"Pr                                                                                                        rtN4 -         ...
F-U                                                11                                                                     ...
because she whined (2) A girl , 4 years, ofiper-                                                           ageW Shaken vio...
1972
1972
1972
1972
1972
1972
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1972

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Artigo de Caffey (1972) SOBRE SBS

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1972

  1. 1. "Pr rtN4 - Atiguat.19721; , • Vol 124 N o 2 Abrah . .„ • e Its Potential Residual ,•E ,.„..,•• •••,,„, •• of 0 . t r # 0 4 p i i t t 9 • ••, ••••••• • • , ,•1 , l . •S i * i t i : • D O . J B e . 0 •l i i t e , 4 - • r n a g e : • c 0s :t : : in 1946 of the paient infant : : ; • M O k i stress öf r y n t i rb * e t • „nct c 4 genie vaalcil;umenaornZhogpentiv:sehlkpilgh?; e s f • syneir:§00;,*4esci7ihecl t 0 , 1 : ; • : : I t e . i r :n e • • oftenh d i s t „r ti b u t i :monthsS ), younger, whtods u t f : 9 s yx o r :t(P th e combination4o f subdural i R a fi g • tiom a n t s , p Ibone lesions i h ie n rf o matomas and characteristic bone ; hi • o n ITS m u s t h 1 e d 3, • r b a t During the last 25(..years lcsLons t : : C p b e i n _ e e a r t g a n t : l i a k e y i d e ri e ; , s t e d i t ; b circumstantial, has gradual* a6;: :sad a t a f cumuIateCivhick:: suggests: tb4,.:::the b o t by " , M § b i ; u iibused infants are common . whli4lObiabaking.:•,::: and je rkin g . i t boneg : k o rc a taisr0100.10,4):•;*.01; aa.;.theeerehro: l ue s te t the o f , t s : , • : vascatArte0Oti§; • t se r 1 o 1 4 4 0 ; c i t 4 e • s • n , the mo s t c ommon cause o f t , ,tle I u 011: iPlic at ic k pl r ma n d a t t e riS ! , t , g9#0;YAWeinvite your agOnt,ion,!,tn.• h e evidence which supports our con- the . o toh a ts: ; , : : : t h : L• m s cept , d a r jerkmg o f t i n t s a re frequently E t lash-shaking is practiced, commonly in, e , f pathogenic and : t v h i O a s h 4 o fh e t l t a Wide variety of Weis; Under a wide iI qf e : a a permanent d a ma g e t o i n f a n t i l e . variety of circumstances, by a nea- kIng,a n variety of persons, for a ytride,jrai:iey„, m t lia t : iii. o p iit ia lly, :b d out , of ireasons: os c4 1 :r : , w de,, m d sn it i n , a fOi, h e : T repeated WhiPlaahahakinge,f, fragments 0 re : : fants and young children is to correct :d irea ,i - iig 3eceivedi$ g:publication,Apr il 12 1972 1 : a 0 o q ii, cfor mn o s n ,r a : , Minor miabeh av ion Such sh ikings are • a c nand p i i * t h e departments of radiology :and pel t tt m .t r taes pemae;,to,irrtchkip i ffee- h e s s , ac diatiiii;:School of Medicine, University of Pitts- generally c oparents : and physicians. :If , s h et e r ,u1- 41 a . both ; r, o c a ! bilitli,"faiid the Childrens Hospital of Pittsburgh, c r .,.• ; Pittsburgh n m o u r / of th e pathogenie, signifi- r r i sa t t t concept ,,o m s c n c 1h:,:tniesla.no pus n gr1I _ : tadt 2 sl haS i t r t c pacnh s - 6ee e i h :Oa e d Read as the Tenth Annual Abraham Jaeabl, o n of whiplash-shaking, is valid, it cance e e ue # i i i i k Aiiy)**FlOaaaif before.:: the 121st annual :con e follows a l r tio e tor nosal m,com i d e r that the prevention o f such r0 , o u tnhonrIt,reoseedr s m , tsheass s ale7wttbsu le / f ods e b n ce ta 1n e n , h:e a e l e n o s t v m o sReprint requests to chi l dr en ; H ospi