Pediatric radiological diagnostic procedures in cases of suspected child abuse

doi:10.4236/health.2010.23034

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Vol.2, No.3, 237-245 (2010)

doi:10.4236/health.2010.23034

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.

ABSTRACT

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

1. INTRODUCTION

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.

2. FORMS OF 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

[3]:

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

238

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

cases.

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

[8].

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.

3. IMAGING PROCEDURES

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

C. Erfurt et al. / HEALTH 2 (2010) 237-245

239

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

240

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].

4. ANATOMY OF THE BONES DURING

CHILDHOOD

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 .

5. SKELETAL TRAUMA

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-

orrhaging.

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.

C. Erfurt et al. / HEALTH 2 (2010) 237-245

241

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-

plied.

Tibial fractures, distal metaphyseal and epiphyseal,

and proximal metaphyseal, may occur through child

abuse.

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.

C. Erfurt et al. / HEALTH 2 (2010) 237-245

242

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

team.

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

etc.)

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

C. Erfurt et al. / HEALTH 2 (2010) 237-245

243

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.

C. Erfurt et al. / HEALTH 2 (2010) 237-245

244

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

Abdomen

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.

6. CONCLUSIONS

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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