Child Abuse

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Chapter 144

Child Abuse

Overview

In the decades since the landmark articles by Caffey (1946) and Kempe and Silverman (1962), the medical community, law enforcement, and Child Protective Services (CPS) have developed a much greater awareness and sensitivity to the diagnosis of child abuse; these groups have not only advocated for protection of the child but have also promoted a more aggressive approach to the identification and prosecution of offending individuals.1,2 Child abuse remains a difficult, emotionally charged topic. The diagnosis of child abuse and the treatment of abused children are intertwined with legal issues of parental rights and family preservation. Because it typically occurs behind closed doors, the abuse is unobserved, and confessions are rare. Presentations are varied, and abuse and neglect may mimic other disease processes.

Etiologies, Pathophysiology, and Clinical Presentation: According to the most recent survey from the U.S. Department of Health and Human Services, in the year 2009 an estimated total of 3,043,000 children were the subject of investigations undertaken by CPS agencies as alleged victims of maltreatment, and approximately 702,000 were found to be victims of maltreatment.3 Thus, in 2009, 40.2 of every 1000 children in the United States were evaluated by CPS for suspected abuse or neglect, and 9.3 of every 1000 children were confirmed by CPS as abused or neglected.3 Of confirmed cases, children were victims of neglect in 78.3%, physical abuse in 17.8%, sexual abuse in 9.5%, psychological maltreatment in 7.6%, and other forms of maltreatment in 9.6% (>100% as many children are victims of multiple forms).3 Young children are at greatest risk for fatality; 81% are younger than 4 years of age at the time of death, and 46% are younger than 1 year of age at death.3 An estimated 1770 children died from abuse or neglect in 2009.3 More than 90% of all confirmed perpetrators have a parental relationship to the victim (mother, father, step-parent, boyfriend or girlfriend of parent).3

Clinical presentations of child abuse are myriad. In some children, abuse is suspected from the start; however, in many, the presentation is cryptic until traumatic findings are made clinically or by imaging.4 Children commonly present with symptoms related to head, abdominal, or extremity trauma. Children may present with bruising, burns, or evidence of neglect. Not infrequently, manifestations of abuse may be found incidentally on imaging performed to evaluate a nontraumatic process. Therefore, the radiologist is occasionally the first to suggest the possibility of child abuse.

Imaging: Initial imaging of the abused child is driven by the clinical presentation.5,6 Imaging is performed to evaluate for processes that need immediate management or may further threaten the child’s well-being if not diagnosed and treated. Once the child’s acute medical issues are addressed and their condition is stable, further imaging in the form of a radiographic skeletal survey can be performed to look for occult injuries and evaluate for child abuse as a diagnosis. The role of such imaging is threefold:

Computed tomography (CT) and magnetic resonance imaging (MRI) are used to evaluate suspected head trauma. There are no firm indications for CT of the chest in suspected physical abuse or infants with blunt traumatic injury. CT of the abdomen and pelvis is indicated only in children with physical examination, laboratory findings, or both suggesting traumatic intraabdominal injury.7–9

In all cases of suspected physical abuse in children younger than 2 years of age, a skeletal survey is mandatory (Box 144-1).5,6,10 A “babygram” consisting of single or few images of the entire infant is unsatisfactory. If radiographic film is used, high-detail film without a grid is recommended.10 Digital radiography has replaced film screen skeletal surveys in many centers; however, further evaluation of the technical elements necessary to produce high-detail images is still needed.

Box 144-1   Skeletal Survey*

*Images are checked by a radiologist before the patient leaves. Poorly positioned or otherwise suboptimal images should be repeated. Lateral views are added for positive or equivocal findings in the extremities. Coned views of positive or equivocal findings (i.e., at the ends of the long bones, ribs) may be obtained.

