Imaging in Child Abuse

Child abuse involves grave and disturbing acts of violence that can have lasting physical and emotional consequences for children and their families. The diagnosis of child abuse is emotionally difficult for those involved, and an error in judgment either way can have a detrimental effect on the health and safety of the child. Physicians rely on the skills of the imaging team to produce high-quality images that assist in differentiating inflicted injuries from accidental trauma.[1]

Caffey's landmark article of 1946 noted an association between healing of long-bone fractures and chronic subdural hematoma (SDH) in infancy, and it was the first to draw attention to physical abuse as a unifying etiology.[2] In 1962, Caffey and Kempe proposed manhandling and violent shaking as mechanisms of injury and emphasized the acute and long-term sequelae of abuse as serious public health problems.[3]  Since the time of 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.

An analysis of the National Inpatient Sample (NIS) examined child abuse and neglect hospitalization in the United States from 1998 to 2016. Researchers found that the rate of child abuse or neglect hospitalizations—on average, 6.9 per 100,000 children annually—did not vary significantly over the study period. Males (53.0%), infants (younger than 1 yr; 47.3%), and young children (ages 1-3 yr; 24.2%) accounted for most child maltreatment cases. Physical abuse was the most frequent type of maltreatment leading to hospitalization. Government insurance was the most common payer source, accounting for 77.3% of all child maltreatment hospitalizations and costing $1.4 billion from 2001 to 2016. Hospitalizations due to child abuse and neglect remain steady and are costly, averaging over $116 million per year. The burden on government sources suggests high potential for return on investment in effective child abuse prevention strategies.[4]

The ability to identify child abuse constitutes an important concern for those involved in the medical care of children. Studies show that at least 10% of children younger than 5 years who are brought to the emergency room with trauma have actually suffered nonaccidental trauma. As many as 65% of all abuse cases are initially seen in the emergency room; therefore, the first step in correctly identifying abuse is to train hospital staff members to recognize abuse indicators. The wide range of findings, which can mimic other disease processes or normal variants, implies that the definitive diagnosis of child abuse can be achieved only through interdisciplinary collaboration. Several studies have reported that 30-80% of confirmed physical child abuse cases were missed on initial presentation and that many infants sustained additional injury because of the delay in diagnosis.[5]

Despite scientific evidence, among disorders of mineralization, nonrachitic disorders of vitamin D have become a popular nonscientific theory to explain fractures identified in abused children. Although infants and young children with rickets can fracture bones, a vast majority of fractures identified in abused infants are not caused by bone disease.[6]

Tokue and associates presented the case of a 5-year-old girl in whom child abuse of severe dental caries was detected through computed tomography scanning when the child fell down the stairs and hit her head. This case shows that although child abuse often involves an action that harms the child, inaction such as neglect can also cause harm. Therefore, physicians should be aware that severe dental caries may be a sign of child abuse.[7]

Imaging modalities

Child abuse is a global public health concern. Injuries from physical abuse may be clinically occult and not appreciable on physical examination. Imaging is therefore critical in identifying and documenting such injuries. The radiologic approach for a child who has potentially been abused has received considerable attention and recommendations according to decades of experience and rigorous scientific study.[8]

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.[9, 10, 11, 12] This survey consists of the acquisition of a series of images collimated to each body region.[13] 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 hands and feet.[14, 15]

The skeletal survey is widely available and is inexpensive in comparison to alternative imaging modalities. Other important advantages of the skeletal survey include high sensitivity for most acute and healing fractures and a relatively low radiation burden.[16]

A babygram, in which the entire skeleton is depicted on a single image, is not an appropriate substitute for a properly performed skeletal 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.

Computed tomography (CT) scanning of the head is the imaging modality of choice for evaluating a child with acute neurologic findings or retinal hemorrhage on physical examination. CT is more sensitive to acute intracerebral and extra-axial hemorrhages than magnetic resonance imaging (MRI). Brain MRI may be helpful as an adjunct for evaluation of axonal shear injuries and for precise dating of intracranial hemorrhage.[17, 18]

Subarachnoid hemorrhages (SAHs) are best shown on CT scans. Use of MRI to detect acute SAH remains controversial. However, MRI is superior to CT for differentiating a hypoattenuating SDH from cerebrospinal fluid (CSF) and for detecting small and chronic extra-axial fluid collections. 

(See the images below.)

Classic metaphyseal lesion (CML), as represented by a corner fracture of the lateral aspect of the humeral metaphysis.

