Radiology Plays Critical Role in the Diagnosis of Child Abuse

Radiologists are often the first clinicians to see evidence of physical child abuse—such as a broken rib at the edge of an abdominal radiograph or a healing fracture near the site of a new fracture. Detection of these cases and appropriate communication can help prevent future patient injury, mistreatment or even death.

New research and continuing education are moving radiology and all of healthcare toward important advances in diagnosing child abuse and neglect that continues to occur at a staggering rate. According to 2014 Child Maltreatment Report from the U.S. Department of Health and Human Services, an estimated 1,580 children died from abuse and neglect and three-quarters (70.7 percent) of all child fatalities that year were younger than 3 years old.

“Diagnosing a child abuse case can be a very complex and difficult process,” said researcher Sarah Sarvis Milla, MD, FAAP, associate professor of radiology and imaging sciences at Emory University School of Medicine, Atlanta. “Fortunately, radiologists are not working in a vacuum, but as part of a team of doctors, nurses, social workers and law enforcement officers who want the best outcome for the child.”

This collaborative approach was the focus of the three-day course in February, “2016 Imaging of Child Abuse: Exam Room, Reading Room and Court Room,” co-sponsored by the Society for Pediatric Radiology (SPR) and the American Academy of Pediatrics (AAP). Dr. Milla is on the Executive Committee of the AAP Section on Radiology (AAP SoRa) and served on the planning committee for the course, which covered neurological, skeletal and visceral injury patterns seen with child abuse, among many other topics.

Course presenters stressed that the rate of physical abuse is highest among infants (<1 year) and young children and fractures are the second most common injury after bruises in this age group. Almost a quarter of fractures in infants are attributable to physical abuse.

“Posteromedial rib fractures are particularly concerning because they suggest that the child has been squeezed, causing the ribs to bend over the spinous process of the vertebral body,” said Sabah Servaes, MD, a pediatric radiologist from the Children’s Hospital of Philadelphia, chair of SPR’s Child Abuse Imaging Committee and course director of the recent SPR-AAP program. As children get older, abuse-related injury patterns change. Older children tend to experience more visceral injuries, from being punched and kicked. Fractures of different ages may be apparent on imaging. Radiologic findings in children are particularly concerning when the incident reported by the parent or caregiver does not match up with the injuries evident on imaging.

“If a 3-month-old baby is brought in because she isn’t moving her arm and the radiograph shows a fracture, without a history of trauma, this would be a concerning injury,” Dr. Milla said. “Other times, we may incidentally detect prior trauma. For instance, a chest radiograph of a baby with a cough and fever showing healing posterior rib fractures.” The first and most important thing radiologists must do in the event of a suspicious finding is discuss it with the referring physician, Dr. Servaes said.

“Communication is imperative,” she said. “In some cases, the radiologist may not have received the entire history and there may be an underlying metabolic disorder that would explain the injury.” If abuse is suspected, additional imaging is likely to begin with a skeletal survey, a series of about 20 X-rays of the child’s entire body.

“On a skeletal series, you might see older fractures in different states of healing, which suggests the child has experienced multiple episodes of trauma,” Dr. Milla said.

Radiologists also play a critical role in ruling out mistreatment and abuse, she said. "In cases when we find no radiologic evidence of abusive injury, that can be helpful to the clinician to support a decision that a child is not being abused."

“Following the ACR appropriateness criteria, a head CT is usually appropriate in a child less than 2 years old with signs of abuse,” Dr. Milla said. “A significant percentage of young children who have radiographic findings of abuse in the body will also have evidence of traumatic injury to the head.”

At many hospitals, brain MRI is performed in the event of a positive head CT finding to help discern the extent of injuries as well as detect more subtle injuries. Some facilities also opt for a cervical spine MRI to look for damage to neck ligaments and other evidence of spinal trauma.

Bone scans with technetium-99 are being used at some medical centers if the skeletal survey is negative but the suspicion of abuse is high. Some medical centers are using PET in child abuse cases as it has demonstrated better specificity. Research has shown that whole body PET has better sensitivity than a skeletal survey in the detection of some fractures related to child abuse, but lower sensitivity in the detection of CMLs.

Abuse cases often end up going to trial, and the radiologist involved in the case may be asked to testify.

