imaging and diagnosis of physical child abuse · imaging technologists should know the child abuse...

45RADIOLOGIC TECHNOLOGY, September/October 2017, Volume 89, Number 1

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Imaging and Diagnosis of Physical Child AbuseMarlene M Johnson, MEd, R.T.(R)

Child abuse and neglect is a global public health problem that can result in lifelong con-sequences for children and

their families.1 Physical abuse of chil-dren is a critical cause of pediatric mor-bidity and mortality and is associated with major physical injuries, permanent disabilities, and behavioral problems that can extend into adulthood.1,2

Child abuse or maltreatment refers to any act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual acts, or exploitation. Child neglect is a broad concept that includes failure to meet the physical, medical, educational, or emotional needs of a child. Other forms of maltreatment include abandonment, threatened abuse, and subjecting a child to the parent’s substance abuse.3,4 Within the context of this article, the term child abuse, unless otherwise specified, directly relates to any type of bodily injury caused by the actions, or lack of action, on the part of a parent or

caregiver. The terms nonaccidental trauma and inflicted injury are used frequently in the scientific literature to describe how an injury occurred.5 Both terms are used interchangeably throughout this article.

The concept of child abuse has been defined and redefined throughout his-tory. Society has evolved slowly from viewing children as property to recog-nizing that children have rights of their own. Parents’ opinions about how chil-dren should be treated largely depend on their cultural and religious backgrounds and family values. Practices and patterns of childrearing, including discipline and healing practices, vary, and parents’ views on concepts such as corporal punishment in schools are diverse. The United States is one of the few devel-oped countries that still allows physical punishment of children in schools. Many parents support abolishing this practice, while others believe it is an effective discipline option. Research data has demonstrated that corporal punishment is ineffective and more

After completing this article, the reader should be able to:�� List the signs of child abuse.�� Specify types of fractures that are common in child abuse.�� Explain the significance and technical components of a skeletal survey.�� Discuss the role of computed tomography, magnetic resonance imaging, and sonography in diagnosing child abuse.�� Describe the radiologic technologist’s role in the diagnosis of child abuse.

Child abuse involves grave and disturbing acts of violence that can have lasting physical and emotional consequences for children and their families. The diagnosis of child abuse is emotionally difficult for those involved, and an error in judgment either way can have a detrimental effect on the health and safety of the child. Physicians rely on the skills of the imaging team to produce high-quality images that assist in differentiating inflicted injuries from accidental trauma. This article explores the significance of imaging in child abuse by discussing the types of injuries that occur and the imaging studies that aid in diagnosing physical child abuse.

46 RADIOLOGIC TECHNOLOGY, September/October 2017, Volume 89, Number 1

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Imaging and Diagnosis of Physical Child Abuse

(19.5%). The total amount of child abuse and maltreat-ment referrals varies by state, with California having the highest number of referrals (see Table 1).4

International studies have shown that 25% of all adults suffered abuse as a child.1 Adults who experienced abuse as children are more likely to report chronic physi-cal and mental health conditions than adults who did not experience childhood abuse, and abused adolescents have demonstrated depression, conduct disorders, drug abuse, and cigarette smoking. In addition, childhood victims of abuse have shown evidence of physically aggressive behaviors, depression, low academic perfor-mance, and decreased cognitive function. Many abused children suffer permanent disfiguring injuries and have an increased risk of obesity, potentially harmful sexual behaviors, and unintended pregnancy.1,2

Children younger than 4 years are at increased risk of abuse compared with other age groups, and preteens and younger teenagers are more likely to be abused than are older teens. Children who were unwanted or fail to meet their parents’ expectations are more likely to be abused, as well as children who persistently cry, have special needs, or have abnormal physical features.1

Children are the victims of abuse and never should be blamed for maltreatment. The perpetrator could be a parent, legal guardian, caregiver, or other family member. Parental characteristics that increase the risk of child maltreatment include difficulty bonding with a newborn,

likely to cause harm than good.6,7 Spanking or other physical discipline generally is not considered abuse as long as it is reasonable and causes no bodily injury.3

Some cultures use alternative and traditional treatment methods, such as coining, cupping, and acu-puncture to treat childhood illnesses. These practices can result in injuries that could be mistaken for abuse. Coining, or cao gio, is a common Southeast Asian treat-ment for minor illnesses, such as colds, f lu, headaches, or fever. The Vietnamese term cao gio translates to “catch the wind.” Some Asians believe that too much “wind” in the blood causes illnesses, and the practice of coining brings the blood to the surface where the bad wind can be released. The skin is rubbed with a coin or spoon until red or purple spots of hemorrhaging tissue appear. The process results in a distinct, symmetrical pattern of bruises, which is characteristic of abuse.8

Virtually every possible act of violence has been documented in child abuse, from beating, kicking, and biting to shaking and aggressively pulling on an extrem-ity. Injuries also can result from a child fending off a violent act or from a fall caused by an adult. Injuries resulting from adult actions are considered abuse regard-less of whether the adult intended to hurt the child.3

Nonaccidental trauma is a leading cause of child-hood traumatic injury and death in the United States. Children younger than 1 year have the highest inci-dence of abuse and neglect, and approximately 75% of all abuse-related childhood fatalities occur in children younger than 3 years.4

Child abuse and neglect are on the rise in the United States. In 2015, child protection agencies received an estimated 4 million child abuse referrals that involved approximately 7.2 million children. The majority of these children were neglected (75%), followed by physi-cal abuse (17%) and sexual assault (8%). In 2015, 1670 children died as a result of physical child abuse and neglect in the United States.4

The majority of perpetrators of child abuse are the parents, with most of these parents aged between 18 and 44 years. Approximately 78% of child abuse fatalities involved at least 1 parent. Boys are victims of abuse more than are girls, and women cause abuse more than do men. The 3 largest racial and ethnic groups responsible for abuse are whites (48.7%), blacks (20%), and Hispanics

Table 1

States With the Most Child Abuse and Maltreatment Referrals in 20154

State Child Abuse Referrals

1. California 379 806

2. Texas 230 467

3. Florida 217 895

4. Indiana 176 713

5. Ohio 172 445

6. New York 156 994

7. Michigan 149 114

8. Georgia 108 718

9. Tennessee 114 914

10. Kentucky 101 094


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Federal and State LawsBy 1973, the need for a federal stand on the issue of

child abuse was obvious, and the federal Child Abuse Prevention and Treatment Act was enacted. The act offers states federal funding to prevent, assess, inves-tigate, prosecute, and treat child abuse, and it offers grants to public agencies and nonprofit organizations for child abuse programs and projects.17 In May 2015, President Obama signed into law an amendment to CAPTA, called the Justice for Victims of Trafficking Act, that requires each state to report the number of children determined to be victims of sex trafficking.18

The states are responsible for determining levels of tolerance of abusive actions and describing any type of abuse that is subject to arrest and prosecution. States also are responsible for prosecuting child abuse perpe-trators.19 Many states have laws that permit physicians to evaluate children who are suspected victims of abuse, including acquiring tests and obtaining photographs without parental consent.20

Mandatory Reporting RequirementsReporting allegations of suspected child abuse and

neglect is critical. Most reports are initiated by educa-tional personnel, legal and law enforcement workers, individuals who work for social services agencies, and medical personnel. Neighbors and relatives also play a critical role in reporting suspected child abuse.4

State laws determine which individuals are legally responsible for reporting allegations of possible child abuse, which usually include any person who is in contact with children on a regular basis in a professional setting (see Box 1).4,7 Medical personnel constitute the fifth most common group to make child abuse referrals, accounting for 9.1% of reported cases and approximately 648 000 children in 2015.21 Mandatory reporting laws generally hold the reporter of suspected child abuse immune from legal liability if the suspicions later are determined to be untrue. As long as the reporter was acting in good faith, he or she is protected from lawsuits for libel, slander, inva-sion of privacy, and breach of confidentiality.7

Imaging technologists should know the child abuse reporting laws in the state where they practice, as well as the child abuse reporting protocol for the facility where they work. When in doubt, technologists should report

inability to nurture the child, personal history of abuse as a child, lack of knowledge about child development, and unrealistic expectations of the child. Parents who are sub-stance abusers, criminal offenders, and having financial difficulties are all more likely to abuse their children.1

HistoryThe discussion of child abuse began in 1860, with

Ambroise Tardieu, a French medical lawyer, describing abuse findings.9 Imaging’s involvement in diagnos-ing child abuse began in 1946 with John Caffey, a radiologist who specialized in pediatrics. He reported 6 cases of otherwise healthy infants with coexisting subdural hematomas and long bone fractures in which the caretakers denied trauma. The long bone fractures appeared to have occurred at different times than the hematomas.10 Caffey wrote many scholarly articles, some of them seminal, including a description of infan-tile cortical hyperostosis, now known as Caffey disease. For 10 years, Caffey studied child abuse and urged his colleagues to recognize multiple fractures in infants caused by trauma and to be aware of false histories given by parents.11 He coined the terms “bucket-handle” and “corner” fracture, which are the unique skeletal metaphyseal fractures found in abused infants.12 Today, classical metaphyseal lesions (CMLs) or fractures are strong radiological indicators of child abuse.13,14

