Abused Child in Radiologic Department.
Stanislav Tůma
Summary
The discovery of nonaccidental injuries is relatively simple, but the differential diagnostic evaluation
and confirmation is more difficult. On the other hand some radiographic findings can mimic child
abuse and may lead to overdiagnosis. Therefore, the report is devoted to only two or three main
items: Classical features of battered child syndrome with examples of diagnostic radiologists´ hints
and up-to-date technique and combination of different imaging modalities as a large pallette of
radiological possibilities, mainly in the differential diagnostic approach. The special form of abused
child syndrome, the so called Munchhausen by proxy syndrome, is remembered. Also the danger of
self-reffering in imaging of abused child by clinicians is introducing. The problems could be
summarized that evaluations of details in x-ray findings belong to the pediatric radiologist.
Moreover, there exists a large pallette of new imaging modalities even without ionizing radiation,
based on different physicle principles, possible to confirm the diagnosis.
Key words: infants –nonaccidental injuries – battered-child syndrome – Munchhausen-by-proxy
syndrome – brain injury – difuse-axonal injury – self-reffering – pediatric radiology.
Nonaccidental children injuries were described in the 19th century by
Ambroise Tardieu. Worldwide known the battered child syndrome was
described by John Caffey as the classical X-ray features on bones in
children with subdural hematomas (1,2).
John Caffey, MD (1895-1978)
They are
 huge asymmetrical periostitic reactions with subperiosteal hematomas,
 multiple, multiform and multitudinous fractures in different phases of healing,
 meta-epiphyseolyses, especially in distal parts of bones
 with tortuous corners with „bucket-handle sign“,
 spiral fractures or transversal interruption of diaphyses,
 fractures of posterior ribs, scapula, sternum, and skull and brain.
In abused infants who died, fractures of ribs and metaphyses were much more common than other
ones. In most of them at least one healing fracture was present (3,4).
Trasversal fractures of the diaphyses of the right
radius and ulna with the prone dislocation ad
axim.
As an example of radiological hints in thoracic findings in infants it could be demonstrated an
important X-ray finding of the acute reopacification as a sign of neurogennic edema due to the
intraventricular hemorrhage. It is to be confirmed by transfontanell ultrasound. To the other signs
belong
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Multiple costal (and vertebral, clavicular, scapular)
fractures
Infirm compactness of the thoracic wall
Asynchronic movements of the thoracic wall
Mechanical ventilation with PEEP
Pneumothorax
Fractures of posterior ribs and different date and
stage of healing.
Reading the examination, the special expressness of the radiological report has to be devoted to
complications and uncommon varieties in the healing of wounds , possibilities of the diseases of
inner organs and recommendation to other imaging modality respectively. Recommendation of
methods prefers
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Ultrasound as a threshold for everything, but confirmation by other modality is
recommended. It is to be used especially in soft tissues, abdominal organs.
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Fluorography is common in musculoskeletal system imaging.
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CT has preferrences in the brain
and skul lor in spine injuries, but
also in cases of fractures of
epiphyses (together with 3D and
multiplanar reconstructions).
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MRI is prefered in abdominal and
pelvic structures and, of course, in brain.
In suspected clinical cases the radiological control is recommended:
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Chest x-ray every day to contro position of catheters or canules and state of aeration of lungs
and intestine.
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CT - pneumothorax
Series US of head – transfontanelle control of intraventricular hemorrhagie (5),
Asphyctic focal brain
oedema in newborn.
Posthypoxic encephalomatic
porencephaly in 5 months boy.
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Echocardiographic control of the heart functions, pulmonary hypertension and ductal shunt
and extracelular fluid in subcutaneous edema or brain edema.
Special short note has to be done to prenatal diagnostic imaging by prenatal ultrasonography or
magnetic resonance. The control of the findings is useful in comparison of postnatal features in
differential diagnostic approach to the nonaccidental possibilities of injuries in newborns and infants.