Ideally, each skeletal survey is reviewed by a radiologist before the child leaves the radiography suite. Poorly positioned and otherwise suboptimal images should be repeated. Additional views may be obtained to further define positive or suspected abnormalities (e-Fig. 144-1). Commonly acquired additional views include lateral views of the extremities, coned views centered at the joints (wrist, ankle, knee), and Townes view of the skull.

A follow-up skeletal survey performed 2 weeks after the initial examination may provide additional information (e-Fig. 144-2).11,12 As noted by Kleinman, the follow-up survey aids by (1) detecting additional fractures; (2) differentiating fractures from normal developmental variants; and, (3) assisting in dating injuries.11 Follow-up surveys may be limited or tailored to areas of interest.13

In infants and children younger than 2 years, nuclear scintigraphy should be viewed as a complementary modality to radiographic evaluation.14–16 In general, nuclear medicine bone scans are used for problem solving and in children with a high suspicion for abuse but with negative or equivocal radiography.

The imaging of children between 2 and 5 years of age must be assessed individually. Beyond 2 years of age, the yield of radiographic skeletal survey is low as fractures are less common, fractures are less commonly occult, and the fracture patterns highly specific for abuse are no longer seen. Nevertheless, a skeletal survey may occasionally be warranted on the basis of clinical presentation and high suspicion for abusive trauma, particularly in children who are mentally incapacitated.

In the child older than 5 years, skeletal scintigraphy may be substituted for the radiographic skeletal survey, but neither radiographic nor scintigraphic screening has proved to be useful in the older child.

Whole-body MRI and positron emission tomography have both been studied for the detection of abuse injuries.17,18 Both modalities lack sensitivity for metaphyseal lesions but do detect many abuse-related lesions.

Radiographic skeletal surveys should be performed in all cases of fatal suspected abuse and unexplained infant death.19–22 Postmortem surveys follow the same imaging protocol as used in living infants.20 At present, little experience with postmortem whole body CT exists; however, this technique does show promise for detecting subtle findings to guide the forensic pathologist.23

Imaging Findings: No one radiographic finding is pathognomonic of child abuse. Individual radiographic findings vary from high specificity to low specificity.24,25 High-specificity lesions are seen with abusive trauma but are rarely seen in other forms of trauma. Low-specificity lesions may be commonly seen with abuse-related trauma but are also common with trauma not associated with trauma.

Paul Kleinman has written extensively on the radiography of child abuse and has classified the findings into categories of high, moderate, and low specificities (Box 144-2).24,25 This categorization is supported by many series in the literature, although a number of reports support slight modifications to the categorization of findings.

Box 144-2

Skeletal Injuries from Child Abuse

Modified from Kleinman PK. Diagnostic imaging of child abuse. 2nd ed. St Louis, MO: Mosby; 1998.

Each case must be considered individually with respect to the history provided and the possibility of underlying abnormalities that would predispose to fracture, for example, history of prematurity, metabolic disease, or dysplasia. Certain patterns and types of skeletal injury may occur as a result of abuse. The plausibility of the injury having occurred from accidental non–abuse-related trauma must also be considered. Is the explanation offered for the injury plausible? Is the developmental level of the child consistent with that history?

Infants who are not ambulatory do not normally incur fractures from unintentional injury events. A fall from 3 to 4 feet to a hard surface may result in a linear parietal skull fracture, but rarely do long bone fractures, complex skull fractures, or central nervous system injuries occur in this circumstance. The appropriateness of the history in relation to the mechanism of injury(s) is, thus, often the first and most important clue to the diagnosis of abuse injuries. Inappropriate delay in seeking treatment is also frequent.

The constellation of radiographic findings within the context of the clinical presentation may carry greater specificity than any single radiographic finding. Multiple fractures in different stages of healing are highly specific for child abuse, unless an underlying bone dysplasia or metabolic abnormality is diagnosed. Fractures to the rib cage, metaphyseal fractures (classic metaphyseal lesions), and skull fractures predominate in infants younger than age 1 year, whereas diaphyseal long bone fractures are more common in older infants and children.

