Introduction
Background
Caffey's landmark article of 1946 noted an association between healing long-bone fractures and chronic subdural hematomas in infancy, and it was the first to draw attention to physical abuse as a unifying etiology.1 In 1962, Caffey and Kempe et al proposed manhandling and violent shaking as mechanisms of injury and emphasized the acute and long-term sequelae of abuse as serious public health problems.2 Since these early reports, investigators have more clearly defined the pathophysiology of abusive injuries. Community-service and law-enforcement authorities have taken a role in protecting potential victims and in prosecuting perpetrators.
In the United States, child abuse is responsible for approximately 1400 deaths per year.3 A variety of injuries may occur as a result of child abuse. Some of the injuries observed in battered children are specific to this population, and certain patterns of injury are highly suggestive of nonaccidental trauma.
Most child abuse–related injuries are readily detectable during imaging. Radiologic examination is the mainstay for diagnosing physical abuse in children. Careful correlation of the observed radiologic findings with the proposed mechanism of injury and with the child's clinical status is imperative in the evaluation of any child in whom abuse is suspected. If such correlation is not performed, important clues of an inflicted injury may be overlooked, and the child may be returned to an abusive environment—with potentially disastrous consequences.4,5,6,7
Related eMedicine topics:
Pediatrics, Child Abuse
Child Abuse & Neglect: Physical Abuse
Pathophysiology
Risk factors for abuse include prematurity, physical disability, low birth weight, and low socioeconomic level. Twins and stepchildren are at increased risk. For additional information about risk factors and how to prevent them, see Risk & Protective Factors, which is available from the Child Welfare Information Gateway of the US Department of Health and Human Services.
Skeletal injury
Skeletal injury is the most common form of injury (excluding external soft tissue injuries). Fractures are documented in 11-55% of physically abused children.8 Injuries to the long bones are the result of a direct blow or, more commonly, a shear force. Shear force is generated by pulling and twisting the body or by vigorously shaking the torso with flailing of the upper and lower extremities.
The resulting fracture may cross the diaphysis in an oblique or transverse plane, or it may create the highly specific and classic metaphyseal lesion (CML). The classic metaphyseal lesion is also referred to as a corner fracture (see Image below and Image 1 in Multimedia Section) or a bucket-handle fracture (see Images below and Images 4-5 in Multimedia Section). A CML occurs when a torsional force is applied to the immature primary spongiosa adjacent to a cartilaginous growth plate.
Classic metaphyseal lesion (CML), as represented by a corner fracture of the lateral aspect of the humeral metaphysis.
Classic metaphyseal lesion (CML) in the distal humerus, in the form of a bucket-handle injury.
CML. The bucket-handle fracture is typical of child abuse. This injury represents a subacute metaphyseal fracture that forms an arc along the proximal margin of the metaphysis. New bone formation causes a thickened appearance and simulates a handle.
Rib fractures
Rib fractures occur when a compressive force is applied simultaneously to the sternum and to the costovertebral junction during violent shaking as the perpetrator compresses the child's chest using both hands. The posterior ribs are most commonly fractured because the greatest force is imparted to the articulation of the head and to the neck of the rib with the transverse process of the vertebral body. However, fractures are not limited to the posterior aspects of the ribs. Anterolateral fractures are also common. Rib fractures are typically noted at several contiguous levels; they are frequently bilateral (see Image below and Image 2 in Multimedia Section).
Rib Fracture. Image shows multiple bilateral rib fractures that are healing. Note the callus formation at the posterior and lateral aspects of the ribs and the healing left clavicular fracture with callus formation.
Head injury
Head injury accounts for 80% of deaths associated with abuse in children younger than 2 years.9 Mechanisms of injury include forceful shaking, either by itself alone or accompanied by abrupt impact (see Images below and Images 9-10 in Multimedia Section). Violent shaking of a child by holding the torso results in severe acceleration-deceleration forces being applied to the brain as the child's head whips forward and backward. Infants are especially susceptible to brain injury because their underdeveloped neck musculature provides minimal support relative to the size of their head.
Subarachnoid Hemorrhage. Acute cerebral ischemic injury and edema secondary to child abuse. Nonenhanced CT scan in the same patient as in Images above and below shows hypoattenuation of the entire right cerebral hemisphere and the parasagittal area of the left frontal lobe. Associated findings are loss of gray matter-white matter differentiation, compression of the right lateral ventricle, and contralateral bowing of the falx. The falx has a slightly irregular contour and is hyperattenuating, findings consistent with subarachnoid hemorrhage (SAH). Note the swelling of the soft tissue in the right parietal extracranial area, which indicates acute injury.