Possibly it should be important in the postponed differential diagnostic approach to
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Polyhydramnion
Fetal hydrops
Fetal hypotrophy
Fetal hypokinesis or akinesis
Fetal skeletal dysplasias
Anomalies of lungs, heart, GIT, CNS
Autosomal recessive renal diseases
In the brain and skull imaging is indicated
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X-ray – traditionally in 2 views (minimally),
CT - most reliable in fractures and in differential diagnostics.
MRI – brain imaging.
Typical findings in brain in battered child syndrome are
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Epi- subdural hematomas in different stage of healing,
Cortical contusions,
Diffuse axonal Indry (6),
Intraventricular and retinal hemorrhagie,
Cerebral ischemia,
Skull and skeletal injuries.
Epidural hematoma
Subdural hematoma on the right parietal side.
Hydrocephalus with shunt
Differential diagnostic possibilities of CT
Craniosynostosis
(3D CT – volume rendered technique)
Deformation of the skull due to fibrous dysplasia of the
base (multiplanar reconstruction)
The closed injuries of abdominal organs are possible. Spleen is the most commonly involved
abdominal organ in trauma, with the serious risk of hemorrhage form the rupture in second time in
case of subcapsular hematoma leading to hemoperitoneum. Liver contusions and renal injuries are
also seen. It is interesting, that the scrotal injury is lacking in abused children. Scrotum is not a target
of violence.
At radiological departments it has to be awared the special form of abused child syndrome, the so
called Munchhausen by proxy syndrome. It is joint with suprisingly special forms of injury together
with medical or iatrogennic injuries - even with the heart catheterization or other invasive methods
and new modalities. Special attention has to be payed to procedures using the contrast media ! (also
MR!).
Generally we have to attend dangers of
 ionizing radiation,
 contrast material,
 invasivity of procedures,
 psychological sequellae: some victims later become perpetrators themselves.
It is very difficult to confirm it. Repeated heart catheterizations and angiographic procedures were
described in literature, for example. Now there are coming to try news in MR imaging, by chance,
without ionizing radiation.
To the end of the article we want to introduce the problem of self-reffering in imaging of abused
child by clinicians. The disadvantage of self-reffering is valuable generally. There is recommended to
consult pediatric radiologist before ordering an investigative procedure. We seem to give warning to
clinicians not to resolve the imaging modality themselves, not to perform the examination and
evaluation of results or to continue at next steps without pediatric radiologists.
In conclusion there is introduced the synthesis of the state-of-the-art instead of the summary:
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Evaluations of details in x-ray findings belong to the pediatric radiologist.
In investigation there exists a large pallette of new imaging modalities even without ionizing
radiation, based on different physical principles:
Literature:
1. Griscom,N.T.: History of pediatric radiology in the United States and Canada: images and
trends. Radiographics 1995; 15, 6:1399-1422.
2. Caffey,J.: Multiple fractures in the long bones of infant suffering from chronic subdural
hemastoma. AJR 1946; 56:163-173.
3. Kleinman,P.K., Marks,S.C.,Jr., Spevak,M.R., Nimkin,K., Richmond,J.M., Blackhourne,B.D.:
Inflicted skeletal injury ín infant facilities: a 10-year experience. Soc.Pediatric Radiology,
1995:98-99.
4. Spevak,M.R., Nimkin,K., Marks,S.C.,Jr., Richmond,J.M., Kleinman,P.K.: Fractures of the hands
and feet in child abuse: radiologi and pathologic features. Soc.Pediatric Radiology, 1995:99.
5. Ridzoň,Š.: Hypoxic ischaemic cerebral changes in mature neonates and infants. Sonographic
picture. Čes. Radiol., 1995; 49, 2:107-111.
6. Neuwirth,J.: Difuzní axonální poranění. In: Kompendium diagnostického zobrazování. Triton,
Praha 1998, p.242.