The Role of Diagnostic Imaging in the Evaluation of Child Abuse

Nita Jain, MD, FRCPC

The role of diagnostic imaging in the evaluation of child abuse

Radiologists experienced in pediatric imaging can provide invaluable assistance to health care teams working to identify child maltreatment and differentiate abusive trauma from accidental trauma and other unusual medical conditions.

ABSTRACT: The assessment of sus- adiological investigations Imaging skeletal trauma pected child physical abuse relies are absolutely essential when In cases of suspected physical abuse, heavily on the use of diagnostic R assessing children who may the radiographic skeletal survey is imaging. The skeletal survey, bone have been subjected to physical abuse. the first choice for imaging the entire scan, cross-sectional intracranial These investigations play a key role bony skeleton in children. To ensure and body imaging, and the recent in child abuse cases because the his- consistent quality, the American Col- use of bedside diagnostic ultrasound tory provided is often incomplete or lege of Radiology has joined with the all present advantages and disad- misleading and the physical examina- Society for Pediatric Radiology to vantages in the investigation of child tion may not readily identify occult publish a practice parameter for skel- maltreatment. Since physicians may injuries, especially in infants and etal surveys in children.4 It is impor- be expected to provide evidence in young children. Diagnostic imaging tant to note that although bony injuries court, it is mandatory that they work can provide objective information are rarely life threatening, they can in close collaboration with radiolo- about skeletal trauma, head trauma, provide compelling evidence for the gists experienced in pediatric imag- and thoraco-abdominal trauma. This diagnosis of physical abuse. Skeletal ing to ensure that imaging studies information is of greatest benefit surveys can help to identify character- are performed to the highest possi- when high-quality images have been istic injury patterns such as the classic ble standard, and reported in a thor- obtained by trained staff and the imag- metaphyseal lesion in long bones, pre- ough and informed fashion. Consul- es have been interpreted by a radiolo- viously referred to as “bucket-handle” tation and communication with the gist who is familiar with the findings and “corner” fractures ( Figure 1 ), radiologist is invaluable in coming to seen in child abuse. It is important to or posterior rib fractures ( Figure 2 ), an accurate diagnosis in these chal- emphasize that diagnostic imaging both of which are strongly sugges- lenging cases. not only helps to identify the extent tive of abuse even when clinical of injury when physical abuse is pres- information is lacking. Radiological ent, but it may also point to a medi- investigations can provide important cal diagnosis when abuse is not pres- information on the dating of skeletal ent.1,2 Fortunately, pre-existing medical conditions that result in increased Dr Jain is a clinical assistant professor in the bone fragility are very rare, occurring Department of Pediatrics at the University in less than 1% of children presenting of British Columbia and a staff pediatrician This article has been peer reviewed. with fractures.3 at BC Children’s Hospital.

336 bc medical journal vol. 57 no. 8, october 2015 bcmj.org The role of diagnostic imaging in the evaluation of child abuse

(a) (b)

Figure 1. Classic metaphyseal lesions: (a) “bucket-handle” Figure 2. Multiple bilateral posterior rib fractures that are healing fracture and (b) “corner” fracture. can be seen in an infant who also has an acute left clavicle fracture. injuries and may help identify perpetrators of abuse and confirm the innocence of nonabusive caregivers. In addition, the information obtained from imaging studies may be presented during legal proceedings. For all of these reasons the skeletal survey needs to be performed at an optimal level of technical quality using high-detail imaging systems, and the images must be obtained accord- ing to a rigorous protocol, with special attention paid to patient positioning (which may require restraining devic- es) and proper centring and coning of images to relevant body parts (with shielding of others). This will ensure the images provide the necessary detail to view subtle skeletal injures while keeping the patient radiation dose “as low as reasonably achievable.”4 A separate radiographic image is required for each ana- tomic region, and some body areas need to be captured in two or more projections. The inclusion of right and left oblique views of the thorax increases the yield for the detection of rib fractures and should be standard protocol.4 In contrast to the skeletal survey examination for medical conditions such as skeletal dysplasias or metabolic disorders, where a greater portion of the skeleton may be imaged on one radiograph, there is no role for a “babygram” ( Figure 3 ) in the assessment of suspected child abuse.1,4 A radiologist should be available to review the skeletal Figure 3. A “babygram”—a radiograph showing the entire body of survey images during their acquisition to ensure that high- the infant using an inappropriately large field of view—is inadequate quality images and appropriate views are obtained and to when evaluating for possible skeletal injury.

