Pediatric Radiology

, Volume 40, Issue 6, pp 932–938 | Cite as

How to explore and report children with suspected non-accidental trauma

  • Catherine AdamsbaumEmail author
  • Nathalie Méjean
  • Valérie Merzoug
  • Caroline Rey-Salmon


Child abuse is a controversial problem of special concern. Recent reports have focused on the broad variability of reporting to child protection services. Radiologists play a key role in the early diagnosis and imaging of suspected inflicted injury. Imaging must be performed and then interpreted with rigour.

The aims of this review are:
  • To review the recent recommended guidelines for imaging in cases of suspicion of abuse. These include a highly detailed complete skeletal survey with centered views, whilst brain CT and/or MRI are mandatory in children younger than 2 years. The use of abdominal imaging is debatable if the child has no symptoms. All siblings younger than 2 years should be assessed in the same way while the diagnosis of abuse is investigated. Body MRI is an interesting modality that remains a “work-in-progress”.

  • To highlight that dating of both brain and skeletal injuries is imprecise. The main point is, however, to determine if the pattern is of “age-different” lesions. This not only provides a strong argument for the diagnosis of abuse, but also indicates repetitive violence with a high risk for further injury and death.

  • To remember that the medical perspective is to protect the child. Thus, radiologists must communicate clearly the suspicion of abuse and the degree of certainty to clinicians to aid reporting or hospitalization.


