AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Background

Caffey's landmark article in 1946¹ noted an association between healing long-bone fractures and chronic subdural hematomas in infancy, and it was the first to draw attention to physical abuse as a unifying etiology. Caffey and Kempe et al in 1962² proposed manhandling and violent shaking as a mechanism of injury and emphasized the acute and long-term sequelae of abuse as serious public health problems. Since these early reports, investigators have more clearly defined the pathophysiology of abusive injuries. Community-service and law-enforcement authorities have taken a role in protecting potential victims and in prosecuting perpetrators.

In the United States, child abuse is responsible for approximately 1400 deaths per year (Child Welfare Information Gateway, 2006).³ A variety of injuries may occur with child abuse. However, some of the injuries observed in battered children are specific to this population, and certain patterns of injury are highly suggestive of nonaccidental trauma.

Most child abuse–related injuries are readily detectable during imaging, and radiologic examination is the mainstay for diagnosing physical abuse in children. Careful correlation of the observed radiologic findings with the proposed mechanism of injury and with the child's clinical status is imperative in the evaluation of any child in whom abuse is suspected. If such correlation is not performed, important clues of an inflicted injury may be overlooked, and the child may be returned to an abusive environment—with potentially disastrous consequences.

Pathophysiology

Risk factors for abuse include prematurity, physical disability, low birth weight, and low socioeconomic level. Twins and stepchildren are at increased risk. For additional information about risk factors and how to prevent them, see Risk & Protective Factors available from the Child Welfare Information Gateway of the US Department of Health and Human Services.

Skeletal injury is the most common form of injury (excluding external soft-tissue injuries). Fractures are documented in 11-55% of physically abused children.⁴ Injuries to the long bones are due to a direct blow or, more commonly, a shear force. This force is generated by pulling and twisting the body or by vigorously shaking the torso with flailing of the upper and lower extremities. The resulting fracture may cross the diaphysis in an oblique or transverse plane, or it may create the highly specific and classic metaphyseal lesion (CML). This lesion is also referred to as a corner fracture (see Image 1) or a bucket-handle fracture (see Images 4-5). A CML is the result of a torsional force applied to the immature primary spongiosa adjacent to a cartilaginous growth plate.

Rib fractures are due to a compressive force applied simultaneously to the sternum and to the costovertebral junction during violent shaking as the perpetrator compresses the child's chest using both hands. The posterior ribs are most commonly fractured because the greatest force is imparted to the articulation of the head and to the neck of the rib with the transverse process of the vertebral body. However, fractures are not limited to the posterior aspects of the ribs. Anterolateral fractures are also common. Rib fractures are typically noted at several contiguous levels, and they are frequently bilateral (see Image 2).

Head injury accounts for 80% of deaths associated with abuse in children younger than 2 years.⁵ Mechanisms of injury include forceful shaking alone or shaking accompanied by abrupt impact (see Images 9-10). Violent shaking of a child by holding the torso results in severe acceleration-deceleration forces applied to the brain as the child's head whips forward and backward. Infants are especially susceptible to brain injury because their underdeveloped neck musculature provides minimal support relative to the size of their head.

Ruptured veins in the subdural spaces are the sources of subdural hematomas. Subdural hematomas (see Image 7, Images 11-12) with or without retinal hemorrhages are highly suggestive of child abuse. Other types of injury are subarachnoid hemorrhage (SAH) (see Image 9), cerebral contusion (see Image 3), shear injury, and ischemic injury with cerebral edema (see Images 8-10).

Visceral injuries account for approximately 2-4% of all abusive injuries. The duodenum and proximal jejunum are the abdominal organs most commonly injured (see Image 15). These areas are susceptible because of their rich vascular supply and because of the fixation to the retroperitoneum. The pancreas, spleen, kidneys, and liver (see Images 13-14) may be injured as a result of direct blows or other blunt trauma. Physical abuse is a reported cause of traumatic pancreatitis in children.

Frequency

United States

Authors of the Third National Incidence Study of Child Abuse and Neglect estimated that 2,815,600 children are harmed or endangered by their caretakers annually. The youngest children are most vulnerable. Infants younger than 1 year account for 44% of all abuse-related fatalities.

International

The majority of child abuse prevalence studies have been carried out in western countries. There is a need for more studies on the prevalence in various countries for comparisons to be valid.

