Child Abuse: Radiologic-Pathologic Correlation

Gael J. Lonergan, Lt Col, USAF MC ; Andrew M. Baker, MD ; Mitchel K. Morey, MD ; Steven C. Boos, Lt Col, USAF MC

1 From the Department of Radiologic Pathology, Armed Forces Institute of Pathology, 14th and Alaska Sts NW, Bldg 54, Rm M-121, Washington, DC 20306-6000 (G.J.L.); Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (G.J.L.); Hennepin County Medical Examiner’s Office, Minneapolis, Minn (A.M.B., M.K.M.); and Armed Forces Center for Child Protection, National Naval Medical Center, Bethesda, Md (S.C.B.). Received February 10, 2003; revision requested March 24 and received March 31; accepted April 4.

In the United States, roughly one of every 100 children is subjected to some form of neglect or abuse; inflicted injury is responsible for approximately 1,200 deaths per year. Child physical abuse may manifest as virtually any injury pattern known to medicine. Some of the injuries observed in battered children are relatively unique to this population (especially when observed in infants) and therefore are highly suggestive of nonaccidental, or inflicted, injury. Worrisome injuries include rib fracture, metaphyseal fracture, interhemispheric extraaxial hemorrhage, shear-type brain injury, vertebral compression fracture, and small bowel hematoma and laceration. As noted, however, virtually any injury may be inflicted; therefore, careful consideration of the nature of the injury, the developmental capabilities of the child, and the given history are crucial to determine the likelihood that an injury was inflicted. The majority of these injuries are readily detectable at imaging, and radiologic examination forms the mainstay of evaluation of child physical abuse. Detection of metaphyseal fracture (regarded as the most specific radiographically detectable injury in abuse) depends on high-quality, small field-of-view radiographs. The injury manifests radiographically as a lucent area within the subphyseal metaphysis, extending completely or partially across the metaphysis, roughly perpendicular to the long axis of the bone. Acute rib fractures (which in infants are strongly correlated with abuse) appear as linear lucent areas. They may be difficult to discern when acute; thus, follow-up radiography increases detection of these fractures. For skull injuries, radiography is best for detecting fractures, but computed tomography and magnetic resonance imaging best depict intracranial injury.