Child Abuse
Eva Ilse Rubio, MD
DIFFERENTIAL DIAGNOSIS
Common
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Long Bone Fractures
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Posterior, Lateral, Anterior Rib Fractures
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Skull Fractures
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Classic Metaphyseal Lesion
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Solid Organ Lacerations
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Inflicted Head Injury
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Mimics of Child Abuse
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Physiologic Periosteal Reaction (Mimic)
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Nutritional Deficiency (Mimic)
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Leukemic Lines (Mimic)
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Birth Injuries (Mimic)
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Infection (Mimic)
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Osteogenesis Imperfecta (Mimic)
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Menkes Syndrome (Mimic)
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Less Common
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Small Bone Fractures
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Spinous Process Fractures
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Scapular Fractures
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Sternal Fractures
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Vertebral Compression Fractures
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Bowel Injury
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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Age of child
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Posterior rib fractures and intracranial injures more common in children < 1 year
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Solid organ injury/blunt trauma more common at toddler age and older
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Clinical presentation
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Ranges from fussy/failure to thrive to frankly obtunded
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Clinicians may detect inconsistent or implausible stories explaining injuries
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Suspicious bruising patterns or soft tissue injuries
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American College of Radiology Guidelines for Skeletal Survey
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Dedicated AP views each of humeri, forearms, femurs, tibia/fibula, hands, feet
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AP chest, AP abdomen
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Lateral views of cervical, thoracic, lumbar spine
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AP and lateral views of skull
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Additional orthogonal views should be obtained of any suspected abnormality
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Consider bilateral oblique rib views
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“Babygram” images are inadequate
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Follow-up skeletal survey performed 10-12 days after initial study is useful to detect fractures not initially seen, confirm equivocal findings
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Helpful Clues for Common Diagnoses
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Long Bone Fractures
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Femur, humerus most common
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Common but nonspecific injury
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May be innocent fractures once children are mobile/toddling
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Metatarsal/metacarpal fractures
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Often buckled appearance, can be subtle
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Posterior, Lateral, Anterior Rib Fractures
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More common on left
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May be subtle if minimally displaced, or acute without callus formation
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Oblique views may increase detection
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Skull Fractures
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Common but nonspecific injury
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Features that raise suspicion
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Complex, displaced fractures
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Crossing suture lines
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Classic Metaphyseal Lesion
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Accepted mechanism is shear injury through primary spongiosa of distal metaphysis due to grabbing, twisting
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Common locations
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Tibia, femur, humerus
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Solid Organ Lacerations
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Liver lacerations/contusions
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Linear or branching, low-attenuation, intraparenchymal foci on CT
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CT bone windows may reveal additional rib fractures overlying organ injury
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Splenic lacerations/contusions
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Linear or branching, low-attenuation, intraparenchymal foci on CT
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Adrenal laceration/hematoma
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Usually globular abnormality
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High attenuation on CT if acute; low attenuation if subacute/chronic
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Inflicted Head Injury
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Subdural hematoma
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Subarachnoid hemorrhage
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Wispy/linear high density following sulci
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Anoxic injury
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Early: Ill-defined, low-attenuation areas
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Late: Progressively low-attenuating parenchyma, loss of gray-white matter differentiation, sulcal effacement
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Mimics of Child Abuse
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Physiologic Periosteal Reaction (Mimic)
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Typically seen ages 1-6 months
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Often symmetric but not exclusively
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Appearance: Thin, smooth, diaphyseal
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Nutritional Deficiency (Mimic)
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Children with liver failure, TPN dependency, short gut syndrome
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Rib and extremity fractures may be seen from normal patient handling
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Leukemic Lines (Mimic)
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Usually in older age group; neonatal leukemia very rare, associated with hepatosplenomegaly and chromosomal abnormalities
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Expect symmetric manifestation
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Birth Injuries (Mimic)
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Most common: Clavicle, humerus fractures; subdural hematomas
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Timing/manner of delivery important
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Infection (Mimic)
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Osteomyelitis, TORCH infections, especially syphilis
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Osteogenesis Imperfecta (Mimic)
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Appearance of bones ranges from near normal to osteopenic and dysmorphic
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Menkes Syndrome (Mimic)
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Intracranial parenchymal volume loss, hemorrhages, and metaphyseal lesions can be mistaken for abuse
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X-linked disorder
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Helpful Clues for Less Common Diagnoses
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Small Bone Fractures
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Buckle fractures of metatarsals, metacarpals
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Spinous Process Fractures
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Avulsion fractures of spinous process tips uncommon but highly specific for abuse
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Scapular Fractures
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Fractures of acromion, scapular body uncommon but highly specific for abuse
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Sternal Fractures
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Associated with blunt trauma
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Consider vascular/cardiac injury
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Vertebral Compression Fractures
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Thoracolumbar compression fractures occur with axial loading force
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Bowel Injury
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Duodenum
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Hematoma protruding as intraluminal mass or intramural lesion
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Perforation: Look for retroperitoneal air
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Jejunum
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Perforation somewhat more likely than hematoma
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Image Gallery
![]() AP radiograph shows callus
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