result in bowel ischemia with pneumatosis intestinalis or portal venous gas. Stricture formation is another complication of bowel ischemia, which in the accidental model occurs within 2 to 3 weeks of the traumatic event.19 Liver The liver is frequently injured, because it is susceptible to traumatic lacerations. The left lobe of the liver is especially vulnerable because it is pushed against the spine. In lethal cases of abuse, liver lacerations are common, resulting in substantial bile and blood spillage into the peritoneum. In milder injuries, hematomas remain subcapsular, and contusions often are undetected. Although CT is the imaging modality of choice, abdominal sonography affords adequate diagnosis and documentation of most complications, including free intraperitoneal fluid. It is interesting to note that rib fractures are rarely associated with hepatic injury,8 presumably because the periumbilical blows avoid the bony thorax. Spleen Although the spleen is frequently injured in accidental trauma, splenic injuries are rare in abuse. The reason for this is unclear. ( FIGS.81-84.)y Pancreas Acute hemorrhagic pancreatitis with or without subsequent development of a pancreatic pseudocyst is a highly suggestive indicator of abuse if accidental injury and hereditary pancreatitis are excluded. Imaging of pancreatitis and its complications is best accomplished with sonography or CT. Percutaneous drainage of pancreatic pseudocysts has proven useful in children and is a good alternative to surgical intervention in selected cases. Pancreatitis may cause periostitis with mixed lytic and blastic lesions in tubular bones of the lower extremities, particularly the feet. These changes, caused by osseous fat necrosis, may be associated with soft tissue swelling over the dorsum of the foot. Bony abnormalities have been identified from 2 to 10 weeks after the onset of abdominal symptoms.9 Because the clinical symptoms of pancreatitis (abdominal pain, fever, and an abdominal mass) may lead to an erroneous search for leukemia, neuroblastoma, or infection, it is important to be aware of the similarities of osseous changes caused by this group of diseases and child abuse. Adrenal Adrenal injury is seen in child abuse. For unknown reasons the right adrenal gland only is involved. The presence these findings can indicate¬Ý trauma ¬Ý summary Visceral trauma is frequently fatal in child abuse because the injuries are severe and often belatedly recognized. As soon as child abuse is suspected as a cause of abdominal signs and symptoms, pneumoperitoneum, hemoperitoneum, and peritonitis must be excluded, as the mortality rate is very high with these complications. Pancreatitis, pancreatic pseudocyst, and duodenal or hepatic hematomas should always suggest abuse unless a well’Äëdocumented traumatic episode explains the findings. CT is the preferred imaging modality. It is pointless and potentially hazardous to subject a critically ill child to a radiographic trauma survey. However, unless the diagnosis of abuse can be excluded on clinical grounds, skeletal examination should be performed when the child is stable. Documentation of abdominal trauma by any imaging modality is also important. The need for legal proof may be overlooked by the physician caring for the moribund child whose course and treatment will remain unaltered by documentation. It is the policy at my institution to obtain postmortem trauma surveys of any child whose cause of death is uncertain. There have been several instances in which exhumation of the body and radiographic examination of the skeleton of abused children have provided sufficient legal evidence to obtain a criminal conviction. INTRACRANIAL INJURY The brain is the organ of greatest concern in nonaccidental trauma. Although skeletal injuries are important in diagnosing child abuse, they seldom result in permanent damage or functional impairment. By contrast, intracranial injuries are the major cause of death and significant permanent, neurologic, visual, and mental deficits. In one study, cerebral atrophy developed in all abused children who had abnormal CT findings at the time of initial diagnosis.25 CT and MR imaging have made it possible to assess acute and chronic brain injury accurately and noninvasively. CT is capable of detecting small amounts of fresh blood and therefore is the imaging modality of choice in children with acute head trauma. While CT is capable of defining acute or subacute hemorrhage, MR imaging is superior in detecting very small amounts of subacute blood and hematoma residuals. In the subacute phase of injury, MR imaging can clarify questionable areas of hemorrhage identified on an initial CT scan.