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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.
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EVALUATION OF SKELETAL TRAUMA
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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
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Skull fractures have been reported in 10% of abused children and although usually linear, they may be multiple, diastatic, complex, bilateral, and depressed.14-16 Skull fractures can occur with ...