Vol.2, No.3, 237-245 (2010)
Copyright © 2010 SciRes Openly accessible at http://www.scirp.org/journal/HEALTH/
Pediatric radiological diagnostic procedures in cases of
suspected child abuse
C. Erfurt1, G. Hahn2, D. Roesner3, U. Schmidt1
1Institute for Legal Medicine, Technical University Dresden, Dresden, Germany; Christine.Erfurt@tu-dresden.de
2Institute and Polyclinic for Radiological Diagnostics, Pediatric Radiology Department, University Hospital “Carl Gustav Carus”,
Dresden, Germany
3Clinic and Polyclinic for Pediatric Surgery, University Hospital “Carl Gustav Carus”, Dresden, Germany
Received 10 November 2009; revised 23 December 2009; accepted 25 December 2009.
Advanced and specialized radiological diag-
nostic procedures are essential in cases of
clinically diagnosed injuries to the head, thorax,
abdomen or extremities of a child, especially if
there is no case history or if the reporting of an
inadequate trauma suggests battered child
syndrome. In particular, these diagnostic pro-
cedures should aim at detecting lesions of the
central nervous system (CNS), so that the
treatment can be immediately initiated. If the
diagnostic imaging reveals findings typically
associated with child abuse, accurate docu-
mentation constituting evidence, which will
stand up in court, is required to prevent any
further endangerment of the child’s welfare.
Keywords: Child Abuse; Battered Child Syndrome;
Shaken Baby Syndrome; Non-Acci dental Injury;
Pediatric Ra diological Diagnostics
Children have the right to a non-violent childhood and
adolescence. This right is enshrined in the UN Conven-
tion on the Rights of the Child, which was adopted by the
United Nations General Assembly in November 1989.
Among the fundamental children’ s ri ghts are the rig ht to a
non-violent upbringing (in Germany Section 1631 Sub-
section 2 of the Civil Code) and the right to protection
from physi cal , emotional or sexual abuse.
The statistics on crime published by the Federal
Criminal Police Office in Germany show that even today
these rights are not secured for all children and adoles-
cents [1].
In 2006, a total of 597, 504 cases of physical injury
(code number 2200) were reported, including 3,640 cases
of child abuse (code number 2231). Boys were the vic-
tims in 55.2% of cases, and in 12 cases the physical injury
resulted in death.
The number of cases of sexual abuse against children
(code number 1310) was much higher, with a total of
15,185 victims in 12,765 registered cases.
These data are consistent with our own daily experi-
ence, in whic h we have observed over the past fe w years a
major increase in the number of childre n examined due t o
suspected physical or sexual abuse.
The term child abuse is very hard to define [2]. The ex-
pression threat to child well-being does not comprise
accidental, intentional or unintentional, violent, mental
or physical damage to a child leading to injuries, abnor-
mal development or even death and affecting or threat-
ening the well-be ing and the rights of a child.
The following forms of violence can be distinguished
2.1. Physical Abuse
Physical abuse occurs when violent behavior on the part
of the parents or other caregivers causes physical injury
to the child. Physical in juries shou ld be considered abus e
if not resulting from an accident; if the type of injury is
not consistent with the alleged cause of the injury or
explanation of how the injury occurred; if there are rea-
sonable grounds for suspicion or an admission has been
made that the injury was caused by a person exercising
parental responsibility for the child, responsible for the
care of the child, or an attachment figure for the ch ild; or
if such a person purposely did not prevent the injury to
the child. Physical abuse also encompasses forms of
injury such as attempted drowning, suffocation or the
administration of damaging substances.
2.2. Emotional Abuse
Emotional abuse is defined as a hostile or neglectful
C. Erfurt et al. / HEALTH 2 (2010) 237-245
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attitude, the rejection or ignoring of the child by the
parents or parental figures—a behavior that seriously
damages the child’s sense of personal identity and self-
esteem. Also included is emotional neglect, when the
parents or caregivers fail through negligence to provide
the child with the family atmosphere required for healthy
emotional development (for example through constant
emotional coldness or ignoring the child, as silent forms
of child abuse).
2.3. Physical Neglect
Physical neglect means that the parents or other caregiv-
ers fail completely or partially to provide for the child’s
survival or well-being, i.e. health care, nourishment, clo-
thing, healt h pr omotion, pr ot ection and supervisio n.
