Abdoo DC, Puls HT, Hall M, Lindberg DM, Anderst J, Wood JN, Parikh K, Tashijan M, Sills MR. Racial and ethnic disparities in diagnostic imaging for child physical abuse.. Child Abuse & Neglect. 2024; 149 : 106648 Section on Radiology; Diagnostic Imaging of Child Abuse..
Keywords: Humans, Infant, Infant, Newborn, Black or African American, *Child Abuse/diagnosis, Hispanic or Latino, Physical Abuse, Radiography, Retrospective Studies, White, *White People
IMPORTANCE: Racial bias may affect occult injury testing decisions for children …
IMPORTANCE: Racial bias may affect occult injury testing decisions for children with concern for abuse. OBJECTIVES: To determine the association of race on occult injury testing decisions at children's hospitals. DESIGN: In this retrospective study, we measured disparities in: (1) the proportion of visits for which indicated diagnostic imaging studies for child abuse were obtained; (2) the proportion of positive tests. SETTING: The Pediatric Health Information System (PHIS) administrative database encompassing 49 tertiary children's hospitals during 2017-2019. PARTICIPANTS: We built three cohorts based on guidelines for diagnostic testing for child abuse: infants with traumatic brain injury (TBI; n = 1952), children <2 years old with extremity fracture (n = 20,842), and children <2 years old who received a skeletal survey (SS; n = 13,081). MAIN OUTCOMES AND MEASURES: For each group we measured: (1) the odds of receiving a specific guideline-recommended diagnostic imaging study; (2) among those with the indicated imaging study, the odds of an abuse-related injury diagnosis. We calculated both unadjusted and adjusted odds ratios (AOR) by race and ethnicity, adjusting for sex, age in months, payor, and hospital. RESULTS: In infants with TBI, the odds of receiving a SS did not differ by racial group. Among those with a SS, the odds of rib fracture were higher for non-Hispanic Black than Hispanic (AOR 2.05 (CI 1.31, 3.2)) and non-Hispanic White (AOR 1.57 (CI 1.11, 2.32)) patients. In children with extremity fractures, the odds of receiving a SS were higher for non-Hispanic Black than Hispanic and non-Hispanic White patients (AOR 1.97 (CI 1.74, 2.23)); (AOR 1.17 (CI 1.05, 1.31)), respectively, and lower for Hispanic than non-Hispanic White patients (AOR 0.59 (CI 0.53, 0.67)). Among those receiving a SS, the rate of rib fractures did not differ by race. In children with skeletal surveys, the odds of receiving neuroimaging did not differ by race. Among those with neuroimaging, the odds of a non-fracture, non-concussion TBI were lower in non-Hispanic Black than Hispanic patients (AOR 0.7 (CI 0.57, 0.86)) and were higher among Hispanic than non-Hispanic White patients (AOR 1.23 (CI 1.02, 1.47)). CONCLUSIONS AND RELEVANCE: We did not identify a consistent pattern of race-based disparities in occult injury testing when considering the concurrent yield for abuse-related injuries.
Boehnke M, Mirsky D, Stence N, Stanley RM, Lindberg DM. Occult head injury is common in children with concern for physical abuse.. Pediatric Radiology. 2018; 48 (8) : 1123-1129.
Keywords: Child Abuse/*diagnosis/statistics & numerical data, Craniocerebral Trauma/*diagnostic imaging/epidemiology, Female, Humans, Infant, Infant, Newborn, Magnetic Resonance Imaging, Male, Neuroimaging/*methods, Prevalence, Retrospective Studies, Risk Factors,
BACKGROUND: Studies evaluating small patient cohorts have found a high, but …
BACKGROUND: Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients. OBJECTIVES: Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury. MATERIALS AND METHODS: This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury. RESULTS: One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-6.8), macrocephaly (OR 8.5, 95% CI 3.7-20.2), and loss of consciousness (OR 5.1, 95% CI 1.2-22.9) had higher odds of occult head injury. CONCLUSION: Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.
Chen SY, Gao L, Imagawa KK, Roseman ER, Shin CE, Kim ES, Spurrier RG. Screening for Child Abuse in Children With Isolated Skull Fractures.. Pediatric Emergency Care. 2023; 39 (6) : 374-377.
