Child Abuse (Radiology)

Background

Among the first to identify issues related to child abuse, Dr. John Caffey studied and published results in 1946 detailing multiple unexplained long-bone fractures of apparent traumatic origin in infants with chronic subdural hematomas. His work is cited in the landmark 1962 article, “The Battered-Child Syndrome,” by Dr. C. Henry Kempe et al. Kempe and colleagues (1962) stated that “the physician’s duty and responsibility to the child requires a full evaluation of the problem and a guarantee that the expected repetition of trauma will not be permitted to occur.” Within several years of the publication of Kempe et al.’s article, every state in the United States mandated that medical professionals report all suspected cases of child abuse. In 1974, the Child Abuse Prevention and Treatment Act (CAPTA) was signed into law.

CAPTA has been amended several times, most recently by the CAPTA Reauthorization Act of 2019. CAPTA defines child abuse and neglect as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm.” Child maltreatment encompasses neglect, physical abuse, emotional abuse, and sexual abuse.

In 2019, an estimated 1840 children died as the result of abuse and neglect in the United States. Based on this estimate and population data, the national rate of child fatalities due to abuse and neglect was 2.5 deaths per 100,000 children. The youngest children are at greatest risk: 7% of all child maltreatment fatalities involved children younger than 3 years.

Based on US Child Protective Services (CPS) data, there were 674,000 victims of child abuse and neglect in 2017, equating to a rate of 9 victims per 1000 children in the US population. This number includes only those cases reported to and substantiated by CPS. Many additional cases go unreported. Children in their first year of life are at greatest risk, with a rate of victimization of 25.3 per 1000 children. Of reported cases of child maltreatment, 74.5% involved cases of neglect. Child physical abuse accounted for 18.3% of reports.

A majority of child physical abuse involves cutaneous injuries that never come to imaging. These injuries include bruises, bite marks, and burns. There are patterns of cutaneous injuries, which pediatricians and emergency medicine providers are trained to recognize as suggestive of physical abuse. Abusive head trauma, thoracic and abdominal organ injury, and orthopedic injuries with their associated soft tissue injures are in the realm of imaging evaluation of child maltreatment. Imaging plays an important role in the diagnosis and follow-up care of these injuries, and it is our duty and responsibility to assist in diagnosing child physical abuse. In a battered child, a missed fracture or an injury misclassified as accidental exposes a child to further abuse and potentially death. This chapter details thoracic, abdominal, and orthopedic injuries of physical abuse. Abusive head trauma is addressed in Chapter 20 .

Fractures Associated With Child Abuse and Fracture Dating

Any fracture can be the result of abuse, but some fractures are found almost exclusively in abused children. These fractures are known to have a higher specificity for abuse than others and when seen by the radiologist should raise higher suspicion for child abuse in infants and toddlers ( Table 21.1 ). The classic metaphyseal lesion (CML) is the most specific type of fracture one can see with child abuse up to the age of 1 year. This injury is caused by shearing, traction, or twisting ( Fig. 21.1 ). Rib fractures (specifically posterior) have high specificity for child abuse, especially in infants ( Fig. 21.2 ). Other highly specific types of injury that are less commonly seen are scapular fractures, spinous process fractures, and sternal fractures.

TABLE 21.1

Specificity of Fractures for Nonaccidental Trauma

Specificity	Fracture
High	Classic metaphyseal lesion (CML) Rib fractures Scapular fractures Sternal fractures Spinous process fractures
Moderate	Multiple fractures Fractures of different ages Epiphyseal separation Digital fractures Complex skull fractures Vertebral body fractures/subluxations
Low	Long-bone fractures Clavicle fractures Linear skull fractures

Multiple fractures or fractures of different ages are moderately specific for child abuse. Other fractures that have moderate specificity include epiphyseal separations, vertebral body fractures, digital fractures in infants, and complex skull fractures. In these cases the radiologist should always take into account the clinical situation and the patient’s age when considering whether to raise concern for child abuse. One example of inappropriate history may be a clinical history that is not commensurate with the patient’s developmental stage, such as a 1-month-old who rolled off of a changing table and presents with multiple injuries.

Although common, the fractures with low specificity for child abuse include long-bone fractures, linear skull fractures, clavicle fractures, and isolated subperiosteal new bone formation; however, keep in mind that abused children may have any or all of these fractures. The femur, humerus, and tibia are the most commonly injured long bones in child abuse. Again, the child’s age is important in determining whether to raise concern for child abuse. For example, a femoral fracture in a nonambulatory child is more suspicious for abuse than in a child who is ambulatory, where the fracture is more likely to be accidental. Fractures of the humeral shaft in a child younger than 18 months is suspicious for child abuse compared with a supracondylar fracture in an ambulatory child. Linear skull fractures are usually not inflicted as opposed to complex or bilateral skull fractures that are more commonly associated with child abuse.