Encephalomalacia. One-month follow-up nonenhanced CT scan in the same patient as in Image above shows extensive encephalomalacia involving the right cerebral hemisphere. Note the hydrocephalus ex vacuo. Anterior craniectomy was performed at the time of acute injury to decompress the skull.
Ruptured veins
Ruptured veins in the subdural spaces are the sources of subdural hematomas. Subdural hematomas (see Subdural Hematoma Images below and Images 7, 11-12 in Multimedia Section) with or without retinal hemorrhages are highly suggestive of child abuse. Other types of injury are subarachnoid hemorrhage (SAH) (see Subarachnoid Hemorrhage Image below and Image 9 in Multimedia Section), cerebral contusion (see Cerebral Contusion Image below and Image 3 in Multimedia Section), shear injury, and ischemic injury with cerebral edema (see Images below and Images 8-10 in Multimedia Section).
Subdural Hematoma. Head CT scan shows acute subdural hemorrhages along the right parietal convexity and in the posterior aspect of the interhemispheric fissure.
Subdural Hematoma. Acute subdural hematoma and chronic subdural hygroma in the left frontoparietal area. Note the contralateral midline shift and compression of the occipital horn of the left lateral ventricle.
Subdural Hematoma. T1-weighted MRI of the brain shows bilateral chronic subdural hematomas related to child abuse.
Cerebral Contusion. Acute cerebral injury in a victim of child abuse. Nonenhanced head CT scan shows a left parieto-occipital contusion, a subdural hygroma, a skull fracture, and swelling of the scalp.
Ischemic Insult. Nonenhanced CT scan obtained at the level of the temporal lobes shows the reversal sign, with hypoattenuation of the cerebral hemispheres. These findings represent a supratentorial ischemic insult with sparing of the cerebellum (see also Images below).
Subarachnoid Hemorrhage. Acute cerebral ischemic injury and edema secondary to child abuse. Nonenhanced CT scan in the same patient as in Images above and below shows hypoattenuation of the entire right cerebral hemisphere and the parasagittal area of the left frontal lobe. Associated findings are loss of gray matter-white matter differentiation, compression of the right lateral ventricle, and contralateral bowing of the falx. The falx has a slightly irregular contour and is hyperattenuating, findings consistent with subarachnoid hemorrhage (SAH). Note the swelling of the soft tissue in the right parietal extracranial area, which indicates acute injury.
Encephalomalacia. One-month follow-up nonenhanced CT scan in the same patient as in Image above shows extensive encephalomalacia involving the right cerebral hemisphere. Note the hydrocephalus ex vacuo. Anterior craniectomy was performed at the time of acute injury to decompress the skull.
Visceral injuries
Visceral injuries account for approximately 2-4% of all abusive injuries. The duodenum and the proximal jejunum are the abdominal organs most commonly injured (see Image below and Image 15 in Multimedia Section). These areas are susceptible because of their rich vascular supply and because of the fixation to the retroperitoneum. The pancreas, spleen, kidneys, and liver (see Images below and Images 13-14 in Multimedia Section) may be injured as a result of direct blows or other blunt trauma. Physical abuse is a reported cause of traumatic pancreatitis in children.
Liver laceration. Enhanced CT scan of the abdomen shows an irregular, hypoattenuating laceration crossing the right hepatic lobe to the porta hepatis.
Pancreatic contusion. The proximal tail of the pancreas has an ill-defined patch of low attenuation, a finding consistent with focal edema (see also Image below).
Duodenal injury (in the same patient as in Image above). The third portion of the duodenum is atonic, is distended with fluid, and has thickening and enhancement of the wall. Note the free fluid in the hepatorenal recess and the left colic gutter.
Frequency
United States
Authors of the Third National Incidence Study of Child Abuse and Neglect estimated that 2,815,600 children are harmed or endangered by their caretakers annually. The youngest children are most vulnerable. Infants younger than 1 year account for 44% of all abuse-related fatalities.
International
Most studies of the prevalence of child abuse have been conducted in Western countries. More studies on the prevalence of child abuse in non-Western countries are needed for comparison with the prevalence of child abuse in the West.
Mortality/Morbidity
The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1400 child fatalities in 2002. This number translates to a rate of 1.98 deaths per 100,000 children in the general population. According to NCANDS, the rate of child abuse and neglect fatalities slightly increased from 1.84 cases per 100,000 children in 2000 to 1.96 in 2001 and 1.98 in 2002.3
- Head injury is the leading cause of morbidity and mortality. It occurs in approximately 12% of physically abused children. Outcomes of head injury in infants who are abused are considerably worse than outcomes in age-matched children with accidental brain injury. In abused infants, head injury is associated with a mortality of 12.5 – 40%.8
- Mental retardation, seizures, and disability are common sequelae in infants who survive abuse. Long-term effects of child abuse include fear, anxiety, depression, anger, hostility, inappropriate sexual behavior, poor self-esteem, tendency for substance abuse, and difficulty with close relationships.
