10 - Plain Radiography in Child Abuse

Summary

INDICATIONS

Complete skeletal survey plain radiographs are essential in the evaluation of suspected child abuse, particularly in infants and toddlers. Extracranial abnormalities are detected in 30% to 70% of abused children with head injuries. Shaken baby syndrome is classically described as subdural hematoma, retinal hemorrhages, and long bone fractures with minimal external signs of trauma. Because of the close association of intracranial injuries with fractures in non-accidental trauma, both CT of the head and complete bone survey radiographs should be minimal standard imaging in any suspected child abuse case.

DIAGNOSTIC CAPABILITIES

Fractures suggestive for non-accidental trauma can be categorized based on specificity for abuse:

1. High specificity: metaphyseal corner or bucket handle fracture, posterior rib fracture, sternal fracture, spinous process fracture, scapular fracture

2. Medium specificity: complex skull fracture, vertebral body fracture, multiple fractures of different ages

3. Low specificity: linear skull fracture, long bone shaft fracture in weight-bearing age

These injuries need to be taken within the context of clinical history and mechanism reported (if any), developmental age, and assessment of family and social dynamics. Any injuries considered medium or high specificity should warrant notification to the appropriate reporting agency, as should any low specificity injuries with unclear mechanisms.

IMAGING PITFALLS/LIMITATIONS

Subtle injuries may be missed on initial acute skeletal survey.