Frequently Asked Questions About Child Abuse and Neglect

It is important to use imaging studies to identify present and past skeletal injuries that a victim of child abuse may have suffered. For infants and small children, health care providers may order skeletal surveys to identify past and present skeletal injuries. Health care providers may order a skeletal survey and then repeat the study again two weeks later. This is because acute fractures may be occult or missed on the first study, but then evidence of a healing occult or missed fracture may be found on the second skeletal survey.
High resolution images are used to avoid a missed diagnosis. Providers generally order multiple views of the chest including anterior and posterior with oblique views of the ribs, two skull views, lateral views of the entire spine, anterior and posterior views of the pelvis, arms, hands, legs, and feet. One x-ray view of any body part is not acceptable.  
Evidence of child abuse is generally present when fractures are correlated clinically and found to involve the ends of long bones in non-ambulatory infants, multiple fractures or fractures in various phases of healing in any child, fractures associated with intracranial bleeds and depressed skull fractures.     

Healthcare providers may order bone scans (also known as bone scinitigraphy) to identify new fractures suspected to have occurred only hours previous to the study but are difficult to identify in certain anatomical locations. A bone scan is not used alone to evaluate the skeleton of a child abuse victim, but is used in conjunction with multiple imaging studies. If occult injuries are suspected, a bone scan may be ordered. Because follow-up skeletal surveys are often used, bone scans are not used as often.
Bone scans require relatively longer scanning times then x-ray studies and may not be possible due to the age or extent of injury to the child. It often requires that the child be sedated to obtain good quality studies. Other draw backs include higher radiation exposure then plain x-ray studies and higher cost for testing.

CT is generally considered a primary screening modality.
Computed tomography (CT) imaging is a very useful test for evaluating the skull and facial bones for fractures and the chest and abdomen for bone and soft tissue (organ) injuries. CT of the head without contrast may be ordered to evaluate for suspected head trauma in children. CT is useful to identify blunt trauma injuries to the chest, intestines, spleen and liver. CT imaging is a quick diagnostic tool. Drawbacks include missed small hemorrhages, hemotomas or fractures.
CT of the head should be utilized when the mechanism of injury may correlate with occult head injury and when physical examination indicates suspicion for head trauma. CT scans are often repeated to evaluate for evolving injury and infarction. 
The American College of Radiology (ACR) recommends that children with neurological symptoms associated with suspected child abuse undergo CT evaluation. In children younger than two years of age, CT is recommended (by ACR) for children suspected to be victims of child abuse that have no focal or neurological signs and symptoms.    

Magnetic resonance imaging is a very sensitive test for detecting soft tissue injuries and infarctions secondary to child abuse injuries. MRI offers greater detail and clarity than CT. If a CT study is questionable, MRI identifies more subtle injurious pathology. MRI is also very useful when neurological symptoms are more severe than that clinically correlated to CT scan. It is also a useful study to identify ligamentous injuries, especially when injury to the child's neck is strongly suspected.

Drawbacks of MRI include prolonged scanning time and necessity for sedation in young children. MRI is a very useful study during the post-injury phase approximately 3 days through 1 month later.  

Ultrasound is a safe diagnostic tool with no radiation exposure. It is cost-effective and simple to perform. To evaluate the head of a child suspected of having head trauma, the victim must have an open anterior fontanelle. Ultrasound may indentify intracranial abnormalities, including cerebral edema, hemorrhage or ventricular enlargement. Ultrasound may also identify abdominal injuries involving bleeding and free fluid. 

Ultrasound provides important but limited diagnostic information that may help guide the provider in child abuse evaluation.   

It is important to do a thorough physical examination with a thorough history of present illness and social history interview. The reported mechanism of injury or unwitnessed injury history are very important. The findings of the interview and examination must be clinically correlated with laboratory and radiographic findings.

There are types of bone fractures that are highly indicative of child abuse. But any type of fracture may be associated with child abuse injuries. A healthcare provider must always evaluate a child's injury in the context of the child's developmental stage. For instance, non-ambulatory children and infants rarely fracture a bone accidentally. Therefore, it is important to correlate clinical evidence, the type and distribution of associated injuries, the developmental stage of the child with the type of fracture. Because the force required to induce fracture exceeds the force of a simple fall.

Fractures are described according to their anatomical location and characteristic features. 

Fractures highly suggestive of child abuse include sternal fractures, scapular fractures, posterior rib fractures, metaphyseal fractures (corner, bucket-handle fractures) and spinous process fractures.  

Healthcare providers should automatically consider a child at high-risk for child abuse when parents or caregivers report unwitnessed injuries or report a mechanism of injury that is not consistent with the actual injuries or when the story changes during interviews. Very minor variation in detail from witnesses may or may not be considered suspicious. Therefore, if fractures are present, not withstanding the aforementioned, multiple fractures, fractures of various stages of healing, complex skull fractures and fractures of the vertebral body are moderately suggestive of child abuse.  

The signs and symptoms of skeletal injuries related to child abuse include visible deformity of the limb or body part, swelling with tenderness and limited use of the affected limb. Some experts report that greater than 1/3 of abused children will have some type of bone fracture. If a child has multiple fractures involving multiple bones or multiple fractures in various stages of healing, child abuse should be strongly suspected in the absence of diseases of the bones.

The AAP recommends that providers obtain a skeletal survey when evaluating children under the age of 2 years old for child abuse.  Some research shows that 80% of occult fractures are found in children less than one year of age.   

The concept of strangers being the most likely perpetrators of child abuse is not correct. Strangers inflicting child abuse account for approximately four percent of child abuse cases. Perpetrators of abuse are most likely known to the child victims prior to child abuse acts. Perpetrators most often are family members, mainly parents or significant others to parents, followed by child care givers and family acquaintances.