Mortality/Morbidity

The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1400 child fatalities in 2002. This number translates to a rate of 1.98 deaths per 100,000 children in the general population. According to NCANDS, the rate of child abuse and neglect fatalities has slightly increased from 1.84 cases per 100,000 children in 2000 to 1.96 in 2001 and 1.98 in 2002 (Child Welfare Information Gateway, 2006).³

• Head injury is the leading cause of morbidity and mortality and occurs in approximately 12% of physically abused children. Outcomes of head injury in infants who are abused are considerably worse than outcomes in age-matched children with accidental brain injury. In abused infants, head injury is associated with a mortality of 12.5-40%.⁴


• Mental retardation, seizures, and disability are common sequelae in infants who survive abuse. Long-term effects of child abuse include fear, anxiety, depression, anger, hostility, inappropriate sexual behavior, poor self-esteem, tendency for substance abuse, and difficulty with close relationships.


• Visceral injury is responsible for 12% of all abuse-related deaths.⁶

Race

Racial differences are documented in the evaluation and reporting of child abuse.

• In a study by Lane et al, minority children had the highest rates of abusive fractures but were also most likely to be evaluated for and reported because of suspected abuse.⁷


• Because of bias in reporting, whether minority children are abused more frequently than white children or whether cases of abuse in white children are underreported is unclear.

Sex

Girls are physically abused slightly more often than boys, with annual rates of 12.8 cases per 1000 girls versus 11.2 cases per 1000 boys (Child Maltreatment Report 2000).

Age

The incidence of physical abuse decreases with age. From birth to 3 years of age, the incidence is 15.7 per 1000 children per year, compared with an incidence of 5.7 per 1000 adolescents aged 16-17 years. Most cases of general neglect and medical neglect affect children and infants younger than 8 years, whereas most cases of physical, sexual, and/or emotional abuse affect children aged 8 years or older (Child Maltreatment Report 2000).

Anatomy

The radiographic appearance of a CML of the long bone is highly specific for physical abuse. In infants younger than 1 year, these fractures are usually found in the distal femur, proximal tibia, distal tibia, or proximal humerus as a result of a series of microfractures across the metaphysis. The fracture is parallel to the growth plate and perpendicular to the long axis of the bone. Differential horizontal motion across the metaphysis is a feature of abusive injury, but it is not characteristic of falls or blunt trauma. The fracture line of the CML courses through the primary spongiosa of the metaphysis, and the metaphyseal fragment tends to be thicker peripherally than centrally. Depending on how it is viewed, the fracture may appear as a corner injury or as a bucket-handle fracture (see Images 4-5).

Acute fracture disrupts the blood supply to the metaphyseal fragment and its neighboring hypertrophic zone, resulting in persistence of the hypertrophic zone and diminished mineralization of the matrix. Therefore, the area distal to the metaphyseal fracture does not mineralize normally, and abnormal chondrocytes persist. Extension of hypertrophic cartilage into the primary spongiosa is an excellent indicator of a subacute fracture.

Periosteal disruption, extension into the physis, and callous formation are relatively rare. However, changes at the physis subjacent to the fracture site may indicate a subacute fracture.

Clinical Details

Inconsistencies between the caretaker's history and the findings from the provider's examination should be sought and investigated. Perpetrators tend to visit several health care providers because of the repetitive nature of the injuries, but they may fail to maintain contact to minimize the risk of establishing an incriminating medical record or history.

Children who are physically abused exhibit specific behavioral clues. They are likely to be withdrawn and to avoid physical contact. They may not be willing to expose their injuries. They may have multiple bruises, often of various ages and in locations other than the shins, knees, elbows, or additional places where accidental injuries usually occur. Burns from cigarettes may be seen on areas of the body generally not covered with clothing. Ocular and head injuries are the most important findings and are often diagnostic injuries suggestive of nonaccidental injury syndrome in children.

Infants who are unresponsive on presentation or who require intubation are most likely to remain vegetative or severely impaired during follow-up. In one series, 60% of patients with acute seizures at presentation remained severely impaired. Most insults to infants younger than 6 months result in severe disability.⁸

Preferred Examination

For infants and children younger than 2 years, a skeletal survey should be performed as the initial screening examination when child abuse is being considered. The survey consists of the acquisition of a series of images collimated to each body region. The series includes frontal and lateral views of the skull, frontal and lateral views of the spine, frontal views of the chest (ribs) and pelvis, and frontal views of the extremities, including the hands and feet.

