Abstract
Non-accidental trauma is a significant source of morbidity and mortality in the pediatric population. Given the vulnerable state of the child, the radiologist can often provide valuable diagnostic information in the setting of suspected abuse. This review focuses on common findings of abusive trauma and serves as a guide to aid in clinical decision-making for providers of emergency medicine and pediatrics. Amid this discussion is an assessment of modern controversies regarding reported mimicking pathologies, recapitulation of the current state of evidence with respect to radiologic findings of abuse, and examination of the contribution that spine imaging may add to the diagnosis of possible abusive head trauma in the acutely injured child. Recommendations for avoiding pitfalls regarding the dating of intracranial injuries are discussed, and illustrated depictions of perpetrator-induced pathology are provided to aid in the understanding of these injuries. Through the use of the appropriate approach to imaging and evidence-based guidelines regarding radiologic findings, the role of radiology is to provide fundamental clues to diagnose and prevent recurrence of abusive injury in patients who cannot speak for themselves.
Similar content being viewed by others
References
U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau (2016) Child maltreatment 2014. Available at http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment. Accessed October 1, 2016
Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics (2015) The evaluation of suspected child physical abuse. Pediatrics 135:e1337–e1354
ACR-SPR Practice Parameter for Performing Skeletal Surveys in Children. American College of Radiology; Amended 2016. Available at http://www.acr.org/~/media/9bdcdbee99b84e87baac2b1695bc07b6.pdf. Accessed October 1, 2016
Marine MB, Corea D, Steenburg SD, Wanner M, Eckert GJ, Jennings SG, Karmazyn B (2014) Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified? Am J Roentgenol 202:872–879
ACR Appropriateness Criteria Suspected Physical Abuse—Child, 2016 Available at https://acsearch.acr.org/docs/69443/Narrative/. Accessed October 1
Rubin DM, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR (2003) Occult head injury in high-risk abused children. Pediatrics 111:1382–1386
Zarella C, Didier R, Berquist C, Bardo DM, Selden NR, Kuang RR (2016) A reduction in radiation exposure during pediatric craniofacial computed tomography. J Craniofac Surg 27:331–333
Mandelstam SA, Cook D, Fitzgerald M, Ditchfield MR (2003) Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child 88:387–390
Conway JJ, Collins M, Tanz RR, Radkowsi MA, Anandappa E, Hernandez R, Freeman EL (1993) The role of bone scintigraphy in detecting child abuse. Semin Nucl Med 23:321–333
Offiah A, van Rijn RR, Mercedes Perez-Rosello J, Kleinman PK (2009) Skeletal imaging of child abuse (non-accidental injury). Pediatr Radiol 39:461–470
Kleinman PK, Marks SC (1995) Relationship of the subperiosteal bone collar to metaphyseal lesions in abused infants. J Bone Joint Surg Am 77:1471–1476
Snedecor ST, Wilson HB (1949) Some obstetrical injuries to the long bones. J Bone Joint Surg Am 31A:378–384
Lyons TJ, Oates RK (1993) Falling out of bed: a relatively benign occurrence. Pediatrics 92:125–127
Ayoub DM, Hyman C, Cohen M, Miller M (2014) A critical review of the classic metaphyseal lesion: traumatic or metabolic? Am J Roentgenol 202:185–196
Brown SD, Serveas S, Hayes LL (2014) Child abuse committee response regarding classic metaphyseal lesion. Am J Roentgenol 203:W232
Thackeray JD, Wannemacher J, Adler BH, Lindberg DM (2016) The classic metaphyseal lesion and traumatic injury. Pediatr Radiol 46:1128–1133
Servaes S, Brown SD, Choudhary AK, Christian CW, Done SL, Hayes LL, Levine MA, Moreno JA, Palusci VJ, Shore RM, Slovis TL (2016) The etiology and significance of fractures in infants and young children: a multidisciplinary review. Pediatr Radiol 46:591–600
Barsness KA, Cha ES, Baensard DD, Calkins CM, Patrick DA, Karrer FM, Strain JD (2003) The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma 54:1107–1110
Bulloch B, Schubert CJ, Brophy PD, Johnson N, Reed MH, Shapiro RA (2000) Cause and clinical characteristics of rib fractures in infants. Pediatrics 105:E48
Maguire S, Mann M, John N, Ellaway B, Sibert JR, Kemp AM (2006) Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review. Child Abuse Negl 30:739–751
Franke I, Pingen A, Schiffmann H, Vogel M, Vlajnic D, Ganschow R, Born M (2014) Cardiopulmonary resuscitation (CPR)-related posterior rib fractures in neonates and infants following recommended changes in CPR techniques. Child Abuse Negl 38:1267–1274
Reyes JA, Somers GR, Taylor GP, Chiasson DA (2011) Increased incidence of CPR-related rib fractures in infants—is it related to changes in CPR technique? Resuscitation 82:545–548