¬Ý (FIG. 85)¬Ý ¬ÝMR imaging is also more sensitive in the detection of subtle focal and diffuse cerebral edema. The sensitivity of MR imaging for detection of small quantities of breakdown products of blood makes it a useful tool in child abuse. The content of methemoglobin in an intracerebral hemorrhage increases with time and produces a strong signal on T1’Äëweighted images. This phenomenon is similar to callus formation in skeletal fractures. The amount of callus and the degree of remodeling clearly indicate multiple fractures in different stages of healing, just as the documentation of separate episodes of intracranial hemorrhage clearly points toward abuse as the cause of the abnormality. ¬Ý¬Ý ( FIGS.86-89.)¬Ý A conservative estimate of the incidence of symptomatic head trauma in cases of child abuse is 25%. Approximately one tenth of all neurologic disease in children is caused by abuse,22 but this figure rises to 64% in infants under 11 months of age in whom acute head trauma is identified on CT or clinical examination.22 Approximately 40% of battered children have ocular involvement, most commonly retinal hemorrhage, periorbital edema, retinal detachment, and lens subluxation. Permanent visual defects are frequent in such children. Many authorities believe that retinal hemorrhages in children who are older than neonates but younger than 3 years of age are pathognomonic for abuse. Other forms of head trauma, including automobile accidents, show a conspicuous absence of this lesion. Unfortunately, 15% to 30% of retinal hemorrhages occur at the time of delivery, making this finding less useful in the neonatal period.¬Ý ( FIG. 90 ) Although much remains to be learned about the precise mechanisms of neurologic injury, shaking of the crying child "until it stops" is a mechanism described by abusers in numerous testimonies. The cause of calvarial fractures is less certain but obviously reflects a direct impact to the skull. Plain skull radiography is an important part of imaging in child abuse, because it can document that trauma occurred. Skull fractures are often missed with CT, MR imaging, and skeletal scintigraphy. Thus, plain films of the calvarium are needed to supplement all of these imaging modalities. CT bone windows are a helpful addition to document fractures or split sutures, but a skull fracture parallel with the plane of section may be missed. Kleinman divides skull fractures into simple and complex.8 A simple fracture is a single line, no more than 2 mm wide, that is straight, curved, or jagged and is confined to one bone in the calvarium. Thus, simple fractures do not cross sutures or synchondroses and are not diastatic or depressed. Complex fractures are composed of more than one fracture line that may branch or radiate from a single point. Isolation of a fracture fragment in a complex injury is termed a comminuted fracture and carries with it the potential complication of a displacement of the fragment into the brain (depressed fracture). A compound fracture is a fracture associated with a laceration of the scalp. Subgaleal hematomas may be produced when the abuser pulls the child's hair or delivers a blow to the head. ¬Ý¬Ý¬Ý¬Ý ( FIGS 91-93. )Both accidental injuries and child abuse can result in simple skull fractures, which are most commonly seen in the parietal bone. One important difference is that skull fractures are very rare (2%) in accidental injury8 and common (10% to 38%) in abuse. Second, 95% of accidentally incurred fractures are simple, whereas 79% of fractures caused by abuse are complex. Finally, accidentally incurred skull fractures are almost never associated with intracranial injury, whereas those caused by child abuse have a high (65%)8 correlation. Although skull fractures are important, their absence does not exclude serious neurologic injury. Retrospective analyses of abused children show that intracranial injury is more commonly seen with an intact calvarium than with an associated fracture (78% versus 65%).3 This is especially true for subarachnoid hemorrhage. Subdural hematomas result from the tearing of veins that run from the brain surface to large superficial venous structures such as the superior sagittal sinus. Movement of the brain substance within the confines of the calvarium, as produced by shaking or deceleration in blunt trauma, ruptures these bridging veins, resulting in hemorrhage into the interhemispheric subdural space. Blood may then dissect the subdural space over the cerebral convexities. An interhemispheric subdural hematoma is often unilateral and is most commonly identified on