S a. ) t i anc i § shaking and jerking might substan- o t:IdW e d a:anor o p weto t iInce r y t i 1 r vu v fia91) as1 l1om,,nslsio a n d oin rme n c . s :e. o t t i o : : n n ala s itially reduce the incidence o f brain e ln6onihqnv V . . Traumatica o Pittsburgh 125 De Sete Si, Pittsburgh 15212: sO t ; : . , l ar i q cA r e vdamagee and mental retardatien. The , • P sav segment r fo o ( c u l only e c n v t minal n t nm t i e s T1 Y: 1 :1 - Cs4 fM e W : o c rvemr h e . tt 2 al 4 Psee:skeibs e l tr peo - .W 0 , ie a 7 u o p lv r etei y s e e n te:: t2 fhf s wit " 1i c9 t i 2 i e aoi al Amer Dip ,Philci/VoI,124,, Aug1972 u s Damage from WhiplaskShaking•of Iirifant0Caffey 1 6 1 a sareteari s h o .0 e M , 3 r c ti tching, e r r 312 4 d i c e tlioehrr h 9es : e . e Y n l a 1 b s d b e 66 e s rdo e xl 1 " - a A s 3 r h y ,r u f r y tsi: e T l s o , e u a p ofli
  2. 2. F-U 11 - •••„••••• • • • ,, , • , : - , s u p e• i • spicuous o f all t i anmatic lesions in imposed on the haft, but after four growing bonesl l t y ea d most con- - U s u a h Tny are not lg te rs a y e ht fracture-dependent They develop due : W to traction-rupture of the abundant .. . . . : : : • • normal p e rf O ra t in g " : ; b lo o d ; .: The entrapped subperiosteal b1oo 0 which course througif.,thelettotieal•Valt t t;then::gradually resorbeci The n a 444 - -: : : v e s s e li, . •l e . . : and distribition of these lesions 440t.no c „ullary cavity and -ivIlicli•047.0.:,00„.iier•Oct...47:•;:,. : be best explained on the basis of i1 ( i- - 4 a n ?1 the junction • .0.10:„Inten.a:,..:•ecike",:of ., V h ii : a- "• . ti0k4r0t,f,0*d.;*gi*iithOperiostetlm e ••:,• • : , . (4 •• V -••• tof "04kO4 : . joint: ,,_•,•.••••• blood •internal• to• tne perieetetiM :: its vessels, and thefp, i a n„l e„4 t pg • : • • •• • • „ , , r On„n ag iz ilAilp it . 1 i - V ••••butextern41 i . whipla •_ .: 4 h e , ithe Periosteurn.off;:.the•••wall t h 0 , . extremities andh s h a 1 N ,h d a e , able: distances and I o - :h distribution can be , : - satisf , t er t h e i r ce teallImatp.mas•Of vanable sizes and # eih ed - o ernt , i* c a ii n a t on theebasis actoi i1y _et:; ••• :;••:, . ••• •• . : n •• ehappa„ m4 b plained u r of•,_ •its vrect s h n ) w o l b ( e r t :!,fOr.; • l • ••analogous. bones. _ •••••••tivoartriS a n Severaltobservers have noted - in •• ,•• " • • • : la. the ",• •••••••,:•••,• r • t o . • ; • legs;„ or they affeet, bones in the aims.• o c i art e d " , d i f f t i s e l S cO r - i la : O f t- •e n e :4 and forearms: • •••• ••„.„: : • : n some o f : : . . . t 1 metaphyseal fr ag- e Or::: •• • ••••••••• : • •• t h •,i the*e • ••• • •• s . Fre- UPrt a infants Th is has - : only , abused - P suggestod i 4 k•.xcessively fragile,:brittle, ,chalk-like .e - . O : - quently i rn y o l y e m ,: , Celaticationi (pzc) on the proximal ti de of , t, o s- _ . A T ec!Mp e .•r:.o thQkneei in the femur and the distal side of a the distal.. p r o x i m a l , sides o f . th e m e t i h i : bonesIto * e . i , U W. 1 1 s r the tibia of a patient 4, months;ii, • ,••_ -• „ ointl , _• ," . b 0 . • , • •_•,•- ) •:: . •:,l . geh . ,ohS y 0 i0 s fi St y nc , lappear radiographically :a 4 : , r rn t , l b e 1 : i o f . . . . .s: . :l 1 t i o n O S i § f . mination:disclosed, 1 1 2n , , • , ; )voven pat- r -: - . t , , , , • a M OsPi e a , • •r • . • , 0a d i o l o g S t t ho S h a ; t S O m 1 , , • , , • , , ee e ::• . . o n s : O e ,: i , i : , ha i. s t s 0e exces- b :• o :t phe :: • • • • • F ,i ; : • • • : , ar- : :•;•- •- " sive :n I ° .