C Henry Kempe, a professor of pediatrics, is cred-ited with raising the public’s interest in and physicians’ awareness of child abuse. Kempe was the first to collect and organize information on the clinical and radiologic manifestations, psychiatric factors, evaluation, and incidence of child abuse.15 Troubled by the number of abused and misdiagnosed children, Kempe organized a child abuse symposium in 1961 and a year later wrote the landmark article, “The Battered-child Syndrome.”16 In the article, Kempe urged consideration of abuse in any child who showed evidence of a fracture of any bone, subdural hematoma, failure to thrive, soft-tissue swellings, or bruising. This publication is regarded as the single most significant event in creating awareness and exposing the reality of child abuse. The phrase “battered child” was partly chosen to create public interest in an idea most people thought too revolting to discuss and many physicians were too wary to diagnose.15


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rate of child abuse is 2 times higher among children with disabilities than with children without disabili-ties.20 Infants cannot communicate pain or explain how an injury occurred. Their bodies are more fragile than older children’s bodies and the variety of childhood diseases that can mimic abuse is higher in infants.5,19,20 Disabled children pose similar challenges because of possible inability to communicate and or physical dif-ferences that make their bodies more susceptible to serious injury. Imaging might be the only way to tell a story that abused children are too young, challenged, or frightened to tell.16

Diagnostic images reveal clues that enable radiolo-gists to determine the severity and timing of injuries and can demonstrate additional, occult trauma. The findings are compared with the medical history pro-vided by the parent or caregiver, and a determination of abuse or nonabuse is given to the patient’s pediatri-cian.13 On a different level, radiologic findings also protect families who could be wrongly accused of child abuse. These findings can provide information on possible alternative causes of injury, such as metabolic diseases or bone fragility syndromes.5,19,20,23

The initial step in helping abused or neglected children is recognizing the signs of child abuse and neglect (see Table 2). One solitary finding does not necessarily mean a child is being abused. However, a more critical analysis of the situation might be warranted when the signs are seen repeatedly or a combination of signs point to abuse.2,20,24,25

Radiologic technologists involved in pediatric imaging are in a unique position to observe a child’s reactions and to visually screen a child’s body for signs of possible abuse. By being observant, technologists can relate to physicians any signs of pain or discomfort a child experiences during a diagnostic study.24 Technologists also might witness a child’s interaction with the parents or hear abusive lan-guage or accusations among those involved.26

Skin InjuriesBruises are the most common and visible inju-

ries of child abuse, yet they frequently go unnoticed. Accidental bruises during the first 9 months of life are rare and a strong indication of abuse. As a child begins to walk, accidental bruises are more common.4,13,20,24,27 Simply stated: “Those who don’t cruise, rarely bruise.”27

suspected cases of abuse to their immediate supervisors, the attending physicians, or the radiologists.

DiagnosisThe physician ultimately is responsible for reporting

cases of child abuse, which requires a careful consid-eration of evidence. A decision not to proceed with an abuse evaluation could return a child to an abusive environment that involves substantial risk. Conversely, erroneously starting an abuse evaluation can have unin-tended negative consequences, including prolonged hospitalization, extreme parental stress, compromise of the physician-patient relationship, increased health costs, and potential exposure of children to unneces-sary sedation or radiation from imaging studies.13,22 Physicians must compare the medical history provided by the parent or caregiver with the type and severity of injuries revealed by clinical investigation and diagnostic images.20,23

Child abuse in young children and the disabled is a serious problem. Significant injuries and fatal abuse are more common among infants and children younger than 2 years compared with other age groups, and the

For more information on state laws, visit asrt.org/as.rt ?KW35by.

Box 1

Examples of Mandatory Reporters of Suspected Child Abuse21

� Animal control and humane association employees � Camp and youth center staff � Child care providers � Commercial photographers � Computer technicians � Counselors and therapists � Domestic violence workers � Educational administrators and faculty � Health care workers, including physicians, nurses, and R.T.s � Law enforcement officers � Medical examiners � Members of the clergy � Probation and parole officers � Social workers � Teachers and other school personnel � Volunteers who work with children


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The anatomical site, number, and pattern of bruises can be giveaways for abuse. Bruises on the torso, ears, head, face, hands, and buttocks are sugges-tive of abuse, especially in children younger than 4 years.20,23 Abused chil-dren generally have more bruises than nonabused children. The number of accidental bruises generally increases with age. It is perfectly normal for preschool and grade school children to sustain a number of accidental bruises, with the majority of them occurring over bony prominences such as the knees and shins. A toddler presenting with many bruises would not be commonplace. The clinical appearance and pattern of accidental bruising differs from inflicted bruises. An intentional bruise might have the imprint of an instrument that was used, such as a hand or belt, and the bruises might be in clusters that are characteristic of a defensive injury.4,20,24

Burns can be common in abuse and nonabuse. Two of the most com-mon types of abusive burns are due to scalding, which occurs from contact with hot liquids, and thermal burns, which are caused by contact with a hot object. Burns on the head, neck, arms, or anterior region of the trunk are more commonly accidental. Burns involv-ing the hands, feet, and buttocks are associated more with abuse. A burn on the anterior aspect of the hand is more likely due to an accidental injury than a burn on the dorsum of the hand.22 Inflicted burns tend to be more seri-ous than accidental burns and usually require medical treatment. A child who touches a hot object usually withdraws his or her hand quickly, whereas with an abusive burn, the hand is held in place and consequently the burn is

Table 2

Possible Signs of Child AbuseSign Type

Displayed by Child

Always watchful and wary, fearful of others AN

Overly compliant, passive, or withdrawn AN

Reluctant to be around a particular person AN

Discloses maltreatment, admits parents harmed them P

Seems frightened of parents P

Shrinks at the approach of parents P

Is dirty and has severe body odor N

Lacks sufficient clothing for weather N

Has unexplained burns, bites, bruises, black eyes, or fractures P

Has difficulty walking or sitting S

Has multiple bruises and is nonambulatory P

Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior

S

Reports sexual abuse by parent or caregiver S

Attaches very quickly to strangers S

Shows extremes in behaviors (eg, overly compliant, demanding, passive, or aggressive)

E

Appears to be delayed physically or emotionally E

Displayed by Parent/Guardian

Blames, belittles, or berates the child E

Overtly rejects the child E

Looks to the child for care, attention, and satisfaction of parent’s emotional needs

AN

Shows little concern for the child AN

Offers conflicting, unconvincing, or no explanation of the child’s injury P

Provides an explanation that is not consistent with injury P

Describes the child as “evil” or in some other negative way P

Appears to be indifferent to the child N

Behaves in a bizarre or irrational manner or seems depressed or apathetic N

Unduly protective of the child, secretive, or isolated S

Displayed by Parent/Guardian and Child

Rarely look at or touch each other AN

State they do not like each other AN

Abbreviations: AN, abuse or neglect of any type; P, physical abuse; S, sexual abuse; E, emotional abuse; N, neglect.


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comprehensive physical evaluation and analyze the medical history, mechanism of injury, overall injury pat-tern, and the child’s developmental level.28-31 Additional findings that might influence a child abuse diagnosis are multiple fractures at different stages of healing, delay in obtaining medical treatment, and the presence of other suspicious injuries (eg, bruises or burns).13,14,33

Approximately 20% of abuse-related fractures go undetected or are attributed to other causes at the time of the initial medical evaluation. This is especially true in nonambulatory children.35 In a retrospective study of a 7-year sample of children diagnosed with abuse, one-third of the children with healing abusive fractures had previous medical visits at which the abuse was not diag-nosed. Multiple previous visits with missed abuse were found in 25% of the patients. The most common reason for missing a diagnosis was failure to recognize a sug-gestive sign of abuse, such as bruising or swelling.36 Boys who present to a primary care physician or emergency setting with an extremity fracture are at a significantly high risk for delayed diagnosis of child abuse.37

Another reason contributing to a missed diagnosis of child abuse is a lack of knowledge about child abuse on the part of the physician or radiologist. Signs of abuse (eg, inflicted fractures) often are subtle or occult and, in most cases, include no external physical findings (eg, bruises).28 In early injuries, the radiographic study might be performed before anatomical changes even are apparent. When a parent or caregiver relays a false his-tory, the physician could focus on the less acute finding, causing a more substantial one to be overlooked.28

Physicians should recognize the importance of evalu-ating a child suspected of being abused in a facility where child abuse studies are performed frequently and the radiologist has a background in diagnosing abuse and pediatric conditions related to abuse.13,23 Pediatricians or other physicians treating children should be familiar with which facilities offer child abuse services and be prepared to make referrals to such facilities when child abuse–related imaging or hospitalization is required. Developing a working relationship with a radiologist or orthopedic surgeon who has clinical experience with child abuse cases could be advantageous to the patient.13,23

The consequences of a missed diagnosis of abuse are serious because children returned to their environment

more serious. Abusive scald burns are often severe, with immersion burns having sharp lines of demarcation, and frequently involve the genitals and lower extremities.13,22,23

Burns caused by hot objects can be challenging. Suspicious burns are characteristically deep and include a distinct pattern of the object that was used to burn (eg, a curling iron or a cigarette).22,23 In the case of any burn, if medical treatment was delayed, the parents could be hiding abuse.22 Bite marks can be a decisive clue of abuse and could be caused by an adult, another child, an ani-mal, or the child himself or herself. The source of a bite is determined by analyzing its size, dentition characteristics within the wound, and anatomical location. If the bite has puncture marks, a DNA analysis might be possible.4,13,20

