Suspected physical abuse
Citation, DOI, disclosures and article data
At the time the article was created Basab Bhattacharya had no recorded disclosures.View Basab Bhattacharya's current disclosures
At the time the article was last revised Khalid Alhusseiny had no financial relationships to ineligible companies to disclose.View Khalid Alhusseiny's current disclosures
Suspected physical abuse (SPA), also known as non-accidental injury (NAI) or inflicted injury, in infants and young children represents both ethical and legal challenges to treating physicians.
Radiologists may be the first clinical staff to suspect non-accidental injuries when confronted with a particular injury pattern. Knowledge of these is essential if the opportunity to save a child from future neglect is not to be missed. At the same time, it is essential that suspicion is not raised inappropriately as the consequences for an innocent but accused parent or guardian are significant.
On this page:
Over recent years, there have been a number of titles given to the constellation of injuries that are the result of the physical abuse of children. Whilst "Non-Accidental Injury (NAI)" is ubiquitous, Suspected Physical Abuse (SPA) and Inflicted Injury (II) are the preferred terms 10.
In 2001 an estimated 903,000 children were victims of maltreatment including:
- neglect: 57%
- physical abuse: 19%
- cutaneous injury: most common
- fractures are noted in ~30% (range 11-55%)
- sexual abuse: 10%
- psychological maltreatment: 7%
- medical neglect: 2%
A number of features have been recognized as suspicious:
- injury in the non-ambulatory/totally dependent child
- injury and history given are inconsistent
- delay in seeking medical attention
- multiple fractures with no family history of osteogenesis imperfecta
- retinal hemorrhage
- torn frenulum
- history of household falls resulting in fracture
- despite falls being common, fractures are uncommon
- abdominal injuries
- thoracic injuries 9
A skeletal survey is performed in cases of suspected abuse to assess and document the extent of skeletal injuries. The so-called babygram (whereby the entire baby is imaged in one view) is not an acceptable substitute due to the overall lower quality that it produces; each anatomical region requires different radiographic exposures to accurately image.
Lead markers should be used in skeletal surveys and some institutions will repeat radiographs that do not have a lead marker within the primary field.
Bone scans are performed in some institutions because of their ability to detect radiographically-occult fractures.
A number of fractures have been recognized as highly specific to non-accidental injuries (rather than accidental injury). They include:
metaphyseal fracture (so-called bucket handle fracture or corner fracture)
- present in up to 39-50% of abused infants <18 months
- said to be virtually pathognomonic of NAI
- especially posterior ribs
- may have no overlying bruising
- although vigorous cardiopulmonary resuscitation can occasionally cause anterior rib fractures, posterior rib fractures do not occur
- costochondral junction injuries and/or fractures
skull fracture: suspicious features include:
- non-parietal skull fracture (a parietal fracture is more suggestive of accidental injury)
- involves multiple bones
- diastatic sutures
- crosses sutures
- depressed fracture (fracture a la signature)
- scapular fractures
- sternal fractures
- outer third clavicular fractures 9
Fractures which are moderately specific for NAI are 9:
- bilateral fractures with fractures of differing ages
- digital fractures in non-ambulant children
- vertebral fractures or vertebral subluxation
- spiral humeral fractures
- separation of epiphysis
- complex skull fractures
Fractures which have low specificity for NAI are 9:
- middle clavicular fractures
- linear simple fractures of parietal bone
- single fractures in diaphysis (spiral humeral fracture is an exception)
- greenstick fractures
It is the most sensitive in detecting fractures of rib, scapula, spine, diaphysis and pelvis. The test becomes positive few hours after injury. Normally there is high uptake in the epiphyses of bones which should not be confused with a fracture 9.
The ability to date injuries is critical for medicolegal purposes and thus must be done carefully (please refer to specialist text for specific guidelines).
Traumatic periosteal injury can be seen up to 7 days post-injury (and therefore can be used for dating). Traumatic periosteal injuries can be seen on diaphyseal and rib injuries. Diaphyseal injuries start healing after one week. Healing should be complete by 12 weeks. Rib fractures are often missed, hence current practice is to repeat chest films in two weeks to observe any healing fractures 11.
Metaphyseal (and costochondral junction) injuries do not heal with periosteal reaction and if visible is less than four weeks old. Skull fractures also do not heal with periosteal reaction and if seen are less than two weeks old.
Neuroimaging in NAI
A CT should be performed in any child who is having a skeletal survey if they are under 1 and in any child between 1 and 2 where there is suspected skull fracture or intracranial injury.