The important thing to remember is that although some fractures may be more specific for child abuse, we must always think about the possibility of child abuse, especially in children younger than 2 years.

Dating the age of fractures is a common request to the radiologist, and care should be used when attempting to determine the approximate age of fractures. There are phases of fracture healing that can be identified on plain radiographs. These include soft tissue swelling, periosteal reaction, soft callus, hard callus, bridging, and remodeling ( Fig. 21.3 ). Even with these stages of fracture healing, it is still difficult to date a fracture exactly, although the fractures can be lumped into relatively broad time frames. Soft tissue swelling is most associated with acute fractures that are less than 1 week old. Periosteal reaction and soft callus with increasing hard callus and bridging are associated with recent fractures that are 8 to 35 days old. Old fractures (>36 days old) show a combination of periosteal reaction, hard callus, bridging, and remodeling. The more important task for the radiologist may be to determine whether fractures are of different ages rather than to specifically date the fractures. Multiple fractures of different ages indicate a pattern of repetitive trauma that places the child at greater risk for additional injuries and possibly even death.

Soft Tissue Injuries in Child Abuse

There are no specific imaging characteristics of soft tissue injury caused by child abuse. Unlike musculoskeletal and neurological findings pathognomonic for child abuse, traumatic radiographic findings of the soft tissues caused by motor vehicle accident or from a child falling on handlebars while bicycling can be identical to intentional injury by a parent, caregiver, or sibling. In addition, children can present with a combination of soft tissue injuries secondary to accidental and nonaccidental mechanisms, confusing the picture. Due to these facts, combined with the knowledge that the radiologist may be the first physician exposed to soft tissue injury caused by child abuse and that we are mandated reporters for intentional trauma, extensive research has been done to help educate radiologists in findings of accidental versus nonaccidental trauma.

Infants less than 1 year of age have the greatest incidence of soft tissue injury caused by child abuse. If a child is younger than 5 years with traumatic soft tissue injury and if the mechanism of injury given by the parent/caregiver does not match the diagnostic findings, abuse must be considered. Research has found accidental trauma causing soft tissue injuries is most often found in older children 7.6 to 10.3 years old. Child abuse that causes soft tissue injuries occurs in younger children, with the average age being 2.5 to 3.7 years. The most common soft tissue injuries associated with child abuse are liver injury, hollow visceral injury (predominately involving the distal duodenum and proximal jejunum), and pancreatic injury. In those scenarios, if there is no reported history of motor vehicle accident, fall onto handle bars while biking, or appropriate high-force blunt trauma history, child abuse should be considered. Suspicious histories that would not be concordant with those injuries include “falling out of bed” or rolling onto a sleeping infant.

As stated, most common injuries are to the liver, duodenum/proximal jejunum, and pancreas ( Figs. 21.4–21.7 ). These injuries are due to lack of coverage by the ribs and fixation of these structures in the epigastric region of the abdomen (e.g., the ligament of Treitz fixates the proximal jejunum). Liver injury associated with child abuse more commonly involves the left lobe than accidental injury; however, abusive or accidental injury can occur in either left or right hepatic lobes. Children who are younger than 5 years and who present with a duodenal injury are most likely to have sustained that injury from abuse with complete transection/perforation being rare and duodenal hematomas causing proximal partial obstruction being the most common presentation (see Fig. 21.7 ). Bowel transections, unless caused by seat belt or bike handlebar injuries, are considered abusive in etiology unless proven otherwise. One-third of pancreatic injuries are nonaccidental, and some researchers claim that if the injury was not caused by motor vehicle accident or bicycle handle bar, then again the etiology is considered to be abuse unless proven otherwise.

Hypoperfusion complex, an entity associated with intracranial injury and severe neurological impairment and/or severe bleeding, can be a consequence of nonaccidental trauma ( Fig. 21.8 ). In hypoperfusion complex, also known as shock abdomen, imaging findings are secondary to severe hypovolemia. Computed tomography (CT) findings include abnormal intense enhancement of the bowel wall, adrenal glands, kidneys, liver, and/or pancreas; decreased caliber of the inferior vena cava and aorta; bowel thickening; and/or dilatation. CT findings may precede clinical ones, making familiarity with this entity critical because the radiologist may be the first person to become aware of a child’s tenuous volume status.