“The courtroom is out of a radiologist’s element,” Dr. Servaes noted. “If you do testify, it’s important to be able to express things in a way that people outside of medical professions can understand.”

Research on Rickets Moves Discussion Forward

Along with searching for fractures and other injuries, radiologists are also examining children for alternative diagnoses or underlying disorders or syndromes such as rickets and metaphysical dysplasia. In fact, differentiation of abuse-related fractures from fractures caused by underlying medical conditions has been a controversial issue in radiology, particularly with respect to rickets, a disease in which a child’s bones soften and weaken, usually due to a vitamin D deficiency. When abuse cases go to court, defense lawyers often raise the specter of rickets as a potential source of fractures, Dr. Milla said.

“There are people in the minority of the radiology community who believe we are misdiagnosing child abuse,” Dr. Milla said. “However, the dominant view among pediatric radiologists is that if there is no radiographic evidence of rickets, it’s unlikely that fractures would be due to undiagnosed rickets.”

A 2015 Radiology study demonstrated that certain types of fractures in young children are more likely to be associated with child abuse than rickets. In the study also presented at RSNA 2015, researchers analyzed nine cases of infant homicide that had been referred from the state medical examiner’s office for the evaluation of possible child abuse. The victims had classic metaphyseal lesions (CMLs), also known as “corner” or “bucket handle” fractures. CMLs are considered highly specific for child abuse in infants. The researchers’ analysis of radiographic and histologic findings revealed no features of rickets among the victims, no support for the view that the CML is due to rickets.

“If you see CMLs, you should be especially concerned about child abuse,” said the Radiology study’s lead author Jeannette M. Peréz-Rosselló, MD, an assistant professor of radiology at Harvard Medical School, Boston Children's Hospital, who was also a presenter at the 2016 AAP seminar. “With rickets, there are labs and other imaging findings that contribute to making the diagnosis.”

A major review published in 2016 in PediatricRadiology echoed that viewpoint. Researchers synthesized relevant scientific data distinguishing clinical, radiologic and laboratory findings of metabolic disease from findings in abusive injury and concluded that fractures with high specificity for child abuse like CMLs are not a consequence of rickets.

“The main focus of the review is to provide the scientifically established basis for the causes of fractures in young children,” Dr. Servaes said.

The Evolving Role of Radiology in Detecting Child Abuse

Since pediatric radiologist John Caffey, MD, first identified radiologic signs of child abuse in 1946, the role of diagnostic imaging in detecting child abuse has grown considerably.

Along with research and education, improvements in existing technology and the development of CT and MRI have helped refine radiologists’ understanding of injuries related to child abuse.

In 2009, the American College of Radiology (ACR) published a set of appropriateness criteria for imaging cases of potential child abuse, although specific protocols may vary among institutions. A head CT is commonly ordered for children suspected of being victims of abuse. CT scans can show skull fractures, identify brain injury and detect bleeding in and/or around the brain.

“Following the ACR appropriateness criteria, a head CT is usually appropriate in a child less than 2 years old with signs of abuse,” Dr. Milla said. “A significant percentage of young children who have radiographic findings of abuse in the body will also have evidence of traumatic injury to the head.”

At many hospitals, brain MRI is performed in the event of a positive head CT finding to help discern the extent of injuries as well as detect more subtle injuries. Some facilities also opt for a cervical spine MRI to look for damage to neck ligaments and other evidence of spinal trauma.

Bone scans with technetium-99 are being used at some medical centers if the skeletal survey is negative but the suspicion of abuse is high. Some medical centers are using PET in child abuse cases as it has demonstrated better specificity. Research has shown that whole body PET has better sensitivity than a skeletal survey in the detection of some fractures related to child abuse, but lower sensitivity in the detection of CMLs.

Abuse cases often end up going to trial, and the radiologist involved in the case may be asked to testify.

“The courtroom is out of a radiologist’s element,” Dr. Servaes noted. “If you do testify, it’s important to be able to express things in a way that people outside of medical professions can understand.”

Web Extras

• Access the study, “Absence of Rickets in Infants with Fatal Abusive Head Trauma and Classic Metaphyseal Lesions,” at RSNA.org/Radiology.
• Access the ACR Appropriateness Criteria for suspected physical abuse of a child at ACR.org.
• The Society for Pediatric Radiology offers reference articles on child abuse at pedrad.org/Specialties/ Child-Abuse-Imaging.