Rib Fractures

Rib fractures are found in approximately 50% of fatally abused infants.26 The ribs may be the only site of skeletal trauma in some abused children.27 In a surviving infant, the astute clinician may palpate callus with healing or, rarely, crepitus, but otherwise, typically, no physical sign of injury is present. Most acute rib fractures are subtle buckle or greenstick type fractures not evident and frequently are not appreciated on radiography until evidence of healing is found (see e-Fig. 144-2).28 Fracture may occur at any point along the arc of the rib (costovertebral, posterior, lateral, anterior, or costochondral) but frequently involve the posterior rib.26,29 Posterior rib fractures at the costovertebral junction have a high specificity for abuse.30–32 Boal and associates reviewed 1463 rib fractures in 141 abused infants and noted that when individual sites along the rib arc were compared, costovertebral junction fractures outnumbered all other individual sites.30 However, fractures at the costovertebral junction represented only 33% of the total number of rib fractures. Fractures at other sites in the rib arc are very common in abused children, too.30 Fractures at the costochondral junction appear radiographically similar to classic metaphyseal lesions of the long bones and have a high association with visceral trauma.33 First rib fractures bear high specificity for child abuse.34

A squeezing injury, shaking injury, or a combination of both results in leveraging of the posteromedial rib over the spinal transverse process. Excessive compression and distraction forces are also placed on the lateral and anterior rib arc and at the metaphyseal equivalent region near the costovertebral junction of the rib (Fig. 144-3).28,35 Multiple fractures may involve a single rib. Oblique views of the ribs increase the sensitivity for rib fractures and aid in their characterization (Fig. 144-4).36 Nuclear scintigraphy aids in the detection of rib fracture and plays a complementary role to that of radiography (e-Fig. 144-5).14,15 Follow-up radiographs (see e-Fig. 144-2) and CT also provide increased sensitivity.37,38 CT may be more sensitive for rib fractures than radiography, but the greater radiation dose of CT limits its use as a screening modality.37 Nevertheless, focused CT may be helpful in problematic cases. If a CT is performed for evaluation of visceral trauma, reconstruction of images with narrow slice thickness, bone detail algorithm, and multiplanar reformats facilitate identification and delineation of rib fractures (Fig. 144-6).

In contrast to adult ribs, fractures rarely occur in infant ribs because of cardiopulmonary resuscitation.39–42 Rare fractures caused by infant cardiopulmonary resuscitation are predominantly anterolateral and are usually radiographically occult.39,40,43 Rib fractures caused by birth trauma are rare.44 A case report noted posteromedial rib fractures from accidental blunt trauma in an infant.45 Rib fractures are commonly seen in infants with metabolic bone disease and have been reported after thoracotomy, chest tube placement, and chest physiotherapy.34,46 However, rib fractures in infants younger than age 12 months without a predisposing condition, for example, instrumentation, prematurity, chronic illness, metabolic bone disease, or all of these, are strongly suspicious for the diagnosis of abuse.34,47

Long Bone Fractures

Metaphyseal Fractures

The classic metaphyseal fracture, first described by Caffey and commonly referred to as a “corner” or “bucket-handle” fracture, was reexamined by Kleinman in 1986 with the use of detailed histopathologic and radiographic studies.1,48 He determined that the lesions represent a complete shearing or planar fracture that extends through the primary spongiosa of the metaphysis and that it is not an avulsion injury as described by Caffey.48,49 Depending on size and displacement of the metaphyseal fragment, the positioning of the child and the radiographic projection, this highly specific lesion caused by abuse may appear as a “corner” fracture or as a “bucket-handle” fracture (Fig. 144-7). Metaphyseal fractures of abuse may also be seen on ultrasonography.50

