ReviewWhich radiological investigations should be performed to identify fractures in suspected child abuse?
Introduction
Non-accidental fractures in children denote severe assault and must be identified if present. Fractures have been recorded in up to 55% of young children who have been physically abused.1, 2 Most of this group are under 3 years of age, with 80% less than 18 months old.3 Abusive fractures are often occult in these young children, who are unable to give a history, and where symptoms and signs can be difficult to interpret.4, 5, 6 The investigating paediatrician must have access to sensitive radiological techniques to identify these fractures, which are frequently multiple,3, 7 widely distributed throughout the skeleton and may show different stages of healing.8 Both acute rib fractures4 and metaphyseal fractures are associated with abuse, but are easily missed on radiographs.9
The first reference to unexplained fractures in association with subdural haemorrhage in infants was by Caffey10 in 1946. Since that time clinicians have attempted to exclude fractures in infants where physical abuse is suspected. The standard investigation has evolved from the simple baby-gram to skeletal surveys (SS) in their current recommended form (Table 1).11, 12 In the early 1980s publications suggested that bone scintigraphy (BS) was an appropriate investigation.13, 14, 15 Currently both investigations are used to delineate the pattern and extent of fractures in the diagnosis and management of child abuse. Radiology findings may be used as medical evidence in court and they can have a significant bearing on the legal outcome in either civil or criminal proceedings.16
The British Society of Paediatric Radiologists (BSPR) and the American College of Radiology (ACR) have produced guidelines for the radiological investigation of suspected abuse, detailing imaging techniques, qualifications of relevant specialists and views to be taken.11, 12 Neither addresses the role of BS. Although both recommend that SS should be performed in infants and young children where physical abuse is suspected, neither defines which age group should be investigated. We have conducted a systematic review to determine the optimal radiological investigations that should be performed to detect fractures in suspected physical abuse and which children should be investigated.
Section snippets
Search criteria
We performed an all-language literature search using the keywords listed in Table 2 of original articles from 1950–October 2005 (Fig. 1). Literature before this date was appropriately hand-searched from 1947 onwards.
Inclusion criteria
We included studies of live children less than 18-years old who had radiological investigations to identify bone fractures in suspected child abuse. The following were excluded: review articles, consensus statements or expert opinion, studies where details on children could not be
Results
Fig. 1 summarizes all of the studies scanned and reviewed; 34 studies were included. The methodological techniques for investigations differed between studies and the rationale for choosing investigations were not stated, age ranges of included cases varied.
Discussion
These studies confirm that the diagnostic rate for occult fractures in young children is significant and that a sensitive radiology investigation strategy is fully justified. Delineation of the full extent of fractures sustained by an abused child is important to inform the degree of certainty of abuse, the extent, severity and chronicity of the physical abuse, and assist in assessing the possible mechanisms of injury.
All children under the age of 2 years, where physical abuse is suspected,
Acknowledgements
The authors thank the NSPCC for their financial support of this systematic review, and all of our reviewers.
References (64)
- et al.
The role of bone scintigraphy in detecting child abuse
Semin Nucl Med
(1993) - et al.
Utility of follow-up skeletal surveys in suspected child physical abuse evaluations
Child Abuse Negl
(2005) The significance of femoral fractures in children
Ann Emerg Med
(1982)- et al.
Use of the skeletal survey in the evaluation of child maltreatment
Am J Emerg Med
(2001) - et al.
A survey of non-accidental injury imaging in England, Scotland and Wales
Clin Radiol
(2003) - et al.
Observational study of skeletal surveys in suspected non-accidental injury
Clin Radiol
(2003) - et al.
Fracture patterns in battered children
J Orthop Trauma
(1991) - et al.
Patterns of injury and significance of uncommon fractures in the battered child syndrome
AJR Am J Roentgenol
(1974) - et al.
Patterns of fractures in accidental and non-accidental injury in children: a comparative study
BMJ
(1986) - et al.
The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children
J Trauma-Injury Infect Crit Care
(2003)
The abused child: A radiological reappraisal
Radiology
Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes
J Paediatr Child Health
Causes of femoral shaft fracture in children under five years of age
J Med Assoc Thai
Fractures in young children. Distinguishing child abuse from unintentional injuries
Am J Dis Children
Factors affecting visualization of posterior rib fractures in abused infants
AJR Am J Roentgenol
Multiple fractures in the long bones of infants suffering from chronic subdural haematoma
AJR Am J Roentgenol
Unsuspected costo-vertebral fractures demonstrated by bone scanning in the child abuse syndrome
Pediatr Radiol
Radiological case of the month. Child abuse
Am J Dis Child
The value of radionuclide bone scanning in the early recognition of deliberate child abuse
J Trauma
Radiologic contributions to the investigation and prosecution of cases of fatal infant abuse
N Engl J Med
Undertaking Systematic Reviews of Research on Effectiveness. CRD's Guidance for those Carrying Out or Commissioning Reviews CRD Report No. 4
Fractures of the hands and feet in child abuse: imaging and pathological features
Radiology
The role of bone scintigraphy in the evaluation of the suspected abused child
Radiology
Comparison of radiographic and radionuclide skeletal surveys in battered children
South Med J
Falsch-negatives skelett-szintigramm bei einer biparietalen schadelfraktur beim “Battered Child”-Syndrom (Falsely negative bone scintigram in a case of a Battered-Child Syndrome with biparietal skull fractures)
Nucl Med (Stuttg)
Comparison of radiography and radionuclide bone scanning in the detection of child abuse
Pediatrics
Somatic manifestations in children suspected of having been maltreated
Acta Paediatr Scand
Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse
Arch Dis Child
Pelvic injuries in child abuse
Pediatr Radiol
Occult humeral epiphyseal fracture in battered infants
Pediatr Radiol
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Welsh Child Protection Systematic Review Group: M. Barber, P. Barnes, M. Bhal, J. Bowen, R. Brooks, A. Butler, S. Datta, R. Frost, C. Graham, S. Harrison, M. James-Ellison, N. John, A. Kemp, A. Maddocks, S. Maguire, S. Morris, A. Mott, A. Naughton, C. Norton, H. Payne, L. Price, I. Prosser, B. Ranton, J. Sibert, P. Thomas, E. Webb, C. Woolley.