Postmortem radiography after unexpected death in neonates, infants, and children: should imaging be routine?

The purpose of this study was to determine whether postmortem radiography of neonates, infants, and children provides additional information that is not detected at autopsy in cases of unexpected death.

Inclusion criteria for 106 consecutive postmortem skeletal surveys (1998-2000) were neonates, infants, and children 2 years old or younger with no preexisting medical condition to account for mortality. Pediatric radiologists interpreted all the radiographic examinations, which consisted of high-detail, collimated anteroposterior radiographs of the appendicular and axial skeleton, lateral radiographs of the axial skeleton, and oblique radiographs of the ribs. Imaging results were compared with those obtained from standard protocol autopsies on all children. Four categories of death were designated: homicide (i.e., abuse, n = 14), accidental (e.g., drowning, n = 28), natural (e.g., acute illness, n = 43), and undetermined (n = 21).

The causes of death in the 14 child abuse victims were blunt force injuries to the intracranial (n = 11) and chest and abdominal (n = 1) areas; asphyxia (n = 1); and shaking injury (n = 1). In six (43%) of these 14 patients, radiography detected 26 extremity fractures that had not been detected at autopsy; four (67%) of these six patients had fractures of different ages that involved more than one extremity. All fractures carried a high index of suspicion of abuse. No skeletal injuries were found in cases of accidental, undetermined, and natural deaths.

Postmortem radiography provides important additional information regarding the extent and chronicity of extremity trauma that may not be documented at autopsy. This finding supports the routine use of radiography in cases of suspected child abuse. Normal findings on postmortem skeletal radiography may help to distinguish cases of natural, accidental, and undetermined causes of death from those of abuse, aiding in the proper handling of these cases by medical and law enforcement personnel.