In 1946 John Caffey described the association of subdural hematomas and skeletal fractures in infants and raised the possibility of maltreatment to explain these injuries.1 Kempe and Silverman later coined the term “battered child syndrome” in a landmark article to the general medical community that described the characteristic radiologic features seen in abused children.2 Child abuse is the second most common cause of brain injury and fractures in infants and young children.3 Diagnostic imaging is crucial in the evaluation of child abuse and its imitators.
EVALUATION OF SKELETAL TRAUMA
Skeletal injures can be classified with regard to their relative specificity for abuse based on their imaging pattern and location (Table 41-1).4-6 Highly specific fractures are usually identified in infants and are typically clinically occult.4 Most of these occur with indirect forces, rather than direct blows, explaining the usual absence of bruising overlying the fracture sites.7 Rib fractures near the costovertebral articulations occur with anteroposterior compression of the thorax that may be associated with violent shaking (Figure 41-1). The classic metaphyseal lesion (CML) results from torsional and tractional forces applied to the extremities (Figure 41-2); it may also occur with accelerational forces associated with infant shaking. Highly specific injuries are not caused by simple falls8-11 or by two-finger cardiopulmonary resuscitation efforts.12,13
TABLE 41-1Specificity of Radiologic Findings for Abuse |Favorite Table|Download (.pdf) TABLE 41-1 Specificity of Radiologic Findings for Abuse
Posterior rib fractures
Spinous process fractures
Multiple fractures, especially bilateral
Fractures of different ages
Vertebral body fractures and subluxations
Complex skull fractures
Common but low specificity
Subperiosteal new bone formation
Long bone shaft fractures
Linear skull fractures
Two-month-old abused infant. The chest film shows multiple healing rib fractures (arrowheads) and a single acute rib fracture (arrow) near the costovertebral articulations. Also note the multiple lateral and anterior rib fractures.
The same patient as in Figure 41-1 manifests classic multiple metaphyseal lesions in a variety of patterns. The anteroposterior and lateral views of the knee show a bucket-handle fracture of the distal femur, metaphyseal irregularity of the proximal tibia, and a corner fracture of the proximal fibula.
Skull fractures have been reported in 10% of abused children and although usually linear, they may be multiple, diastatic, complex, bilateral, and depressed....