Rib fracture. Image shows multiple bilateral rib fractures that are healing. Note callus formation at the posterior and lateral aspects of the ribs and the healing left clavicular fracture with callus formation.

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.

Most child abuse–related injuries are readily detectable during imaging. Radiologic examination is the mainstay for diagnosing physical abuse in children.[19, 20, 21] Careful correlation of observed radiologic findings with the proposed mechanism of injury and with the child's clinical status is imperative in evaluating 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.[22, 23, 24, 25]

The radiologist has important medical and legal roles in cases of child abuse. The radiologist may be the first to raise the question of abuse if characteristic or unexplained findings are encountered during imaging. Immediate, direct communication with the referring physician is imperative in such cases.

A radiologist's testimony regarding findings of possible abuse may be required, and the radiologist may be asked to give an opinion as to the likely age of the child's fractures and the possibility of alternative diagnoses. Familiarity with radiographic patterns and mechanisms of abuse generally allows the radiologist to provide an interpretation with a high degree of certainty.

Because imaging studies document occult injuries, they may justify implementation of protective measures when the patient's clinical presentation suggests abuse.

Kleinman et al reported the utility of high-detail, postmortem radiography in identifying skeletal injuries that had otherwise been overlooked.[26]

Skeletal injury is the most common form of injury (excluding external soft tissue injuries) in child abuse. Any fracture in infants and young children is significant and indicates a traumatic event. The classical metaphyseal corner or bucket-handle fracture is virtually pathognomonic for abuse, although a differential diagnosis does exist. Rib fractures are very common and are highly specific for abuse in children younger than 2 years. The positive predictive value of posterior rib fractures with respect to child abuse has been reported to be 80-90%. Fractures of the acromion, sternum, and spinous processes are so rare in accidental conditions that this gives them high specificity for abuse.[5]

ACR guidelines

The American College of Radiology (ACR) has published recommendations for suspected physical abuse in children that include the following[27, 28, 29] :

• Appropriate imaging of pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, and evidence of visceral thoracic or abdominopelvic injuries.
• A skeletal survey is indicated for initial imaging evaluation of children 24 mo of age or younger. In older children, it is usually appropriate to target imaging to the area(s) of suspected injury.
• Skeletal survey and CT of the head without contrast are indicated for emergent/initial imaging evaluation of a child with neurologic signs and symptoms, complex skull fracture, apnea, multiple fractures, spine trauma, or facial injury. These examinations are not indicated for general screening.
• MRI of the head may provide additional diagnostic information over head CT in about 25% of children.
• MRI of the cervical spine should be considered at the time of head MRI because unsuspected injury (usually ligamentous) may be present in over 33% of children with intracranial injury.
• Skeletal survey and CT of the chest/abdomen/pelvis with IV contrast are indicated if there are signs or symptoms of intrathoracic or intra-abdominal visceral injury (eg, abdominal pain/distention/bruising, abnormal liver, pancreatic enzymes).
• In children 24 mo of age or younger with an equivocal skeletal survey or with high clinical suspicion for abuse and a negative initial skeletal survey, a repeat limited/focused skeletal survey performed at 2 wk may yield additional diagnostic information.

Long-bone injuries

Injuries to long bones are the result of a direct blow or, more commonly, a shear force.[2, 30, 31]  

The resulting fracture may cross the diaphysis in an oblique or transverse plane, or it may create the highly specific classic metaphyseal lesion (CML). The CML is also referred to as a corner fracture or a bucket-handle fracture. CMLs occur when a torsional force is applied to the immature primary spongiosa adjacent to a cartilaginous growth plate.

Callus in diaphyseal fractures generally forms no earlier than 5 days after a fracture but will usually form by 14 days. Thus, fractures without visible callus may be up to 14 days old, and fractures that demonstrate a little bit of callus are at least 5 days old. Large amounts of callus indicate that the fracture is at least 2 weeks old.[5]

(See the image below.)

Classic metaphyseal lesion (CML) in the distal humerus, in the form of a bucket-handle injury.

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.[32]

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 posterior aspects of the ribs. Anterolateral fractures are also common. Rib fractures are typically noted at several contiguous levels; they are frequently bilateral.

Rib fractures in abused children may be found incidentally on chest radiography performed for other reasons such as evaluation for pneumonia. Rib fractures are highly specific for abuse. Rib fractures pose difficulties similar to those of metaphyseal injuries in that they are easily overlooked on radiography. In the acute stage, they are not evident on radiography, as little displacement occurs. They are often identified on the repeated skeletal survey when they are in the healing stage showing callus.[5]

(See the image below.)