2.4. Sexual Abuse
Sexual abuse is the involvement of children and adoles-
cents in all types of sexual activity and/or sexual explo i-
tation by adult reference persons to whom the child
cannot give informed consent owing to ignorance, de-
pendence, developmental immaturity or fear.
Child pornography is a form of sexual abuse, as is
also the confrontation of minors with representations of
sexuality in a manner that is inappropriate to the child’s
stage of development. In every case, responsibility for
such mistreatment is borne by the perpetrator. Incest is a
special form known as ‘intrafamilial child sexual abuse’,
committed by a member of the family group. Child sex-
ual abuse also refers to actions performed with the inten-
tion of sexually stimulating a child or using a child for
the purpose of sexual arousal, either of the perpetrator or
of another person.
Children in particular are often unable to speak out—
either because they are insufficiently developed as in-
fants or toddlers, or as a result of fear. A thorough
physical examination in cases of suspected mistreatment
or sexual abuse is an important milestone in both the
diagnosis and ‘therapy’ of the abuse. The detection and
ascertainment of traumatic findings and their attribution
is an important diagnostic criterion in cases of suspected
child abuse.
Infants and toddlers are particularly challenging in
this context. In instances of suspected physical abuse,
the examination should not be restricted solely to the
external inspection of the body, since osseous injuries
are frequently not detected through clinical examination.
A full skeletal survey using radiological imaging tech-
niques can detect or rule out bone lesions resulting fro m
traumatic injury, therefore constituting an essential
component of the investigations in suspected child abuse
Both action and failure to provide care can constitute
a threat to a child.
The following text briefly deals with the possible
consequences of physical violence. Based on the daily
experiences made by the Doctor of Legal Medicine and
the Pediatric Radiologist it can be said that any form of
physical violence one can think of can also occur when a
child is abused. Typical forms of violence are punches,
kicks, pushes against the wall and the use of objects
(sticks, etc.).
Consequently, the affected children suffer from inju-
ries such as hematomas, swellings of soft parts or inju-
ries to the soft parts and skin (contused wounds or cuts).
Additionally, there can be hidden injuries, such as dam-
aged organs and fractures.
A special form of physical abuse is the shaken baby
syndrome. The term “Whiplash shaken baby syndrome”
goes back to Caffey [4]. Severe shaking of a baby leads
to strong shearing forces due to acceleration and decel-
eration. Babies and toddlers are not able to hold their
head, which is very heavy compared with their body,
when they are shaken severely. As a result there will be
cranial hemorrhages (subdural and subarachnoid hem-
orrhages), hemorrhages in the retina and lesions of cra-
nial tissue [5]. The shaken baby syndrome can lead to
death. The affecting forces have been determined exten-
sively in the finite element analysis [6]. The scope of
injuries resulting from shaken baby syndrome comprises
not only intracranial injuries, but also frequently injuries
of the skeletal system in particular rib fractures and fin-
ger marks [7]. Based on literature one can assume that
shaken babies show clinically diagnosable symptoms
The strategy of examination depends on the clinical
situation and the age of the child.
Besides the clinical examination , radiological imaging
examination methods are to be app lied.
Accordingly, we aim to presently discuss the various
uses of radiological diagnostic imaging in this context,
including an assessment of their respective valu e and the
necessary indications.
In instances of clinical suspicion of child abuse, the
following imaging procedures may be used: skeletal
radiography, computer tomography (CT) and/or, pref-
erably, magnetic resonance imaging (MRI) investiga-
tions and sonography [9,10].
3.1. Full Radiographic Skeletal Survey
A full radiographic skeletal survey should always be
performed in children up to 2 to 3 years old if child
abuse is suspected [11]. All the extremities, the thorax
and pelvis should be x-rayed from one viewing angle
and the cranium, spine and fracture areas should be
x-rayed from two viewing angles (Figure 1). The radio-
graphic images of the extremities should include the
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Figure 1. Skeletal radiographs in an instance of suspected child abuse in a child under the age of 2–3 years.
hands and feet, or these should be x-rayed selectively.
The procedure known as a ‘babygram’, i.e. producing a
single radiographic image of the whole child, is not
suitable for the purpose of con firming or ruling out child
abuse, because the metaphyses, in particular, cannot be
adequately assessed. In older children, selected skeletal
areas should be x-rayed from two viewing angles if there
is clinical suspicion of trauma-induced lesions (hemato-
mas, palpable callus formation, axial deviation).
3.3. Computer Tomography
Computer tomography of the skull is often the first im-
aging procedure used for the investigation of injuries to
the skull and brain.
