Haukeland Universitetssykehus, Bergen
Battered Child Syndrome
Karen Rosendahl
Consultant Paediatric Radiologist,
Professor II, Department of Clinical Medicine, K1,
University of Bergen, Norway
The Battered-Child Syndrome
C. Henry Kempe, M.D.; Frederic N. Silverman, M.D.;
Brandt F. Steele, M.D.; William Droegemueller, M.D.;
Henry K. Silver, M.D.
JAMA. 1962;181(1):17-24.
Definition
• injuries sustained by a
child as a result of
physical abuse, usually
inflicted by an adult
caregiver
• shaken baby; shaken
baby syndrome; child
abuse; and non-
accidental trauma / injury
(NAT / NAI).
Incidence, age
• Incidence UK (Barlow et al. Lancet
2000)
– 2.5 per 10 000 children younger than
1 year (95% CI 14.9-38.5)
Clinical Presentation
• Unexpected soft tissue swelling
• Seizures/Collapse
• Irritability
• No history of a trauma…….
5 w old female, swelling left thigh for the last 1-2
days. ?infection
Imaging in non-accidental trauma
Imaging Clinical suspicion
Fractures
uncommonly seen
in accidental
injuries
discuss with the
Named and
Designated Doctor in
Child Protection for
your Institution
Recommended imaging in children
< 2-3yrs of age
• Head CT
• Skeletal survey (within 24 hrs, or asap)
• If findings on head CT, or if pos. neurology; add a MRI, including the spinal canal
• If positive MRI; repeat head CT on day 10, + FU MRI (after 2-3 months – 6-12 months)
• If abdominal trauma; abdominal CT
• In children older than 2-3yrs; individual imaging strategy
Refs.: 1) ESPR Task Force on Child Abuse: www.ESPR.org 2) Håndbok for helsepersonell ved mistanke om barnemishandling
http://www.nkvts.no/aktuelt/Sider/HandbokBarnemishandling.aspx
Head CT
Ref.: ESPR Task Force on Child Abuse: www.ESPR.org
3 months old girl
Skeletal survey
• Skull (AP and lateral: Townes if ? occipital fracture)
• Spine (lateral views cervical, thoracic + lumbar)
• Chest (AP + oblique views both sets ribs)
• Abdomen, pelvis and hips (AP)
• Long bones (AP views both humeri, both rad/ulna, both femora and both tib/fib)
• Hands (DP)
• Feet (AP)
• Coned views of suspected abnormality d/w supervising Consultant Radiologist
Ref.: ESPR Task Force on Child Abuse: www.ESPR.org
Skeletal survey - standards
• Technical requirements for technique – small focal spot,
– suitable computed radiography systems (including standard resolution imaging plates) may be used for skeletal surveys if they have dedicated paediatric software
• Personnel requirements – Radiographers trained in paediatric radiography techniques
should perform skeletal surveys in children
– Appropriately trained radiographic staff must be available in all radiology departments where children are imaged
• Procedural standards
Ref.: ESPR Task Force on Child Abuse. www.ESPR.org
Additional, initial imaging
• CT chest if suspicion of rib fractures
Ref.: ESPR Task Force on Child Abuse: www.ESPR.org
Scintigraphy
• High sensitivity new rib fractures
• Low sensitivity skull fractures
Ref.: ESPR Task Force on Child Abuse: www.ESPR.org
MRI
• Low sensitivity for metaphyseal injury
and rib fractures
Kleinman et al. Whole body MRI in suspected infant abuse. AJR 2010
Ultrasound
Ref.: ESPR Task Force on Child Abuse: www.ESPR.org
Imaging- follow-up
• Repeat skeletal survey (except for skull,
pelvis, lateral spine) after 2 weeks
Ref.: Harper NS, Eddleman S, Lindberg DM et al. The Utility of Follow-
up Skeletal Surveys in Child Abuse. Pediatrics 2013; 131; 672-
The role of imaging is to answer the
following Q:
• Q1: Is there skeletal injury, and if so, are
there specific features suggestive of NAI?
• Q2: …….evidenced by?
• Q3: Most likely mechanisms – evidence?
• Q4: How old is the fracture - evidence?
• Q5: If the injury is suspicious of NAI – what
other options are there?
Skeletal injury in NAI
• Ribs (26%)
• Metaphysis (23%)
• Long bones (36%)
• Skull (15%)
Ref.: Carty H. Eur Radiol 1997; 7(9); 1365-1376
Skeletal injury; «specificity» for NAI
• High
– Methaphyseal lesions
– Rib fractures, particularly posterior
– Scapular, spinous process and sternal fractures
• Moderate
– Multiple fractures, especially bilateral
– Fractures of different ages
– Epiphyseal separations
– Vertebral body fractures and subluxations
– Digital fractures
– Complex skull fractures
Skeletal injury; «specificity» for NAI
• Low (but common)
– Subperiosteal new bone formation
– Clavicular fractures
– Linear skull fractures
Rib fractures
• costovertebral articulations
• costochondral junctions and anterior rib
ends, lateral fractures
• often multiple and bilateral
• may be clinically silent
Rib fractures
Issues
• Acute rib fractures difficult to diagnose:
– Use the best available XR technique
– Additional CT on the same day or repeat XR in 12-
14 days?
kV 64, mA 2.0 kV 62, mA 3.0 kV 60, mA 3.2
Radiographic technique
2 weeks later…
Male, 16 months
7th rt rib
8th rt rib
Classic metaphyseal lesion (CML)
• fracture along the primary
spongiosa of the metaph.