John SD, Moorthy CS, Swischuk LE (1997) Expanding the concept of the toddler’s fracture. Radiographics 17:367–376
Bruce DA, Zimmerman RA (1989) Shaken impact syndrome. Pediatr Ann 18:482–492
Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH (2003) A population-based study of inflicted traumatic brain injury in young children. JAMA 290:621–626
Girard N, Brunel H, Dory-Lautrec P, Chabrol B (2016) Neuroimaging differential diagnoses to abusive head trauma. Pediatr Radiol 46:603–614
Fernando S, Obaldo RE, Walsh IR, Lowe LH (2008) Neuroimaging of nonaccidental head trauma: pitfalls and controversies. Pediatr Radiol 38:827–838
Meservy CJ, Towbin R, McLaurin RL, Myers PA, Ball W (1987) Radiographic characteristics of skull fractures resulting from child abuse. AJR Am J Roentgenol 149:173–175
Foerster BR, Petrou M, Lin D, Thurnher MM, Carlson MD, Strouse PJ, Sundgren PC (2009) Neuroimaging evaluation of non-accidental head trauma with correlation to clinical outcomes: a review of 57 cases. J Pediatr 154:573–577
Hahnemann ML, Kinner S, Schweiger B, Bajanowski T, Karger B, Pfeiffer H, Wittschieber D (2015) Imaging of bridging vein thrombosis in infants with abusive head trauma: the “Tadpole Sign”. Eur Radiol 25:299–305
Choudhary AK, Bradford R, Dias MS, Thamburaj K, Boal DK (2015) Venous injury in abusive head trauma. Pediatr Radiol 45:1803–1813
Vezina G (2009) Assessment of the nature and age of subdural collections in nonaccidental head injury with CT and MRI. Pediatr Radiol 39:586–590
Cramer JA, Rassner UA, Hedlund GL (2016) Limitations of T2*-gradient recalled-echo and susceptibility-weighted imaging in characterizing chronic subdural hemorrhage in infant survivors of abusive head trauma. AJNR Am J Neuroradiol 37:1752–1756
Colbert CA, Holshouser BA, Aaen GS, Sheridan C, Oyoyo U, Kido D, Ashwal S (2010) Value of cerebral microhemorrhages detected with susceptibility-weighted MR imaging for prediction of long-term outcome in children with nonaccidental trauma. Radiology 256:898–905
Choudhary AK, Bradford RK, Dias MS, Moore GJ, Boal DK (2012) Spinal subdural hemorrhage in abuse head trauma: a retrospective study. Radiology 262:216–223
Choudhary AK, Ishak R, Zacharia TT, Dias MS (2014) Imaging of spinal injury in abusive head trauma: a retrospective study. Pediatr Radiol 44:1130–1140
Jacob R, Cox M, Koral K, Greenwell C, Xi Y, Vinson L, Reeder K, Weprin B, Huang R, Booth TN (2016) MR imaging of the cervical spine in nonaccidental trauma: a tertiary institution experience. AJNR Am J Neuroradiol 37:1944–1950
Somers JM, Halliday KE, Chapman S (2014) Humeral fracture in non-ambulant infants—a possible accidental mechanism. Pediatr Radiol 44:1219–1223
Perez-Rossello JM, McDonald AG, Rosenberg AE, Tsai A, Kleinman PK (2015) Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions. Radiology 275:810–821
Hamza M, Bodensteiner JB, Noorani PA, Barnes PD (1987) Benign extracerebral fluid collections: a cause of macrocrania in infancy. Pediatr Neurol 2:218–221
Amodio J, Spektor V, Pramanik B, Rivera R, Pinkney L, Fefferman N (2005) Spontaneous development of bilateral subdural hematomas in an infant with benign infantile hydrocephalus: color Doppler assessment of vessels traversing extra-axial spaces. Pediatr Radiol 35:1113–1117
Ghosh PS, Ghosh D (2011) Subdural hematoma in infants without accidental injury: benign external hydrocephalus, a risk factor. Clin Pediatr 50:897–903
Ravid S, Maytal J (2003) External hydrocephalus: a probable cause for subdural hematoma in infancy. Pediatr Neurol 28:139–141
Pittman T (2003) Significance of a subdural hematoma in a child with external hydrocephalus. Pediatr Neurosurg 39:57–59
Kyllerman M, Steen G (1980) Glutaric aciduria. A “common” metabolic disorder. Arch Fr Pediatr 37:279
Kolker S, Christensen E, Leonard JV, Greenberg CR, Boneh A, Burlina AB, Burlina AP, Dixon M, Duran M, Carcia Cazorla A, Goodman SI, Koeller DM, Kyllerman M, Muhlhausen C, Muller E, Okun JG, Wilcken B, Hoffmann GF, Burgard P (2011) Diagnosis and management of glutaric aciduria type I—revised recommendations. J Inherit Metab Dis 34:677–694
Arita JH, Faria EC, Peruchi MM, Lin J, Rodrigues Masruha M, Vilanova LC (2009) Menkes disease as a differential diagnosis of child abuse. Arq Neuropsiquiatr 67:507–509
Bacopoulou F, Henderson L, Philip SG (2006) Menkes disease mimicking non-accidental injury. Arch Dis Child 91:919
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
No financial support was provided for this study.
Conflict of interest
The authors declare that they have no conflict of interest.
Rights and permissions
About this article
Cite this article
Pfeifer, C.M., Hammer, M.R., Mangona, K.L. et al. Non-accidental trauma: the role of radiology. Emerg Radiol 24, 207–213 (2017). https://doi.org/10.1007/s10140-016-1453-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10140-016-1453-7