Rib fracture. Image shows multiple bilateral rib fractures that are healing. Note callus formation at the posterior and lateral aspects of the ribs and the healing left clavicular fracture with callus formation.

Head injuries

Head injuries account for 80% of deaths associated with abuse in children younger than 2 years. Mechanisms of injury include forceful shaking alone or accompanied by abrupt impact.[17, 18, 30, 31]

The neck muscles of a baby are very weak, and the head is large and heavy in proportion to the rest of the body. The infant brain is poorly myelinated and is surrounded by larger subarachnoid spaces than the brain of older children and adults. When a baby is shaken, the neck snaps back and forth, much as in a whiplash injury, causing the brain to rotate and hit the front and back of the skull. This can damage the brain and cause it to bruise, bleed, and swell. Imaging studies of the head may show subdural or subarachnoid bleeding, diffuse axonal injury, and associated cerebral edema, as well as older injuries such as subdural effusions.[5]

Skull fractures are common child abuse injuries, but they are also common in accidental trauma. Patterns of skull fracture that suggest child abuse include multiple “eggshell” fractures and occipital impression fractures. The infant's skull is rather resistant to trauma, so any fracture that is not consistent with the history should raise the question of nonaccidental injury.[5]

MRI is most sensitive in detecting subdural hematomas (SDHs). In all cases, susceptibility weighted imaging (SWI) sequences should be added to the imaging protocol. SDHs can also be found along the spine, with preference for the lumbar spine. MRI child abuse protocols should therefore include imaging of the spine.[5]

In abusive head trauma victims, optic nerves and optic sheath hemorrhages are commonly associated with retinal hemorrhages.[33]

It is important to note that there are no pathognomonic radiologic findings for abusive head trauma. For each case, multidisciplinary input and collaboration is mandatory.[5]

(See the images below.)

Skull fracture secondary to child abuse horizontally crosses the left frontal region superior to the orbital rim.

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.

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.

A gastrografin upper GI study under fluoroscopic guidance is occasionally indicated for evaluating submucosal hemorrhage 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.[34] 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.

Abdominal injuries

Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse.[35]  The current recommendation is to perform routine abdominopelvic ultrasonography in any child younger than 2 years in whom abuse is suspected.[36]

It is estimated that 2-10% of all abdominal injuries result from child abuse. The mean age of these children is about 2 years. Abdominal injuries are more common in boys than in girls. Mortality associated with abdominal injury is 50% because of delay in evaluation: the children are brought to the hospital days after injury, when a perforation already has resulted in peritonitis and sepsis. The history given by the abusers usually does not correlate with the symptoms, which makes these cases very difficult for the clinician to evaluate.[5]

Sexual child abuse

Use of biomarkers in medicine is a common and valuable approach in several clinical fields, including pedophilia and child sexual abuse. In the context of forensic psychiatry, biomarkers and their potentially beneficial effects are of growing interest. The development of a composite diagnostic biomarker to assess deviant sexual interest, combining several measures such as functional MRI, electroencephalography, eye tracking, and behavioral approaches, seems most promising. A valid and reliable measurement of deviant sexual interest that is insensitive to manipulations could significantly support the clinical diagnostic process.[37]

Limitations of techniques

Fractures that are parallel or nearly parallel to the section orientation may be missed during CT scanning. Therefore, radiography of the skull is preferred over CT scanning for examining these injuries.

Disadvantages of scintigraphy include diminished sensitivity in detecting skull fractures and CMLs, as these are contiguous with normal isotope-avid growth plates. In addition, because all abnormal sites must be confirmed radiographically, an osseous survey is the preferred initial examination.

Scintigraphy is limited by its expense, lack of availability, amount of gonadal radiation exposure relative to plain radiography, and lack of reader expertise.

Several studies have reported that 30 to 80% of confirmed physical child abuse cases were missed on initial presentation and many infants sustained additional injury because of the delay in diagnosis.[5]

It is important to note that there is no evidence base for dating SDH on CT or MRI. From a medicolegal perspective, radiologists therefore should refrain from dating SDHs.[5]

A classic metaphyseal lesion (CML) of the long bones is seen in 39-50% of abused infants and children younger than 18 months who are shaken violently.[2, 16, 23, 30, 31]

(See the images below.)

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 produces a thickened appearance and simulates a handle.

The radiographic appearance of a 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 the 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.

Other injuries that are highly specific to child abuse are posterior rib fractures and fractures of the scapula, spinous process, and sternum because these bones are ordinarily difficult to break. Fractures at different stages of healing are also highly specific findings for child abuse.