Keywords: Child, Humans, Infant, *Skull Fractures/diagnosis/epidemiology, *Child Abuse/diagnosis, *Craniocerebral Trauma, Emergency Service, Hospital, Social Work, Retrospective Studies
OBJECTIVE: Head trauma is the most common cause of death from child abuse, and …
OBJECTIVE: Head trauma is the most common cause of death from child abuse, and each encounter for recurrent abuse is associated with greater morbidity. Isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We determined patterns of physical abuse screening in a children's hospital ED for children with ISF. METHODS: A retrospective review was performed for children aged 3 years and younger who presented to the ED with ISF from January 1, 2015 to December 31, 2019. Children were stratified by age (<12 mo, ≥12 mo) and witnessed versus unwitnessed injury. Primary outcome was social work (SW) assessment to prescreen for abuse. Secondary outcomes were suspicion for abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year. RESULTS: Sixty-six ISF patients were identified. Of unwitnessed injury patients aged younger than 12 months (n = 17/22), 88.2% (n = 15/17) underwent SW assessment and 47.1% (n = 8/17) required CPS referral. Of witnessed injury patients aged younger than 12 months (n = 23/44), 60.9% (n = 14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (n = 4/22) unwitnessed and 20.5% (n = 9/44) witnessed injury patients returned to our ED: 2 were aged younger than 12 months and had recurrent trauma. CONCLUSIONS: To decrease risk of missed physical abuse, SW consultation should be considered for all ISF patients.
Christian CW, Crawford-Jakubiak JE, Flaherty EG, Leventhal JM, Lukefahr JL, Sege RD. The evaluation of suspected child physical abuse. Pediatrics. 2015; 135 (5) : e1337-e1354.
Child physical abuse is an important cause of pediatric morbidity and mortality …
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
Christian CW, Levin AV. The Eye Examination in the Evaluation of Child Abuse.. Pediatrics. 2018; 142 (2).
Keywords: Child, Child Abuse/*diagnosis/prevention & control, Craniocerebral Trauma/complications/diagnosis/prevention & control, *Diagnostic Techniques, Ophthalmological/standards, Eye Injuries/*diagnosis/*etiology/prevention & control, Humans, Physical Examinatio
Child abuse can cause injury to any part of the eye. The most common …
Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.
Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management.. Journal of Neurosurgery. Pediatrics. 2019; 24 (5) : 481-488.
Keywords: Brain Injuries, Traumatic/diagnosis/therapy, Child, Child Abuse/*diagnosis/legislation & jurisprudence, Child Protective Services, Child, Preschool, Craniocerebral Trauma/*diagnosis/therapy, Hematoma, Subdural, Intracranial/diagnosis/therapy, Humans, Infa
Abusive head trauma remains the major cause of serious head injury in infants …
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA Jr, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria(®) Suspected Physical Abuse-Child.. Journal of the American College of Radiology : Jacr. 2017; 14 (5S) : S338-S349.
Keywords: Child Abuse/*diagnosis, Contrast Media, Craniocerebral Trauma/*diagnostic imaging, Fractures, Bone/*diagnostic imaging/etiology, Humans, Infant, Infant, Newborn, Radiology, Rib Fractures/diagnostic imaging/etiology, Societies, Medical, Tomography, X-Ray C
The youngest children, particularly in the first year of life, are the most …
The youngest children, particularly in the first year of life, are the most vulnerable to physical abuse. Skeletal survey is the universal screening examination in children 24 months of age and younger. Fractures occur in over half of abused children. Rib fractures may be the only abnormality in about 30%. A repeat limited skeletal survey after 2 weeks can detect additional fractures and can provide fracture dating information. The type and extent of additional imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and social considerations. Unenhanced CT of the head is the initial study for suspected intracranial injury. Clinically occult abusive head trauma can occur, especially in young infants. Therefore, head CT should be performed in selected neurologically asymptomatic physical abuse patients. Contrast-enhanced CT of the abdomen/pelvis is utilized for suspected intra-abdominal or pelvic injury. Particular attention should be paid to discrepancies between the patterns of injury and the reported clinical history. Making the diagnosis of child abuse also requires differentiation from anatomical and developmental variants and possible underlying metabolic and genetic conditions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL, Christian CW, Crawford-Jakubiak JE, Leventhal JM, Lukefahr JL, Sege RD, MacMillan H, Nolan CM, Valley LA, Hurley TP, Cassady CI, Bulas DI, Cassese JA, Mehollin-Ray AR, Mercado-Deane MG, Milla SS, Thorne V, Sills IN, Blo. Evaluating children with fractures for child physical abuse. Pediatrics. 2014; 133 (2).