A CT may reveal extra-axial collections such as a subdural hemorrhage, skull fractures, and parenchymal injury 12,14. Dose reduction techniques should be utilized while performing these scans due to risks associated with radiation exposure 12,14. Performing a volume or spiral acquisition with reconstruction at 1 mm or less allows MPR and 3D reconstruction which maximizes skull fracture detection.
MRI of the brain and spine should be performed in any child where the CT scan is abnormal. MRI brain can also be performed in an older child or when there is no acute history of head trauma. MRI is more sensitive for parenchymal injury, but less sensitive for skull fracture. It is an excellent modality to assess for extra-axial blood.
See: neuroimaging in NAI.
skeletal dysplasias: one of the major - albeit uncommon - pitfalls in diagnosing NAI (e.g. Schmid-type metaphyseal chondrodysplasia, osteogenesis imperfecta I and IV), which may lack the florid features of the full-blown disease and can be easily confused with NAI
- features to differentiate osteogenesis imperfecta from NAI include
- the presence of osteopenia
- bowing or remodeling of bones
- the presence of Wormian bones
- features to differentiate osteogenesis imperfecta from NAI include
- growth plates can also cause a degree of confusion, most notably at the hip, base of the fifth metatarsal, elbow and the acromion
- birth injuries
- 1. Barnes PD. Ethical issues in imaging nonaccidental injury: child abuse. Top Magn Reson Imaging. 2002;13 (2): 85-93. Top Magn Reson Imaging (link) - Pubmed citation
- 2. Andy Adam, Adrian K. Dixon, Jonathan H Gillard, Cornelia Schaefer-Prokop, Ronald G. Grainger, David J. Allison. Grainger & Allison's Diagnostic Radiology E-Book. (2014) ISBN: 9780702061288
- 3. Kemp AM, Butler A, Morris S et-al. Which radiological investigations should be performed to identify fractures in suspected child abuse? Clin Radiol. 2006;61 (9): 723-36. doi:10.1016/j.crad.2006.03.017 - Pubmed citation
- 4. Kleinman PL, Kleinman PK, Savageau JA. Suspected infant abuse: radiographic skeletal survey practices in pediatric health care facilities. Radiology. 2004;233 (2): 477-85. doi:10.1148/radiol.2332031640 - Pubmed citation
- 5. Lonergan GJ, Baker AM, Morey MK et-al. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. 23 (4): 811-45. doi:10.1148/rg.234035030 - Pubmed citation
- 6. Mogbo KI, Slovis TL, Canady AI et-al. Appropriate imaging in children with skull fractures and suspicion of abuse. Radiology. 1998;208 (2): 521-4. Radiology (abstract) - Pubmed citation
- 7. Tenney-soeiro R, Wilson C. An update on child abuse and neglect. Curr. Opin. Pediatr. 2004;16 (2): 233-7. Curr. Opin. Pediatr. (link) - Pubmed citation
- 8. McNeely PD, Atkinson JD, Saigal G et-al. Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse. AJNR Am J Neuroradiol. 2006;27 (8): 1725-8. Pubmed citation
- 9. Lee A Grant, Nyree Griffin. Grainger & Allison's Diagnostic Radiology Essentials. (2018) ISBN: 9780323568845
- 10. Paddock M, Sprigg A, Offiah AC. Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 1: initial considerations and appendicular skeleton. (2017) Clinical radiology. 72 (3): 179-188. doi:10.1016/j.crad.2016.11.016 - Pubmed
- 11. Amaka C. Offiah, Catherine Adamsbaum, Rick R. van Rijn. ESPR adopts British guidelines for imaging in suspected non-accidental injury as the European standard. (2014) Pediatric Radiology. 44 (11): 1338. doi:10.1007/s00247-014-3153-3 - Pubmed
- 12. Nguyen A & Hart R. Imaging of Non-Accidental Injury; What is Clinical Best Practice? J Med Radiat Sci. 2018;65(2):123-30. doi:10.1002/jmrs.269 - Pubmed
- 13. https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr174_suspected_physical_abuse.pdf
- 14. Gunda D, Cornwell B, Dahmoush H, Jazbeh S, Alleman A. Pediatric Central Nervous System Imaging of Nonaccidental Trauma: Beyond Subdural Hematomas. Radiographics. 2019;39(1):213-28. doi:10.1148/rg.2019180084 - Pubmed