In cases of blunt trauma to the abdomen, ultrasound
should be the first imaging procedure used for detecting
free abdominal fluid or injuries to the parenchymatous
organs in the upper abdomen and kidneys. In instances
of suspected child abuse, the subsequent performance of
a computer tomography (using a contrast medium) on
the abdomen is the gold standard. Serious thoracic trau-
mas can also be investigated further by means of com-
puter tomography.
3.2. Sonography
It depends on the clinical situation whether an ultrasound
examination is advisable. Sonography is of utmost im-
portance in case of suspected organic injuries to the ab-
domen and the soft parts of the extremities. 3.4. Magnetic Resonance Imaging
Sonographic examination of the skull can be used in
infants with an open fontanelle. However, the value of
such examination must be critically assessed. Non-de-
tection of objective findings in the sonogram (fresh and
older areas of bleeding) does not necessarily rule out the
existence of such lesions, as shown by some cases in the
investigation material examined at the Dresden Institute
of Legal Medicine.
Magnetic resonance imaging is primarily used when
investigating intracranial or spinal injuries.
3.5. Skeletal Scintigraphy
Skeletal scintigraphy has now practically ceased to be
used in Germany in cases of suspected child abuse, be-
cause this procedure is unable to provide relevant an-
C. Erfurt et al. / HEALTH 2 (2010) 237-245
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swers in the context of ch ild abuse, since epiphyseal and
metaphyseal fractures in the zones characterized by
physiological activity (growth areas of the epiphyses)
cannot be detected, and the age of existing fractures
cannot be determined by this method. Furthermore, the
child would be subjected to high radiation exposure de-
spite the limited usefulness of the procedure. Only in
cases of occult rib fractures can skeletal scintigraphy be
helpful [10].
The skeletal anatomy of a child is considerably different
from that of an adult. On a conventional radiograph only
the ossified parts are visible, while the cartilaginous ar-
eas of the growth zones do not appear on a radiographic
image. The zones on the long bones which are relevant
for height growth are the epiphysis, epiphyseal plates
and the metaphysis (Figure 2).
Typical childhood fractures are greenstick fractures, in
which the cortex is not completely ruptured due to the
high degree of elasti ci ty of the bone .
A fracture can be the result of various forms of violence.
Its localization and the age of the fracture are essential
indicators for its assessment. Skeletal traumatic lesions
are not usually life-threatening injuries, but often a de-
finitive indicator of child maltreatment [12]. The radio-
graphic skeletal images should meet the very highest
quality standards (spatial resolution: 10 line pairs per
mm, without grid) and should be performed by experi-
enced personnel under the supervision of an experienced
pediatric radiologist, when available.
Figure 2. Anatomy of a child’s bones in a radio-
graph, as ex em pl ified b y th e lowe r l eg with th e kn ee
joint (A–ossification nucleus of the epiphysis, B–
epiphyseal plate, C–metaphysis, D–diaphysis).
5.1. Determining the Age of a Fracture
A question often posed both in criminal and in family
law proceedings pertains to the age of fractures or the
possible occurrence of the traumatic injuries at different
times. When determining the age of fractures, particu-
larly when multiple fractures are detected, the following
parameters have to be taken into account:
1) 0–10 days: soft tissue swelling, edemas, bleeding,
fracture lines and fragments (Figure 3);
2) 7–10 days: earliest callus formation;
3) 10–14 days: clearly evident callus formation;
4) up to 8 weeks: perio s t eal ne w bo ne f ormation;
5) subsequent resorption: after 3 months the fracture
may have heale d wi t ho ut re si due.
Skull fractures do not result in callus formation, so
that the age of a fracture cannot be determined by means
of an x-ray image alone. The approximate age of the
injury (fresh or older) can be determined, however, by
reference to soft tissue trauma, such as swelling or hem-
5.2. Types of Fracture
5.2.1. Met aphyseal and Epiphyseal Fractures
Metaphyseal and epiphyseal fractures have a high speci-
ficity for child abuse [13].
Multiple subphyseal micro-fractures at the connection
between the metaphysis and the epiphyseal plate are
usually attributable to centrifugal and rotational forces.
Metaphyseal corner/chip fractures, bucket-handle frac-
tures and metaphyseal fractures are indicators of mal-
treatment via this mechanism and are virtually proof-
positive when summing up all assessments (Figure 3).
