Suspected physical abuse (head injury)

Last revised by Henry Knipe on 19 Jan 2024

Suspected physical abuse, also known as non-accidental injury (NAI), can result in a range of head injuries.


Infants have a relatively large head size as compared to their body mass, weak neck muscles, large subarachnoid space, relatively flat skull base and pliable, thin skull. The infant's brain is relatively soft due to higher water content, lack of myelinated axons and immature glial cells. These factors make infants more prone to shearing injuries. A relatively flat skull base makes them prone to rotational injuries. The large head to body ratio makes them prone to cervical spine injuries 1,2. Skull fractures are seen in 30% of children who suffer from non-accidental injuries 3.

Radiographic features

A neuroimaging approach in suspected physical abuse includes skeletal survey (in children younger than 2 years), CT head, and MRI head in non-acute settings 3. Children who are older than one year and have external evidence of head injury and/or abnormal neurological symptoms or signs should have a CT head 3. MRI head should be performed in all cases in 2-5 days where CT head has demonstrated intracranial hemorrhage, parenchymal brain injury and/or skull fracture 3

Plain radiograph

Skull x-ray may demonstrate the presence of skull fractures (complex fractures with sutural diastasis; multiple fractures) 1-3


CT head may demonstrate complex skull fractures, stellate fractures, depressed skull fractures and sutural diastasis 1,2. CT head in NAI can demonstrate bilateral chronic subdural hematoma (multiple ages of the subdural hematoma with subdural membranes) and is performed in critically ill children that require neurosurgical procedures1,2.

Dose reduction techniques should be utilized while performing these scans due to risks associated with radiation exposure 3.


In non-acute settings, the MRI head is the investigation of choice 1,2. MRI can demonstrate parenchymal injuries, subacute and chronic subdural hematomas, and may provide prognostic information in the management of the child 1,2.

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