Rib fractures pose difficulties similar to metaphyseal injuries in that they are easily overlooked on radiography. In the acute stage, they are not evident on radiography, as little displacement occurs. They are often identified on the repeated skeletal survey, when fractures are in the healing stage showing callus.[5]

(See the image below.)

Rib fracture. Image shows multiple bilateral rib fractures that are healing. Note callus formation at the posterior and lateral aspects of the ribs and the healing left clavicular fracture with callus formation.

Relatively nonspecific lesions are long-bone fractures (in infants), digital fractures, and complex skull fractures.[27, 38, 39, 40, 41]

It is important to note that there are no pathognomonic radiologic findings for abusive head trauma. For each case, multidisciplinary input and collaboration is mandatory.[5]

Degree of confidence

Acute fractures may be missed on plain radiography, especially if optimal technique is not followed. A follow-up skeletal survey may be obtained 2 weeks after the initial study when abuse is strongly suspected but initial radiographic findings are negative.

Skeletal dysplasias, especially osteogenesis imperfecta, may mimic injuries resulting from physical abuse. Osteogenesis imperfecta types I and IV may be confused with abusive injury.

Differentiating features include the invariable presence of osteopenia in osteogenesis imperfecta and telltale abnormalities of modeling and bowing of long bones. Other helpful clues are wormian (intrasutural) bones of the skull and at the site of fracture. Abusive injuries and fractures seen in osteogenesis imperfecta typically occur at different locations.

Other causes of multiple fractures include Menkes syndrome and congenital indifference to pain. Additional radiographic or clinical signs of these diseases are invariably present, and they are rarely confused with findings of child abuse.

Periosteal reaction may be seen with congenital syphilis, leukemia, or Caffey disease.

Fracture-dislocation of the hip that occurs before the femoral head ossifies may be mistaken for developmental dysplasia of the hip. Hip ultrasonography is indicated to differentiate these conditions under appropriate clinical circumstances.

Computed tomography (CT) scanning of the head is useful in patients with head injury, especially those with skull fracture. With advancements in technology, low-dose techniques are now available for pediatric head CT scanning, and automatic regional adjustments to radiation doses are possible during scanning.[17, 18, 30, 31]

In a retrospective analysis, Sanchez and coworkers reported that most rib fractures are nondisplaced and are located posteriorly or anteriorly—in areas that are often difficult to assess, especially at the acute stage. CT is more sensitive for evaluating these types of fractures. Low-dose chest CT can be an important imaging modality for suspected cases of child abuse when initial radiographic findings are inconclusive.[42]

(See the image below.)

Skull fracture secondary to child abuse horizontally crosses the left frontal region superior to the orbital rim.

CT scans may reveal subarachnoid, subdural, or epidural hemorrhage. Subdural hemorrhage (see first and second images below), especially interhemispheric bleeds, and SAH (see the third image below) are common injuries of abuse.

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.

Subarachnoid hemorrhage. Acute cerebral ischemic injury and edema secondary to child abuse. Nonenhanced CT scan shows hypoattenuation of the entire right cerebral hemisphere and the parasagittal area of the left frontal lobe. Associated findings include 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 swelling of the soft tissue in the right parietal extracranial area, which indicates acute injury.

CT is superior in detecting skull fractures (especially 3-dimensional [3D] reconstructions) and in revealing SDH.[5]  In infants and small children, SDH indicates rotational brain movement or shear injury; it is commonly associated with retinal hemorrhage and retinoschisis. Epidural hemorrhage is more common with accidental injury than with inflicted injury; it may result from falls from a relatively short distance.

Focal or diffuse cerebral edema may also be seen. This edema may be a manifestation of primary injury or a consequence of hypoxia resulting from strangulation, suffocation, posttraumatic apnea, or other causes. Edema may manifest as sulcal effacement, loss of distinction between gray matter and white matter, and/or cerebral hypoattenuation (ie, the reversal sign).

The abdominal organs most commonly injured in cases of child abuse are the duodenum and the proximal jejunum. Hematomas, lacerations, and mesenteric injuries may be evident on CT scans.

In an acute setting, CT is readily available and is more cost-effective than MRI. MRI is used as a problem-solving modality when CT findings are unexplained or confusing.

CT scanning of the abdomen is indicated if abdominal injury is suspected. CT shows visceral injuries and retroperitoneal hematomas.

(See the image below.)

Duodenal injury. The third portion of the duodenum is atonic, is distended with fluid, and shows thickening and enhancement of the wall. Note free fluid in the hepatorenal recess and in the left colic gutter.

