Pictorial ReviewImaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 2: axial skeleton and differential diagnoses
Introduction
Part 1 discussed important initial considerations of imaging inflicted injury (II) and specific fracture patterns of the appendicular skeleton. Fractures of the axial skeleton can be subtle and have a strong association with II. In this second article of a two-part series, we review the important fracture patterns of the axial skeleton, including rib and skull fractures, in addition to examining the important differential diagnoses of II.
Section snippets
Specific fracture patterns of the axial skeleton in II
The axial skeleton forms the longitudinal axis of the body and comprises the thoracic cage, the vertebral column, and the skull.1
Dating of fractures
Although fracture dating is difficult, there are recognised stages of fracture healing.72, 73 There is an element of subjectivity in dating, even between experienced experts and as such, the non-expert radiologist may wish to limit their report to whether the fracture shows soft-tissue swelling or any evidence of healing. All radiologists involved in the investigation of suspected II should be aware of the broad time frames discussed below.74 An important caveat is that imaging in a cast can
Mechanism of injury
The precise amount of force required to produce a fracture in any individual infant is unknown. Biomechanical studies give some information, but these tend to be either mechanical or animal models, or are based on dead human bones. In the live child, it is probably not just the amount of force but also the speed of application of that force that causes the bone to fracture. Understanding the interplay between the underlying complex processes that determine “bone strength” is fundamental to
Differential diagnoses
A wide range of differential diagnoses must be considered (including normal variants85) before diagnosing II. If misreported, the consequences for the child and family can be devastating. As such, as much information as possible should be obtained when reporting imaging undertaken for suspected II, including clinical history, index of suspicion, and results of appropriate biochemical investigations.
The radiologist may be able to detect an underlying predisposition to easy fracturing such as an
Normal variants
There are numerous normal variants that may simulate II. A detailed discussion of all possible normal variants is beyond the scope of this article and further reading is strongly recommended.85 Two common variants with which the non-expert radiologist should be familiar are discussed below.
What to do once abuse is suspected
Radiologists play a key role in the detection of II; however, this becomes redundant if any suspicions or concerns are not appropriately and speedily communicated to the relevant clinical team. Failure to instigate child-protection measures may result in an infant being exposed to further (potentially fatal) injury if allowed to remain in an abusive environment. An infant may be removed to a place of safety whilst full investigations are conducted.
In the context of suspected II, independent
Conclusion
The two articles provide an overview of the key radiographic features related to the diagnosis of II in infants and young children. The radiologist who identifies an injury that is out of context with the clinical history provided, for example, an “incidental” rib fracture in an infant, provides a diagnosis that is as important as spotting the lung cancer in an adult: they are both potentially lethal.
The diagnosis of child abuse is complex and imaging plays a large and important role. The
Acknowledgements
The authors are grateful to Dr David Hughes, Consultant Paediatric Radiologist at Sheffield Children's Hospital for providing some of the images and Dr Sheetij Shekhar for his insights.
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Cited by (23)
Safeguarding children in trauma and orthopaedics
2022, Paediatrics and Child Health (United Kingdom)Citation Excerpt :This is related to the mechanism of injury where the posterior rib end is levered over the transverse process of the adjacent vertebral body by an adult squeezing the infant’s chest with their hands.26,32 Lateral rib fractures are related to compression of the chest and anterior rib fractures results from direct blunt trauma to the chest.33 First rib fractures, which require a higher energy, are highly suspicious for inflicted injury.34
Bone Pathology and Antemortem Trauma
2022, Encyclopedia of Forensic Sciences: Volume 1-4, Third EditionPaediatric radiology: child abuse imaging in the national spotlight
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2021, Fundamentals of Pediatric Imaging, Third EditionSafeguarding children in trauma and orthopaedics
2020, Orthopaedics and TraumaCitation Excerpt :This is related to the mechanism of injury where the posterior rib end is levered over the transverse process of the adjacent vertebral body by an adult squeezing the infant's chest with their hands.26,32 Lateral rib fractures are related to compression of the chest and anterior rib fractures results from direct blunt trauma to the chest.33 First rib fractures, which require a higher energy, are highly suspicious for inflicted injury.34
Pediatric Fractures: Identifying and Managing Physical Abuse
2020, Clinical Pediatric Emergency MedicineCitation Excerpt :Their discovery should therefore prompt consideration of NAT. The presence of rib fractures in young children is highly concerning for abusive injury.7,23-26 The finding of a rib fracture in a young child increases the probability of abusive injury by 7 times,11 and, in children under 3 years old, has a 95% positive predictive value for abuse.27