Keywords: Fractures
Fractures are common injuries caused by child abuse. Although the consequences …
Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Copyright \textcopyright 2014 by the American Academy of Pediatrics.
Glenn K, Nickerson E, Bennett CV, Naughton A, Cowley LE, Morris E, Murtagh U, Kontos K, Kemp AM. Head computed tomography in suspected physical abuse: time to rethink?. Archives of Disease in Childhood. 2021; 106 (5) : 461-466.
Keywords: Humans, Infant, *Tomography, X-Ray Computed/methods/statistics & numerical data, *Child Abuse/diagnosis/statistics & numerical data, Retrospective Studies, Male, Female, *Craniocerebral Trauma/diagnostic imaging, Child, Preschool, Practice Guidelines as T
BACKGROUND: National guidance recommends CT-head for all children <1 year old …
BACKGROUND: National guidance recommends CT-head for all children <1 year old with suspected physical abuse, and to be considered for those <2 years old to exclude abusive head trauma. OBJECTIVES: To investigate whether this guidance is followed, and the associations between clinical presentation and CT findings, to determine whether guidance could be refined. MATERIALS AND METHODS: A retrospective case note review of all children <2 years old who underwent medical assessment for suspected abuse (2009-2017). Outcome measures were frequency of CT-head, and diagnostic yield of intracranial injury, skull fracture or both. RESULTS: CT-head was undertaken in 60.3% (152/252) of children <12 months old and 7.8% (13/167) of those aged 12-24 months. The diagnostic yield in children who had a CT-head was 27.1% in children <6 months old, 14.3% in those 6-12 months old (p=0.07) and 42.6% (6/13) in those 12-24 months old. For those with head swelling or neurological impairment, it was 84.2% (32/38). In children <12 months old without these clinical features, the estimated prevalence of occult head injury was 6.1% (7/115). The strongest predictors of an abnormal CT-head were swelling to the head (OR 46.7), neurological impairment (OR 20.6) and a low haemoglobin (OR 11.8). CONCLUSION: All children <2 years of age with suspected physical abuse and neurological impairment or head swelling should undergo CT-head. Where the technical skills and the requisite expertise to interpret MRI exist, an MRI scan may be the optimal first-line neuroimaging investigation in infants who are neurologically stable with injuries unrelated to the head to minimise cranial radiation exposure.
Haney S, Scherl S, DiMeglio L, Perez-Rossello J, Servaes S, Merchant N. Evaluating Young Children With Fractures for Child Abuse: Clinical Report.. Pediatrics. 2025; 155 (2).
Keywords: Humans, *Child Abuse/diagnosis, *Fractures, Bone/diagnosis, Infant, Child, Preschool, Diagnosis, Differential, Child
Fractures are common injuries in childhood and can be caused by unintentional …
Fractures are common injuries in childhood and can be caused by unintentional injury, medical conditions, and child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, the consequences of incorrectly diagnosing child abuse in a child whose fractures have another etiology are also significant. This report aims to review recent advances in the understanding of fracture specificity, fracture mechanisms, and other medical conditions that predispose infants and children to fracture. This clinical report will aid pediatricians and pediatric care providers in developing an evidence-based differential diagnosis and performing appropriate evaluations when assessing a child with fractures.
Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse.. Pediatrics. 2009; 124 (6) : 1595-602.
