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Child Abuse
Battered Child Syndrome

  • Most common cause of serious intracranial injuries in children less than 1 year of age
  • 3rd most common cause of death in children after sudden infant death syndrome and true accidents
  • Prevalence
    • 1.7 million cases reported, 833,000 of which were substantiated in United States in 1990
    • Results in 2,500-5,000 deaths/year
    • 5-10% of children seen in emergency rooms suffer from child abuse
  • Radiologist has legal obligation to report suspected child abuse, usually to the referring physician
  • Age
    • Usually <2 years
  • In children <2 years of age, a skeletal survey may be best to demonstrate other fractures
    • In children >2 years of age, a bone scan may be best
  • Clinical findings
    • Skin burns
    • Bruises
    • Lacerations
    • Hematomas
  • Skeletal trauma is seen in 50-80%



Skeletal Trauma Suspicious for Child Abuse



Distal Femur, distal humerus, wrist, ankle

Metaphyseal corner fractures


Fractures in different stages of healing

Femur, humerus, tibia

Spiral fractures < 1 year of age

Posterior ribs, avulsed spinous processes

Unusual “naturally-occurring” fractures <5years of age

Multiple skull fractures

Multiple fractures of occipital bone should suggest child abuse

Fractures with abundant callous formation

Implies repeated trauma and no immobilization

Metacarpal and metatarsal fractures

Unusual “naturally-occurring” fractures <5years of age

Sternal and scapular fractures

Vertebral body fractures and subluxations


  • Sites of skeletal trauma
    • Multiple ribs
    • Transverse fracture of sternum
    • Costochondral / costovertebral separation
    • Lateral end of clavicles
    • Scapula
    • Acromion
    • Skull
    • Vertebral bodies
      • Anterior-superior wedging of vertebral bodies
      • Vertebral compression
      • Vertebral fracture dislocation
      • Disk space narrowing
      • Spinous processes

child abuse

Frontal radiograph of the chest demonstrates multiple rib fractures with callous formation, including a fracture of the left 2nd and 6th ribs posteriorly. Posterior rib fractures are highly suggestive of child abuse (from forceful squeezing)

  • Appearances of skeletal trauma
    • Hallmark of the syndrome are multiple, asymmetric fractures in different stages of healing
    • Separation of distal epiphysis
    • Marked irregularity and fragmentation of metaphyses
      • "Corner" fracture (11%) or "Bucket-handle" fracture = avulsion of a metaphyseal fragment overlying the lucent epiphyseal cartilage secondary to a sudden twisting motion of extremity
    • Isolated spiral fracture (15%) of diaphysis secondary to external rotatory force applied to femur / humerus
    • Extensive periosteal reaction from large subperiosteal hematoma
    • Exuberant callus formation at fracture sites
    • Cortical hyperostosis extending to epiphyseal plate
    • Avulsion fracture at site of ligamentous insertion
      • Frequently seen without periosteal reaction
  • Head trauma (13-25%)
    • Most common cause of death and/or physical disability
      • Skull fracture (flexible calvaria + meninges decrease likelihood of skull fractures)
      • Subdural hematoma
      • Brain contusion
      • Cerebral hemorrhage
      • Infarction
      • Generalized edema
      • Shearing injuries with associated subarachnoid hemorrhage
      • Skull film (associated fracture in 1%):
        • Linear fracture > comminuted fracture
    • CT findings in head trauma
      • Subdural hemorrhage (most common)
        • Interhemispheric location most common
      • Subarachnoid hemorrhage
      • Epidural hemorrhage (uncommon)
      • Cerebral edema (focal, multifocal, diffuse)
      • Acute cerebral contusion appears as ovoid collection of intraparenchymal blood with surrounding edema
    • MR findings of head trauma
      • More sensitive in identifying hematomas of differing ages
      • White matter shearing injuries as areas of prolonged T1 + T2 at corticomedullary junction, centrum semiovale, corpus callosum
  • Viscera (3%)
    • Second leading cause of death in child abuse
    • Cause
      • Crushing blow to abdomen (punch, kick)
    • Age
      • Often >2 years
    • Small bowel and/or gastric rupture
    • Hematoma of duodenum and/or jejunum
    • Contusion and/or laceration of lung, pancreas, liver, spleen, kidney
    • Traumatic pancreatic pseudocyst
  • Differential diagnosis of child abuse
    • Normal periostitis of infancy
    • Osteogenesis imperfecta
    • Congenital insensitivity to pain
    • Infantile cortical hyperostosis
    • Menkes kinky hair syndrome
    • Schmid-type chondrometaphyseal dysplasia
    • Scurvy
    • Congenital syphilitic metaphysitis
child abuse

Child abuse. Frontal and oblique views of the radius demonstrate multiple fractures present at the metaphysis of the distal radius (white arrows). A history of child abuse was elicited.
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Dahnert 5th edition
Requisites-Pediatric Radiology
Requisites-Musculoskeletal Radiology