Skeletal FracturesSkeletal fractures are the second most common

injury cited in child abuse and usually the most power-ful radiologic indicator of a child who has sustained inflicted injuries.13,23,28-31 Because childhood fractures caused by accidental trauma are relatively common, the physician must thoroughly analyze the child and the situation before an allegation of abuse.13,14,28-31

The true incidence of child abuse is difficult to determine, but it has been estimated to account for 10% of trauma evaluated in the emergency department and 85% of fractures occurring in children younger than 3 years.28 In a wide-scale database study that included dis-charge data on 80% of acute pediatric hospitalizations in the United States, researchers assessed the propor-tion of fractures caused by and attributed to abuse. Among children younger than 3 years, the proportions of cases attributable to abuse were 11.9% in 1997, 11.9% in 2000, and 12.1% in 2003. The proportion of cases attributable to abuse decreased with increasing age.32

Diagnosing child abuse rarely is easy and requires a careful and thorough consideration of sociobehavioral factors and clinical findings.13,14 The majority of abuse-related fractures occur in children younger than 18 months, with 1 in 9 fractures due to confirmed abuse.33 Most fractures reported in abused children are in the long bones, skull, and ribs34; however, no specific frac-ture type or pattern excludes abuse.13,14,29,30

Awareness is the most critical component in mak-ing a diagnosis.13,14,28 The physician must conduct a


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children with rib fractures were identified and the cause of injury was noted. Among these children, 128 were abused, 24 had a bone dysplasia, 17 were preterm infants with perinatal complications, 43 had fractures involving a motor vehicle accident or violent trauma, 7 had postsurgical fractures, 3 had birth injuries, and 11 had fractures from unknown causes.33 In isolated instances, direct impact at the site of the fracture might cause a rib fracture. If this is the case, a bruise from the impact most likely is visible.13,29

Posterior rib fractures require excessive levering of the posterior ribs at the costotransverse process articu-lation. This mechanism of injury is common in child abuse cases. It often is seen when the adult picks up the child, with his or her hands encircling the child’s rib cage, and vigorously shakes the child (see Figure 1). This action generally is used in response to a crying child.14 For an accidental posterior fracture to occur, massive forces that resemble the mechanics similar to those occurring in child abuse must be exerted.14

A diagnostic dilemma occurs when a child presents with rib fractures after cardiopulmonary resuscitation (CPR) in which child abuse is suspected as the cause of collapse.43 Rib fractures caused by CPR are extremely rare and virtually impossible in the posteromedial region when the child is supine and the back is supported. The forces involved in CPR generally cause fractures to begin on the external surface of the rib rather than its inner surface, resulting in an anterior rib fracture.14,29,43

Fractures of the ribs create diagnostic challenges that can lead to a missed diagnosis, especially when little displacement occurs (see Figure 2). The fracture lines usually are oblique to the radiographic projection and frequently are obscured by superimposed soft-tissue structures and vertebral transverse processes. Oblique projections of the ribs and a follow-up study 2 weeks after the initial evaluation can assist in the diagnosis of rib fractures.29,44,45 Once a rib is healing, the fracture becomes more obvious radiographi-cally because of callus formation and subperiosteal new bone growth (see Figure 3).29 The radiographic appearance of a healing fractured rib fades over time; therefore, CT might be considered because it better demonstrates the healing process.14,29 When rib dis-placement occurs, a chest radiograph or CT scan could

without intervention are likely to face further abuse and have increased mortality risk.2,23,38 Diagnosis requires a collaborative evaluation by a multidisciplinary team, in which communication is essential to completing a com-prehensive diagnosis of the potentially abused child. Physicians should interact with radiologists directly when abuse is being considered—before and after the radiographic study—to increase awareness of possible occult and subtle findings.39

In all cases of skeletal fractures, the physician and the radiologist must consider several pediatric condi-tions or syndromes that could cause bone fragility and result in fractures of all types, even though the incidence of these conditions is rare, occurring in less than 1% of children who have fractures. Metabolic dis-eases that must be considered with any skeletal fracture include osteogenesis imperfecta, rickets, osteopenia, ligamentous laxity, fibrous dysplasia, Langerhans cell histiocytosis, dysplasia, and renal disease.2,13,14,20,23,29

Fracture ClassificationsThe universal system of fracture classification as it

relates to abuse was published in an early report of Dr Paul Kleinman.40,41 The system categorizes fractures as high, moderate, and low specificity for abuse based on research data and child abuse guidance organizations.13,14,40 Attempts have been made to develop algorithms to predict the likelihood of nonaccidental trauma, yet no particular tool is recommended at this time. The classifi-cations serve as guidance for physicians and radiologists who are screening children for child abuse and increase awareness among physicians and other professionals.13,22 Research has demonstrated that virtually any type of frac-ture could be the result of abuse, and, it bears repeating, no specific pattern excludes abuse.13,14

High Specificity for AbuseRib Fractures

Posteromedial rib fractures have the highest speci-ficity for abuse, with a demonstrated predictive value of 95% as an indicator of abuse in children younger than 3 years.13,42 Rib fractures are atypical in children younger than 2 years because of their relatively f lexible skeleton.13,29 In a systematic review of skeletal fracture patterns in child abuse, 7 studies that included 233


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demonstrate a pneumothorax, pneumomediastinum, or surgical emphysema.14

Classical Metaphyseal LesionsCMLs, also referred to as avulsion fractures, are

highly specific for abuse and the most noticeable form of abuse radiographically. A CML almost always is caused by abuse in nonambulatory infants, who are incapable of exerting the force necessary for this frac-ture to occur.13,14,23,41,46 Because accidental CMLs have been documented in toddlers and young children, the predictive value of a CML to indicate abuse decreases in children older than 1 year.13,14,31

CMLs are a series of microplanar fractures that travel across the metaphysis region of the bone in a

Figure 1. Violent shaking and squeezing of an infant could result in subdural hemorrhage and shear-type brain injury (A) and rib fracture (B). Reprinted with permission from Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 2003;23(4):811-845.

Figure 2. Acute lateral and healing posterior rib fractures (arrows)in a fatally smothered 7-week-old boy. Reprinted with permission from Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 2003;23(4):811-845.

Figure 3. Rib fractures detected in an abused 1-month-old boy. Posterior Tc-99m methylene diphosphonate bone scan demonstrates increased uptake in multiple adjacent posterior left ribs. Incidentally noted is increased uptake of both proximal humeri, determined at skel-etal survey to be secondary to a classicalmetaphyseal lesion of the left proximal humerus (arrow) and periostitis of the right proximal humer-us (*). Reprinted with permission from Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 2003;23(4):811-845.

A

B


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that might cause bone fragility in children when a CML is diagnosed. Household falls rarely cause CMLs; how-ever, fractures resembling CMLs have been detected after breech delivery. CMLs also have been document-ed following treatment of clubfoot.13,31,41

Scapula, Sternum, and Spinous ProcessesFractures involving the scapula, sternum, or spinous

processes of the vertebrae also have a high specificity for child abuse, mainly because of their infrequency in accidental trauma.5,13,41,47 The acromion is the most com-mon site of a scapula fracture as a result of abuse.5,13

All spinal fractures without a plausible explana-tion should be considered suggestive of abuse because of the amount of force necessary to cause such a fracture.13,22,26,47-49 In 1984, Kleinman made the first cor-relation of thoracic and lumbar spinous process fractures in shaken infants.47 A shaking episode lasting 5 seconds can cause extreme extension and flexion at the thoraco-lumbar junction, resulting in spinous process fractures

parallel arrangement (see Figure 4).13,14,29 The fractures are caused by torsional and tractional shearing strains applied to the bone as a result of violent shaking, pull-ing, or twisting of an infant’s extremity.14 CMLs are frequently bilateral and most prevalent in the knees, fol-lowed by the ankle and proximal humerus.5,41,46

The CML often is unremarkable initially on radio-graphic examination, and the appearance depends on the radiographic projection.41 The fracture can look either like it occurs at the “corner” of the metaphy-sis or can assume the shape of a “bucket handle” (see Figure 5).13,14 When the x-ray beam is 90° to the long axis of the diaphysis, it is a corner fracture; if the radiographic tube is angled more or less than 90°, the fracture is a bucket handle. If the CML is difficult to detect, the radiologic technologist should use a slight cranial or caudal angle to make it more visible.14,29 The healing cycle of a CML is short; it becomes undetectable radiographically within 4 to 8 weeks. A 2-week follow-up study can increase the detection of a CML fracture.13,14

Regardless of the high specificity of CMLs for abuse, the physician must consider diseases and syndromes

Figure 4. Illustration depicts the discoid metaphyseal fracture fragment (arrows). Reprinted with permission from Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 2003;23(4):811-845.

Figure 5. Classical metaphyseal fracture in an abused 2-month-old girl. Lateral radiograph depicts the tibial and fibular fractures as corner fractures (arrows). Reprinted with permission from Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 2003;23(4):811-845.