The “classic metaphyseal lesion,” a term coined by Kleinman, occurs from violent shaking as the infant is held by the trunk or extremities (Figs. 144-8 and 144-9; e-Fig. 144-10; and Fig. 144-11). Some lesions are probably also caused by torsional pulling on a limb. Typically, no bruising or outward sign of injury is evident with a classic metaphyseal lesion. Classic metaphyseal lesions are most commonly seen at the proximal humerus, distal radius, distal femur, proximal tibia, and distal tibia and fibula.51–54

Occasionally, classic metaphyseal lesions become more conspicuous on short-term follow-up radiography.49 With healing, classic metaphyseal lesions typically become indistinct and sclerotic. Kleinman demonstrated subtle extension of physeal cartilage into the metaphysis as a sign of healing.55 Subperiosteal new bone is not seen unless there is an associated periosteal injury.

Transverse, greenstick, and buckle fractures of the metaphysis may also be caused by child abuse but do not carry the same specificity as the classic metaphyseal lesions. Such fractures are considered to be of low specificity. Small stepoffs, beaks, and spurs at the metaphyseal margins may mimic abusive injury.56 Slight fragmentation of metaphyseal margins with physiologic bowing may also mimic abuse.57 Iatrogenic classic metaphyseal-like lesions have been reported with birth trauma and as a complication of treatment of clubfeet.50,58,59 Such reports are rare and it is likely that the reported fractures occurred with a similar torsional mechanism as occurs in child abuse.

Physeal Fractures

Physeal fractures are uncommon in child abuse. Fractures may be occult or subtle at presentation and some are not recognized until healing occurs.60 Ultrasonography or MRI may be helpful to image the unossified epiphyses and assess the integrity of the physis.61 Common sites of physeal fracture are the proximal humerus (Fig. 144-12), the distal humerus, and the proximal femur.60–62 As opposed to classic metaphyseal lesions, which heal without sequelae, physeal fractures may be complicated by malunion and premature physeal fusion.

Diaphyseal Fractures

Transverse, oblique and spiral diaphyseal fractures of the long bones in the nonambulatory young infant should raise suspicion for abuse.63–66 Once ambulatory, true accidental fractures become common.67 Solitary long bone fractures may occur after accidental trauma in the older infant and child; however, factors that increase the likelihood of an abuse-related injury include association with another fracture and other clinical features that produce a high level of suspicion for abuse, inappropriate clinical history, failure to seek medical attention, and discovery of the fracture in a healing state (Fig. 144-9; also see Fig. 144-13).66,68,69

It is risky to assign significance to the pattern of diaphyseal fracture because all patterns occur with unintentional or true accidental trauma as well as with abuse.65,67,70 Particular note is made of the spiral diaphyseal fracture because this fracture has erroneously become synonymous with abuse.65 The spiral nature of the fracture indicates only that torque was a component of the stress applied, which resulted in fracture. The fracture is thought to occur when an infant is grabbed or shaken, with the extremity used as a handle. However, spiral fractures also occur in a child who is ambulatory, and we now know that they may occur accidentally in younger infants. One mechanism was graphically illustrated and reported by Hymel and Jenny: a 5-month-old infant was being videotaped while lying prone and being rolled to a supine position by his 2-year-old sister; an extended upper extremity was unable to adduct and was pinned under the child as he rolled; an oblique humeral diaphyseal fracture was incurred.71 It is important to consider whether the explanation offered and the developmental level of the child are appropriate, also considering the apparent age of the fracture at presentation and whether or not other injuries are apparent.

Fractures of the Scapula and Sternum

Any part of the skeleton may be traumatized from abuse. Although uncommon, fracture of the scapula, in particular the acromion, is highly specific for abuse (e-Fig. 144-14).72 Acromial fracture results from abnormal indirect forces applied during shaking. It is usually accompanied by other bony thoracic trauma. Anatomic variants in the ossification of the acromion may present a diagnostic dilemma.73,74 Follow-up radiographs taken to assess whether or not healing has occurred allow discrimination between fracture and ossification variant.