- Visceral injury is responsible for 12% of all abuse-related deaths.10
Race
Racial differences are documented in the evaluation and reporting of child abuse.
- In a study by Lane et al, minority children had the highest rates of abusive fractures but were also most likely to be evaluated for and reported because of suspected abuse.11
- Because of bias in reporting, whether minority children are abused more frequently than white children or whether cases of abuse in white children are underreported is unclear.
Sex
Girls are physically abused slightly more often than boys; the annual rates are 12.8 cases per 1000 girls and 11.2 cases per 1000 boys (Child Maltreatment Report 2000).
Age
The incidence of physical abuse decreases with age. From the time of birth to 3 years of age, the incidence is 15.7 per 1000 children per year; the incidence is 5.7 per 1000 adolescents aged 16-17 years. Most cases of general neglect and medical neglect affect children and infants younger than 8 years, whereas most cases of physical, sexual, and/or emotional abuse affect children 8 years of age or older (Child Maltreatment Report 2000).
Anatomy
The radiographic appearance of a classic metaphyseal lesion (CML) of the long bone is highly specific for physical abuse. In infants younger than 1 year, these fractures are usually found in the distal femur, the proximal tibia, the distal tibia, or the proximal humerus as a result of a series of microfractures across the metaphysis. The fracture is parallel to the growth plate and perpendicular to the long axis of the bone. Differential horizontal motion across the metaphysis is a feature of abusive injury, but it is not characteristic of falls or blunt trauma. The fracture line of the CML courses through the primary spongiosa of the metaphysis, and the metaphyseal fragment tends to be thicker peripherally than centrally. Depending on how it is viewed, the fracture may appear as a corner injury or as a bucket-handle fracture (see Images below and Images 4-5 in Multimedia Section).
Classic metaphyseal lesion (CML) in the distal humerus, in the form of a bucket-handle injury.
CML. The bucket-handle fracture is typical of child abuse. This injury represents a subacute metaphyseal fracture that forms an arc along the proximal margin of the metaphysis. New bone formation causes a thickened appearance and simulates a handle.
Acute fracture disrupts the blood supply to the metaphyseal fragment and its neighboring hypertrophic zone, resulting in persistence of the hypertrophic zone and diminished mineralization of the matrix. Therefore, the area distal to the metaphyseal fracture does not mineralize normally, and abnormal chondrocytes persist. Extension of hypertrophic cartilage into the primary spongiosa is an excellent indicator of a subacute fracture.
Periosteal disruption, extension into the physis, and callous formation are relatively rare. However, changes at the physis subjacent to the fracture site may indicate a subacute fracture.
Presentation
Inconsistencies between the caretaker's history and the findings from the provider's examination should be sought and investigated. Perpetrators tend to visit several health care providers because of the repetitive nature of the injuries, and they may fail to maintain contact to minimize the risk of establishing an incriminating medical record or history.
Children who are physically abused exhibit specific behavioral clues. They are likely to be withdrawn and to avoid physical contact. They may not be willing to expose their injuries. They may have multiple bruises, often of various ages and in locations other than the shins, knees, elbows, or other places where accidental injuries usually occur. Burns from cigarettes may be seen on areas of the body generally not covered with clothing. Ocular and head injuries are the most important findings; these are often diagnostic injuries suggestive of nonaccidental injury syndrome in children.
Infants who are unresponsive on presentation or who require intubation are most likely to remain vegetative or severely impaired during follow-up. In one series, 60% of patients with acute seizures at presentation remained severely impaired. Most insults to infants younger than 6 months result in severe disability.12
Preferred Examination
For infants and children younger than 2 years, a skeletal survey should be performed as the initial screening examination when child abuse is being considered. The survey consists of the acquisition of a series of images collimated to each body region. The series includes frontal and lateral views of the skull, frontal and lateral views of the spine, frontal views of the chest (ribs) and pelvis, and frontal views of the extremities, including the hands and feet.13
A babygram, in which the entire skeleton is depicted on a single image, is not an appropriate substitute for a properly performed survey. Geometric distortion and varying exposures are unacceptable limitations of this image. Use of a high-detail, high-contrast, screen-film system with good spatial resolution is mandatory. All abnormal areas should be viewed on at least 2 projections. The skeletal survey is widely available and inexpensive in comparison with alternative imaging modalities. Other important advantages of the skeletal survey include a high sensitivity for most acute and healing fractures and a relatively low radiation burden.