CT in the posterior interhemispheric space as an increased density that is broader, slightly more irregular, and more ill defined laterally than the pristine, sharply marginated falx. One study demonstrated this finding in 65% of abused infants with acute head injury.25 Epidural hemorrhage is unusual in abuse. Contusion is the most common brain injury in child abuse. On CT, parenchymal injuries may appear isodense or of high or low density, depending on the relative extent of hemorrhage and edema. Parenchymal lesions of low density may represent ischemic infarcts. Cerebral edema may be generalized or focal; when diffuse, it may be recognized by compression or obliteration of the ventricles and cisternal spaces. Early, diffuse edema may cause indistinctness of the gray’Äëwhite matter interface. Severe, diffuse edema produces diminished density of the gray and white matter, which contrasts with the high density of the unaffected cerebellum, brain stem, and thalamus. This phenomenon has been called the reversal sign.8 Focal edema is more readily visible than mild diffuse edema and may cause a mass effect. Ipsilateral ventricular compression, obliteration of cortical sulci and cisterns, and midline shift may result. It is important to understand that a normal CT scan may be seen soon after injury in children with neurologic damage of sufficient magnitude to cause death. The patient may expire before abnormalities become visible or a repeat scan is performed. DIAGNOSIS OF ABUSE BY CLINICAL HISTORY For the primary care physician, the clinical history is often the first and best clue that the child has been abused. The following characteristics of the history are helpful in suggesting the possibility of child battering. 1.¬Ý A history that is clearly implausible. Frequently the explanation that is presented is so unlikely that the abuser appears to be inviting disbelief. For example, "The cat fell on the child and broke his leg." "The rope marks around his neck happened when he drove his tricycle into the clothesline." "The father was so surprised when the child stopped breathing that he dropped him." 2.¬Ý An inconsistent history. The account of the accident is plausible, but the incident clearly could not have caused the injury. In this setting, the abuser obviously attempts to invent a logical explanation. For example, "The child fell off the couch and broke all those bones." "The child rolled against the side of his crib and broke his skull." "The toddler fell off his tricycle and broke his femur." 3.¬Ý Conflicting histories. Different explanations are given by the same parent at different times, or conflicting stories are obtained from each parent when questioned separately. Another historical clue to abuse is an unexplained delay in seeking medical help. Nonabusive parents usually obtain medical aid as soon as the child appears to be genuinely injured. In child abuse, medical intervention may be sought as a last resort, often days or weeks after the injury. Even if the parents refuse to admit that the injuries are not acute, partial healing of burns or lacerations and periosteal new bone indicate that such is the case. DIAGNOSIS OF ABUSE BY CUTANEOUS INJURY Frequently, in nonabused as well as in abused children, the examining physician finds skin or soft tissue abnormalities for which there is no obvious explanation. Bruises and scars from accidental trauma can be indistinguishable from those incurred in abuse, but certain features may be suggestive of one or the other. For example, bruises along the forearms and anterior tibial surfaces are often seen in active children. Abuse should be suspected when the bruise is located in a place in which accidental injury is unlikely to occur, such as the perineum, the medial aspect of the upper arms and thighs, or the buttocks. Some bruises reflect the shape of the battering object; outlines of hands, straps, or sticks on the face or buttocks are virtually diagnostic of abuse. Fingerprints or thumbprints on the inner aspects of the child's upper arms is a common cutaneous injury incurred when the abuser forcibly immobilizes the child. Human bites are easily recognized, and the size of the imprint not only may indicate that the assailant was an adult (as opposed to an animal or another child), but also may permit exact medicolegal identification of the abuser. Burns are present in approximately one tenth of all abuse cases. The most common injury is a cigarette burn, usually on the hands, feet, or buttocks. Bullous impetigo and infected cigarette burns often have a similar appearance. Forceful immersion burns occur in a characteristic stocking pattern