Keywords: Abdominal Injuries/*diagnosis/*epidemiology, Alanine Transaminase/blood, Amylases/blood, Aspartate Aminotransferases/blood, Child Abuse/*diagnosis/*statistics & numerical data, Child Welfare/statistics & numerical data, Child, Preschool, Cross-Sectional S
OBJECTIVES: The goals were (1) to determine the prevalence of occult abdominal …
OBJECTIVES: The goals were (1) to determine the prevalence of occult abdominal trauma (OAT) in a sample of children with suspected physical abuse, (2) to assess the frequency of OAT screening, and (3) to assess factors associated with screening. METHODS: Charts of children evaluated for abusive injury were identified through a search of hospital discharge codes. Identified charts were reviewed to determine whether OAT screening occurred. Data on results of screening tests, abusive injuries identified, family demographic features, and characteristics of the emergency department visit were collected. RESULTS: Screening occurred for 51 (20%) of 244 eligible children. Positive results were identified for 41% of those screened and 9% of the total sample; 5% of children 12 to 23 months of age had OAT identified through imaging studies. Screening occurred more often in children presenting with probable abusive head trauma (odds ratio [OR]: 20.4 [95% confidence interval [CI]: 3.6-114.6]; P < .01), compared with those presenting with other injuries. Consultation with the child protection team (OR: 8.5 [95% CI: 3.5-20.7]; P < .01) and other subspecialists (OR: 24.3 [95% CI: 7.1-83.3]; P < .01) also increased the likelihood that OAT screening would occur. CONCLUSIONS: Our findings support OAT screening with liver and pancreatic enzyme measurements for physically abused children. This study also supports the importance of subspecialty input, especially that of a child protection team. Although many identified injuries may not require treatment, their role in confirming or demonstrating increased severity of maltreatment may be critical.
Lindberg DM, Blood EA, Campbell KA, Laskey AL, Berger RP. Predictors of screening and injury in contacts of physically abused children.. The Journal of Pediatrics. 2013; 163 (3) : 730-5.e1-3.
Keywords: Child, Child Abuse/*diagnosis/statistics & numerical data, Child Health Services/standards/*statistics & numerical data, Child, Preschool, *Family, Female, Guideline Adherence/*statistics & numerical data, Health Care Surveys, Humans, Infant, Infant, Newb
OBJECTIVE: To determine rates of screening in contacts of children evaluated …
OBJECTIVE: To determine rates of screening in contacts of children evaluated for physical abuse, and the relationship of clinical characteristics to screening recommendation and completion and injury identification. STUDY DESIGN: This is a planned secondary analysis of a prospective study of 1918 contacts of 1196 children referred for subspecialty abuse consultation in 20 US centers. We used multivariable logistic models to determine the relationship of index child characteristics, contact child characteristics, and shared characteristics to screening and injury identification. RESULTS: We identified injuries or disclosures of abuse in 180 (9.4%) contacts. Recommended screening was omitted in >20% of subjects for each screening modality. At least 1 screening test was more likely to be completed in contacts of index children of non-White race or Hispanic ethnicity (OR 1.45, 95% CI 1.13-1.87), with abuse-specific injuries (OR 2.15, 95% CI 1.63-2.83), with a confession (OR 2.18, 95% CI 1.17-4.07), when the history changed (OR 1.65, 95% CI 1.05-2.61), when an occult injury was found by imaging in the index child (OR 1.84, 95% CI 1.39-2.43), and when families lacked private insurance (OR 1.63, 95% CI 1.15-2.31). CONCLUSION: Completion of screening recommended for contacts of potentially abused children is relatively poor, despite high risk of injury. Several clinical and demographic factors were associated with increased contact screening.
McNamara CR, Wood JN, Lindberg D, Campbell KA, Poston S, Valente M, Antonucci M, Wolford J, Coombs C, Sahud H, Clarke J, Brink FW, Bachim A, Frasier LD, Harper NS, Melville JD, Laub N, Anderst J, Berger RP. Yield of skeletal surveys in national network of child abuse pediatricians: Age is key.. Child Abuse & Neglect. 2024; 157 : 106992.