The readaptation of metaphyseal corner fractures gener-
ally takes place within approximately 18 days [14].
5.2.2. Diaphyseal Fractures
Diaphyseal fractures have a low specificity for child
abuse, since they also occur frequently in accidental
traumas. However, they occur significantly more fre-
quently than metaphyseal fractures [15].
Humerus fractures are suspicious signs of non-acci-
dental injury, particularly in children under the age of 15
months (Figure 4).
Figure 3. Radiograph of the distal lower leg with metaphy seal
fractures evident as bucket-handle fracture and corner fractures.
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Lower arm fractures in the middle of the shaft can be
evaluated as self-defense injuries (parry fractures) re-
sulting from an impact effect (Figure 5).
Femoral fractures during the first year of life are sus-
picious as indicators of external force having been ap-
Tibial fractures, distal metaphyseal and epiphyseal,
and proximal metaphyseal, may occur through child
Fractures of the sternum, scapula and pelvis are ob-
served very rarely in cases of child abuse, as the applica-
tion of great force is required to cause them.
Spinal fractures are also the result of massive traumas
and only occur very rarely as compression fractures in
instances of child abuse.
Figure 4. Radiograph of the left upper arm: spiral
fracture of the humeral shaft in an infant.
Figure 5. Radiograph of the left arm: proximal
fracture of the ulna, healed with callus formation.
5.2.3. Periosteal Reactions
Rotational and flexion forces, in particular, can result in
the detachment of the periosteum, which is elastic in the
diaphysis but stiff in the metaphysis. The sub-periosteal
hemorrhaging thus caused leads to the development of
areas of periosteal ossification, which later become visi-
ble (Figure 6).
5.2.4. Rib Fractures
Rib fractures and particularly serial rib fractures have a
high specificity for the detection of child abuse. When
thorax compression has taken place in cases of shaken
baby syndrome, serial rib fractures are often observed
[16]. These are found in both the posterior paravertebral
and in the lateral regions. These fractures only become
visible on a radiograph after the start of callus formation
after approximately 7 days (Figure 7).
Figure 6. Radiograph of the left lower leg from two viewing
angles: healing metaphyseal fracture on the distal tibia with
periosteal calcification.
Figure 7. Radiograph of the thorax: left paravertebral region of
ribs 7-9 showing post-fracture callus formation.
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5.3. Differential Diagnoses of Skeletal
Injuries Following Child Abuse
The evaluation of ossified lesions always requires im-
portant differential diagnoses to be considered [10] and
should therefore be conducted by an interdisciplinary
Significant differential diagnoses are:
1) accidental traumas
2) birth trauma (clavicle, humerus)
3) premature infant osteopenia (Figur e 8)
4) metabolic disorders (rickets, Menkes syndrome
5) medication (Methrotrexate, Prostaglandin E etc.)
6) infections (syphilis, osteomyelitis etc.)
7) neuromuscular disorders (infantile cerebral palsy)
8) neoplasias (leukemia, histiocytosis X, metastases)
9) infantile cortical hyperostosis
10) osteogenesis imperfecta
5.4. Cranial Trauma/Shaken Baby Sy ndrome
Indicators of child abuse are calvarial fractures (Figures
9 and 10) and sutural diastasis, with the ping-pong ball
fracture of the soft calvarium of the young infant and the
growing skull fracture being particularly significant.
In the case of the ping-pong ball fracture, the exertion
of external force leads to a permanent inward deforma-
tion of the elastic cranial vault of the young infant (Fig-
ure 11).
The growing skull fracture is caused by brain tissue
and cerebral membranes being trapped in the fracture
fissure, preventing the healing of the bone (Figure 12).
In this paper, we do not intend to discuss the clinical
characteristics and mechanisms involved in shaken baby
syndrome. A detailed presentation on this topic has been
publishe d i n di fferent j ournals [17 -1 9] .
Figure 8. Radiograph of the thorax: premature infant os-
teopenia and bronchopulmonary dysplasia with condition after
multiple rib fractures.
Figure 9. Radiograph of the skull from two viewing angles:
cranial burst fracture on the left parietal bone.
Figure 10. CT image of the skull: biparietal calvarial fracture
crossing the sagittal suture.
Figure 11. Radiograph of a skull with a ping-pong
ball fracture on the right parietal bone.
