“Although skeletal injuries rarely pose a threat to the life of the abused child, they are often the strongest radiologic indicators of abuse. In fact, in an otherwise normal infant,certain patterns of injury are sufficiently characteristic to permit a firm diagnosis of inflicted injury in the absence of clinical information,” says a 2002 Pediatric Radiology article entitled “Pelvic injuries in child abuse.”Dating of skeletal injuries may provide investigators with critical temporal data, which may help in identifying potential assailants
Types of Fractures
Several types of fractures occur in childhood and may be observed in physical abuse. Diaphyseal fractures are breaks in the mid shaft of the long bones. These fractures may be transverse if the force is applied perpendicular to the long axis of the bone; spiral if the force applied is rotational in nature.
Metaphyseal fractures are microfractures through the immature part of the bone edge and often appear like chips or corner fractures on radiographs. The metaphysis is an area of rapid bone turnover in the growing infant and toddler. Rapid acceleration and deceleration forces to the extremity generate fractures.
Skull bones may be fractured as a result of direct impact to the head with a solid surface or object. The skull bones are different than long bones in that they develop within a membrane and not from cartilage as do the long bones.
Rib fractures may be observed in physical abuse as well. Rib fractures occur as a result of direct blows to the chest and via anteroposterior compression. Most abusive rib fractures are posterior, adjacent to the vertebral body, with the rib levering over the transverse process of the vertebra.
High-energy forces associated with impact or violent shaking result in a variety of central nervous system injuries that can be detected by modern neuroimaging techniques. The evolution of these injuries, as well as processes that develop secondary to the original insult, are often effectively displayed on serial imaging studies.
Imaging Studies
All infants and children with suspected intracranial injury must undergo cranial CT, MRI, or both. Strategies should be directed toward the detection of all intracranial sequelae of abuse and neglect with a thorough characterization of the extent and age of the abnormalities. In the acute-care setting, efforts are directed toward rapid detection of treatable conditions.Subsequent studies are designed to more fully delineate all abnormalities, determine the timing of the injuries, and monitor their evolution (Pediatric Radiology).
CT without intravenous contrast should be performed as part of the initial evaluation for suspected acute inflicted head injury. CT has high sensitivity and specificity for diagnosing acute intraparenchymal, subarachnoid, subdural, and epidural hemorrhage. Abnormalities that require emergency surgical intervention generally are well demonstrated.
Abused infants may not demonstrate neurologic signs and symptoms despite significant central nervous system injury. MRI offers the highest sensitivity and specificity for diagnosing subacute and chronic injury and should be considered whenever typical skeletal injuries associated with shaking or impact are identified.
Abused children have an increased occurrence of pancreatic injuries and duodenal hematomas. Bowel injury should be suspected when there is peritoneal fluid without evidence of solid organ injury and assumed when free intraperitoneal air or extraluminal contrast is observed. Bone windows should be monitored not only for rib fractures but also for signs of pelvic or spine fractures(Pediatric Radiology).
No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse.
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