Fractures of the sternum are very uncommon in infants, including those who are abused.72,75 Although Kleinman classifies sternal fractures as highly specific for child abuse, a recent series found these fractures less specific.75

Clavicle Fractures

Fractures of the clavicle (Fig. 144-15) are common in child abuse but are also common from accidental and birth trauma. Fractures of the clavicle are therefore considered to be of low specificity for child abuse. Clavicle fractures occur in 0.5% of newborns.76 Frequently, a history of dystocia exists. It is not uncommon for such fractures to escape detection on the newborn physical examination.77 Clavicle fractures from birth usually exhibit callus by 10 to 14 days after birth.77 A fracture which appears acute, without visible callus, in a child older than 10 to 14 days therefore becomes suspicious for having been incurred after birth.

Spinal Fractures

Although rare, spinal fractures in infants and young children are strongly associated with abuse.72,78–80 The mechanism is thought to be hyperextension, hyperflexion, axial loading, or all. Radiographically, these injuries manifest as compression deformities of the vertebral body, often with associated end plate defects and avulsive injuries of the spinous processes.79 Fractures may result in listhesis.80,81 Injuries often involve multiple adjacent vertebral bodies, most often located near the thoracolumbar junction (Fig. 144-16).78,80

Cervical spine fractures are fortunately uncommon in child abuse but may be devastating.80 More severe fracture-dislocations have been described, including classic hangman’s fracture of the C2 vertebra (e-Fig. 144-17).82 Although spinal cord injury is uncommon, severe “spinal cord injury without radiographic abnormality” has been described in the shaken infant.83,84

Isolated spinous process fractures are considered highly specific for child abuse.85 Avulsions may be caused by hyperflexion with axial loading or shaking.

Skull Fractures

Skull fractures are frequent in abuse and are indicative of an impact injury. Poor correlation has been shown between the presence of fracture and associated intracranial injury.86,87 Skull fractures also commonly result from true accidental injury. Several authors have tried to characterize specific patterns of injury that occur in abuse, thereby distinguishing abuse skull fractures from true accidental skull fractures. Some agreement has been expressed that multiple fractures, bilateral fractures, diastasis of fractures and sutures, and fractures that cross suture lines are significantly associated with abuse (Fig. 144-18).88–90 However, no particular pattern of skull fracture is diagnostic of abuse.91 Bilateral complex fractures that cross the sagittal suture may result from a single high-impact blow to the midline, and simple linear fractures are seen in abuse and in accidental trauma. One must consider the appropriateness of the history with respect to the type of injury to make the distinction between abuse and accidental trauma. Simple linear skull fractures are considered to be of low specificity for child abuse.24 Such fractures are common in short-distance falls onto a hard surface. Other, more complex skull fractures are not expected from short-distance falls in the home environment and are thus considered to be of moderate specificity.24 Soft tissue swelling is seen with acute fractures; lack of soft tissue swelling suggests that a fracture is not acute.92 Diastatic fractures or widened skull sutures may indicate a space occupying process within the cranium such as diffuse swelling or large subdural hematoma (Fig. 144-19).

Anteroposterior and lateral skull radiographs are part of the radiographic skeletal survey in suspected abuse, and additional views may be necessary. A Townes view is helpful to evaluate the occipital bone and look for wormian bones in the sutures. Wormian bones are accessory intrasutural bones associated with metabolic bone disease, most notably osteogenesis imperfecta and Menke syndrome.93 CT alone is inadequate to assess for skull fractures because fractures in the axial plane may be difficult to detect. CT may be indicated to evaluate for suspected intracranial injury; bone window images should be evaluated for signs of skull and other fractures; extracranial soft tissue swelling is also well delineated.

Accessory sutures of the skull may mimic fractures on both radiography and CT. Findings suggesting a fracture are a sharp linear lucency with nonsclerotic edges, widening of the lucency approaching a suture, crossing of a suture, unilaterality or asymmetry, and associated soft tissue swelling.94 Findings suggesting an accessory suture are a zigzag pattern with sclerotic borders merging with an adjacent suture, bilaterality and symmetry, and lack of associated soft tissue swelling.94 Accessory sutures tend to occur at characteristic locations.