Keywords: Humans, *Child Abuse/statistics & numerical data/diagnosis, Cross-Sectional Studies, Child, Preschool, Infant, Male, Female, United States/epidemiology, Age Factors, Fractures, Closed/diagnosis, Pediatricians/statistics & numerical data, Fractures, Bone/e
BACKGROUND: Skeletal surveys (SS) are recommended for the evaluation of …
BACKGROUND: Skeletal surveys (SS) are recommended for the evaluation of suspected physical abuse in children <2 years old. No guidelines exist for SS completion in children between 2 and 5 years old. OBJECTIVE: To determine rates of SS completion by age and examine variables associated with occult fracture identification in older children. PARTICIPANTS AND SETTING: Observational cross-sectional multi-center study of 10 US pediatric centers 2/2021-9/2022 including children <6 years old evaluated for physical child abuse. METHODS: The principal outcome is occult fracture identified on SS. Non-parametric tests were conducted from comparison between age groups and those with and without occult fractures. RESULTS: The rate of SS completion declined with increasing age from a high of 91 % in infants <6 months old to 7 % in children 5-5.9 years old. The proportion of SS with occult fractures also decreased with age. Of 450 children 2-5 years old with a SS, 20 [4 % (95 % CI: 3-8 %)] had an occult fracture. The rate of occult fractures among children 2-5 years old who were diagnosed with abuse and not admitted to the hospital was 0.3 % (95 % CI 0-0.6 %)]. Over 30 % of children 2-5 years old were diagnosed with child abuse by a child abuse pediatrician without completion of a SS. CONCLUSION: In children 2-5 years of age being evaluated for physical abuse, use of SS and the rate of occult fractures is low. The number of SS performed in children in this age group could potentially be decreased by up to 60 % by limiting SS to children admitted to the hospital.
Nguyen A, Hart R. Imaging of non-accidental injury; what is clinical best practice?. Journal of Medical Radiation Sciences. 2018; 65 (2) : 123-130.
Keywords: Child, *Child Abuse, Humans, Practice Guidelines as Topic, Wounds and Injuries/*diagnostic imaging/*etiology
Non-accidental injury (NAI) remains the leading cause of morbidity and …
Non-accidental injury (NAI) remains the leading cause of morbidity and mortality in children. Fractures are the second most common findings of NAI, after cutaneous lesions such as bruises and contusions. Imaging in NAI remains a controversial issue with little agreement concerning how, when and what imaging modalities should be used in the investigation of suspected cases. This review addresses the radiological investigations and findings of NAI, and the differential diagnoses of these findings. Adherence to the international guidelines for skeletal survey imaging is recommended. This ensures the content and quality of the radiographic series are of an optimal standard to improve the detection of occult fractures, and ensuring the accurate reporting of images. The involvement of a paediatric radiologist is important, if not essential in the diagnosis of NAI. In the evaluation of suspected cases, the role of the radiologist includes the detection of radiological findings suggestive of NAI, and the differentiation of these findings from normal variants and underlying pathologies. The diagnosis of NAI relies not only on radiological imaging, but also a combination of clinical and social findings. It is mandatory that all physicians work in close collaboration to improve diagnostic accuracy, as failure to diagnose NAI carries significant risk for morbidity.
Pfeifer CM, Henry MK, Caré MM, Christian CW, Servaes S, Milla SS, Strouse PJ. Debunking Fringe Beliefs in Child Abuse Imaging: AJR Expert Panel Narrative Review.. Ajr. American Journal of Roentgenology. 2021; 217 (3) : 529-540.
Keywords: Child Abuse/*diagnosis, Denial, Psychological, Diagnostic Imaging/*methods, Female, Humans, Infant, Magnetic Resonance Imaging, Male, Radiology, Reproducibility of Results, Tomography, X-Ray Computed
Child abuse is a global public health concern. Injuries from physical abuse may …
Child abuse is a global public health concern. Injuries from physical abuse may be clinically occult and not appreciable on physical examination. Imaging is therefore critical in identifying and documenting such injuries. The radiologic approach for a child who has potentially been abused has received considerable attention and recommendations according to decades of experience and rigorous scientific study. Nonetheless, fringe beliefs describing alternative explanations for child abuse-related injuries have emerged and received mainstream attention. Subsequently, imaging findings identified in abused children have been attributed to poorly supported underlying medical conditions, clouding the evidence basis for radiologic findings indicative of nonaccidental trauma. Fringe beliefs that attribute findings seen in child abuse to alternate pathologies such as genetic disorders, birth trauma, metabolic imbalances, vitamin D deficiency, and short-distance falls typically have limited evidence basis and lack professional society support. Careful review of the scientific evidence and professional society consensus statements is important in differentiating findings attributable to child abuse from fringe beliefs used to discount the possibility that a child's constellation of injuries is consistent with abuse. This review refutes fringe beliefs used to provide alternative explanations in cases of suspected child abuse and reinforces the key literature and scientific consensus regarding child abuse imaging.