Solid-organ contusions, lacerations, hemoperitoneum, and pneumoperitoneum are easily diagnosed on abdominal and pelvic CT scans. None of these organ injuries are specific for child abuse, but making the diagnosis is important for clinical treatment of the patient.

CT scanning has had a major effect on early diagnosis of visceral injuries of the liver, spleen, pancreas, and kidneys. Grading of injuries via CT scanning facilitates patient care and surgical planning.

(See the images below.)

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.

Degree of confidence

SDH may be hypoattenuating on the day of trauma as the result of various factors. For example, in children with anemia, the blood may be hypoattenuating. Disruption of the arachnoid membrane during trauma may allow CSF to mix with the SDH, diluting the hemorrhage and reducing its attenuation on CT scans.

On CT scanning, nondepressed fractures of the calvaria may be missed, especially if the fracture lies in an axial plane parallel to the plane of imaging.

Nonhemorrhagic brain contusions, early global ischemia, and shear injury (diffuse axonal injury) may be missed on CT scanning because of limitations in resolution that cause subtle differences in tissue attenuation to be overlooked.

Magnetic resonance imaging (MRI) is more sensitive in detecting SDH. In all cases, susceptibility weighted imaging (SWI) sequences should be added to the imaging protocol.[5]

Brain parenchymal injuries most commonly observed in cases of child abuse are shear injury, edema, and contusion. Shear injury most often occurs at the gray matter–white matter junction, at the corpus callosum, and at the midbrain. Findings appear as hyperintense foci on T2-weighted or inversion recovery images.

Brain contusions are admixtures of edema, hemorrhage, and necrosis. They usually are cortical and adjacent to bony surfaces; they result from direct contact forces. Contusions are distinctly rare in infants. Shear injury and brain edema account for most abnormalities.

Perfusion defects are a major component of long-term damage. Therefore, diffusion-weighted imaging (DWI) should also be part of the standard MRI protocol.[5]

Degree of confidence

MRI is useful for detecting small, extra-axial fluid collections; early global ischemia; and shear injury, which may be missed on CT scans. MRI also aids in dating hemorrhage, depending on blood products present in the collections. Diffusion-weighted imaging (DWI) is useful in detecting early ischemia.

MRI is superior to CT scanning for differentiating hypoattenuating SDH from prominent extracerebral spaces of infancy.

(See the image below.)

Subdural hematoma. T1-weighted MRI of the brain shows bilateral chronic subdural hematomas related to child abuse.

Scattered reports mention that MR spectroscopy may provide complementary information in diagnosing posttraumatic neuronal loss.[43]

Use of MRI to detect acute SAH remains controversial. Although one may observe SAH on fluid-attenuated inversion recovery (FLAIR) or susceptibility on MRI scans, CT is preferable to MRI because it easily depicts sulcal hyperattenuation, which confirms early SAH.

Head ultrasonography has no role in the evaluation of acute abusive injury.

Fractures at the ventral ends of the ribs are challenging to assess. Ultrasonography is helpful in detecting dislocation at the ventral costochondral junction.[5]

For unstable patients examined in the emergency department, portable abdominal ultrasonography may be used for initial screening for visceral injuries and free fluid.

Ultrasonography is less sensitive than CT scanning for detecting acute intracranial hemorrhage and cerebral edema, especially after the fontanelles have partially closed.

Limitations of ultrasonography include its relatively poor depiction of the posterior fossa and of far convexities of the brain and its inability to reveal the nature of abnormal fluid collections. In the presence of excessive gas or ileus, abdominal ultrasonography may be difficult to perform.

Nuclear bone scan usually is not necessary. This should be performed only if there are equivocal findings on the skeletal survey or if there is high clinical suspicion of skeletal injury but the skeletal survey is normal. Conventional radiographs of areas of abnormality identified at bone scan are still needed to ascertain the exact nature of the abnormality.[5]

Scintigraphy complements the radiographic skeletal survey.

Abnormalities detected on scintigraphy should be confirmed radiographically. Scintigraphy improves sensitivity in detection of acute rib fractures, especially those at the costovertebral junction.

Skeletal scintigraphy has high sensitivity and low specificity in cases of child abuse. On bone scanning, a hot lesion may be indicative of trauma, infection, or healing infarction. Therefore, correlation with radiography is always necessary when abnormalities are identified on scintigraphy.

Skull fractures are difficult to identify on scintigrams; plain radiographs of the skull are always required.

On scintigraphy, CML may be overlooked because it lies adjacent to a metabolically active and isotope-avid epiphyseal growth plate.