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request additional images of areas limit further radiation exposure to skeletal survey. Although it has great- where there is initial uncertainty. In sensitive organs.8,9 er sensitivity than X-ray for detecting some jurisdictions, there is a recom- The skeletal survey is considered rib and subtle long bone shaft frac- mended standard of having two radi- a mandatory study whenever physical tures, it is less sensitive than X-ray for ologists with expertise in child abuse abuse is suspected in children young- detecting classic metaphyseal lesions. imaging review all such skeletal sur- er than 2 years of age and in older In addition, a bone scan cannot reli- veys.5 This is the standard practised children with developmental delay or ably detect skull fractures; therefore, in the Department of Radiology at BC limited verbal skills where there may at least two X-ray views of the skull Children’s Hospital. be difficulties in detecting fractures must always be done. Further evaluation of all areas showing abnormalities on bone scan must be carried out with X-ray. A review of the literature on yield of skeletal survey compared to yield on bone scan showed that nei- ther investigation alone was as good The skeletal survey with oblique as the two combined; however, the skeletal survey with oblique views views of the ribs still remains of the ribs still remains the gold stan- the gold standard for evaluating dard for evaluating occult skeletal trauma.11 occult skeletal trauma. The use of bedside ultrasound to diagnose skull and long bone fractures in the emergency department has had some recent attention.12,13 Ultrasound in these cases is used as an extension of the physical examination and as an adjunct to, not replacement for, tradi- tional imaging methods. Intact corti- A limited repeat skeletal survey, clinically. Additionally, skeletal sur- cal bone almost completely reflects done approximately 2 weeks follow- veys need to be considered in young ultrasound waves, thus fracture planes ing the initial one, is recommended siblings of those found to have inju- can be identifiable as breaks in this when there is a high clinical suspicion ries consistent with physical abuse. pattern. Ultrasound examination may for abuse and when the initial survey Generally speaking, the utility of be of some value in identifying occult shows findings that are abnormal or the skeletal survey decreases in chil- or unsuspected bony injures and peri- equivocal.1 The follow-up survey can dren beyond the age of 2 years, and osteal hematoma in child abuse cas- increase the likelihood of detecting an is felt to provide little value in chil- es.12 Ultrasound examination must occult fracture not visible at the time dren older than 5.1 A recent review of be performed and interpreted by, or of the initial skeletal survey, can clar- data on the yield of skeletal surveys under the supervision of, a physician ify indeterminate findings, and can be by age showed a similar rate of detec- who has had training in this modal- valuable in estimating the age of frac- tion of fractures in children 24 to 36 ity. The clinician should be aware that tures.6 A large prospective study pub- months old and those 12 to 24 months fractures might be missed with ultra- lished in 2013 showed that in 21.5% old—results supporting a low thresh- sound. For example, in the case of a of cases the follow-up skeletal sur- old to obtain a skeletal survey in chil- skull fracture that is not situated under vey helped identify new fractures or dren up to the age of 3 years.10 Thus, a scalp hematoma, scanning only the provided clarification about concern- in children age 2 to 5, it is reasonable area of hematoma may miss the frac- ing findings that were not fractures.7 to make decisions regarding the type ture.13 Appropriate images need to be Views of the skull, pelvis, and lateral of imaging needed on a case-by-case kept as part of the permanent record spine may be omitted on follow-up basis.1 both for legal purposes and for qual- surveys due to the low yield of addi- A radionuclide bone scan can be ity review. While bedside ultrasound tional information and the desire to used in some cases to complement the shows some potential as an adjunct to