Ruiz-Maldonado TM, Alsanea Y, Coats B. Age-related skull fracture patterns in infants after low-height falls.. Pediatric Research. 2023; 93 (7) : 1990-1998.
Keywords: Humans, Infant, Accidental Falls, *Skull Fractures/diagnostic imaging, *Craniocerebral Trauma, Tomography, X-Ray Computed, Head, Skull
BACKGROUND: Prior research and experience has increased physician understanding …
BACKGROUND: Prior research and experience has increased physician understanding of infant skull fracture prediction. However, patterns related to fracture length, nonlinearity, and features of complexity remain poorly understood, and differences across infant age groups have not been previously explored. METHODS: To determine how infant and low-height fall characteristics influence fracture patterns, we collected data from 231 head CT 3D reconstructions and quantified length and nonlinearity using a custom image processing code. Regression analysis was used to determine the effects of age and fall characteristics on nonlinearity, length, and features of fracture complexity. RESULTS: While impact surface had an important role in the number of cracks present in a fracture, younger infants and greater fall heights significantly affected most features of fracture complexity, including suture-to-suture spanning and biparietal involvement. In addition, increasing fracture length with increasing fall height supports trends identified by prior finite-element modeling. Finally, this study yielded results supporting the presence of soft tissue swelling as a function of fracture location rather than impact site. CONCLUSIONS: Age-related properties of the infant skull confer unique fracture patterns following head impact. Further characterization of these properties, particularly in infants <4 months of age, will improve our understanding of the infant skull's response to trauma. IMPACT: Younger infant age and greater fall heights have significant effects on many features of fracture complexity resulting from low-height falls. Incorporating multiple crack formation and multiple bone involvement into computational models of young infant skull fractures may result in increased biofidelity. Drivers of skull fracture complexity are not well understood, and skull fracture patterns in real-world data across infant age groups have not been previously described. Understanding fracture complexity relative to age in accidental falls will improve the understanding of accidental and abusive head trauma.
Strouse PJ, Owings CL. Fractures of the first rib in child abuse.. Radiology. 1995; 197 (3) : 763-5.
Keywords: Academic Medical Centers, Biomechanical Phenomena, Bone Diseases, Metabolic/diagnostic imaging, Brain Injuries/complications/diagnosis, Child Abuse/*diagnosis, Child, Preschool, Female, Humans, Incidence, Infant, Infant, Newborn, Male, Osteogenesis Imperf
PURPOSE: To evaluate the incidence and specificity of fracture of the first rib …
PURPOSE: To evaluate the incidence and specificity of fracture of the first rib as an indicator of child abuse and to determine a mechanism of fracture. MATERIALS AND METHODS: All infants and young children with rib fractures who were seen at the radiology department of an academic medical center over a 2-year period were identified from the radiology data base. RESULTS: Rib fractures were attributed to child abuse in 12 of 35 children identified. Apart from a neonate with congenital osteogenesis imperfecta, only three children, all abused, had first-rib fracture, one bilaterally. Two additional children with first-rib fracture were identified from years prior to the study period. In four children, first-rib fractures were "isolated," without fractures of adjacent bones. CONCLUSION: Child abuse should be considered in cases of pediatric rib fracture, particularly fracture of the first rib. Possible mechanisms for first-rib fracture include impact force, compressive force, and shaking or acute axial load (slamming), which cause an indirect fracture.
Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD. Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use?. Pediatric Radiology. 2011; 41 (1) : 92-8.
