Child Abuse

Eva Ilse Rubio, MD

DIFFERENTIAL DIAGNOSIS

Common

Long Bone Fractures
Posterior, Lateral, Anterior Rib Fractures
Skull Fractures
Classic Metaphyseal Lesion
Solid Organ Lacerations
Inflicted Head Injury
Mimics of Child Abuse
- Physiologic Periosteal Reaction (Mimic)
- Nutritional Deficiency (Mimic)
- Leukemic Lines (Mimic)
- Birth Injuries (Mimic)
- Infection (Mimic)
- Osteogenesis Imperfecta (Mimic)
- Menkes Syndrome (Mimic)

Less Common

Small Bone Fractures
Spinous Process Fractures
Scapular Fractures
Sternal Fractures
Vertebral Compression Fractures
Bowel Injury

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Age of child
- Posterior rib fractures and intracranial injures more common in children < 1 year
- Solid organ injury/blunt trauma more common at toddler age and older
Clinical presentation
- Ranges from fussy/failure to thrive to frankly obtunded
- Clinicians may detect inconsistent or implausible stories explaining injuries
- Suspicious bruising patterns or soft tissue injuries
American College of Radiology Guidelines for Skeletal Survey
- Dedicated AP views each of humeri, forearms, femurs, tibia/fibula, hands, feet
- AP chest, AP abdomen
- Lateral views of cervical, thoracic, lumbar spine
- AP and lateral views of skull
- Additional orthogonal views should be obtained of any suspected abnormality
- Consider bilateral oblique rib views
- “Babygram” images are inadequate
- Follow-up skeletal survey performed 10-12 days after initial study is useful to detect fractures not initially seen, confirm equivocal findings

Helpful Clues for Common Diagnoses

Long Bone Fractures
- Femur, humerus most common
  - Common but nonspecific injury
  - May be innocent fractures once children are mobile/toddling
- Metatarsal/metacarpal fractures
  - Often buckled appearance, can be subtle
Posterior, Lateral, Anterior Rib Fractures
- More common on left
- May be subtle if minimally displaced, or acute without callus formation
  - Oblique views may increase detection
Skull Fractures
- Common but nonspecific injury
- Features that raise suspicion
  - Complex, displaced fractures
  - Crossing suture lines
Classic Metaphyseal Lesion
- Accepted mechanism is shear injury through primary spongiosa of distal metaphysis due to grabbing, twisting
- Common locations
  - Tibia, femur, humerus
Solid Organ Lacerations
- Liver lacerations/contusions
  - Linear or branching, low-attenuation, intraparenchymal foci on CT
  - CT bone windows may reveal additional rib fractures overlying organ injury
- Splenic lacerations/contusions
  - Linear or branching, low-attenuation, intraparenchymal foci on CT
- Adrenal laceration/hematoma
  - Usually globular abnormality
  - High attenuation on CT if acute; low attenuation if subacute/chronic
Inflicted Head Injury
- Subdural hematoma
  - Fluid collection overlying brain convexity, layering along tentorium and interhemispheric falx
  - Swirling low attenuation within high attenuation fluid may indicate active bleeding or dural injury with CSF leak
  - Interhemispheric hematoma increases suspicion for inflicted trauma
- Subarachnoid hemorrhage
  - Wispy/linear high density following sulci
- Anoxic injury
  - Early: Ill-defined, low-attenuation areas
  - Late: Progressively low-attenuating parenchyma, loss of gray-white matter differentiation, sulcal effacement
Mimics of Child Abuse
- Physiologic Periosteal Reaction (Mimic)
  - Typically seen ages 1-6 months
  - Often symmetric but not exclusively
  - Appearance: Thin, smooth, diaphyseal
- Nutritional Deficiency (Mimic)
  - Children with liver failure, TPN dependency, short gut syndrome
  - Rib and extremity fractures may be seen from normal patient handling
- Leukemic Lines (Mimic)
  - Usually in older age group; neonatal leukemia very rare, associated with hepatosplenomegaly and chromosomal abnormalities
  - Expect symmetric manifestation
- Birth Injuries (Mimic)
  - Most common: Clavicle, humerus fractures; subdural hematomas
  - Timing/manner of delivery important
- Infection (Mimic)
  - Osteomyelitis, TORCH infections, especially syphilis
- Osteogenesis Imperfecta (Mimic)
  - Appearance of bones ranges from near normal to osteopenic and dysmorphic
- Menkes Syndrome (Mimic)
  - Intracranial parenchymal volume loss, hemorrhages, and metaphyseal lesions can be mistaken for abuse
  - X-linked disorder

Helpful Clues for Less Common Diagnoses

Small Bone Fractures
- Buckle fractures of metatarsals, metacarpals
Spinous Process Fractures
- Avulsion fractures of spinous process tips uncommon but highly specific for abuse
Scapular Fractures
- Fractures of acromion, scapular body uncommon but highly specific for abuse
Sternal Fractures
- Associated with blunt trauma
- Consider vascular/cardiac injury
Vertebral Compression Fractures
- Thoracolumbar compression fractures occur with axial loading force
Bowel Injury
- Duodenum
  - Hematoma protruding as intraluminal mass or intramural lesion
  - Perforation: Look for retroperitoneal air
- Jejunum
  - Perforation somewhat more likely than hematoma