CT of the head is the imaging modality of choice for evaluating a child with acute neurologic findings or retinal hemorrhage on physical examination. It is more sensitive to acute intracerebral and extra-axial hemorrhages than MRI. Brain MRI may be helpful as an adjunct for the evaluation of axonal shear injuries and for a precise dating of intracranial hemorrhage. CT of the abdomen is indicated if abdominal injury is suspected. CT demonstrates visceral injuries and retroperitoneal hematomas.
Gastrografin upper-GI study under fluoroscopic guidance is occasionally indicated for evaluating submucosal hemorrhages of the duodenum or for identifying perforation of the duodenum.
Skeletal scintigraphy may be used when clinical suspicion remains high despite normal findings on a skeletal survey. Advantages of scintigraphy include increased sensitivity for acute posterior rib fractures, because the spine tends to obscure these injuries on radiographic examination. Fractures of the spine may be better depicted with scintigraphy than with radiography. Disadvantages of scintigraphy include diminished sensitivity in detecting skull fractures and CMLs, as these are contiguous with the normal isotope-avid growth plates. Scintigraphy is also limited because of its expense, lack of availability, amount of gonadal radiation exposure relative to plain radiography, and lack of reader expertise.
Limitations of Techniques
Fractures parallel or nearly parallel to the section orientation may be missed during CT. Therefore, radiography of the skull is preferred over CT for examining these injuries (see Image below and Image 6 in Multimedia Section).
Skull fracture secondary to child abuse horizontally crosses the left frontal region superior to the orbital rim.
SAH is best demonstrated with CT. The use of MRI to detect acute SAH remains controversial. MRI is superior to CT for differentiating a hypoattenuating subdural hematoma from CSF and for detecting small and chronic extra-axial fluid collections (see Image below and Image 11 in Multimedia Section). In an acute setting, CT is more readily available and more cost-effective than MRI. MRI is used as a problem-solving modality when CT findings are unexplained or confusing.
Subdural Hematoma. Acute subdural hematoma and chronic subdural hygroma in the left frontoparietal area. Note the contralateral midline shift and compression of the occipital horn of the left lateral ventricle.
Scintigraphy is limited in its sensitivity for metaphyseal fractures because of avid uptake in growth plates. In addition, because all abnormal sites must be confirmed radiographically, an osseous survey is the preferred initial examination.
Differential Diagnoses
Other Problems to Be Considered
Accidental injury
Obstetric trauma
Congenital indifference to pain
Leukemia
Congenital syphilis
Menkes disease
More on Child Abuse |
 Overview: Child Abuse |
| Imaging: Child Abuse |
| Follow-up: Child Abuse |
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References
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Child Welfare Information Gateway. Child Abuse and Neglect Fatalities: Statistics and Interventions. 2004. Updated July 24, 2006. Available at: http://www.childwelfare.gov/pubs/factsheets/fatality.cfm. [Full Text].
Greenberg MI, Hendrickson R, Silverberg M, et al, eds. Greenberg's Text-Atlas of Emergency Medicine. 2005.
Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. Oct 2 2008;337:a1518. [Medline].
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Makoroff KL, Cecil KM, Care M, Ball WS Jr. Elevated lactate as an early marker of brain injury in inflicted traumatic brain injury. Pediatr Radiol. Jul 2005;35(7):668-76. [Medline].
Kleinman PK, Blackbourne BD, Marks SC, et al. Radiologic contributions to the investigation and prosecution of cases of fatal infant abuse. N Engl J Med. Feb 23 1989;320(8):507-11. [Medline].
Belfer RA, Klein BL, Orr L. Use of the skeletal survey in the evaluation of child maltreatment. Am J Emerg Med. Mar 2001;19(2):122-4. [Medline].
Conway JJ, Collins M, Tanz RR, et al. The role of bone scintigraphy in detecting child abuse. Semin Nucl Med. Oct 1993;23(4):321-33. [Medline].
Dedouit F, Sévely A, Costagliola R, Otal P, Loubes-Lacroix F, Manelfe C, et al. Reversal sign on ante- and postmortem brain imaging in a newborn: Report of one case. Forensic Sci Int. Oct 31 2008;[Medline].
Kleinman PK, Marks SC. A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol. May 1996;166(5):1207-12. [Medline].
Kleinman PK, Nimkin K, Spevak MR, et al. Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol. Oct 1996;167(4):893-6. [Medline].
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Further Reading
Related eMedicine topics:
Pediatrics, Child Abuse
Child Abuse & Neglect: Physical Abuse
Keywords
child abuse, battered child, nonaccidental trauma, long-bone fractures, subdural hematoma, physical abuse, maltreatment, skull fracture, classic metaphyseal lesion, CML, corner fracture, bucket-handle fracture, shaken baby syndrome, shaken-baby syndrome, retinal hemorrhages, traumatic pancreatitis, nonaccidental injury syndrome
