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Post-mortem imaging in suspected child physical abuse: a systematic review
Brendan S Kelly1,2, Rick R van Rijn3, Harry Bliss4
1Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
Insights
Post-mortem (PM) imaging aids in detecting child physical abuse injuries missed by autopsy. However, current evidence is limited by study bias and heterogeneity, necessitating standardized methods and prospective trials.
Area of Science:
- Forensic radiology
- Pediatric pathology
- Child abuse investigation
Background:
- Post-mortem (PM) imaging is increasingly used in pediatric forensic investigations.
- Evidence for its diagnostic yield in suspected child physical abuse requires synthesis and quality assessment.
Purpose of the Study:
- To review and synthesize current evidence on the diagnostic utility of PM imaging in suspected child physical abuse.
- To assess the quality of existing studies and identify challenges in the field.
Main Methods:
- A systematic review following PRISMA guidelines was conducted, searching databases until December 2024.
- Included original research with at least ten children undergoing PM imaging for suspected abuse.
- Data extraction and risk of bias assessment (ROBINS-I) were performed by experts; descriptive synthesis was used due to heterogeneity.
Main Results:
- Eighteen studies were included, utilizing PM radiography, PMCT, or PMMR.
- Most studies were retrospective with moderate-to-high risk of bias.
- PM imaging modalities detected subtle fractures and soft-tissue injuries, but correlation with autopsy findings is crucial.
Conclusions:
- PM imaging can reveal injuries missed during autopsy in child abuse cases.
- Standardized imaging protocols and larger prospective trials are essential to improve diagnostic accuracy and establish best practices.
- Current evidence is limited by study heterogeneity and bias, highlighting the need for higher-quality research.
Objectives:
As post-mortem (PM) imaging in children becomes more common, there is a need to review the available evidence for its diagnostic yield in suspected child physical abuse. The aim of this review is to synthesise current evidence, assess study quality, and identify ongoing challenges.
Materials And Methods:
Following PRISMA guidelines, databases were searched until 31 December 2024. Original research articles reporting data on at least ten children with PM imaging in the context of physical abuse were included. Titles and abstracts were screened by two expert reviewers; full texts were assessed by a third, independent reviewer and one of the previous reviewers. Data was extracted by one of 12 experts and independently verified. The study risk of bias was evaluated with the ROBINS-I tool. Study heterogeneity precluded meta-analysis, resulting in descriptive synthesis.
Results:
Eighteen out of 1687 potential papers were included. Seven described PM radiography, five post-mortem computed tomography (PMCT), four both PM radiography plus PMCT, and two post-mortem magnetic resonance imaging (PMMR). All but one were retrospective, and most (11/18, 61%) had a moderate-to-high risk of bias. Post-mortem skeletal survey (PMSS) detected subtle fractures, particularly corner metaphyseal fractures. PMCT provided a high-resolution assessment of injuries, particularly rib fractures. PMMR contributed soft-tissue and intracranial detail. All studies emphasised the importance of correlating autopsy findings. Technical variation and potential biases limited direct comparisons between studies.
Conclusion:
PM imaging can reveal important injury patterns that may be overlooked by autopsy. Nevertheless, standardised imaging methods and larger prospective trials are needed to reduce bias and establish best-practice guidelines.
Key Points:
Question What is the evidence for PM radiologic imaging in suspected physical abuse of children? Findings PM imaging complements autopsy, but diagnostic accuracy varies by modality. Study heterogeneity and bias limit current evidence. Clinical relevance PM imaging can detect injuries missed at autopsy in child abuse cases. Standardised protocols and higher-quality studies are urgently needed.
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