or result in a perineal burn that involves the buttocks, perineum, and upper thighs. Rarely, the tendency to bruise easily may be related to clotting abnormalities or leukemia. Laboratory tests identify children who have an underlying hematologic cause of bruising. Vasculitis can also suggest bruising caused by child abuse; rarely, "Mongolian spots," common in Hispanic patients, are erroneously identified as bruises. SUMMARY Child abuse is a major pediatric problem that can result in death, mental retardation, and serious neurologic deficits. As indicated in this chapter, most skeletal trauma in cases of abuse is diagnostically specific. Common accidental injuries have typical signs, mechanisms by which injury is incurred, and clinical histories that almost always distinguish them from nonaccidental trauma. In infants less than 1 year old, any fracture or crainnl¬Ý should raise the question of the possibility of child abuse, as should visceral and cranial injuries in older children. Significant progress in diagnosing child abuse can be achieved by an increase in the awareness of the condition by all health professionals involved in the care of children. CHAPTER 14 REFERENCES ¬Ý1.¬Ý Ablin DS, Greenspan A, Reinhart M, et al. Differentiation of child abuse from osteogenesis imperfecta. AJR 154:1035’Äë1046, 1990. ¬Ý2.¬Ý Billmire ME, Meyers PA. Serious head injury in infants: Accident or abuse? Pediatrics 75:340’Äë342, 1985. ¬Ý3.¬Ý Cohen RA, Kaufman RA, Myers PA, et al. Cranial computed tomography in the abused child with head injury. AJR 146:97’Äë102, 1986. ¬Ý4.¬Ý Cumming WA. Neonatal skeletal fractures. Birth trauma or child abuse? J Can Assoc Radiol 30:30’Äë33, 1979. ¬Ý5.¬Ý Edwards DK. The battered child: Your day in court. In Gosink BB, ed. Syllabus of 12th Annual San Diego Postgraduate Radiology Course. San Diego: University of California, San Diego, 1987, pp 47’Äë59. ¬Ý6.¬Ý Feldman KW, Brewer DK. Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics 73(3):339’Äë342, 1984. ¬Ý7.¬Ý Franken EA, Fox M, Smith JA, et al. Acute gastric dilatation in neglected children. AJR 130:297’Äë299, 1978. ¬Ý8.¬Ý Kleinman PK. Diagnostic Imaging of Child Abuse. Philadelphia: Williams & Wilkins, 1987. ¬Ý9.¬Ý Kleinman PK. Diagnostic imaging in infant abuse. AJR 155:703’Äë712, 1990. 10.¬Ý Kleinman PK. Differentiation of child abuse and osteogenesis imperfecta: Medical and legal implications. AJR 154:1047, 1990. 11.¬Ý Kleinman PK. Schmid’Äëlike metaphyseal chondrodysplasia simulating abuse. ¬Ý¬Ý¬Ý¬Ý¬Ý AJR 156:576’Äë578, 1991. 12.¬Ý Kleinman PK, Belanger PL, Karellas A, et al. Normal metaphyseal radiologic variants not to be confused with findings of infant abuse. AJR 156:781’Äë783, 1991. 13.¬Ý Kleinman PK, Marks SC, Adams VI, et al. Factors affecting visualization of posterior rib fractures in abused infants. AJR 150:635, 1988. 14.¬Ý Kleinman PK, Marks SC, Spevak MR, et al. Extension of growth’Äëplate cartilage into the metaphysis: A sign of healing fracture in abused infants. AJR 156:775’Äë779, 1991. 15.¬Ý Kleinman PK, Raptopoulos VD, Brill PW. Occult nonskeletal trauma in the battered’Äëchild syndrome. Radiology 141:393’Äë396, 1981. 16.¬Ý Kleinman PK, Spevak MR. Soft tissue swelling and acute skull fracture. J Pediatr, 121:737’Äë739, 1992. 17.¬Ý Kleinman PK, Spevak MR, Hansen M. Mediastinal pseudocyst caused by pharyngeal perforation during child abuse. AJR 158:1111’Äë1113, 1992. 18.¬Ý Kravitz H, Driessen G, Gomberg R, et al. Accidental falls from elevated surfaces in infants from birth to one year of age. Pediatrics 44(suppl):869’Äë876, 1969. 19.¬Ý National Safety Council. Accident Facts, 1989. 20.¬Ý Sivit CJ, Taylor GA, Newman KD, et al. Safety belt injuries in children with lap belt ecchymosis. AJR 157:111’Äë114, 1991. 21.¬Ý Spevak MR, Kleinman PK. Does cardiopulmonary resuscitation cause rib fractures in infants? A post’Äëmortem radiologic’Äëpathologic study. Present at the Seventy’Äësixth Assembly and Annual Meeting of the Radiological Society of North America, Chicago, IL, November 25’Äë30, 1990. 22.¬Ý Sty JR, Starshak RJ. The role of bone scintigraphy in the evaluation of the suspected abused child. Radiology 146:369’Äë375, 1983. 23.¬Ý Thomas PS. Rib fractures in infancy. Ann Radiol 20(1):115’Äë122, 1977. 24.¬Ý Thomas SA, Rosenfield NS, Leventhal JM, et al. Long’Äëbone fractures in young children: Distinguishing accidental injuries from child abuse. Pediatrics 88(3):471’Äë476, 1991. 25.¬Ý Zimmerman RA, Bilaniuk LT, Bruce D, et al. Computed tomography of craniocerebral injury in the abused child. Radiology 130:687’Äë690, 1979. Curriculum Vitae
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