Imaging strategy in suspected abuse
The examination algorithm depends on the patient's age and the presence of concomitant symptoms. According to criteria from authoritative radiological societies, all children under two years of age with suspected non-accidental injury indicated a complete skeletal survey.
- Radiography: Each anatomical region is imaged separately. Performing a whole-body overview image ("babygram") is strictly unacceptable. If required, follow-up radiographs are ordered: at 11–14 days to search for missed rib fractures, and at 2 and 5–6 weeks to assess metaphyseal injuries dynamically.
- Brain CT: Mandatory for any infant under 1 year with signs of physical abuse or for children with encephalopathy and retinal hemorrhages.
- Brain MRI: Performed urgently if CT reveals brain injuries or subdural hematomas. It is also indicated when CT is normal but neurological deficits persist (better detects hypoxic-ischemic changes on days 3–5).
- Bone scintigraphy: Used in complex cases if radiography is normal but clinical suspicion remains high. The method requires experience in infant scanning.
Abusive Head Trauma
Historically, this condition was described as "Shaken Baby Syndrome" (Shaken Baby Syndrome). However, modern biomechanical studies have proven that shaking alone is insufficient to form the classic triad (subdural hematoma, encephalopathy, retinal hemorrhage). Most often, shaking is accompanied by an impact, which is why the broader term is used today — abusive head trauma (abusive head trauma, AHT).
The condition is typical for children under 2–3 years of age. Injuries often run occult: infants are admitted to the hospital with non-specific complaints of lethargy, persistent vomiting, seizures, or apnea. It is AHT that causes the death of a quarter of children admitted with head trauma resulting from abuse.
Fracture specificity and "red flags"
To assess the probability of abuse, it is important to correlate the fracture pattern with the child's developmental ability to move independently and the stated mechanism of injury. The presence of fractures in infants younger than 18 months always requires including physical abuse in the differential diagnosis.
High specificity:
- Classic metaphyseal lesion (Classic metaphyseal lesion, CML).
- Posterior rib fractures.
- Scapula, sternum, and spinous process fractures.
Moderate specificity:
- Multiple and bilateral fractures.
- Injuries in different stages of healing.
- Epiphyseolysis and complex skull fractures.
It is necessary to differentiate injuries from the physiological norm. For example, subperiosteal new bone formation occurs in 35% of healthy infants aged 1–4 months, but in pathology, it can arise from occult fractures or severe compression (strictly within the diaphysis, without affecting the metaphysis).
Hidden threat: rib fractures
The rib cage of a healthy infant has high elasticity, making accidental rib fractures a casuistry. If a child is found to have a rib fracture with no convincing explanation (motor vehicle accident, severe congenital bone pathologies), the probability of abuse is 7 out of 10.
- Clinical presentation: Fractures are often occult, without skin bruising, and become an incidental finding on radiographs.
- Mechanism: Occur during severe compression of the chest by the perpetrator's hands (e.g., during shaking). The posterior end of the rib acts as a lever, resting against the transverse process of the vertebra.
- Localization: Posterior segment fractures have historically been considered most specific for abuse. They may be aligned one above the other in a single line.
Briefly: answers to topical questions
Which congenital and metabolic bone diseases must be differentiated from non-accidental fractures in children?
When non-accidental trauma is suspected, differential diagnosis is performed with a number of metabolic disorders and genetic conditions. The main diseases include:
- Rickets (rickets) — metabolic disorders where the zone of provisional calcification can mimic a fracture.
- Menkes syndrome (Menkes syndrome) — a pathology associated with copper deficiency.
- Schmid-type metaphyseal chondrodysplasia (metaphyseal chondrodysplasia of the Schmid type) — requires exclusion due to similarities in metaphyseal involvement.
- Spondylometaphyseal dysplasia (spondylometaphyseal dysplasia) — metaphyseal fragmentation resembles angular fractures.
- Osteogenesis imperfecta (osteogenesis imperfecta) — may be accompanied by corner fractures and fragmentation.
What specific radiological types of classic metaphyseal lesion (CML) are distinguished in infants?
Radiographs distinguish three specific types of classic metaphyseal lesions in infants. These include the following manifestations:
- "Corner fracture" (Corner fracture) — only the thick edge (rim) is visualized.
- "Bucket handle" (Bucket handle) — the thick edge projects away from the diaphysis.
- Thin disc with a thick rim — a specific variant of injury without additional eponyms.
Which anatomical regions and in which projections are included in the mandatory protocol of a complete skeletal survey?
The mandatory protocol of a complete skeletal survey includes the following anatomical regions in standard projections:
- Skull — anteroposterior (AP) and lateral projections.
- Spine — lateral projections of the cervical, thoracic, and lumbar spine.
- Chest — AP projection (including clavicles) and oblique projections of both hemithoraces (for ribs).
- Abdomen — AP projection, including the pelvis and hip joints.
- Extremities — AP projections of both humeri, forearms, femurs, lower legs, and feet; posteroanterior (PA) projection of the hands.
Mechanism and fracture type correlation: • Spiral = Torsion • Transverse = Direct blow • Oblique = Limb as a lever
Class and exam questions
Why is it forbidden to perform a whole-body plain X-ray of an infant ("babygram")?
An overview image does not provide the necessary detail to search for subtle metaphyseal injuries. The standard requires high-quality coned-down views of each anatomical region separately.
Does it make sense to perform a brain MRI if the CT scan showed no abnormalities?
Yes, if the child has persistent unexplained neurological deficits. MRI has greater sensitivity in detecting subarachnoid hemorrhages, hypoxic-ischemic, and cortical shear injuries at 3–5 days post-injury.
Which long bone fractures are least likely to be associated with physical abuse?
Supracondylar fractures. Unlike diaphyseal fractures of the humerus or femur in non-ambulatory children, supracondylar injuries are most often non-criminal in nature.
What does the detection of rib fractures at different stages of healing indicate?
The presence of old healing fractures combined with fresh bone injuries is a striking radiological marker of systematic and repeated child abuse.
What else to study on this topic
- Technique and projections of a complete skeletal survey
- Classic metaphyseal lesion (CML): biomechanics and differential diagnosis
- Subperiosteal bone formation: normal vs. pathological
- Tactics of interaction between the radiologist, attending physician, and child protective services
- The role of bone scintigraphy in pediatric radiology
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