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Dating FracturesConventional radiography can determine an approxi-

mate timing of injuries because of the sequence of healing stages that are radiographically visible.13,25,29 In the pres-ence of multiple fractures, each must be evaluated closely for type and specificity. The responsible adult should be able to provide a convincing history of each event. In most family situations, children are cared for by various indi-viduals and determining the timing of injuries is helpful for prosecuting the correct perpetrator.14

Radiographic dating of fractures is not an exact sci-ence, yet findings significantly affect decisions in child protection.29,31,51 Because of the lack of standardized reproducible guidelines, most radiologists base the tim-ing of fractures on their clinical experience and guidance from textbooks.51 Experienced pediatric trauma radiolo-gists can determine the presence of multiple fractures in different stages of healing and differentiate them as being acute, healing, and healed.5,29,51 Authors generally agree that an acute fracture has well-defined margins. However, considerable overlap can exist when estimating the timing of fracture healing, especially in the later heal-ing stages.29,51 Infants create a further challenge because of the acceleration of the healing process common to this age group.5,29,31

In general, the first radiologic finding of a healing fracture is a periosteal reaction, which typically appears 10 to 14 days following an injury. This finding can appear as early as 4 days after the injury occurs and last up to 21 days after the injury.5,29 Subsequent findings include the loss of fracture line definition, soft callus formation, hard callus development, and remodeling, which is the stage of acute healing.29 About 8 weeks after the injury, a hard callus and early remodeling usu-ally are visible.29,31,51 Because many abused children are subjected to trauma repeatedly, and medical treatment generally is not sought for each episode, an abundance of callus might be evident.14 Once the fracture reaches the remodeling stage, the fracture line is discernible.29 Other radiologic findings can be seen months to years after abusive trauma, such as an abnormal curvature of a long bone or leg length discrepancy.25

CMLs and skull fractures are the exception to the healing process because they usually do not mend with a periosteal reaction. The most reliable method

and, at times, thoracolumbar compression.25,47 External injury usually is absent but can have serious consequenc-es.48 According to the literature, shaking trauma causes death in 12% to 20% of cases. For children who survive a shaking episode48:

� 5% to 10% of victims remain in a vegetative state. � 30% to 40% are blind or visually impaired in one

or both eyes. � 30% to 50% suffer from spastic paralysis or

marked motor developmental delays. � 30% develop epileptic seizures.

Vertebral fractures can be underestimated and easily overlooked.25,49 Most physicians consider them extremely rare in cases of abuse and, as a result, might eliminate radiographic projections of the spine during the initial evaluation.49 At other times, spinal fractures are overdiagnosed as being caused by abuse.25 False pos-itives occur when the interpreter confuses the normal anterior wedging of vertebral bodies commonly seen in childhood with an abusive fracture. For a more accurate diagnosis, the radiologist should search for multiple lev-els of vertebral involvement.25 In abusive head trauma cases, spinal evaluation is warranted because vertebral body compression is strongly associated with abusive head trauma.50 As with all injuries, it is possible for accidental trauma to cause a fracture of the sternum, scapula, or vertebra if an appropriate mechanism of injury is presented. Therefore, the patient’s history and images always must be correlated. For example, loss of vertebral body height also can be attributed to a meta-bolic disorder.25

Moderate Specificity for AbuseThe evaluation of injuries that are moderately spe-

cific for abuse is more circumstantial and depends on the child’s mobility. The plausibility of the medical history offered or denied by the parent or caregiver is important. For many patients, it is a combination of factors that raises concern. The physician can consider the predictive value of the fracture, whether the injury is bilateral or unilateral, and the presence or absence of multiple fractures in different healing stages. If a child has multiple fractures, particularly bilaterally, and several of them are in different stages of healing, the diagnosis of abuse becomes more obvious.13,14,25,26


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for all patients younger than 3 years who present with a femur fracture. However, fewer than half of physicians comply with the practice.56

Tibia fractures associated with abuse have been docu-mented, but the prevalence is low compared with fractures of the humerus and femur. A tibia fracture in a nonambu-latory child should be evaluated closely.13,26,30,33 A hairline fracture of the tibial shaft, known as a “toddle fracture,” occurs accidentally in early ambulatory children.

The radius and ulna are the least-fractured long bones in child abuse, although these fractures easily can occur accidentally in the ambulatory child. However, cases of inflicted forearm fractures in older children as a result of a child falling during an abusive episode or attempting to fend off an abusive blow have been documented.26

Epiphyseal Separation FractureEpiphyseal separation fractures are moderately

specific for abuse, with the shoulder and elbow being frequent sites of injury. A separation becomes more evident in delayed images because of the periosteal hemorrhage that occurs along the humeral shaft. An epiphyseal separation in the elbow often is mistaken for a dislocation, even though dislocations of infant elbows are nearly nonexistent. When an epiphyseal separation is suspected based on radiography, the diagnosis can be confirmed with sonography or MR imaging.14,23

Vertebral Body Fractures and SubluxationVertebral body fractures and subluxation are

moderately specific for abuse.13,31 The biomechanical properties of a young child’s immature spine differ from those of an adult, which results in unique characteris-tics of trauma. Furthermore, significant differences are seen in spinal injury of infants and toddlers compared with older children because of the increased size of infants’ heads compared with their body sizes.5,57 The very young are susceptible to severe injuries of the spine and spinal cord in abusive situations.58 Infants who have suffered a rigorous shaking episode can incur devastating injuries to their upper cervical vertebrae and brainstem.5 In a retrospective review of 342 cases of pediatric spinal injury across age groups, 3.2% were caused by child abuse. However, among patients young-er than 2 years with spinal trauma, child abuse was

of dating a CML or skull fracture is by assessing the fracture line.29,52 For skull fractures, evidence of scalp swelling can assist with dating and is best evaluated on CT using bone window settings.29

Long Bone Diaphyseal FracturesSingle long bone diaphyseal fractures are seen

frequently in nonaccidental trauma and inflicted inju-ries.13,29,33 Childhood fractures of long bones from short falls are not unusual and rarely result in significant inju-ry. The physician, radiologist, or both must consider the mechanism of injury that resulted in a specific fracture type. A transverse fracture is caused by the application of a bending load perpendicular to the bone or direct impact of a hard object at the site of the fracture. In con-trast, a spiral fracture is caused by torsion or twisting of a long bone along its axis.13 Oblique fractures are a result of combined bending and torsional loads.13,14,29

Although studies vary regarding the most com-mon inflicted diaphyseal fracture, fractures involving the femur, humerus, and tibia are cited most often.29 Accidental fracture of the humerus in a nonambula-tory child occurs rarely and should initiate a complete nonaccidental trauma evaluation. In a database analysis of common childhood fractures, the most common pat-tern of an abusive humeral fracture was spiral oblique.33 In contrast, supracondylar fractures of the humerus in ambulatory children usually are noninflicted injuries from short falls.13,33

Femur fractures are the most common musculoskel-etal injury requiring hospitalization and commonly are evaluated by clinicians in the emergency department (see Figure 6).53-55 Accidental femur fractures in ambulatory children can occur with a low-velocity injury such as a short fall or a twisting, stumbling injury.13,54 Conversely, a femur fracture in a nonambulatory child is concern-ing.13,26,53-55 The prevalence of abusive femur fractures in children younger than 3 years ranges from 11.0% to 31.2%.55 One-third of femur fractures in children younger than 4 years and 80% of femur fractures in children who are not yet walking have an abusive etiology.53

In 2009, the American Academy of Orthopedic Surgeons published clinical practice guidelines about the treatment of pediatric diaphyseal femur fractures, which recommended a nonaccidental trauma evaluation


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50% of child abuse cases involving the head.33,57 When spinal trauma is diagnosed, multiple levels of vertebral involvement generally are found.25

Complex Skull FracturesAbusive head trauma is the most common cause

of death in young abused children, with 80% of child abuse fatalities occurring in children younger than 1 year.22,59 Skull fractures might or might not be present in cases of abusive head trauma. If an infant presents with a skull fracture, there is a 30% probability that it was caused by abuse.60

Abusive skull fractures are caused by a blunt impact to the cranium.14,28,29 The speed of the object striking

the mechanism in 38% of the cases, with 73% of these patients having associated head injuries. These data support the inclusion of a spine assessment in all young nonaccidental trauma patients.57

Pediatric spinal cord injury is a rare consequence of child abuse, which leads to some practices eliminating the spinal evaluation during acute medical treatment. As a result, spinal fractures frequently go undiagnosed and most likely underreported.25,57 In nonfatal cases of child abuse involving the head, the focus of clinical diagnosis is on evaluating intracranial injuries because of their potential high risk. Spinal injuries that are vaguer on imaging might go unnoticed.5,22,57 In a clinical review, spinal injuries were not recognized in more than

Figure 6. A. Femoral shaft fracture in an abused 5-year-old boy. Frontal radiograph shows a transverse fracture of the diaphysis in femoral pin traction. The mother’s boyfriend confessed to pushing a television cabinet on top of the boy. B. Spiral femoral fracture in an abused 3-month-old boy. Lateral radiograph shows a displaced, spiral fracture of the femur. Reprinted with permission from Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic- pathologic correlation. Radiographics. 2003;23(4):811-845.