• tibiae, distal femur and
proximal humerus often
bilateral
• minimal or no periosteal
reaction
• heal without callus
formation
• may be clinically silent
Ref.: Kleinman et al.
Reformatted coronal micro-CT scan
shows transmetaphyseal extent of
fracture
9 months old infant
Classic methaphyseal lesion
• rotation / traction
Issues
• Positioning!
• Differentiation between injury and
physiological irregularities
– additional views, high-res.
– repeat x-ray in 10-12 days, or 4-6
weeks
at presentation
2 days later
9 days after
presentation
follow-up 4 weeks later
3 mo old,
died from
his head
injury
25.5.07 3.7.07 6.9.07
Male, 8 months, subdural haematoma
Long bones
• Femur and humerus most common
– femur
• midshaft
• transverse / spiral / oblique
• (no differences between NAI and accidental)
– humerus
• midshaft, but also supracondylar
Long bones
• spiral fracture = twisting
force
• oblique fracture =
levering (e.g. lifting a
child by a limb)
• transverse fracture may
be the result of a direct
impact, a greenstick or
buckle fracture will be
caused by
compression, e.g. a fall
Issues
• ”physiological” periosteal reaction
– < 3-4 months of age
– most often symmetrical
– <2mm
Skull fractures (15%)
Skull fractures
“the shaken infant – (impact) syndrome” (Caffey)
Skull Fractures
Accidental
• Simple linear
“hair-line”
unilateral parietal
Non-Accidental
• Wide (> 5mm)
• Fissured
• Non-Parietal
• Crossing Sutures
• Affecting + one
bone
• Depressed
• Growing
Reference: Hobbs C. J. (1984). Skull fracture
and the diagnosis of abuse; Arch. Dis. Child. 59:246-252.
Fracture healing - dating
• Dating of fractures is of medico legal
importance
• Most radiologists date fractures based on
their personal clinical experience
• Few studies
1) A timetable for the radiologic features of fracture healing in young children. Prosser I,
Lawson Z, Evans A, Harrison S, Morris S, Maguire S, Kemp AM. AJR Am J Roentgenol.
2012 May;198(5):1014-20.
2) How old is this fracture? Radiologic datin gof fractures in children: a systematic review.
Prosser I, Maguire S, Harrison SK, Mann M, Sibert JR, Kemp AM.
AJR Am J Roentgenol. 2005 Apr;184(4):1282-6. Review.
Fracture healing
• SPNBF
– Early: 4-10 d
– Top: 10-14 d
– Late: 14-21 d
Fracture healing
• Endosteal callus
formation
– Soft
• 10-14 d (early)
• 14-21 d (peak)
– Hard
• 14-21d (early)
• 21-42d (peak)
• 42-90 d (late)
14/08/2006 7/9/2006
Table 1. Chronology (in days) of radiographic changes during fracture healing.
Kleinman 1998.
Fracture healing
• fractures in young children may be dated as
acute (< 1 week), recent (8-35 days), or old (≥
36 days) on the basis of the presence of six
key radiologic features in combination
• good interobserver agreement suggests
these results are reproducible
A timetable for the radiologic features of fracture healing in young
children. Prosser I, Lawson Z, Evans A, Harrison S, Morris S,
Maguire S, Kemp AM. AJR Am J Roentgenol. 2012
May;198(5):1014-20.
Differentials
1. Birth trauma (most common clavicle,
femur and humerus). The absence of
callus 11 days or more after birth
excludes a birth-related injury
2. Accident
3. Bone disorder
Literature
• Kemp A et al. patterns of skeletal fractures in child abuse: systematic review. BMJ 2008;337:1518-
• Kleinman, P.K. Diagnostic imaging of child abuse, 3.ed. Mosby, 2016
• Tatantino et al. Short vertical falls in infants. Pediatr Emerg Care 1999;15:5-8
• Barkovich AJ. Pediatric neuroimaging. 4th ed. 2005.
• Carty H, Brunelle F, Stringer D, Kao CS. Imaging Children.2nd ed. Elsevier 2005.
• Chapman S. Non-accidental injury. Imaging (2004) 16, 161-173.
• Carty H, Pierce A. Non-accidental injury: a retrospective analysis of a large cohort. Eur Radiol 2002;12:2919–25.
• Jaspan et al. Neuroimaging for Non-Accidental Head Injury in Childhood: A Proposed Protocol. Clinical Radiology 2003:58;44-53.
• The British Society of Paediatric Radiology. Standard for skeletal surveys in suspected non-
accidental injury (NAI) in children.
• Flaherty, E. G., Perez-Rossello, J. M., Levine, M. A., Hennrikus, W. L., American Academy
of Pediatrics Committee on Child, A., Neglect, Society for Pediatric, R. (2014). Evaluating
children with fractures for child physical abuse. Pediatrics, 133(2), e477-489.
doi:10.1542/peds.2013-3793
• Harper NS, Eddleman S, Lindberg DM et al. The Utility of Follow-up Skeletal Surveys in
Child Abuse. Pediatrics 2013; 131; e672.
• Ashwal S, Wycliffe ND, Holshouser BA. Advanced neuroimaging in children with
nonaccidental trauma. Developmental neuroscience 2010;32(5-6):343-60.
• Choudhary AK, Ishak R, Zacharia TT, Dias MS. Imaging of spinal injury in abusive head
trauma: a retrospective study. Pediatric Radiology. 2014;44(9):1130-1140
Acknowledgements
• Professor Christine Hall
• Dr Amaka Offiah
• Superintendent Radiographer Jenny Grehan
• Dep. Cons. Frank Marshall