A babygram, in which the entire skeleton is depicted on a single image, is not an appropriate substitute for a properly performed survey. Geometric distortion and varying exposures are unacceptable limitations of this image. Use of a high-detail, high-contrast, screen-film system with good spatial resolution is mandatory. All abnormal areas should be viewed on at least 2 projections. The skeletal survey is widely available and inexpensive as compared with alternative imaging modalities. Other important advantages of the skeletal survey include a high sensitivity for most acute and healing fractures and a relatively low radiation burden.

CT scanning of the head is the imaging modality of choice for evaluating a child with acute neurologic findings or retinal hemorrhage on physical examination. It is more sensitive to acute intracerebral and extra-axial hemorrhages than MRI. Brain MRI may be helpful as an adjunct for the evaluation of axonal shear injuries and for a precise dating of intracranial hemorrhage. CT of the abdomen is indicated if abdominal injury is suspected. CT demonstrates visceral injuries and retroperitoneal hematomas.

Gastrografin upper-GI study under fluoroscopic guidance is occasionally indicated for evaluating submucosal hemorrhages of the duodenum or for identifying perforation of the duodenum.

Skeletal scintigraphy may be used when clinical suspicion remains high despite normal findings on a skeletal survey. Advantages of scintigraphy include increased sensitivity for acute posterior rib fractures, as the spine tends to obscure these injuries on radiographic examination. Fractures of the spine may be better depicted with scintigraphy than with radiography. Disadvantages of scintigraphy include diminished sensitivity in detecting skull fractures and CMLs, as these are contiguous with the normal isotope-avid growth plates. Scintigraphy is also limited because of its expense, lack of availability, gonadal radiation exposure relative to plain radiography, and lack of reader expertise.

Limitations of Techniques

Fractures parallel or nearly parallel to the section orientation may be missed during CT. Therefore, radiography of the skull is preferred over CT for examining these injuries (see Image 6).

SAH is best demonstrated with CT. The use of MRI to detect acute SAH remains controversial. MRI is superior to CT for differentiating a hypoattenuating subdural hematoma from CSF and for detecting small and chronic extra-axial fluid collections (see Image 11). In an acute setting, CT is more readily available and more cost-effective than MRI. MRI is used as a problem-solving modality when CT findings are unexplained or confusing.

Scintigraphy is limited in its sensitivity for metaphyseal fractures because of avid uptake in growth plates. In addition, because all abnormal sites must be confirmed radiographically, an osseous survey is the preferred initial examination.

DIFFERENTIALS

Section 3 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Other Problems to Be Considered

Accidental injury
Obstetric trauma
Congenital indifference to pain
Leukemia
Congenital syphilis
Menkes disease

RADIOGRAPH

Section 4 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

A CML of the long bones is highly specific for physical abuse, as it is seen in 39-50% of abused infants and children younger than 18 months who are shaken violently (see Image 1, Images 4-5).

Other injuries that are highly specific for child abuse are posterior rib fractures (see Image 2) and fractures of the scapula, spinous process, and sternum, because these bones are ordinarily difficult to break. Fractures in different stages of healing are also highly specific findings of child abuse.

Relatively nonspecific lesions are long-bone fractures in infants, digital fractures, and complex skull fractures.

Degree of Confidence

Acute fractures may be missed on plain radiographs, especially if optimal technique is not followed. A follow-up skeletal survey may be obtained 2 weeks after the initial study when abuse is strongly suspected but initial radiographic findings are negative.

False Positives/Negatives

Skeletal dysplasias, especially osteogenesis imperfecta, may mimic injuries due to physical abuse. Osteogenesis imperfecta types I and IV may be confused with abusive injury. Differentiating features include the invariable presence of osteopenia in osteogenesis imperfecta and telltale abnormalities of modeling and bowing of the long bones. Other helpful clues are wormian (intrasutural) bones of the skull and the site of the fracture. Abusive injuries and the fractures seen in osteogenesis imperfecta typically occur in different locations.

Other causes of multiple fractures include congenital indifference to pain and Menkes syndrome. Additional radiographic or clinical signs of these diseases are invariably present, and they are rarely confused with findings of child abuse. Periosteal reaction may be seen with congenital syphilis, leukemia, or Caffey disease.

A fracture-dislocation of the hip occurring before the femoral head ossifies may be mistaken for developmental dysplasia of the hip. Hip ultrasonography is indicated to differentiate the conditions in the appropriate clinical circumstances.