A B


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in conjunction with intracranial injury, and retinal hem-orrhage.61 Subdural hemorrhage is a common imaging finding associated with abuse. The incidence of subdural hemorrhage is low and often not the direct cause of dev-astating brain injuries in abused children.25 In many head trauma cases, abuse can be confirmed by the presence of extensive and multilayered retinal hemorrhages. This finding can be confirmed easily with a clinical ophthal-mological examination.5

Skeletal injuries commonly are associated with abusive head trauma in infants and young children. Therefore, a skeletal fracture might influence the diagnosis of abusive head trauma.50 Abusive head trauma also has been linked to the presence of seizures, apnea, or both at the time of medical treatment or within 24 hours of treatment and in cases where no medical history is available.61

Digital FracturesFractures of the small tubular bones of the hands

and feet in the first year of life should be considered as

the skull or the skull striking a stationary object deter-mines the magnitude of the contact forces and the likelihood of a fracture.28

Linear skull fractures of the parietal bone as a result of accidental trauma have been seen in children younger than 1 year. Although rare, a simple linear fracture can occur with falls from a height of 3 to 6 feet. A fall from a height of more than 6 feet usually results in a more complex fracture. The majority of stairway falls are insignificant to the skull because of their low height and subsequent impact. If a child presents with a solitary skull fracture with a history of a fall, an abuse evaluation likely is unwarranted. Conversely, if a child presents with a skull fracture and multiple other injuries, child abuse should be considered.4,13,14,28,29

The majority of skull fractures resulting from child abuse cannot, on their own, be differentiated from those occurring in accidental trauma.29 However, nonparietal fractures, complex skull fractures (especially if both sides of the head are affected), multiple fractures, fractures equal to or greater than 4-mm wide, growing fractures, and fractures associated with intracranial injury are more suggestive of abuse.13,29 A skull fracture crossing a suture line and involving more than 1 cranial bone could be the result of a single blow. This injury is seen most often in the parietal bones and occasionally the occipi-tal.29 Patterns of fractures having a higher association with abuse compared with accidental trauma include depressed fractures (especially in the occipital bone), diastatic fractures, and compressed fractures.5 Figure 7 shows a complex skull fracture in an abused infant.

Diagnosis of head trauma in pediatric patients is dif-ficult for several reasons. The caregiver might lie about the injury or be unable to explain how it happened, the symptoms might be mild and nonspecific, and clinical diagnosis of an infant is extremely difficult. In some cases, minor head injuries, such as bruises or abrasions, do not raise suspicions, the images are misinterpreted, or both.2,61

Distinguishing between abusive and nonabusive head trauma is critical because failing to do so can result in re-injury and even death.53 Specific patterns of abusive head trauma and the prevalence of other findings can assist physicians in distinguishing abuse from nonabuse. Factors associated with abusive head trauma include subdural hemorrhage, cerebral ischemia, skull fractures

Figure 7. Complex skull fractures in an abused 3-month-old girl. Lateral skull radiograph reveals multiple skull fractures (arrows). Reprinted with permission from Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 2003;23(4):811-845.


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decreases in children older than 2 years and is question-able in children aged 5 years or older.19,64 Research data have shown that skeletal surveys can be effective for diagnosing fractures in children up to 3 years of age. Decisions regarding the types of imaging needed for children aged 2 to 5 years often are made on an indi-vidual basis. From 2 to 3 years of age, a child’s verbal ability significantly increases and he or she becomes able to communicate pain and other symptoms to some degree. A survey might be considered in children older than 5 years if he or she has developmental delays or limited verbal skills.19,64

Children who have siblings close to their age are at greater risk for abuse than are children whose siblings are several years apart. This situation is referred to as close spacing, and twin births are an extreme example. Health providers should be aware that multiple pregnancies and births, especially twins, could result in significant stress on families, and the providers should provide appropriate support and intervention.65 Twins are at a higher risk of abusive fractures compared with nontwins. Families with multiple births also have an elevated risk for fatal child maltreatment.65-67 In cases of twins, siblings, or other chil-dren in a household, if 1 is injured, the other is at risk and should undergo a skeletal survey if he or she is younger than 2 years.2,13,23,66 In acute settings, hospitalization of all potentially involved children within the abusive house-hold might be necessary until a complete and accurate diagnosis of abuse can be made.23

The American College of Radiology and the Royal College of Radiologists published practice parameters for skeletal surveys, recommending the acquisition of 21 radiographic images that encompass the entire skeleton (see Table 3).62,67 The radiologist might request supplemental images if clinically indicated. Adhering to standardized imaging protocols for the initial skeletal survey is essential. The value of cer-tain projections, such as the hands, feet, and spine, in the initial skeletal survey has been debated.49,67 Until guidelines are updated, it is strongly recommended that all of the radiographic projections be included in the initial study.49,67 In cases where other diseases, conditions, or syndromes are suspected, the skeletal survey is adjusted according to the clinical indication (see Box 2).62,67

a possible result of abuse.13,25 Research data on digital fractures are scarce, yet child abuse case studies have demonstrated the presence of fractures in the hands and feet. These fractures usually are caused by an adult forcefully gripping and twisting the tiny extremity.25,29

Low Specificity for AbuseInjuries considered to have a low specificity for abuse

are usually common fractures that are incompatible with the history and include13,14,29-31:

� Clavicle fractures. � Linear skull fractures. � Isolated findings of subperiosteal new bone growth. � Long bone fractures other than a CML.

There are 2 ways subperiosteal new bone growth is seen in child abuse cases: as a normal response to a fracture healing or, in the absence of a fracture, as a radiological feature of abuse.10,25 Periosteal trauma is caused by the rough gripping, twisting, or pulling of an extremity. This causes the osteogenic layer of the periosteum to be stripped from the underlying cortex and collections of subperiosteal blood to pool around the shaft and ends of the bone. The finding often is overlooked or nonevident because the bone changes are subtle and usually only seen approximately 7 days after the injury. If detected, a careful analysis of the underly-ing bone should be made to look for a subtle hairline fracture.29 Subperiosteal new bone growth also can be caused by an infection or neoplastic disease.

Imaging Studies in the Diagnosis of Child AbuseConventional radiography is the standard modality

for imaging children when abuse is suspected or con-firmed. Radiographic studies are performed on obvious areas of trauma and a skeletal survey is used to screen a child for abuse or search for additional areas of injury in a child with confirmed abuse.62 Studies have shown that the results of a skeletal survey directly influence the decision to diagnose abuse.63 Skeletal surveys also are used to rule out alternative reasons for skeletal abnor-malities, such as skeletal dysplasias, certain syndromes, metabolic disorders, and neoplasia.62

A skeletal survey is considered mandatory for any child younger than 2 years who is suspected of being physically harmed.13,23,62 The survey’s effectiveness


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of and experience in pediatric imaging and is compe-tent in positioning, patient restraint, and practices that minimize radiation exposure.62 A keen awareness of the circumstances specific to abuse is helpful. The technol-ogist must realize that the emotions of an abused child might be exaggerated and include a high level of fear, stress, and lack of trust.62

Effective communication is imperative for the safety and cooperation of the child. Depending on age, the child’s verbal abilities could be limited or nonexistent. Because children think and act differently from adults, efficacious communication requires an understanding of the variances among children of different ages and adults. Children react to pain and discomfort in their own way. The technologist should recognize common misunderstandings and misconceptions that can occur

Initially, skeletal damage might not be evident radio-graphically because some injuries require 14 days to be noticeable. For this reason, a 2-week follow-up survey is recommended for a more thorough and accurate assess-ment of any skeletal injury.62 Research data have shown that follow-up studies increase the diagnostic yield by approximately 20%.19,35,67 Conversely, a lack of interval change could demonstrate that an apparent abnormal-ity found on the initial study is a normal variant or is related to a bone dysplasia.13,23,62 Many times a complete repeat examination is appropriate, although a limited examination could be considered.62,67 Eliminating non-essential projections, such as the spine and pelvis, could reduce the relatively high levels of radiation exposure to sensitive organs. This practice is endorsed by the American College of Radiology.13,35,62

Radiographic Positioning and Technical ConsiderationsFor best results, child abuse imaging should be per-

formed by a radiologic technologist who has knowledge

Table 3

Recommended Radiographic Projections for a Complete Pediatric Skeletal Survey62

Body Part Projection

Appendicular Skeleton

Humeri AP

Forearms AP

Hands PA

Femurs AP

Lower legs AP

Feet AP

Axial Skeleton

Thorax AP, lateral, right and left oblique (to include the sternum, ribs, thoracic and upper lumbar spine)

Abdomen AP (to include the pelvis)

Lumbosacral spine Lateral

Skull Frontal and lateral (to include cervical spine if not completely demonstrated on lateral skull image)

Abbreviations: AP, anteroposterior; PA, posteroanterior.

Box 2

Skeletal Survey Modifications by Condition62

Skeletal Dysplasias and SyndromesEntire arms and legs can be exposed on a single image when the size of the child permits.

For newborns and infants: Whole-body AP and lateral radio-graphs might be appropriate. Separate projections of the skull, hands, and feet are advisable. Lateral projections of the feet and ankles are useful in selected cases.

Review by a physician is essential; extra projections, includ-ing flexion and extension laterals of the cervical spine, might be required for certain types of skeletal dysplasia.

For some patients, selected images of specific regions or additional projections are appropriate depending on the differential diagnosis being considered.

Metabolic Disorders (eg, Rickets/Rickets-like Disorders)Entire survey not required but might be warranted. Examination should focus on anatomic region of interest.

Recommended: PA projections of the wrist and AP projec-tions of knees.

Neoplasias, Metastases, and Related ConditionsLangerhans cell histiocytosis can present with a single bone lesion or widely disseminated disease.

