Imaging of Non-accidental Trauma

Imaging of Non-accidental Trauma - Unmasking Abuse

• Definition: Non-Accidental Injury (NAI) includes child abuse and neglect.
• Epidemiology: Most common in children <1-2 years. Skeletal survey for those <2 years.
• Clinical Red Flags:
  • Inconsistent history with injury.
  • Delay in seeking care.
  • 📌 TEN-4 FACES Rule: Bruising on Torso, Ears, Neck (TEN) in child ≤4 years; OR any bruise on infant ≤4 months.
  • Specific burn patterns (e.g., immersion, stocking/glove).

⭐ Discrepancy between history and injury severity is a major red flag. oka

Imaging of Non-accidental Trauma - Osseous Omens

• Indications for Skeletal Survey (SS):
  • Suspected Non-Accidental Trauma (NAT) in children <24 months.
  • Siblings of abused children.
  • Unexplained fractures, bruising, or severe injuries in young children.
• Technique:
  • Dedicated multi-view radiographic skeletal survey (AP & lateral views of long bones, AP/PA & lateral views of chest, skull, spine, pelvis).
  • "Babygram" (single whole-body view) discouraged due to ↓ sensitivity.
  • Follow-up SS in ~2 weeks to detect initially occult fractures.
• High-Specificity Fractures (Hallmarks of NAT):
  • Classic Metaphyseal Lesions (CMLs) (from shearing/tensile forces):
    • Corner fractures.
    • Bucket-handle fractures.
  • Posterior rib fractures (from AP chest compression; highly specific).
  • Scapular fractures (acromion, glenoid, body).
  • Sternal fractures.
  • Spinous process fractures.

  ⭐ Classic Metaphyseal Lesions (CMLs) are virtually pathognomonic for NAT.

• Fracture Dating:
  • Radiographic dating is imprecise; use with caution.
  • Presence of multiple fractures in different stages of healing is highly suggestive of NAT.

Imaging of Non-accidental Trauma - Hidden Harms

• Head: Critical for detecting inflicted injuries; CT initially, MRI for detail/dating.
  • Subdural Hematoma (SDH): Common; interhemispheric, convexity, posterior fossa.
  • Hypoxic-Ischemic Injury (HII): Often associated, especially with SDH.
  • Diffuse Axonal Injury (DAI): From shear forces; MRI superior.
  • Retinal hemorrhages: Strong indicator (ophthalmology exam vital).

  ⭐ Interhemispheric subdural hematomas, especially with associated hypoxic-ischemic injury, are highly suggestive of abusive head trauma.

• Thorax: Injuries often occult; high specificity for NAT.
  • Rib fractures: Especially posterior, multiple, varied healing stages.
  • Lung contusions or lacerations.
• Abdomen: Second leading cause of NAT fatality. CT with IV contrast is crucial.
  • Solid organ injury: Liver (most common), spleen, pancreas (lacerations, hematomas).
  • Hollow viscus injury: Duodenal hematoma (classic), bowel perforation, mesenteric tears.

Imaging of Non-accidental Trauma - Diagnostic Duty

• Crucial Differentials (Mimics of NAT):
  • Osteogenesis Imperfecta (OI): Blue sclera, multiple #, wormian bones. Note bone density.
  • Rickets: Metaphyseal cupping/fraying, widened physes, osteopenia.
  • Birth Trauma: Clavicle, humerus, skull # (parietal, linear). Often isolated.
  • Normal Variants: Physiological periostitis (symmetric), metaphyseal spurs.
• Radiologist's Reporting Duty:
  • Objective description of findings; avoid accusatory language.
  • Mention limitations (e.g., incomplete survey).
  • Recommend follow-up imaging, MDT/CPS communication.

⭐ Classic Metaphyseal Lesions (CMLs) and posterior rib fractures are highly specific for NAT, rarely seen in Osteogenesis Imperfecta.

High‑Yield Points - ⚡ Biggest Takeaways

• Skeletal survey is the primary imaging modality for suspected NAT in infants < 2 years.
• Metaphyseal corner fractures (bucket-handle fractures) are highly specific for NAT.
• Posterior rib fractures, especially multiple and in different healing stages, are highly suspicious.
• Complex skull fractures (e.g., depressed, bilateral, crossing sutures) raise significant concern.
• Subdural hematomas, particularly of varying ages, are common intracranial findings.
• CT head is crucial for acute intracranial injuries; MRI for subacute/chronic findings and hypoxic injury.
• A repeat skeletal survey in approximately 2 weeks can reveal initially occult fractures an_d monitor healing_