CT SCAN

Section 5 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

CT scanning of the head is useful in patients with head injury, especially skull fractures (see Image 6). With advancements in technology, low-dose techniques are now available for pediatric head CT, and automatic regional adjustments in radiation doses are now possible during scanning.

CT scans may reveal subarachnoid, subdural, or epidural hemorrhages. Subdural hemorrhage (see Image 7, Image 11), especially interhemispheric bleeds, and SAH (see Image 9) are common injuries of abuse. In infants and small children, subdural hemorrhage indicates rotational brain movement or shear injury, and it is commonly associated with retinal hemorrhages and retinoschisis. Epidural hemorrhage is more common with accidental injury than with inflicted injury, and it may result from falls from a relatively short distance.

Focal or diffuse cerebral edema (see Images 8-9) may also be seen. This edema may be a manifestation of primary injury or a consequence of hypoxia due to strangulation, suffocation, posttraumatic apnea, or other causes. Edema may manifest as sulcal effacement, loss of distinction between gray matter and white matter, and/or cerebral hypoattenuation (ie, reversal sign).

The abdominal organ most commonly injured in cases of child abuse is the duodenum or the proximal jejunum (see Image 15). Hematomas, lacerations, or mesenteric injuries may be present on CT scans.

Solid-organ contusions, lacerations, hemoperitoneum, and pneumoperitoneum are easily diagnosed on abdominal and pelvic CT scanning. None of these organ injuries is specific for child abuse, but making the diagnosis is important for the clinical treatment of the patient. CT has had a major effect on the early diagnosis of visceral injuries of the liver (see Image 13), spleen, pancreas (see Image 14), and kidneys. Grading of injuries by means of CT facilitates patient care and surgical planning.

Degree of Confidence

Subdural hematomas may be hypoattenuating on the day of trauma because of various factors. For example, in children with anemia, the blood may be hypoattenuating. Disruption of the arachnoid membrane during trauma may allow CSF to mix with the subdural hematoma, diluting the hemorrhage and reducing its attenuation on CT scans.

False Positives/Negatives

On CT, nondepressed fractures of the calvaria may be missed, especially if the fracture lies in an axial plane parallel to the plane of imaging.

Nonhemorrhagic brain contusions, early global ischemia, and shear injury (diffuse axonal injury) may be missed on CT because of limitations in resolution that cause subtle differences in tissue attenuation to be overlooked.

MRI

Section 6 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

The brain parenchymal injuries most commonly observed are shear injury, edema, and contusion. Shear injury most often occurs at the gray matter–white matter junction, at the corpus callosum, and at the midbrain. Findings appear as hyperintense foci on T2-weighted or inversion recovery images.

Brain contusions are admixtures of edema, hemorrhage, and necrosis. They usually are cortical, are adjacent to the bony surfaces, and result from direct contact forces. Contusions are distinctly rare in infants, with shear injury and brain edema accounting for most abnormalities.

Degree of Confidence

MRI is useful for detecting small extra-axial fluid collections, early global ischemia, and shear injury, which can be missed on CT. MRI also aids in dating hemorrhage depending on the blood products present in the collections (see Image 12). Diffusion-weighted images are useful in detecting early ischemia. Scattered reports mention that MR spectroscopy may also provide complementary information in diagnosing posttraumatic neuronal loss.⁹

The use of MRI to detect acute SAH remains controversial. Although one may observe SAH on fluid-attenuated inversion recovery (FLAIR) or susceptibility in MRI, CT is definitely preferred to MRI because it easily depicts sulcal hyperattenuation that confirms early SAH.

False Positives/Negatives

MRI is superior to CT for differentiating hypoattenuating subdural hemorrhage from prominent extracerebral spaces of infancy.

ULTRASOUND

Section 7 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Head ultrasonography has no role in the evaluation of acute abusive injury.

In unstable patients being examined in the emergency department, portable abdominal ultrasonography may be used for initial screening for visceral injuries and free fluid.

Degree of Confidence

Sonography is less sensitive than CT in the detection of acute intracranial hemorrhage and cerebral edema, especially after the fontanelles partially close.

Limitations of ultrasonography include its relatively poor depiction of the posterior fossa and of the far convexities of the brain and its inability to demonstrate the nature of abnormal fluid collections. In the presence of excessive gas or ileus, abdominal sonography may be difficult to perform.