Complete survey is recommended for initial evaluation.

A complete skeletal survey may be obtained for the evalua-tion for metastatic bone disease.

Abbreviations: AP, anteroposterior; PA, posteroanterior.


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skeleton, skull, and spine of infants. For toddlers, the kilovoltage peak can be increased as necessary for images of the skull and spine. Chest images require the use of a bone detail technique to visualize rib fractures adequately. The amount of milliampere second is calcu-lated according to the kilovoltage peak and equipment design, including filtration and generator type.29,62

Most imaging facilities have converted to digital radiographic systems with inherent capabilities of high diagnostic efficiency, high spatial resolution, and the ability to use the lowest possible dose consistent with acceptable diagnostic image quality. If the digital system has multiple resolution mode capability, the higher reso-lution mode should be employed. This might require an increase in milliampere second to maintain the signal-to-noise ratio and optimize visualization of the skeletal structures. The use of digital processing menus and image display parameters enhances bone detail.62

Radiation ProtectionRadiographers are responsible for keeping radia-

tion exposure to patients and themselves as low as reasonably achievable (ALARA). Without question, the radiographer involved in child abuse imaging must understand the critical principles of justification, opti-mization of protection, application of dose limits, and the proper management of radiation dose to patients.62,69

Skeletal surveys require relatively high doses of radiation exposure because of the necessity of acquir-ing multiple images of different body regions, the high number of repeat images to ensure high-quality images, and the use of follow-up imaging to identify bone frac-tures and evidence of healing.70 Any increase in patient dose must be within acceptable limits and improve the clinical indication. Dose increases due to high-resolution systems can be offset with meticulous positioning and avoiding repeats. Obtaining a current and complete medical history ensures that images are not being repeated unnecessarily from prior studies.23,62

Automated dose reduction features should be used as long as they do not interfere with the technique necessary for skeletal images. The technologist should formulate manual techniques individually based on the size of the infant. An antiscatter grid should not be used for any body part that is less than 12 cm thick. Gonadal

during an imaging procedure and realize that the neces-sary steps for a procedure most likely will be unfamiliar and frightening to a child.68

For older children, the technologist can explain the procedure with wording appropriate to the patient’s level of understanding. Each topic should be separated into fundamental elements and every action should be slow and gentle. This approach helps alleviate fear and encourages cooperation, which in turn aids in produc-ing a high-quality imaging study.62,68

The skeletal study should be performed following standard traditional principles of radiographic imaging, diligently observing practices that enhance the contrast and resolution of images.62,69 To visualize the subtle, highly specific, bony abnormalities characteristic of abuse, the radiologic technologist must62:

� Ensure proper technique factors to produce high-quality images.

� Use correct positioning that might require restraining methods.

� Apply precise collimation to limit the field of exposure.

� Use conventional image identification. � Use shielding devices to ensure radiation protection.

Each anatomic area should be imaged with a separate exposure to ensure uniform image density and maximize sharpness. The practice of acquiring a single projection of the child or infant with 1 exposure, commonly referred to as a “baby gram,” is unacceptable and contrary to tradi-tional principles of imaging.13,19,23,62 Exposing the anatomy this way causes areas of underexposure and overexpo-sure and loss of resolution due to geometric distortion.23 Precise positioning should be exercised, using immobi-lization devices when needed.69 The radiographic beam must be restricted to the area of interest and a 40-inch source-to-image-receptor distance should be used. Both joints should be included on all long bone images.23,29,62

When using analog film-screen systems, a high detail combination should be selected. For toddlers and older children, a medium-speed system can be used to minimize patient dose. Radiographic images of infants should be obtained table-top; however, a grid can be used for toddlers and older patients. The kilovolt-age peak used in skeletal survey imaging is 55 to 70, which is appropriate for all images of the appendicular


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noncontrast head CT for children who have neurological signs or symptoms, difficulty breathing, a complex skull fracture, or other fractures or injuries highly suspicious for child abuse.71 In clinical practice, a head CT scan often is acquired on any child younger than 1 year who has a suspicious fracture of any type.25,29

Multidimensional reconstructions of head and facial CT scans are important because fractures could be missed if they are oriented in the same plane as the axial slice.5,19,29 The decision to eliminate skull projections in the skeletal survey when a head CT scan is performed is a debatable practice. Advocates for retaining skull projections believe that adherence to skeletal survey protocol is essential for consistency, and conventional radiographic images still are needed to measure the size of any skull fracture. Opponents argue that a CT scan should capture any necessary cranial information.14,19,25,29

In cases where chest or abdominal injuries are involved, the use of CT is beneficial. Such injuries are more common in toddlers and older children, as opposed to infants.19,23,73 Abused children have a high incidence of pancreatic and duodenal injury in addition to bowel perforations caused by blows to the abdomen.19,74 The use of oral contrast depends on the stability of the child at the time of imaging. Contrast is generally the best choice for evaluating abdominal injuries; however, a risk of aspira-tion is evident or a possibility that surgery is necessary, it is best to forgo the use of contrast.23,74

Magnetic Resonance ImagingMR imaging primarily is used to diagnose subacute

and chronic brain injury in the nonemergent setting.71 A head MR scan without contrast that includes the cervical spine is the superior choice for assessing intra-cranial injury, including cerebral hypoxia, ischemia, extra-axial collections, intraparenchymal hemorrhages, contusions, shear injuries, and brain edema. MR imag-ing is indicated in children who have abnormal CT scans and in some cases for those who have normal CT results but show strong clinical concerns for intracranial injury.23,71,75

MR imaging, either in addition to CT or alone, is being used more frequently in early, first-line abuse trauma imaging for specific indications, such as venous thrombosis in the brain.23,60,75 The use of

shielding should be used when appropriate or required by department protocol.69

Radionuclide Bone ScanA radionuclide bone scan (bone scintigraphy) can

be used as an adjunct to the skeletal survey to solve a diagnostic problem or when a clinical suspicion of abuse remains high and documentation is necessary.23,71,72 Bone scans have high sensitivity and low specificity in cases of child abuse.72 They have proven useful in diagnosing rib and long bone fractures and have a high diagnostic yield in fractures of complex anatomical areas, such as the spine, pelvis, and feet.19,72 This imaging technique rarely is used in the acute setting and is limited in the diagno-sis of skull fractures because of the lack of radioisotope uptake in the skull. Conversely, high radioisotope uptake around a growth plate fracture obscures this particular finding. Estimating the time of injury is not possible with a bone scan.14,29 Any abnormal finding on a bone scan must be documented with conventional radiogra-phy.19,72 Clinical studies comparing bone scintigraphy to the skeletal survey have demonstrated neither procedure alone is as good as the 2 combined. Potential harms and limitations of bone scans include limited availability, high radiation dose, increased risk due to sedation, and high procedural costs.19

Computed TomographyThe use of computed tomography (CT) in diagnos-

ing child abuse is increasing, and CT is the standard choice for first-line triage in the acute setting.13,71 CT can detect treatable emergency conditions quickly and efficiently and guide acute surgical and medical inter-ventions.23,71 Evidence suggests that CT outperforms conventional radiography in detecting rib fractures. Because of the relatively high radiation exposure from CT, this modality often is restricted to the critically ill.31

CT has had a dramatic effect on diagnosing acute emergent cases of infant abuse because of its abil-ity to identify small subdural collections quickly and efficiently.40 CT can help physicians differentiate between subdural and epidural hemorrhages. Because epidural hemorrhages more commonly are associated with accidental injuries, this is a critical finding.5,13,14,73 The American College of Radiology recommends


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who are entering a residential treatment center for help with issues that include child abuse.

Reprint requests may be mailed to the American Society of Radiologic Technologists, Publications Department at 15000 Central Ave SE, Albuquerque, NM 87123-3909, or emailed to [email protected].

© 2017 American Society of Radiologic Technologists

References1. World Health Organization. Child maltreatment. http://

www.who.int/mediacentre/factsheets/fs150/en/. Reviewed September 2016. Accessed May 7, 2017.

2. Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspect-ed child physical abuse. Pediatrics. 2015;135(5):e1337-e1354. doi:10.1542/peds.2015-0356.

3. Definitions of child abuse & neglect. Children’s Bureau web-site. https://www.childwelfare.gov/topics/can/defining/. Accessed February 10, 2017.

4. Children’s Bureau. Child maltreatment 2015. https://www.acf.hhs.gov/cb/resource/child-maltreatment-2015. Published March 2017. Accessed June 27, 2017.

5. Blumfield E. Imaging in child abuse. J Am Osteopath Coll Radiol. 2015;4(4):5-11.

6. Crosson-Tower C. The maltreatment of children from a historical perspective. In: Understanding Child Abuse and Neglect. 9th ed. Upper Saddle River, NJ: Pearson Education Inc; 2014:10-20.

7. Krohn Arnest L. Child abuse reporting laws. In: Skaine R, ed. Abuse: An Encyclopedia of Causes, Consequences, and Treatments. Santa Barbara, CA: ABC-CLIO, LLC; 2015:69-70.

8. Zamani AR; California Childcare Health Program. Coining: what you need to know. http://cchp.ucsf.edu/sites/cchp.ucsf .edu/files/Coining_En0210.pdf. Accessed May 7, 2017.