Keywords: Abdominal Injuries/*diagnostic imaging, Child Abuse/*diagnosis, Child, Preschool, Female, Humans, Infant, Infant, Newborn, Male, Pelvis/*diagnostic imaging, Physical Examination/methods, Retrospective Studies, Tomography, X-Ray Computed, Ultrasonography
BACKGROUND: Incomplete history and concern for occult injury in suspected child …
BACKGROUND: Incomplete history and concern for occult injury in suspected child abuse occasionally results in CT screenings of the abdomen and pelvis. At our institution, we noted that these exams were infrequently positive. OBJECTIVE: To identify clinical or laboratory criteria that may predict intra-abdominal injury and guide the use of abdominal and pelvic CT in this population. MATERIALS AND METHODS: This retrospective review involved 68 children older than 36 months who had a CT of the abdomen/pelvis for suspected abuse. CT results and patient charts were reviewed for physical exam and historical and laboratory variables. RESULTS: CTs were positive in 16% of patients (11/68). Hypoactive/absent bowel sounds (P = 0.01, specificity = 94.7%) and AST and ALT values greater than twice normal (P = 0.004 and P = 0.003 respectively, NPV = 93.6%) were significantly associated with positive CTs. Multiple abnormal physical exam or laboratory findings were also significantly associated with positive CTs (P = 0.03 and P = 0.002 respectively, specificity = 91.3% and NPV = 93.6% respectively). CONCLUSION: CTs of the abdomen and pelvis are infrequently positive in cases of suspected abuse. To reduce radiation exposure, CTs should only be ordered if there are findings indicating that they may be positive. In our population, these findings include absent/hypoactive bowel sounds, LFTs greater than twice normal and ≥2 abnormal labs or physical exam findings.
Wood JN, Fakeye O, Feudtner C, Mondestin V, Localio R, Rubin DM. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 2014; 134 (1) : 45-53.
Keywords: Child abuse,Child maltreatment,Fracture,Skeletal survey,Trauma
OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in …
OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties. METHODS: Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children <24 months old. After discussion on the initial ratings, panelists rerated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary. RESULTS: Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type. CONCLUSIONS: A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse. Copyright \textcopyright 2014 by the American Academy of Pediatrics.
Yeung F, Smith J, Mendoza-Londono R, O'Connor C, Howard A, Sorbara J, Schwartz S. Fracture prevalence in children diagnosed with Ehlers-Danlos Syndrome and Generalized Joint Hypermobility.. Child Abuse & Neglect. 2024; 153 : 106828.
Keywords: Humans, *Ehlers-Danlos Syndrome/epidemiology/complications, *Joint Instability/epidemiology, Male, Female, Prevalence, Retrospective Studies, Child, Preschool, Child, Infant, *Fractures, Bone/epidemiology/etiology, Adolescent
BACKGROUND: There is limited understanding of the hypothesized association …
BACKGROUND: There is limited understanding of the hypothesized association between the Ehlers-Danlos Syndromes (EDS), hypermobility and fractures in children. Despite this, EDS and hypermobility continue to be raised in the legal setting as possible causes of unexplained fractures in infants where there is a concern for physical abuse. Further understanding is needed regarding fractures in children with EDS and hypermobility. OBJECTIVE: This study assessed fracture prevalence and characteristics in children diagnosed with EDS and Generalized Joint Hypermobility (GJH). The secondary outcome was fracture prevalence in infants <1 year of age. PARTICIPANTS AND SETTING: Children aged <18 years with EDS or GJH seen in a single-center EDS clinic from April 2017 to December 2021 were included. Diagnoses were based on the 2017 international classification. Exclusion criteria were concurrent medical conditions associated with bone fragility. METHODS: This retrospective descriptive study examined variables including fracture history, fracture location, fracture type, age of sustaining fracture, and injury mechanism. Descriptive statistics were used for analysis. RESULTS: Fracture prevalence was 34.6 % (9/26, 95 % CI [16.3, 52.9]) in the EDS population and 25.4 % (15/59, 95 % CI [14.3, 36.5]) in the GJH population. No fractures occurred in infancy. Most fractures occurred in the limbs. There were no rib or skull fractures. Most fractures were the result of an identifiable injury event. CONCLUSION: In a cohort of children with formally diagnosed EDS or GJH, fractures occurred commonly in ambulatory children and generally in the limbs from identifiable events. This study does not support EDS or GJH as a cause of fractures in infancy.
