Child Abuse

A frontal radiograph of the femur demonstrates classic metaphyseal lesions of the distal femur and proximal tibia medially (arrows)

Facts:

• The two most common injuries in child abuse = soft tissue injuries and fractures
• Failure to recognize child abuse may result in the child's return to hostile environment, leading to repeated injuries and possible death
• Highly specific fractures = rib, spinous process, and sternal fractures and classic metaphyseal lesions
• High suspicion = multiple fractures of differing ages

The Skeletal Survey

• To evaluate children less than 2 years old for signs of physical abuse
• American College of Radiology (ACR) recommends a single frontal view of each region of the appendicular skeleton (arms, forearms, thighs, legs, hands and feet), frontal and lateral views of the axial skeleton (skull, C-spine, LS spine and thorax) and a frontal view of the pelvis <=== these are a minimum of 20 radiographs
• In a recent report of 930 abused children, prevalence of fractures was 34%. Skeletal survey added value in 13% of cases in which new fractures were discovered only at skeletal survey but not on prior imaging. Most fractures occur in long bones, ribs and skull. Pelvis, spine, hands and feet were much less common to be fractured (only 1% of all cases, which also had other fractures diagnostic of abuse). The authors called for eliminating x-rays of the pelvis, spine, hands and feet from skeletal survey performed for suspected child abuse

Reference:

Karmazyn B, Lewis ME, Jennings SG, et al. Prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? AJR 2011; 197:W159-W163.