- , newly• r pf o :,. i , : ; f o r i n e d : r i n i t t; i . e o : : .c i .i : , V n• 0. e c . v_, : a l under the perlosteOrn" f5 a ,: : ks .1 4 n t e hp: .Fig::• b r o u s ly • l.rnur,& with . , O e . 5 A - : _ e. : _ curve:::,.;..:::::„: :: : : :.: ,„.::,;:.. ,.,;,: .:::• :::: .;:t,...„ : ,: : ; ,: .::.;,,..:: : .,. : „.„.;•,....:, :, ,:,...:•::::::":•; ! " „, _D•:• " . " • . • • „! ; , : , l. *. 1 1 thickeningsn - s(___;;;..,,;.:::::;:.; :., , d line (arri74/4/s :, opaque: ?...:. , , „ s , tom " 4 *i: , : in g ls of e ,l i . ,:,.,„-•, - iap • oe 0i ; - :i the external s u b p e riu S t -e rg:f r-A r n l ) .. O io „ ris n;t s l i ti y a fi n e . nn n i g i•4 •t , :: n e S y r u po r i m p o s e d or ,l , r o s:pi U . The epiphyseaLOSSift i s sm m e b o t l h . ea1 ,,,ii :tos n. _ n to t h o a yt c e -,- !s i •• , •—• ,, • T r u m a t i 444,611 :ie cs e n - : ,-• T h e sclerotic. shafts are -d e. t r w .e e „ i p O . l . ! - -•••-_1 s t0 ;:ro n g e r than nortriallSh44ts. ,#0 - ls i .c he t ;n m, e , ni k •::„ - • , , ) ap i p h y s li n - . , , :e TraumatictmetaphySeal:::!•.:eilpptut.,: is - •::: o f h ef• • , , „ ,,_ - „e . .io d : li ep ,.• • d us e to traumatic obstructive:;ipPrY,: to •e ms l ,fo i a , y. e .hthe epiphyseal : a ,. . d e. e f e : 1t -t d h . „, fdboring r i o l e s plate. . . . acr t e cartilage „. ,h g _ t, s - * - e e a: , r i ;• t •ei t n , "loop7,, d e . o r, Miie e ! taphyseal - f eto stretching , and••!ciio#onSiOn.,:;O ,g e 4 •p . :l :-fvtii aumatie i n v O l i i :• - . ; .: p, i i rh s , e o: . .l h o . . 1o h •a . r :,..: e.. fl..these .l e s i o n S- ofi:Ahe ,l io : r , e the t , : :n : r on.a#U cca u„sa l: : h a . ••• , , :,O •,,,,, : • ssi: •„ :, .v y , f " s ,l t . : :t ; C,• • m s; *•„4 u e t h o : , e ] t t re n squeezing 0 a •,•,: .:g r e : , l : h O S t l •i. si : h. : t a -a- h i sailants hands, and „whiplash-shaking : e n i ei f„:n e , t F i l - !,s ;- e, : : r :qei,.tinfants ; , M e - , the 1 , , : . 1 e . o,S : • i , Despite the fa 4 n t..0 . ,i, a. :o t : d o- t , t M ia:l4hrOn di i .tg l y , , ; t en ie, i 1: l . ,n i, h r u.physicians o tol,apprepia,t,tho,- hl : a d . . e :, tsignificande...; -a ". , , b 1 m o n. ol . t...,:;Pt4 t0 - • f- o ; B o :. younger infants, and •- a : :, , i u dh• • „h , l ? a e • ::::•,. .•. ,y : -, :• l: f i • • , - :,..,:,.• :, z n n :",:kS : , , l, _ • d -- e- n1 * .n d ! i:. : q g •••„•,,••••••••••,„••„ o -n p1 • ..,..,..,•:,„,:••••••••• • ,•• • ••• • • • • • , - ,-A • u 2 7 9 1 g d :: ..ing• t h:e ,: : : • ,,• Brain Damage. From Whiplash-Shaking of Infants/Caffc , l ; ,e i:::of ve : • 4 : • , • z , b :w :ia ,e :. .i.g , t -o e: . , c o - . i::::, :- (; ,as " - i f A: • . n l i,e : O g , :: Jih :: f : s f e - : j:: ! , • • • : :
  3. 3. because she whined (2) A girl , 4 years, ofiper- ageW Shaken violently because Of inces- asfour e sant crying : .(3) A, girl 4, months Of ,age;was new some and,At,thp,„ same time, the most sig- shaken faUlly during Which , fRind iufi banged , h e ragainst, the crib h e a d , yetm a. whe ca iplaSh141 a wr s a s counted i n k t fi g A t n i b i f - 4 1 s)d is - na . t •ture - o 31(THREE CAs - 0r M0 , * nt fote l , * Y o y , : i l l O d 4 mont swiss explained cOnvulsioni, and h ts h, can ported a n t 0, liit l 4t fever • His mother Was • too shockedndi- maimed I t VtlieriAtiiiiii.a;;Iier,idrlof eight. , . h t k 0t h , t 7lO Og :O,V I 4 y years, V9sera- , a i n i ea r l,. : and t heir blood vessels 4antile brains I n 0 i ;: , and e ndied, ,three days later Eventuall a k he iA ,- , These assaults all occurred in the homes of;ules sh l n l p , fii f a a t s : I p•p e r - mi d d l i 4n 4 n S s i a t d y4 O , a 1 s thehm her•aclinitiecl thatshehad shak m i ot the u 1l parents, who provided expert medical: . a u several times t6 f r o p t b , •" c h o - d do , en to death" cltirine a violent PitroXYM of Og 5 WYd : : •- h i g h . i k „ ; . - t 4 4 1 n1 n n ? iing rcoughing StiP ,ha t t e mp t e d " c l e a r his 61,I a the caree n . )y (4;heir f services 1 4 . i .; throat: and he went into convulsions l b ex- 7 demand n o, jp e d i b t . 0 0 0 S , . :lowing the Shaking. ( 2) , A boy, 6 m onths ns : . : edt , 00; t ed. V e . 5 for bein tion e0 4 began to vomit and cnnVulSe., There old,pact f c , Sarc t 6 . ; P awere no external signs of head injury but infant . u s charges Both parents d o c t o r s g a 0t l n g , p: ia e r . : : : t n :0 u , • - ;hemorrhages were seen in both ) tretinal appareiltlY:Jliakitilegnfidence in her in one . " ee x t r a r , lodder fundi. Subdural hematornas were insto.4e4d..Wkin),i,ited back by the par- . b au v g e ents , i opa7i C t s ee c o n d infant h : atreated surgically:, (3) -Qifle i t i lhad shaken their first child to death_ ; Ate :f jt e r g n 4 . , patients twin brother came to the hos- this , v a , n O tA 1 e w andunexplained broken femur. fragmentst ; both ends •of pz0 tAf t ,tef , ?inf ant W found dead without . n l tpital1 Fig 3.L.,11nexplamod a e . as o r with , f a y-like u y aVdt adt pry oShortly thereafter, the first twin returned, - s d t ipn M m1 ; persistent subdural hematomal By •with , : y• s tures) of the left femur with fine thin2ent p l444 P - t( rn p m a t i c auO p n i d a t e r , nal thickenings of its cortex which 1:0Iiee_sent ex- ,: p abubble up " I 0004 him tin and tried to , a time bruises had appeared,on both elthis , r a c f f r a c t u r n t o!, 5. ))14,; p,: .,441: ).do-anything aI nhe.1 0 , e forearms, which fitted the pads in the • o0 lget e k o :o :T: 4 whis e tAe a c P i a t i a to o * p r ,..p f twxongyy,Ne i : i o a fingers and thumbs, cif: the , examiners the distal t h e two ,i;:,Shafts;-pat- - e o n ;4 tsuccumbed unexpectedly, she admitted o fbands, where the boys forearms had t s theselesienS;indieafe•:that the infantatesb, h: a:ces, h s S he O . s ( o h . that . t egripped by his assailant during t h Eventually, the mother admitted that l r,ponths) had been splidd by hoth, ,erous e e r P a ti e n ts h e h liecropsisliselcided.,tranmatiebrain injury. : g i e u t i tra l i y : : h n ing, s h a k he x and her husband "might have shaken B a h n w she d r nt seand maiming two others. When these -04 e! : s f • c ihim when he cried, at night " Guthkelch rvent his t d :raü d .1 n a d M xt t e d e admissions became t o the commu- o i iopines that ,a.• "good shaking" is f elt by Si*..:WOqns;latOi;:;itiftftsIv:iItiVOluera?,!Oine l; : tBritish parents to be more socially accept: r adius and Oink iff.the: SOlidlifOiO4fn. were ed- o i. l , in a d , g in disclosed that ten additional nitYPEirenta - s y h m , ,n fl t r a t e d : : t e o4 k ll l: had been significantly injured by n n i infants g h able, and physically lefts dangerous, than de o s c , eh : r e v thin nurse t e 7 rO 3, ; . , O of r weeks wass ai dY, y h i m a blows or punches to the head. : , : to have suddenly de44V e Tile primar d ExAmhz 4 (ONE C A s E ) . tf a d il o gar S r : t * a veloped unexplained swelling, t r r a, : described radiographic bone lesions caused eu t k i Iy o p n i - iS 1 .inaA ttii .g j! * g k : hours latei i. 4) 4diatr i- 4 fi . d l and fever. ,Twelve ln e e O l # 4 h4Y.:heOn:,yiolent::. whiplash shaking and byK e m p e the repeatedeparental shaking of a pre- . f o r e t ieian diagnosed g s t e o r n S r e l i t i s : g o eiC8diaiit.e:Whiplash;•Pennding on the back maturely born twin girl of 7 months; who because o f p o i n t : ly r §c e d a l had been abused by the mother since the -and ; 0 . 