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Child AbuseRadiological Features a.offiah@sheffield.ac.uk

DISCLOSURESEXPERT WITNESS WORK

Historical• Pathological

� Ambroise Tardieu� 1860

• Radiological� John Caffey� 1946

� Multiple long bone fractures + chronic subdural haemorrhage(s)

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https://learning.nspcc.org.uk/media/1181/child-protection-register-statistics-england.pdf

Children subject to child protection plans -England 2014 – 2018 (Years ending 31st March)

Category of abuse

2014 2015 2016 2017 2018

Neglect 20,970 22,230 23,150 24,590 25,820

Physical 4,760 4,350 4,200 3,950 4,120

Sexual 2,210 2,340 2,370 2,260 2,180

Emotional 15,860 16,660 17,770 17,280 18,860

Multiple 4,500 4,110 2,810 3,010 2,820

Total 48,300 49,690 50,310 51,080 53,790

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• Infants (< 1 year old)� Non-ambulant

• Multiple injuries occurring over a period of time• Inappropriate / changing / absent explanation• Injury specific for abuse

Non-Radiological Features

• Retinal haemorrhages

• Bruises/burns/bites/torn frenulum

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However…• There may be NO external sign of underlying fracture• Bruising does NOT necessarily imply underlying fracture

• The infant may NOT appear distressed• If abuse is suspected, imaging MUST be performed

Imaging Modalities• Conventional radiography• Ultrasound

• CT• MRI• Nuclear Medicine

Challenges• What imaging is required?• Should the child be sedated?

• Is it a fracture?• If it’s not a fracture, then what is it?• How old is the fracture?• Does the child have an underlying bony disease?

• Is bone density normal?• What was the mechanism of injury?• What force was required?

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Challenges• What imaging is required?• Should the child be sedated?

• Is it a fracture?• If it’s not a fracture, then what is it?• How old is the fracture?• Does the child have an underlying bony disease?

• Is bone density normal?• What was the mechanism of injury?• What force was required?

� Children < 2yrs � Children ≥ 2yrs

� As indicated� PLUS

� Children < 2yrs� Siblings � Children in same household

• Imaging in the IDEAL situation

Challenges

DAY 1 DAY 14

� Do NOT cone off half the chest� Follow-up of long bones also

Challenges

DAY 2 DAY 11DAY 1

11% to 56%

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Challenges• What imaging is required?• Should the child be sedated?

• Is it a fracture?• If it’s not a fracture, then what is it?• How old is the fracture?• Does the child have an underlying bony disease?

• Is bone density normal?• What was the mechanism of injury?• What force was required?

Diaphyseal Fractures• 4x commoner than metaphyseal fractures• Site

� Humerus/femur/tibia

• Clinical Changes � Swelling/bruising/deformity

• Dating� Callus/soft tissues

• Causation � Spiral; twisting force� Transverse; direct blow, indirect

Diaphyseal Fractures

• Specificity increased if associated with� An additional injury� An inappropriate history� Delay in presentation

� Evidence of healing

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Differential• Trauma

� Toddler’s fracture� No history of trauma� Spiral / oblique hairline fracture of tibia� Repeat radiograph in 10 days – periosteal reaction

• Osteogenesis imperfecta

Metaphyseal Fractures• Sites

� Knees/ankles/wrists

• Dating � Difficult (no callus)

• Cause� Gripping, twisting, pulling � Shaking?

• Clinical� Usually no swelling / bruising

Metaphyseal/Metadiaphyseal

Classic metaphyseal lesion (CML)

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Metaphyseal Fractures• Differential diagnosis

� Normal variants� Metaphyseal spur

� Menke’s kinky hair syndrome� Metabolic disease (rickets) � Deficiency disorders (scurvy)� Osteomyelitis� Skeletal dysplasias (metaphyseal)

Rib Fractures• 90% abuse-related rib #s < 2yrs• Frequency in abuse 5%-29%

• 80% rib fractures occult� Alignment of beam with fracture� Overlying structures

Costotransverse

Mid axillary

Mid clavicular

Posterior arc

Anterior arc

Anatomy of a rib

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Rib Fractures• Dating

� Callus� Acute; 2-4 weeks; 5-7 weeks; ≥ 8 weeks

• Causation � Severe compressive (squeezing) forces

Rib Fractures• Clinical findings

� Usually no swelling / bruising at # sites� Sometimes bruising from finger-tip squeezing

• Specificity� High

Costochondral

Anatomy of a rib

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Costochondral Junction Fractures• Dating

� Difficult - often no callus (< 4 weeks)

• Causation� Squeezing or blow to the epigastrium

• Clinical� Visceral injuries 40% - high mortality

• Specificity� High

Incidence of Rib #'s in Infants

• Chest radiographs of 10,000 infants

• 25 had rib #'s� Several abuse victims� Birth trauma (shoulder dystocia) � Whooping cough

• Rib #'s are extremely rare

Thomas P, (1977) Rib fractures in Infancy Ann Radiol 20: 115-122

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Birth Related Rib Fractures• Rare• Risk factors

� Birth weight more than 4000g� Shoulder dystocia� Forceps delivery

Force Required• Feldman K W, Brewer D F. (1984) Child abuse, cardiopulmonary

resuscitation and rib fractures. Pediatrics 73: 339-342� 50 children survived CPR (mean age 27 months)

• Spevak M R, Kleinman P K, Belanger P L, Primack C, Richmond J M, (1994)Cardiopulmonary resuscitation and rib fractures in infants JAMA 272: 617-618� 91 infants had CPR before death (mean age 2.4 months)� Inexperienced lay people & healthcare professionals� Autopsy & skeletal survey

No rib fractures

SUDI, CPR & Rib Fractures

• 78% fresh rib fractures missed on radiographs

• All SUDI cases had CPR � 1.3% fresh fractures occurred in isolation� All isolated fresh fractures

� Involved the anterior rib segments� L:R:Bilateral = 4:2:1� Ribs 3-5

Weber MA et alForensic Sci Int 2009;189:75 - 81

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Skull FracturesAbuse§ Wide (more than 5mm)§ Fissured§ Non-Parietal§ Crossing Sutures§ Affecting more than one bone§ Depressed§ Growing

Accidental§ Simple linear “hairline” § Unilateral § Parietal

Hobbs CJ Arch Dis Child 1984;59:246-252

Skull Fractures: Mechanism & Force• Accidental falls from elevated surfaces in infants• 256 infants fell from a height of 2-5 feet

• 3 Skull Fractures� Simple and linear� No serious intracranial injury

Kravitz H Pediatr (suppl) 1969;44: 869-876

Dating Skull Fractures• Bone changes unhelpful• Soft tissue swelling

� < 7 - 10 days

• Underlying haematomas & contusions etc� CT and MRI

• Correlation with clinical findings

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Traumatic Periosteal Reaction• Sites

� Shafts & metaphyses of long bones � Usually asymmetrical

• Causation � Gripping / twisting

• Dating� First seen 7 days after trauma

Traumatic Periosteal Reaction

• Clinical Changes � No swelling or bruising

• Differential Diagnosis� Physiological periosteal reaction

Physiological PeriostealReaction• 4 weeks to 4 months• Femur / tibia

• Symmetrical• Never extends to metaphysis• Rarely > 2mm thick

Kwon DS AJR 2002;179:985 – 988

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Unusual Fractures• Hands• Feet

• Acromion• Pubic ramus• Spine• Epiphyseal fracture separation

• 1st rib

High specificity for abuse

Case 1

Case 1

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Case 2

Case 2

Case 3

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Case 3

Case 4

Case 4

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Case 5

Case 5

Further Reading