9. Tardieu A. Etude medico-legale sur les services et mauvais traitements exerces sure des infants. Ann Hyg Publ Med Leg. 1860;13:361-398.

10. Caffey J. Multiple fractures in the long bones of infants suf-fering from chronic subdural hematoma. Am J Roentgenol Radium Ther. 1946;56(2):163-173.

11. Brand RA. Biographical sketch: John Caffey, MD (1895-1978). Clin Orthop Relat Res. 2011;469(3):753-754. doi:10.1007/s11999-010-1665-1.

12. Caffey J. Some traumatic lesions in growing bones other than fractures and dislocations: clinical and radiologic fea-tures. Br J Radiol. 1957;30:225-238. doi:10.1259/0007-1285 -30-353-225.

diffusion-weighted imaging in the initial days of treat-ing a critically injured infant can provide information about cerebral blood f low before any abnormalities are visible on CT.23,75 Because abused infants might not demonstrate neurologic signs and symptoms of signifi-cant central nervous system injury, it is imperative to use MR imaging in cases of skeletal injuries that result from shaking or impacts.23

SonographyThe use of sonography in diagnosing child abuse is

limited. However, the modality is cited as a useful supple-ment to the skeletal survey or head CT scan in cases of head trauma. Sonography can be used as a rapid screening tool prior to CT or conventional radiographic imaging to screen for a skull or long bone fracture.2,19,23 Sonography also can demonstrate early periosteal bone reactions that might not be evident radiographically.19

ConclusionImaging plays a significant role in the diagnosis of

child abuse. All radiologic technologists have the ethical responsibility to be prepared for potential child abuse cases, regardless of the type of facility in which they practice. When a child presents with signs of abuse, the technologist should understand how to report the findings and to whom. If the technologist is assigned to complete an imaging study on a child for whom abuse is suspected or confirmed, he or she must be vigilant in observing the patient and confident in producing a diagnostically useful and high-quality study. The extra time, patience, and expertise required to image an abused child can make a substantial difference in that child’s life.

Marlene M Johnson, MEd, R.T.(R), has worked in the radiology profession for more than 40 years as a technologist and educator. She has served as a clinical instructor, professor, and program director. Before she retired, Johnson developed education programs in nuclear medicine, CT, and MR imaging for the University of Utah. She enjoys her retirement in Salt Lake City, Utah, as a part-time author and a volunteer pet-therapy team member with her golden doodle, Nikki. She is doing pet therapy work with children

https://doi.org/10.1542/peds.2015-0356

https://doi.org/10.1007/s11999-010-1665-1

https://doi.org/10.1259/0007-1285-30-353-225

https://doi.org/10.1259/0007-1285-30-353-225


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who don’t cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153(4):399-403. doi:10.1001/archpedi.153.4.399.

28. Sink EL, Hyman JE, Matheny T, Georgopoulos G, Kleinman P. Child abuse: the role of the orthopaedic surgeon in nonaccidental trauma. Clin Orthop Relat Res. 2011;469(3):790-797. doi:10.1007/s11999-010-1610-3.

29. Offiah AC, Hall CM. Radiological Atlas of Child Abuse. London, England: Radcliffe Publishing LTD; 2009.

30. Leaman LA, Hennrikus WL, Bresnahan JJ. Identifying non-accidental fractures in children aged <2 years. J Child Orthop. 2016;10(4):335-341. doi:10.1007/s11832-016-0755-3.

31. van Rijn RR, Sieswerda-Hoogendoorn T. Educational paper: imaging child abuse: the bare bones. Eur J Pediatr. 2012;171(2):215-224. doi:10.1007/s00431-011-1499-1.

32. Leventhal J, Martin K, Asnes A. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics. 2008;122(3):599-604. doi:10.1542/peds.2007-1959.

33. Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518. doi:10.1136/bmj.a1518.

34. Karmazyn B, Lewis M, Jennings S, Hibbard RA, Hicks RA. The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? AJR Am J Roentgenol. 2011;197(1):W159-W163. doi:10.2214/AJR.10.5733.

35. Harper NS, Eddleman S, Lindberg DM; ExSTRA Investigators. The utility of follow-up skeletal surveys in child abuse. Pediatrics. 2013;131(3):e672-e678. doi:10.1542 /peds.2012-2608.

36. Thorpe EL, Zuckerbraun NS, Wolford JE, Berger RP. Missed opportunities to diagnose child physical abuse. Pediatr Emerg Care. 2014;30(11):771-776. doi:10.1097/PEC.0000000000 000257.

37. Ravichandiran N, Schuh S, Bejuk M, et al. Delayed iden-tification of pediatric abuse-related fractures. Pediatrics. 2010;125(1):60-66. doi:10.1542/peds.2008-3794.

38. Swoboda SL, Feldman KW. Skeletal trauma in child abuse. Pediatr Ann. 2013;42(11):236-243. doi:10.3928/00904481 -20131022-11.

39. Bates BN. Putting together the pieces: radiology’s role in detecting, reporting, and diagnosing potential cases of child abuse. ACR Bulletin website. https://acrbulletin.org/current -issue/1030-radiology-in-child-abuse. Accessed February 7, 2017.

40. Kleinman PK. Diagnostic imaging in infant abuse. AJR Am J Roentgenol. 1990;155(4):703-712. doi:10.2214/ajr.155.4.211 9097.

13. Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL; American Academy of Pediatrics; Society for Pediatric Radiology. Evaluating children with fractures for child phys-ical abuse. Pediatrics. 2014;133(2):e477-e489. doi:10.1542 /peds.2013-3793.

14. Dwek JR. The radiographic approach to child abuse. Clin Orthop Relat Res. 2011;469(3):776-789. doi:10.1007/s11999 -010-1414-5.

15. History. Kempe website. http://www.kempe.org/about /history/. Accessed February 9, 2017.

16. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA. 1962;181 (1):17-24. doi:10.1001/jama.1962.03050270019004.

17. Federal laws. Children’s Bureau website. https://www.child welfare.gov/topics/systemwide/laws-policies/federal/. Accessed April 17, 2017.

18. H.R. 181 (114th): Justice for Victims of Trafficking Act of 2015. GovTrack website. https://www.govtrack.us/congress /bills/114/hr181/summary. Accessed February 8, 2017.

19. Jain N. The role of diagnostic imaging in the evaluation of child abuse. B C Med J. 2015;57(8):336-340. http://www .bcmj.org/articles/role-diagnostic-imaging-evaluation-child -abuse. Accessed June 27, 2017.

20. Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-1241. doi:10.1542/peds.2007-0883.

21. Mandatory reporters of child abuse neglect. Children’s Bureau website. https://www.childwelfare.gov/topics/sys temwide/laws-policies/statutes/manda/. Published 2016. Accessed February 10, 2017.

22. Paul AR, Adamo MA. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagno-sis and treatment. Transl Pediatr. 2014;3(3):195-207.

23. Section on Radiology; American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics. 2009;123(5): 1430-1435. doi:10.1542/peds.2009-0558.

24. What is child abuse and neglect? Recognizing the signs and symptoms. Children’s Bureau website. https://www.childwelfare.gov/pubs/factsheets//whatiscan.cfm. Published 2013. Accessed June 27, 2017.

25. Oestreich AE, Caré MM. Recognizing Child Abuse in Radiology. Cham, Switzerland: Springer International Publishing; 2017.

26. Wright I. Domestic violence reporting. Radiol Technol. 2011;82(4):381.

27. Sugar NF, Taylor JA, Feldman KW; Puget Sound Pediatric Research Network. Bruises in infants and toddlers: those

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https://doi.org/10.1097/PEC.0000000000000257

https://doi.org/10.1097/PEC.0000000000000257


https://doi.org/10.3928/00904481-20131022-11

https://doi.org/10.3928/00904481-20131022-11



https://doi.org/10.1007/s11999-010-1414-5

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https://doi.org/10.1001/jama.1962.03050270019004

http://www.bcmj.org/articles/role-diagnostic-imaging-evaluation-child-abuse





https://www.childwelfare.gov/pubs/factsheets//whatiscan.cfm

https://www.childwelfare.gov/pubs/factsheets//whatiscan.cfm


CEDirected Reading


54. Hui C, Joughin E, Goldstein S, et al. Femoral fractures in children younger than three years: the role of nonaccidental injury. J Pediatr Orthop. 2008;28(3):297-302. doi:10.1097 /BPO.0b013e3181653bf9.

55. Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Prevalence of abuse among young children with femur fractures: a systematic review. BMC Pediatr. 2014;14:169. doi:10.1186/1471-2431-14-169.

56. Blatz Am, Gillespie CW, Katcher A, Matthews A, Oetgen ME. Factors associated with nonaccidental trauma evaluation among patients below 36 months old presenting with femur fractures at a level-1 pediatric trauma center. J Pediatr Orthop. 2016. [Published online ahead of print.] https://www.ncbi .nlm.gov/pubmed/27851666. Accessed April 3, 2017.

57. Knox J, Schneider J, Wimberly RL, Riccio AI. Characteristics of spinal injuries secondary to nonaccidental trauma. J Pediatr Orthop. 2014;34(4):376-381. doi:10.1097/BPO.000000000 0000111.

58. Ghatan S, Ellenbogen RG. Pediatric spine and spinal cord injury after inflicted trauma. Neurosurg Clin N Am. 2002; 13(2):227-233. doi:10.1016/S1042-3680(01)00002-X.

59. Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH. A population-based study of inflicted traumatic brain injury in young children. JAMA. 2003;290(5):621-626. doi:10.1001/jama.290.5.621.

60. Vázquez E, Delgado I, Sánchez-Montañez A, Fábrega A, Cano P, Martín N. Imaging abusive head trauma: why use both computed tomography and magnetic resonance imaging? Pediatr Radiol. 2014;44(suppl 4):S589-S603. doi:10.1007/s00247-014-3216-5.

61. Piteau SJ, Ward MG, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012;130(2):315-323. doi:10.1542/peds.2011-1545.

62. American College of Radiology. ACR-SPR practice param-eter for the performance and interpretation of skeletal sur-veys in children. https://www.acr.org/~/media/9bdcdbee99b84e87baac2b1695bc07b6.pdf. Revised 2016. Accessed February 7, 2017.

63. Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 con-secutive skeletal surveys. Pediatrics. 2011;127(1):e47-e52. doi:10.1542/peds.2010-0298.

64. Lindberg DM, Berger RP, Reynolds MS, Alwan RM, Harper NS; Examining Siblings To Recognize Abuse Investigators. Yield of skeletal survey by age in children referred to abuse specialists. J Pediatr. 2014;164(6):1268-73.e1. doi:10.1016 /j.jpeds.2014.01.068.

41. Kleinman PK. Common abusive skeletal injuries. http://www.pedrad.org/Portals/5/Events/2012/Child%20Abuse /Kleinman-CommonAbusiveHeadInjuries.pdf. Published October 5, 2012. Accessed May 10, 2017.

42. Barsness KA, Cha ES, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonacci-dental trauma in children. J Trauma. 2003;54(6):1107-1110. doi:10.1097/01.TA.0000068992.01030.A8.

43. Maguire S, Mann M, John N, Ellaway B, Sibert JR, Kemp AM; Welsh Child Protection Systematic Review Group. Does cardiopulmonary resuscitation cause rib frac-tures in children? A systematic review. Child Abuse Negl. 2006;30(7):739-751. doi:10.1016/j.chiabu.2005.12.007.

44. Marine MB, Corea D, Steenburg SD, et al. Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified? AJR Am J Roentgenol. 2014;202(4):868-871. doi:10.2214/AJR.13.11068.

45. Singh R, Squires J, Fromkin JB, Berger RP. Assessing the use of follow-up skeletal surveys in children with suspected physical abuse. J Trauma Acute Care Surg. 2012;73(4):972-976. doi:10.1097/TA.0b013e31825a773d.

46. Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinman PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol. 2011;197(4):1005-1008. doi:10.2214/AJR.11.6540.

47. Kleinman PK, Zito JL. Avulsion of the spinous processes caused by infant abuse. Radiology. 1984;151(2):389-391. doi:10.1148/radiology.151.2.6709908.

48. Jacobi G, Dettmeyer R, Banaschak S, Brosig B, Herrmann B. Child abuse and neglect: diagnosis and management. Dtsch Arztebl Int. 2010;107(13):231-239.

49. Kleinman PK, Morris NB, Makris J, Moles RL, Kleinman PL. Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. AJR Am J Roentgenol. 2013;200(3):641-644. doi:10.2214/AJR .12.8878.

50. Barber I, Kleinman PK. Imaging of skeletal injuries associ-ated with abusive head trauma. Pediatr Radiol. 2014;44(4)(suppl 4):S613-S620. doi:10.1007/s00247-014-3099-5.

51. Prosser I, Lawson Z, Evans A, et al. A timetable for the radio-logic features of fracture healing in young children. AJR Am J Roentgenol. 2012;198(5):1014-1020. doi:10.2214/AJR.11.6734.

52. Bhattacharya B, et al. Non-accidental injuries. Radiopaedia website. https://radiopaedia.org/articles/non-accidental -injuries. Accessed February 23, 2017.

53. Baldwin K, Pandya NK, Wolfgruber H, Drummond DS, Hosalkar HS. Femur fractures in the pediatric popula-tion: abuse or accidental trauma? Clin Orthop Relat Res. 2011;469(3):798-804. doi:10.1007/s11999-010-1339-z.

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CEDirected Reading

Johnson

65. Ooki S. Fatal child maltreatment associated with multiple births in Japan: nationwide data between July 2003 and March 2011. Environ Health Prev Med. 2013;18(5):416-421. doi:10.1007/s12199-013-0335-9.

66. Lindberg DM, Shapiro RA, Laskey AL, et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012;130(2):193-201. http://pediatrics.aappublications.org/content/pediatrics /early/2012/07/03/peds.2012-0085.full.pdf. Accessed May 15, 2017.

67. Paddock M, Sprigg A, Offiah AC. Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 1: initial considerations and appendicular skeleton. Clin Radiol. 2017;72(3):179-188. doi:10.1016/j.crad.2016.11.016.

68. Adkins H. Effective communication during pediatric exami-nations. Radiol Technol. 2016;88(1):95-98.

69. American College of Radiology. ACR-SPR practice param-eter for general radiography. https://www.acr.org/~/media /ACR/Documents/PGTS/guidelines/General_Radiog raphy.pdf. Accessed February 12, 2017.

70. Furlow B. Domestic violence. Radiol Technol. 2010;82(2): 133-153.

71. American College of Radiology. ACR appropriateness crite-ria suspected physical abuse-child. 2016. https://acsearch .acr.org/docs/69443/Narrative/. Revised 2016. Accessed February 7, 2017.

72. Geller E. Imaging in child abuse: nuclear imaging. Medscape website. http://emedicine.medscape.com/article/407144 -overview#a6. Revised March 23, 2017. Accessed May 15, 2017.

73. Choudhary AK, Bradford RK, Dias MS, Moore GJ, Boal DK. Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology. 2012;262(1):216-223. doi:10.1148/radiol.11102390.

74. Sheybani EF, Gonzalez-Araiza G, Kousari YM, Hulett RL, Menias CO. Pediatric nonaccidental abdominal trauma: what the radiologist should know. Radiographics. 2014;34(1):139-153. doi:10.1148/rg.341135013.

75. Ichord RN, Naim M, Pollock AN, Nance ML, Margulies SS, Christian CW. Hypoxic-ischemic injury complicates inflicted and accidental traumatic brain injury in young chil-dren: the role of diffusion-weighted imaging. J Neurotrauma. 2007;24(1):106-118. doi:10.1089/neu.2006.0087.

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https://doi.org/10.1089/neu.2006.0087


Directed Reading Quiz

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Read the preceding Directed Reading and choose the answer that is most correct based on the article.

QUIZ ID: 17805-02

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1. Significant injuries and fatal abuse are more common among children and infants younger than ______ compared with other age groups.a. 2 monthsb. 6 monthsc. 2 yearsd. 3 years

2. Which of the following is a sign of physical abuse?a. child shrinks at approach of parentsb. child is dirty and has severe body odorc. ambulatory child has a few bruises on his or her

kneesd. child attaches very quickly to strangers

3. What are the most common and visible injuries of child abuse?a. fracturesb. burnsc. bite marksd. bruises

4. Which of the following findings might influence a child abuse diagnosis?

1. delay in obtaining medical treatment2. multiple fractures of different stages of

healing3. additional suspicious injuries, such as

bruises or burns

a. 1 and 2b. 1 and 3c. 2 and 3d. 1, 2, and 3

5. Which of the following fractures have the highest specificity for abuse and commonly are seen in babies who have been shaken vigorously?a. classical metaphyseal lesions (CMLs) of the

lower legb. posteromedial rib fracturesc. transverse process of the femurd. linear skull fractures



Directed Reading Quiz

10. A follow-up skeletal survey is recommended in ______ to more thoroughly and accurately assess any skeletal injury in cases of suspected child abuse.a. 5 daysb. 1 weekc. 2 weeksd. 30 days

11. The American College of Radiology recommends ______ imaging in children who have neurological signs or symptoms, difficulty breathing, complex skull fractures, or other fractures or injuries highly suspicious for child abuse.a. noncontrast head computed tomography (CT)b. contrast-enhanced head CTc. noncontrast head and neck magnetic resonance

(MR) d. contrast-enhanced head and neck MR

12. A head MR scan without contrast that includes the cervical spine is the superior choice for assessing nonemergent:

1. brain edema.2. intraparenchymal hemorrhages.3. shear injuries.

a. 1 and 2b. 1 and 3c. 2 and 3d. 1, 2, and 3

6. If the CML is difficult to detect, the radiologic technologist should:a. decrease the source-to-image-receptor distance

to 32 inches.b. turn the body part 90º.c. apply stress to the extremity.d. use a slight cranial or caudal angle.

7. In general, the first radiologic finding of a healing fracture is a ______ , which typically appears ______ days following an injury.a. remodeling; 2 to 5b. soft callus development; 5 to 9c. periosteal reaction; 10 to 14d. hard callus development; 8 to 12

8. ______ fractures frequently are seen in nonaccidental trauma and inflicted injuries.a. Single long bone diaphyseal b. Scapulac. Clavicled. Posterior rib

9. What are the 3 most common inflicted diaphyseal fractures cited in studies concerning child abuse cases?a. femur, tibia, clavicleb. femur, ulna, humerusc. humerus, femur, tibiad. fibula, radius, humerus

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