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From the archives of the AFIP. Child abuse: radiologic-pathologic correlation
Gael J Lonergan1, Andrew M Baker, Mitchel K Morey
1Department of Radiologic Pathology, Armed Forces Institute of Pathology, 14th and Alaska Sts NW, Bldg 54, Rm M-121, Washington, DC 20306-6000, USA. glonergan@mac.com
Insights
Child physical abuse can cause various injuries, with specific patterns like metaphyseal fractures being highly indicative of abuse. Radiologic imaging is crucial for detecting these inflicted injuries in children.
Area of Science:
- Pediatrics
- Radiology
- Forensic Medicine
Background:
- Child physical abuse affects approximately 1 in 100 children in the US, causing around 1,200 deaths annually.
- Inflicted injuries in children can mimic almost any known medical injury pattern.
- Certain injuries, particularly in infants, are highly suggestive of nonaccidental trauma.
Purpose of the Study:
- To highlight specific radiographically detectable injuries that are highly suggestive of child physical abuse.
- To emphasize the importance of radiologic evaluation in diagnosing inflicted injuries.
- To detail the radiographic appearances of key injuries associated with child abuse.
Main Methods:
- Review of radiologic findings in cases of suspected child physical abuse.
- Focus on characteristic injury patterns, including metaphyseal fractures, rib fractures, and head injuries.
- Correlation of imaging findings with the child's developmental stage and historical context.
Main Results:
- Metaphyseal fractures are the most specific radiographically detectable injury in child abuse.
- Acute rib fractures in infants are strongly correlated with abuse and may require follow-up imaging for detection.
- Radiography excels at detecting skull fractures, while CT and MRI are superior for intracranial injuries.
Conclusions:
- Radiologic examination is the cornerstone for evaluating suspected child physical abuse.
- High-quality imaging, particularly small field-of-view radiographs, is essential for detecting subtle fractures.
- A comprehensive assessment integrating injury characteristics, child development, and history is vital for accurate diagnosis.
Abstract:
In the United States, roughly one of every 100 children is subjected to some form of neglect or abuse; inflicted injury is responsible for approximately 1,200 deaths per year. Child physical abuse may manifest as virtually any injury pattern known to medicine. Some of the injuries observed in battered children are relatively unique to this population (especially when observed in infants) and therefore are highly suggestive of nonaccidental, or inflicted, injury. Worrisome injuries include rib fracture, metaphyseal fracture, interhemispheric extraaxial hemorrhage, shear-type brain injury, vertebral compression fracture, and small bowel hematoma and laceration. As noted, however, virtually any injury may be inflicted; therefore, careful consideration of the nature of the injury, the developmental capabilities of the child, and the given history are crucial to determine the likelihood that an injury was inflicted. The majority of these injuries are readily detectable at imaging, and radiologic examination forms the mainstay of evaluation of child physical abuse. Detection of metaphyseal fracture (regarded as the most specific radiographically detectable injury in abuse) depends on high-quality, small field-of-view radiographs. The injury manifests radiographically as a lucent area within the subphyseal metaphysis, extending completely or partially across the metaphysis, roughly perpendicular to the long axis of the bone. Acute rib fractures (which in infants are strongly correlated with abuse) appear as linear lucent areas. They may be difficult to discern when acute; thus, follow-up radiography increases detection of these fractures. For skull injuries, radiography is best for detecting fractures, but computed tomography and magnetic resonance imaging best depict intracranial injury.