Fractures of Hands and Feet

Nonaccidental fractures of the hands and feet occur in abused infants and toddlers (Fig. 144-21).98 These fractures are often subtle torus fractures and may be better appreciated on oblique views or follow-up radiographs.98 Fractures of the tubular bones of the hands and feet are probably caused by squeezing by the hands of the abuser.

Dating of Fractures

Dating of fractures is dependent on many variables, including the age of the child, the state of nutrition, immobilization or lack thereof, repetitive injury, and fracture location.99,100 Fractures of the skull and spine cannot be satisfactorily dated, and the classic metaphyseal lesion is difficult to date with any degree of precision.

In general, a young infant develops subperiosteal new bone much earlier and forms callus more quickly. The range for the appearance of subperiosteal new bone is 4 days to several weeks.100 Soft tissue swelling resolves during this same period with subsequent loss of fracture line definition and the appearance of soft callus followed by hard callus. Although it is often possible to identify separate fractures as acute or subacute and others as healing, it is very difficult is ascribe different ages to fractures which are healing. Remodeling of fractures occurs over a span of months to years. Precise dating of fractures is not possible and speculation of fracture age is merely an estimate. Some general guidelines are provided in Table 144-1 (Fig. 144-22).99,100

Table 144-1

Timetable of Radiographic Changes in Children’s Fractures*

image

*Repetitive injuries may prolong the presence of findings.

From Kleinman PK. Diagnostic imaging of child abuse. 2nd ed. St Louis: Mosby; 1998.

Differential Diagnosis

The differential diagnosis for child abuse is broad and varies considerably, depending on both the clinical presentation and the radiologic findings (Box 144-3).101,102 True accidental injury is not the only consideration. Unrecognized obstetric trauma may not be noted until days or weeks after birth. Normal processes including metaphyseal variants, physiologic new bone formation, accessory ossification centers, and accessory skull sutures may initially suggest an abuse-related lesion.103,104 Iatrogenic injury may mimic abuse-related injury.42,44,46,58,59,105

Box 144-3   Radiographic Differential Diagnostic Considerations for Child Abuse

Metabolic bone disease of prematurity may result in multiple rib fractures, diaphyseal fractures, and metaphyseal fractures.106–108 Such fractures are typically buckle or transverse fractures, not classic metaphyseal lesions. Other disease processes, including inherited bone dysplasias, copper deficiency (Menke syndrome), congenital syphilis, Caffey disease, neurologic disorders, and osteogenesis imperfecta may have radiographic features that overlap with those of abuse (see Box 144-3).101,102,109–113 Most of these disorders are discussed individually in this text. Underlying fragility of the bones may, in turn, predispose some children to iatrogenic injury, which may mimic abuse.

Metaphyseal abnormalities similar to child abuse are seen with some rare skeletal dysplasias, notably spondylometaphyseal dysplasia, Sutcliffe (“corner fracture”) type, and metaphyseal dysplasia, Schmid type.114,115 In such patients, findings may be asymmetric. Clues as to the presence of a dysplasia include family history, short stature, and lack of change of the findings on follow-up radiographs.

Kleinman’s seminal text Diagnostic Imaging of Child Abuse presents an excellent overview of the differential diagnosis and a review of diseases that simulate abuse.24 Fortunately, it is almost always possible to make an accurate determination as to the presence or absence of genetic disease on the basis of clinical and radiographic examination, along with a review of family and social history. It should be remembered that the presence of an underlying bone disease or dysplasia does not exclude the possibility of physical abuse or neglect.

With regard to the differential diagnosis of the radiographic findings of child abuse, two topics of recent controversy warrant mention—temporary brittle bone disease (TBBD) and vitamin-D deficiency.