Intracranial injuries, however, are usually more seri-
ous and can be life-threatening [20]. In the case of a ch-
ild presenting with neurological abnormalities, a cranial
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CT scan is of decisive importance in the highly acute
phase owing to its almost unlimited availability and the
rapidity in which it can be performed enabling decisions
to be made quickly about the diagnosis and the neces-
sary treatment. The CT has a high degree of sensitivity
in detecting acute intraparenchymatous, subarachnoid,
subdural and epidural hemorrhaging (Figure 13). Patho-
logical changes which may require neurosurgical inter-
vention can be detected with certainty, and critically ill
children can be treated quickly. Accompanying cranial
and facial fractures can also be diagnosed. Sonography
via the open large fontanelle of an infan t is an important
examination method in the follow-up monitoring of an
intracranial injury. MRI is the best imaging method for
showing the full extent of the cranial injuries. The detec-
tion of extraparenchymatous fluid accumulation, intra-
parenchymatous hemorrhaging, contusion areas, diffuse
axonal injury and cerebral edema requires T1-weighted,
T2-weighted, FLAIR, T2-gradient echo and diffusion-
weighted sequences from several viewing angles (Fig-
ure 14). MRI has the highest degree of sensitivity and
specificity for the diagnosis of child abuse, and therefore
this form of imaging should always be performed in
cases of suspected child abuse.
Figure 12. MRI image of a skull: T2-weighted se-
quence with growing skull fracture on the right pa-
rieto-occipital bone and trapped cerebral parenchyma
in the subperiosteal area.
A further aspect is the follow-up monitoring in cases
of suspected shaken baby syndrome. Due to the serious
lesions of the cerebral tissue caused by shaking, these
injuries can lead to general cerebral atrophy with dilation
of the inner and outer subarachnoid spaces, or to a circu-
mscribed cystic encephalomalacy (Figures 15 and 16).
Bilateral subdural hemorrhaging is generally indica-
tive of child abuse involving shaken baby syndrome.
Subdural hemorrhaging in the supra and infratentorial
regions or in the interhemispheric fissure su bstantiate th e
suspicion of shaken baby syndrome. Unilateral subdural
hemorrhaging may also be caused by a simple fall.
Figure 13. CT image of a skull: subdural hematoma
in the right frontotemporal region and focal cerebral
edema in the left frontotemporal region.
Figure 14. MRI image of a skull: diffusion- weighted
sequence with hypoxically damaged basal ganglia and
cerebral parenchyma in the occipital region on both
sides as an indicator of a highly acute fresh parenchy-
mal lesion.
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Figure 15. MRI image of a skull: clearly evident bilateral cys-
tic encephalomalacy with a hemorrhage component in the cor-
tical region and a subdural hematoma in the left occipital area
extending into the interhemispheric fissure.
Figure 16. MRI image of a skull: subdural hematomas on both
sides in the supra and infratentorial regions with different sig-
nal intensity, which may be indicative of the injuries having
been sustained at different times.
When assessing cerebral changes using MRI imaging,
it is essential that consequences of abuse are distin-
guished from perinatal brain damage. In premature and
newborn infants, specific patterns of brain damage occur,
the dynamics of which can be observed in follow-up
monitoring and which can therefore usually be distin-
guished from injuries resulting from child abuse (for
assessment purposes, the birth mechanism should be
known, if possible). For the purposes of differential di-
agnosis, vitamin K deficiency and glutaraciduria must be
ruled out.
5.5. Blunt Trauma to the Thorax and
Serious injuries to the thorax with suspected intratho-
racic organ damage can be diagnosed quickly and safely
using computer tomography. In cases of suspected child
abuse, a blunt abdominal trauma is initially investigated
through sonographic examination of the abdomen. If this
reveals free abdominal fluid or suspected organic inju-
ries, computer tomography must be used, since it is the
most sensitive imaging technique. By this method, rup-
tures or intramural hematomas in the gastrointestinal
tract or tears in the parenchymatous organs can easily be
detected through abdominal or retroperitoneal examina-
tion. However, serious thoracic or abdominal traumas do
not occur frequently in child abuse.
The assessment of child abuse requires a multi-profes-
sional interdisciplinary approach. In cases of suspected
physical abuse, differential diagnosis is necessary taking
into account the age of the child and the clinical symp-
toms. The radiological investigations should comply
with the very highest quality standards, so as to be able
to produce a diagnosis that will stand up in court while
also minimizing the child’s exposure to radiation. Final
assessment of the images should be left to an experi-
enced pediatric radiologist.
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