Caffey-Kempe syndrome

 Caffey's landmark article of 1946 noted an association between healing long-bone fractures and chronic subdural hematomas in infancy, and it was the first to draw attention to physical abuse as a unifying etiology. In 1962, Caffey and Kempe et al proposed manhandling and violent shaking as mechanisms of injury and emphasized the acute and long-term sequelae of abuse as serious public health problems. Since these early reports, investigators have more clearly defined the pathophysiology of abusive injuries. Community-service and law-enforcement authorities have taken a role in protecting potential victims and in prosecuting perpetrators.

Caffey-Kempe syndrome

In the United States, in 2015, there were 683,000 victims of child abuse, and approximately 1670 children died of abuse and neglect, a rate of 2.25 per 100,000 children. Almost 75% of those deaths occurred in children younger than 3 years. Most reports of abuse were submitted by educational personnel (18.4%) and legal and law enforcement personnel (18.2%). Approximatley 9% of reports were submitted by medical personnel.

For infants and children younger than 2 years, a skeletal survey should be performed as the initial screening examination when child abuse is being considered. The survey consists of the acquisition of a series of images collimated to each body region. The series includes frontal and lateral views of the skull, frontal and lateral views of the spine, frontal views of the chest (ribs) and pelvis, and frontal views of the extremities, including the hands and feet. 

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The skeletal survey is widely available and inexpensive in comparison with alternative imaging modalities. Other important advantages of the skeletal survey include a high sensitivity for most acute and healing fractures and a relatively low radiation burden. 

A babygram, in which the entire skeleton is depicted on a single image, is not an appropriate substitute for a properly performed survey. Geometric distortion and varying exposures are unacceptable limitations of this image. Use of a high-detail, high-contrast, screen-film system with good spatial resolution is mandatory. All abnormal areas should be viewed on at least 2 projections.

Computed tomography (CT) scanning of the head is the imaging modality of choice for evaluating a child with acute neurologic findings or retinal hemorrhage on physical examination. It is more sensitive to acute intracerebral and extra-axial hemorrhages than is magnetic resonance imaging (MRI). Brain MRI may be helpful as an adjunct for the evaluation of axonal shear injuries and for a precise dating of intracranial hemorrhage. 

Subarachnoid hemorrhages (SAHs) are best demonstrated on CT scans. The use of MRI to detect acute SAH remains controversial. However, MRI is superior to CT scanning for differentiating a hypoattenuating subdural hematoma from cerebrospinal fluid (CSF) and for detecting small and chronic extra-axial fluid collections. (See the images below; both images reveal a subdural hematoma, the first with a CT scan and the second with an MRI scan.)

Rib Fracture. Image shows multiple bilateral rib fractures that are healing. Note the callus formation at the posterior and lateral aspects of the ribs and the healing left clavicular fracture with callus formation.

Rib fractures occur when a compressive force is applied simultaneously to the sternum and to the costovertebral junction during violent shaking as the perpetrator compresses the child's chest using both hands. 

The posterior ribs are most commonly fractured, because the greatest force is imparted to the articulation of the head and to the neck of the rib with the transverse process of the vertebral body.

However, fractures are not limited to the posterior aspects of the ribs. Anterolateral fractures are also common. Rib fractures are typically noted at several contiguous levels; they are frequently bilateral.

Skull fracture secondary to child abuse horizontally crosses the left frontal region superior to the orbital rim.

Head injury accounts for 80% of deaths associated with abuse in children younger than age 2 years. Mechanisms of injury include forceful shaking, either by itself or accompanied by abrupt impact.

John Patrick Caffey (1895 - 1978), American paediatrician.

John Patrick Caffey

John Patrick Caffey was born in 1895, the year Wilhelm Conrad Röntgen (1845-1923) discovered the x-rays. Caffey graduated in medicine at the University of Michigan in 1919, and served his internship at the Barnes Hospital, St. Louis. In 1920 he went to Warsaw in 1920 with the American Red Cross in Poland and Russia, but contracted typhus. Immense medical problems had arisen in these countries following World War I, and it was the lack of medical care for children that made him remain in Europe for three years after the convalescence, working with the Hoover Commission in Russia.

After returning to the USA, Caffey became chief resident at the University Hospital in Ann Arbor, Michigan. He then worked for a short period of time at the Babie’s Hospital in Columbia University, New York, before he went into private practice in New York. In 1929 he was appointed to the new Babie’s Hospital where he was assigned to take charge of radiology as the hospital's first in-house roentgenologist.

In 1950 he became professor of clinical paediatrics at the College of Physicians and Surgeons, Columbia University, New York, and four years later was appointed professor of radiology.

After his compulsory retirement in 1960 he became emeritus of radiology. Caffey had no intentions of leaving his work, however, and became visiting professor of paediatrics and radiology at the Children’s Hospital, University of Pittsburgh. He continued working until the day of his death in September 1978, at the age of 83 years.

Charles Henry Kempe (1922 - 1984), Poland paediatrician.

Charles Henry Kempe 

In 1958, C. Henry Kempe, together with Elizabeth Boardman and Betty Elmer, created the Child Protection Team, Colorado General Hospital, Denver.

In 1961 Kempe, Dr. Brandt F. Steele and other colleagues made their first presentation about "The Battered Child Syndrome" in Chicago at the 30th Annual Meeting of the American Academy of Pediatrics, October 3. This was published in the Journal of the American Medical Association the next year. In the 1980's this publication was cited by the American Medical Association as one of the 60 most important contributions of American medicine in the 20th Century.

In 1972 The National Center for the Prevention and Treatment of Child Abuse and Neglect was established at the University of Colorado as a national resource on issues of child abuse and neglect. In 1981 the centre was renamed in honour of its founder, as The C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse & Neglect. It is now named Kempe Children's Center.

In 1977 Kempe established the international journal Child Abuse and Neglect.

The C. Henry Kempe Award, established in 1984, is given every 2 years by ISPCAN, The International Society for the Prevention of Child Abuse and Neglect, to an outstanding young professional or organization working in any discipline in the field of child abuse and neglect.

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