NUCLEAR MEDICINE

Section 8 of 11  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Scintigraphy complements the radiographic skeletal survey.

Degree of Confidence

Abnormalities detected on scintigraphy should be confirmed radiographically. Scintigraphy improves sensitivity in the detection of acute rib fractures, especially those at the costovertebral junction.

False Positives/Negatives

Skeletal scintigraphy has high sensitivity and low specificity in cases of child abuse. A hot lesion on bone scanning may be due to trauma, infection, or healing infarction. Therefore, correlation with radiographs is always necessary when abnormalities are identified on scintigrams. Skull fractures are difficult to identify on scintigrams, and plain radiographs of the skull are always required.

On scintigraphy, a CML may be overlooked because it lies adjacent to a metabolically active and isotope-avid epiphyseal growth plate.

INTERVENTION

Section 9 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Medical/Legal Pitfalls

• In the United States, the law requires physicians, counselors, teachers, nurses, and other professionals to report suspected child abuse to local law enforcement, social services, or child protective services. The source of information is kept confidential to promote the reporting of child abuse and to protect victims.


• The radiologist has important medical and legal roles in cases of child abuse.
• • The radiologist may be the first to raise a question of abuse if characteristic or unexplained findings are encountered during imaging. Immediate, direct communication with the referring physician is imperative in such cases.
  
  
  • A radiologist's testimony regarding findings may be required, and the radiologist may be asked to give an opinion about the likely age of the child's fractures and about the possibility of alternative diagnoses. Familiarity with radiographic patterns and mechanisms of abuse generally allows the radiologist to give an interpretation with a high degree of certainty.


• Because imaging studies document occult injuries, they may justify the implementation of protective measures when the patient's clinical presentation suggests abuse.
• • Legal authorities may need specific, firm evidence to proceed with an investigation and prosecution of the individuals thought to be responsible for the suspected abuse.
  
  
  • In 1989, Kleinman et al reported the utility of high-detail, postmortem radiography in identifying skeletal injuries that had otherwise been overlooked.¹⁰

Special Concerns

• Often, children who are abused become abusers themselves unless they are helped and supported with counseling and intervention.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Media file 1:  Classic metaphyseal lesion (CML), as represented by a corner fracture of the lateral aspect of the humeral metaphysis.
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Media file 2:  Image shows multiple bilateral rib fractures that are healing. Note the callus formation at the posterior and lateral aspects of the ribs and the healing left clavicular fracture with callus formation.
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Media type:  X-RAY

Media file 3:  Acute cerebral injury in a victim of child abuse. Nonenhanced head CT scan shows a left parieto-occipital contusion, a subdural hygroma, a skull fracture, and swelling of the scalp.
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Media type:  CT

Media file 4:  Classic metaphyseal lesion (CML) in the distal humerus, in the form of a bucket-handle injury.
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Media type:  X-RAY

Media file 5:  The bucket-handle fracture is typical of child abuse. This injury represents a subacute metaphyseal fracture that forms an arc along the proximal margin of the metaphysis. New bone formation causes a thickened appearance and simulates a handle.
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Media type:  X-RAY

Media file 6:  Skull fracture secondary to child abuse horizontally crosses the left frontal region superior to the orbital rim.
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Media type:  X-RAY

Media file 7:  Head CT scan shows acute subdural hemorrhages along the right parietal convexity and in the posterior aspect of the interhemispheric fissure.
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Media type:  CT

Media file 8:  Nonenhanced CT scan obtained at the level of the temporal lobes shows the reversal sign, with hypoattenuation of the cerebral hemispheres. These findings represent a supratentorial ischemic insult with sparing of the cerebellum (see also Images 9-10).
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Media type:  CT

Media file 9:  Acute cerebral ischemic injury and edema secondary to child abuse. Nonenhanced CT scan in the same patient as in Images 8 and 10 shows hypoattenuation of the entire right cerebral hemisphere and the parasagittal area of the left frontal lobe. Associated findings are loss of gray matter–white matter differentiation, compression of the right lateral ventricle, and contralateral bowing of the falx. The falx has a slightly irregular contour and is hyperattenuating, findings consistent with subarachnoid hemorrhage (SAH). Note the swelling of the soft tissue in the right parietal extracranial area, which indicates acute injury.
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Media type:  CT

