Child Abuse Imaging

NAI Basics & Skeletal Scan - Bones Don't Lie

• Non-Accidental Injury (NAI): Harm to a child due to non-accidental means by a caregiver.
• Red Flags: Inconsistent/vague history, delayed medical attention, multiple injuries of different ages, specific fracture patterns (e.g., metaphyseal, posterior ribs, sternal, scapular).
• Imaging Indications:
  • All suspected NAI cases in children < 2 years.
  • Older children with suspicious injuries if history is inconsistent.
• Skeletal Survey Components:
  • AP/Lat: Skull, chest, spine.
  • AP: Pelvis, hands, feet.
  • AP/Lat: Long bones (humeri, femora, tibiae/fibulae).
  • Oblique views of ribs.
• Follow-up Survey: Crucial in 10-14 days to detect initially occult fractures (e.g., healing periosteal reactions).

⭐ Skeletal survey is the primary imaging modality for suspected NAI in children <2 years old due to its ability to detect a wide range of fractures, including those not clinically apparent.

NAI Fracture Patterns - Twists & Telltales

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NAI: Head & Viscera - Beyond Broken Bones

• Abusive Head Trauma (AHT): Critical intracranial injuries.
  • Subdural Hematoma (SDH): Interhemispheric, convexity, posterior fossa; often thin.
  • Retinal Hemorrhages: Highly specific; often bilateral, multilayered, extending to ora serrata.
  • Hypoxic-Ischemic Injury (HII): From shaking/impact; diffuse cerebral edema, watershed infarcts.
• AHT Imaging:

![Child Abuse Imaging: Brain MRI, CT, Skeletal Survey](https://ylbwdadhbcjolwylidja.supabase.co/storage/v1/object/public/notes/L1/Radiology_Pediatric_Radiology_Child_Abuse_Imaging/b0054159-d028-4a03-b9ac-6e46880d343e.png)
-   CT for acute bleeds; MRI for subacute/chronic changes, HII, and small SDHs.

• Visceral Injuries (Often Occult):
  • Liver laceration: Most common (posterior right lobe).
  • Pancreatic injury, bowel (hematoma/perforation), adrenal hemorrhage.
  • High mortality; suspect with unexplained shock/anemia. CT abdomen with contrast.
• Cutaneous Clues: Patterned bruises (e.g., handprints), specific burn types (e.g., cigarette, immersion).

⭐ The triad of subdural hematoma, retinal hemorrhages, and encephalopathy is highly suggestive of Abusive Head Trauma.

NAI Imaging Mimics - Innocent Impostors

• Osteogenesis Imperfecta (OI): Blue sclera, wormian bones, gracile bones, recurrent fractures (minor trauma).

  ⭐ Osteogenesis Imperfecta is a key differential for multiple fractures, but Classic Metaphyseal Lesions (CMLs) and posterior rib fractures are rare in OI.

• Rickets: Cupping/fraying/splaying of metaphyses, Looser zones, rachitic rosary.
• Scurvy: Subperiosteal hemorrhage, Wimberger's sign (ring epiphysis), Pelkan spur, Frankel's line.
• Caffey Disease: Infantile cortical hyperostosis (mandible, clavicle, ulna); irritability, fever.
• Normal Variants: Physiologic periostitis (newborn), distal clavicular erosions (resolves by 2 yrs).
• Birth Trauma: Clavicle, humerus, femur fractures.
• Metabolic bone disease workup if suspected.

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High‑Yield Points - ⚡ Biggest Takeaways

• Skeletal survey is crucial for suspected abuse in children < 2 years.
• Classic metaphyseal lesions (CMLs) are highly specific for non-accidental injury.
• Posterior rib fractures, especially multiple and healing, strongly indicate abuse.
• Subdural hematomas (SDH), particularly interhemispheric, are common in abusive head trauma.
• Retinal hemorrhages are strongly associated with abusive head trauma.
• Multiple fractures at various stages of healing are a key indicator.
• CT head for acute injury; MRI for detailed brain assessment and timing of injury.