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X-ray and bone scan, it should never in some cases where CT findings are be the sole modality for imaging of normal but a strong clinical suspicion skeletal trauma in cases of suspected of abusive head injury exists. physical abuse. Until recently it was accepted that the appearance of subdural hemato- Imaging intracranial injury mas on CT and MRI could provide Abusive head trauma is the lead- information about the time of injury. ing cause of death from head injury Typically, subdural blood found to in children under 2 years of age, and be hyperdense or of mixed density serious neurological sequelae may on head CT was thought to indicate be seen in those that survive.2 When an acute injury, whereas blood that intracranial injury is suspected, the was found to be hypodense was con- brain and extra-axial spaces should sidered to be several days old. More be imaged with computed tomog- recently, studies have shown that the Figure 4. An acute subdural hemorrhage raphy (CT), magnetic resonance appearance of subdural blood can can be seen here along with significant imaging (MRI), or a combination of vary widely and the density found injury to the left cerebral hemisphere these. These cross-sectional imag- on imaging is not sufficient to date a associated with midline shift. ing modalities allow characterization subdural hemorrhage.14,15 However, of the extent of injury and facilitate the time frame of injury can be estab- hemorrhage in patients with abusive intervention. Serial imaging may be lished with some reasonable certainty head trauma.16 helpful in monitoring the evolution using radiological findings combined of the injury and dating the age of the with the child’s history and informa- Imaging thoraco- abnormalities found. tion from a physical exam.15 abdominal trauma CT is highly sensitive and spe- In young infants with open fon- Significant visceral injuries of the cific for the detection of acute intra- tanelles and sutures, head ultrasound chest and abdomen are uncommon parenchymal, subarachnoid, subdu- has been considered a modality for in infants, but become increasingly ral, and epidural bleeding and the the immediate bedside diagnosis of important in toddlers and older chil- consequences of these abnormalities both skull and intracranial injury. dren as they are associated with high ( Figure 4 ). Additionally, it can pro- There is concern, however, that clini- mortality. Although there may be vide information on skull and facial cians using ultrasound findings may an initial role for use of ultrasound, fractures, as well as soft tissue inju- not have sufficient skill or experience the mainstay of imaging is contrast- ries. The ability to reveal such injuries in infants to reliably detect injury, and enhanced CT scanning.1 While inju- and abnormalities, coupled with the there may be limited opportunity for a ries may be similar to those seen in speed and near universal availabil- permanent record of the images to be accidental trauma, children who have ity of CT, make it the first choice for made for legal purposes and for qual- been subjected to abuse have a high- evaluating acute cases when inflicted ity review. Therefore, if this modal- er incidence of pancreatic and duo head trauma is suspected. ity is used to assess head trauma, it denal injury, as well as bowel perfo- In contrast to the advantages of CT must be done in conjunction with CT ration caused by direct blows to the in the acute setting, MRI offers better or MRI. abdomen.2 sensitivity and specificity for detecting subacute and old injury and may Imaging spinal trauma Communication and miss acute subdural or subarachnoid While plain films of the cervical, tho- collaboration hemorrhage. MRI is the best modal- racic, and lumbar spine are included The complex nature of suspected child ity for overall assessment of intra- as part of the skeletal survey, cross- abuse cases requires detailed and on- cranial trauma and can provide infor- sectional images of the spine are going communication and collabora- mation on brain edema, contusions, increasingly being obtained in those tion between the whole team of health intraparenchymal, and extra-axial found to have evidence of abusive care professionals and community in- hemorrhages. MRI should be used head trauma.5 This practice reflects vestigators. Primary care physicians in all cases with head CT findings of a recent study confirming the sig- and pediatricians who are evaluating abnormalities and may even be useful nificant incidence of spinal subdural children for possible abuse must pro-