TBBD was proposed as a variant of osteogenesis imperfecta by Paterson and colleagues, who identified a group of young infants who were thought to have diminished bone strength, possibly because of temporary deficiency of a metalloenzyme related to copper deficiency.116 Evidence provided to support the existence of TBBD included denial by caregivers of wrongdoing, absence of episodes of trauma that may explain fractures, lack of bruising, absence of systemic injury, radiographs revealing normal bones, and normal laboratory studies.116 The purported evidence and the particular diagnosis of TBBD has been refuted by others, including the authors of a critical review of TBBD prepared by the Committee on Child Abuse of the Society for Pediatric Radiology.113,117,118 To date, no scientific proof definitively supports the existence of TBBD.

More recently, fractures consistent with abuse have been ascribed to vitamin D deficiency by some authors.119 While literature supports a high prevalence of infants with low vitamin D levels, the authors did not provide evidence of predisposing low vitamin D levels in their patients or convincing evidence as to the causation of the fractures related to low vitamin D levels.120 Currently, no evidence exists in the literature to support low levels of vitamin D predisposing children to the high-specificity lesions characteristic of child abuse.121 It is true, however, that infants and young children with frank rickets caused by vitamin D deficiency are at risk for fracture; however, the pattern of such fractures differs from the high-specificity classic metaphyseal lesions and posterior rib fractures seen with abuse.122

Treatment: Treatment of the individual patient with abuse-related injuries is dictated by the injuries that are present. Injuries to the brain, spinal cord, and viscera may be life threatening. Brain and spinal cord injuries may cause substantial lifelong morbidity. Treatment is aimed at preserving the life of the child and limiting permanent morbidity. Fortunately, most skeletal injuries heal without permanent sequelae, with fractures of the growth plate being an occasional exception.

Intracranial trauma is the leading cause of death and permanent morbidity in abused infants. It has been nearly 40 years since Caffey proposed his theory on the shaking of infants.123 In contrast to true accidental head injury, the neurologic deficits that occur in shaken baby syndrome are out of proportion to the degree of physical trauma and to the changes evident on CT and MRI. Debate is ongoing about whether or not shaking alone is sufficient to result in brain injury or whether an impact injury must accompany the shaking event.124 Apnea and cerebral hypoxia also play a role.

Infants with shaken baby syndrome commonly have subdural hematomas, retinal hemorrhages, and characteristic skeletal injuries (posterior rib fractures and classic metaphyseal lesions). The presence of these osseous lesions is an indication for brain imaging (CT, if emergently indicated; MRI, for more detailed evaluation) and for ophthalmologic evaluation of the eyes for retinal hemorrhage. Retinal hemorrhages are present in 80% to 85% of shaken babies.125

Reporting of suspected child abuse is mandated by law. Failure to report suspected child abuse may result in fines, censure, and even prosecution. Radiologists should be aware of the legal requirements and mechanisms for reporting in their state. Fortunately, in nearly every case, responsible treating clinicians or child protection team personnel will take ownership of this task. Nevertheless, the radiologist bears responsibility for reporting if he or she suspects child abuse and no one else reports it.

Imaging findings are just one piece of the clinical, social, and legal investigation of possible child abuse. The radiologist must function as part of the child protection team by providing timely and accurate interpretations that are properly communicated, by providing expertise on the significance of the radiologic findings, and by providing guidance as the utility of additional imaging studies. Radiology reports should be complete, precise, and must appropriately consider the specificity of the findings and the possibility of differential diagnoses. Verbal communications of the report should be properly documented. Proper wording and careful editing of reports avoids embarrassment or confusion in court.

Radiologists are frequently called upon to testify in civil and criminal court proceedings related to cases of suspected child abuse. If called to testify, it is the duty of the radiologist to do so in a professional manner, providing only honest opinions based on personal experience and scientific evidence. Theoretical considerations with no scientific basis have no place in the court room.

imageWhat the Clinician Needs to Know

Key Points

References

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