Media file 10:  One-month follow-up nonenhanced CT scan in the same patient as in Images 8 and 9 shows extensive encephalomalacia involving the right cerebral hemisphere. Note the hydrocephalus ex vacuo. Anterior craniectomy was performed at the time of acute injury to decompress the skull.
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Media type:  CT

Media file 11:  Acute subdural hematoma and chronic subdural hygroma in the left frontoparietal area. Note the contralateral midline shift and compression of the occipital horn of the left lateral ventricle.
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Media type:  CT

Media file 12:  T1-weighted MRI of the brain shows bilateral chronic subdural hematomas related to child abuse.
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Media type:  MRI

Media file 13:  Liver laceration. Enhanced CT scan of the abdomen shows an irregular, hypoattenuating laceration crossing the right hepatic lobe to the porta hepatis.
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Media type:  CT

Media file 14:  Pancreatic contusion. The proximal tail of the pancreas has an ill-defined patch of low attenuation, a finding consistent with focal edema (see also Image 15).
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Media type:  CT

Media file 15:  Duodenal injury (in the same patient as in Image 13). The third portion of the duodenum is atonic, is distended with fluid, and has thickening and enhancement of the wall. Note the free fluid in the hepatorenal recess and the left colic gutter.
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Media type:  CT

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

1. Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. AJR Am J Roentgenol. 56:163-173.
2. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA. Jul 7 1962;181:17-24. [Medline].
3. Child Welfare Information Gateway. Child Abuse and Neglect Fatalities: Statistics and Interventions. 2004. Updated July 24, 2006. Available at: http://www.childwelfare.gov/pubs/factsheets/fatality.cfm. [Full Text].
4. Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. Jul-Aug 2003;23(4):811-45. [Medline].
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6. Kirks DR. Radiological evaluation of visceral injuries in the battered child syndrome. Pediatr Ann. Dec 1983;12(12):888-93. [Medline].
7. Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. Oct 2 2002;288(13):1603-9. [Medline].
8. Rustamzadeh E, Truwit CL, Lam CH. Radiology of nonaccidental trauma. Neurosurg Clin N Am. Apr 2002;13(2):183-99. [Medline].
9. Makoroff KL, Cecil KM, Care M, Ball WS Jr. Elevated lactate as an early marker of brain injury in inflicted traumatic brain injury. Pediatr Radiol. Jul 2005;35(7):668-76. [Medline].
10. Kleinman PK, Blackbourne BD, Marks SC, et al. Radiologic contributions to the investigation and prosecution of cases of fatal infant abuse. N Engl J Med. Feb 23 1989;320(8):507-11. [Medline].
11. Belfer RA, Klein BL, Orr L. Use of the skeletal survey in the evaluation of child maltreatment. Am J Emerg Med. Mar 2001;19(2):122-4. [Medline].
12. Caffey J. On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child. Aug 1972;124(2):161-9. [Medline].
13. Carty H. Non-accidental injury: a review of the radiology. Eur Radiol. 1997;7(9):1365-76. [Medline].
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15. Greenberg MI, Hendrickson R, Silverberg M, et al, eds. Greenberg's Text-Atlas of Emergency Medicine. 2005.
16. Kleinman PK, Marks SC. A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol. May 1996;166(5):1207-12. [Medline].
17. Kleinman PK, Nimkin K, Spevak MR, et al. Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol. Oct 1996;167(4):893-6. [Medline].
18. Laor T, Jaramillo D. Metaphyseal abnormalities in children: pathophysiology and radiologic appearance. AJR Am J Roentgenol. Nov 1993;161(5):1029-36. [Medline].
19. Lynch MA. Child abuse before Kempe: an historical literature review. Child Abuse Negl. 1985;9(1):7-15. [Medline].
20. Merten DF, Carpenter BL. Radiologic imaging of inflicted injury in the child abuse syndrome. Pediatr Clin North Am. Aug 1990;37(4):815-37. [Medline].
21. Nimkin K, Kleinman PK. Imaging of child abuse. Radiol Clin North Am. Jul 2001;39(4):843-64. [Medline].
22. Rao P, Carty H, Pierce A. The acute reversal sign: comparison of medical and non-accidental injury patients. Clin Radiol. Aug 1999;54(8):495-501. [Medline].
23. Slovis TL, Smith W, Kushner DC, et al. Imaging the child with suspected physical abuse. American College of Radiology. ACR Appropriateness Criteria. Radiology. Jun 2000;215 Suppl:805-9. [Medline].

Article Last Updated: May 2, 2007