Suspected physical abuse

Last revised by Francis Deng on 25 Nov 2023

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.

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:

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.

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.

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Cases and figures

  • Case 1a
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  • Case 1b
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  • Case 2
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  • Case 3: bilateral subdural hemorrhages
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  • Case 4
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  • Case 5: metaphyseal corner fracture
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  • Case 6: skull fracture
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  • Case 7
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  • Case 8: metaphyseal corner fracture
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  • Case 9
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  • Case 10: skull fracture
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