0 § 0 4 a during burping One is amazed that she o d : , O tslight fever a n d : i 9 second month of life. She was shaken while ,a . .,re n d e i t , s h a ,, t k 0n satt4l*thiS Much.better-than7aVerage so- o ; k i n gripped by the legs and held inverted. Mul- y l e begun. e y t o S i showecUOUld,On rwas : . nkO Radiographs ciat,and a a t medical milieu for eight years. I t tiple massive involucra and several me- fracture fragments at,::th0:;.1.PlYPt,,* one g t i , g likely that she did not realize the full .a e l ,sh: 0 :i *e§ ; ! n Srei s (g45i is lc a taphyseal avulsions developed In her fe- tproximal tibial metapnysis w n t q l e „ — murs and tibias. n * e l: Later films showed ; the evolution * trauma pOW4r. and violence generated in her shak- k ls : i- t an k X EXAM 5 (ONE C A s E ) PLE o a longf:;tratiMati,inYnitiOtn*.Offiis of4.0 i oo u i n d wha tn .d : d ie k iC ethe t ;(2,33Ab), and was said to have had very d scribed compression fractures of vertebral b ,-- tibia, e , th nf lart,Onands,,Il.be last infant she shook to h bodies iin c h uinfant, which were believed rthe 19.tki day;,.. Sw s one k m . . s ma idOft,thi:WOignftd:.:497 k g (11 lb). Had the e n !l l to be due to whiplash-shaking. l u .i. . prior to the.aPPearandS.Of the SWAing mjust , . frnOkneetishanOnhy a caretaker of corre- EXAMPLE 6 ( T H R E E CA S E S ) . —W e h a v e : d examples of protective jerking e - a the n o she had E of knee, s, h leg and jerked;her M t t •e h h o t t ; t • n f iSOncling, W ght.,.1. and :•strength, the mon- ei found two the a g a a a n would haye weighed 21 times her ster and one of repeated sibling whiplash-shak- e e hfrom falling y g a hard wood floor t ye r , r a n onto f O e A! Wa s; her - h n ing. We have encountered two patients in , t; ) W ab t s f fi d i sthe:same time she had, fallen,forwatd*ith tweight or 2 , 2 2 6 kg. (5,000 113) bs . y •t I, s u n ; , t. a n d whom a single, sudden, violent jerk of one .ther and onto her ThdPedietricianWtaitill iWOnIct;hayOlhaid,the s . . ,g . : t Oa women srengt h. t : extremity apparently produced metaphy- T in . S 1 # 4 0 C t ,#.0 aAT,44py,,2:(Fpn*CAsEs):.:LWeston seal avulsions and traumatic involucra. (1) rO c h r i a d t r a u nn d . • b e e a u d e of rwith the frequency of feYeranctileuko- h f and Pollock. report: low cases of o 2 1 A boy, 41/2 months old, had always been Steele d p6 : a tn r o n g a t e c y e t .täJ ,s epathOgenie:Shaking,in battered babies (1) well until his mother grabbed him by one e : h O , after traumatic,. ,iiitdrnal!,:[....;:lieinor- cytosis p , : forearm and yanked him upward to pre- a l, y : rhage.t. (3): This boy of 8 months had hadar e iiilgirl2W,::Yeara old, was shaken violently • w , • u 4 • •t• , • ; • • • ,••••• • " e ••••• • "• • •• tT t : e a Me l Wa S t t f t f 4 i n i l i a r c , t i Pis Child/Vol 1 2 4 , Brain Damage From Whiplash-Shaking of Infaidts/Caffey 1fey r et i o g , s na t ; h Aug 1 9 7 2 , t n t: : e o t O * i c d t tf o 1

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