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conditions. Since physicians may 7. Harper NS, Eddleman S, Lindberg DM. be expected to provide evidence in The utility of follow-up skeletal surveys in Consultation court, it is mandatory that they work child abuse. Pediatrics 2013;131:e672-8. in close collaboration with radiolo- 8. Harlan SR, Nixon W, Campbell KA, et al. with a pediatric gists experienced in pediatric im- Follow-up skeletal surveys for nonacci- radiologist is of aging to ensure that imaging studies dental trauma: Can a more limited survey are performed to the highest possible be performed? Pediatr Radiol 2009;39: great value in standard, and reported in a thorough 962-968. understanding and informed fashion. A collaborative 9. Sonik A, Stein-Wexler R, Rogers KK, et al. approach will ensure that abuse is ac- Follow-up skeletal surveys for suspected the nature of curately identified and reliably differ- non-accidental trauma: Can a more limited the injuries seen entiated from both accidental trauma survey be performed without compromis- and other unusual medical conditions. ing diagnostic information? Child Abuse and in providing Neglt 2010;34:804-806. guidance about Acknowledgments 10. Lindberg DM, Berger RP, Reynolds MS, Special thanks are due to Dr John Mawson, et al. Yield of skeletal survey by age in chil- further studies. pediatric radiologist, BC Children’s Hospital, dren referred to abuse specialists. J Pedi- for his advice and assistance in the prepara- atr 2014;164:1268-1273.e1. tion of this article. 11. Kemp AM, Butler A, Morris S, et al. Which radiological investigations should be per- Competing interests formed to identify fractures in suspected None declared. child abuse? Clin Radiol 2006;61:723-736. vide accurate information about the 12. Warkentine FH, Horowitz R, Pierce MC. extent and possible mechanism of in- References The use of ultrasound to detect occult or juries seen. As such, direct personal 1. Section on Radiology. American Academy unsuspected fractures in child abuse. communication with subspecialty of Pediatrics. Diagnostic imaging of child Pediatr Emerg Care 2014;30:43-46. clinical and pediatric radiology col- abuse. Pediatrics 2009;23:1430-1435. 13. Rabiner JE, Friedman LM, Khine H, et al. leagues who assist with identification 2. Kleinman PK (ed). Diagnostic imaging of Accuracy of point-of-care ultrasound for of traumatic injuries is mandatory. In child abuse. 2nd ed. St. Louis: Mosby Inc.; diagnosis of skull fractures in children. cases of trauma identified by diagnos- 1998. Pediatrics 2013;131:e1757-1764. tic imaging, consultation with a pedi- 3. Leventhal J, Martin KD, Asnes AG. Inci- 14. Sieswerda-Hoogendoorn T, Postema FA, atric radiologist in the local commun- dence of fractures attributable to abuse in Verbaan D, et al. Age determination of ity is of great value in understanding young hospitalized children: Results from subdural hematomas with CT and MRI: A the nature of the injuries seen and analysis of a United States database. Pedi- systematic review. Eur J Radiol 2014; in providing guidance about further atrics 2008;122:599-604. 83:1257-1268. studies that may be helpful or neces- 4. American College of Radiology. ACR-SPR 15. Bradford R, Choudhary AK, Dias MS. Se- sary. Further, it is always possible for practice parameter for skeletal surveys in rial neuroimaging in infants with abusive physicians and radiologists to review children. Amended 2014 (Resolution 39). head trauma: Timing abusive injuries. challenging cases with their local Accessed 12 August 2015. www.acr J Neurosurg Pediatr 2013;12:110-119. Suspected Child Abuse and Neglect .org/~/media/9bdcdbee99b84e87baac 16. Choudhary AK, Bradford R, Dias MS, et al. (SCAN) team, or the Child Protection 2b1695bc07b6.pdf. Spinal subdural hemorrhage in abusive Service Unit and pediatric radiolo- 5. Hulson OS, van Rijn RR, Offiah AC. Euro- head trauma: A retrospective study. Radi- gists at BC Children’s Hospital. pean survey of imaging in non-accidental ology 2012;262:216-223. injury demonstrates a need for a consen- Conclusions sus protocol. Pediatr Radiol 2014;44: Diagnostic imaging in cases of sus- 1557-63. pected child abuse should be per- 6. Kleinman PK, Nimkin K, Spevak MR, et al. formed with the same level of tech- Follow-up skeletal surveys in suspected nical excellence used when evaluat- child abuse. AJR Am J Roentgenol 1996; ing accidental trauma and medical 167:893-896.

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