Abuse Fractures Brain Subdural haematoma Radiograph CT MRI Child 


  1. 1.
    van Rijn RR (2009) How should we image skeletal injuries in child abuse? Pediatr Radiol 39:S226–S229CrossRefPubMedGoogle Scholar
  2. 2.
    Hobbs C, Childs AM, Wynne J et al (2005) Subdural haematoma and effusion in infancy: an epidemiological study. Arch Dis Child 90:952–955CrossRefPubMedGoogle Scholar
  3. 3.
    Jenny C, Hymel KP, Ritzen A et al (1999) Analysis of missed cases of abusive head trauma. JAMA 281:621–626CrossRefPubMedGoogle Scholar
  4. 4.
    Kleinman PK (1998) Diagnostic imaging of child abuse, 2nd edn. Mosby, St LouisGoogle Scholar
  5. 5.
    Jones R, Flaherty EG, Binns HJ et al (2008) Clinicians’ description of factors influencing their reporting of suspected child abuse: report of the Child Abuse Reporting Experience Study Research Group. Pediatrics 122:259–266CrossRefPubMedGoogle Scholar
  6. 6.
    Hobbs CJ, Bilo RA (2009) Nonaccidental trauma: clinical aspects and epidemiology of child abuse. Pediatr Radiol 39:457–460CrossRefPubMedGoogle Scholar
  7. 7.
    Lindberg DM, Lindsell CJ, Shapiro RA (2008) Variability in expert assessments of child physical abuse likelihood. Pediatrics 121:e945–e953CrossRefPubMedGoogle Scholar
  8. 8.
    Kleinman PK (2008) “The roentgen manifestations of unrecognized skeletal trauma in infants”—a commentary. AJR 190:559–560CrossRefPubMedGoogle Scholar
  9. 9.
    Offiah A, van Rijn RR, Perez-Rossello JM et al (2009) Skeletal imaging of child abuse (non-accidental injury). Pediatr Radiol 39:461–470CrossRefPubMedGoogle Scholar
  10. 10.
    O’Connor JF, Cohen J (1998) Dating fractures. In: Kleinman PK (ed) Diagnostic imaging of child abuse, 2nd edn. Mosby, St Louis, pp 168–177Google Scholar
  11. 11.
    Lonergan GJ, Baker AM, Morey MK et al (2003) From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics 23:811–845CrossRefPubMedGoogle Scholar
  12. 12.
    Section on Radiology, American Academy of Pediatrics (2009) Diagnostic imaging of child abuse. Pediatrics 123:1430–1435CrossRefGoogle Scholar
  13. 13.
    Alexander RC, Schor DP, Smith WL Jr (1986) Magnetic resonance imaging of intracranial injuries from child abuse. J Pediatr 109:975–979CrossRefPubMedGoogle Scholar
  14. 14.
    Offiah AC, Hall CM (2003) Observational study of skeletal surveys in suspected non-accidental injury. Clin Radiol 58:702–705CrossRefPubMedGoogle Scholar
  15. 15.
    Schmit P, Abdolell M, Bellemare S et al (2007) Inflicted injury in children: variability of imaging practice among pediatric radiologists. Pediatr Radiol 37:S49Google Scholar
  16. 16.
    American College of Radiology (2006) ACR practice guideline for skeletal surveys in children. At updated 5 Feb 2009
  17. 17.
    British Society of Paediatric Radiology (2009) Standard for skeletal surveys in suspected non-accidental injury (NAI) in children. At
  18. 18.
    Ingram JD, Connell J, Hay TC et al (2000) Oblique radiographs of the chest in nonaccidental trauma. Emerg Radiol 7:42–46CrossRefGoogle Scholar
  19. 19.
    American Academy of Pediatrics (1998) Medical necessity for the hospitalization of the abused and neglected child. American Academy of Pediatrics. Committee on Hospital Care and Committee on Child Abuse and Neglect. Pediatrics 101:715–716CrossRefGoogle Scholar
  20. 20.
    American Academy of Pediatrics (2000) Diagnostic imaging of child abuse. Pediatrics 105:1345–1348CrossRefGoogle Scholar
  21. 21.
    Kleinman PK, Nimkin K, Spevak MR et al (1996) Follow-up skeletal surveys in suspected child abuse. AJR 167:893–896PubMedGoogle Scholar
  22. 22.
    Wootton-Gorges SL, Stein-Wexler R, Walton JW et al (2008) Comparison of computed tomography and chest radiography in the detection of rib fractures in abused infants. Child Abuse Negl 32:659–663CrossRefPubMedGoogle Scholar
  23. 23.
    Darge K, Jaramillo D, Siegel MJ (2008) Whole-body MRI in children: current status and future applications. Eur J Radiol 68:289–298CrossRefPubMedGoogle Scholar
  24. 24.
    Kemp AM, Stoodley N, Cobley C et al (2003) Apnoea and brain swelling in non-accidental head injury. Arch Dis Child 88:472–476CrossRefPubMedGoogle Scholar
  25. 25.
    Stoodley N (2002) Non-accidental head injury in children: gathering the evidence. Lancet 360:271–272CrossRefPubMedGoogle Scholar
  26. 26.
    Rubin DM, Christian CW, Bilaniuk LT et al (2003) Occult head injury in high-risk abused children. Pediatrics 111:1382–1386CrossRefPubMedGoogle Scholar
  27. 27.
    Aldrich EF, Eisenberg HM, Saydjari C et al (1992) Predictors of mortality in severely head-injured patients with civilian gunshot wounds: a report from the NIH Traumatic Coma Data Bank. Surg Neurol 38:418–423CrossRefPubMedGoogle Scholar
  28. 28.
    American College of Radiology (2005) ACR appropriateness criteria. At
  29. 29.
    Vezina G (2009) Assessment of the nature and age of subdural collections in nonaccidental head injury with CT and MRI. Pediatr Radiol 39:586–590CrossRefPubMedGoogle Scholar
  30. 30.
    Sivit CJ, Taylor GA, Eichelberger MR (1989) Visceral injury in battered children: a changing perspective. Radiology 173:659–661PubMedGoogle Scholar
  31. 31.
    Le Dosseur P (1999) Imaging in battered child syndrome. J Radiol 80:549PubMedGoogle Scholar
  32. 32.
    Lane WG, Dubowitz H, Langenberg P (2009) Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics 124:1595–1602CrossRefPubMedGoogle Scholar
  33. 33.
    Prosser I, Maguire S, Harrison SK et al (2005) How old is this fracture? Radiologic dating of fractures in children: a systematic review. AJR 184:1282–1286PubMedGoogle Scholar
  34. 34.
    Kleinman PK (2008) Problems in the diagnosis of metaphyseal fractures. Pediatr Radiol 38:S388–S394CrossRefPubMedGoogle Scholar
  35. 35.
    Stoodley N (2006) Controversies in non-accidental head injury in infants. Br J Radiol 79:550–553CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Catherine Adamsbaum
    • 1
    Email author
  • Nathalie Méjean
    • 2
  • Valérie Merzoug
    • 2
  • Caroline Rey-Salmon
    • 3
  1. 1.Radiology Department, Pediatric ImagingParis Descartes University, St Vincent de Paul HospitalParis Cedex 14France
  2. 2.Radiology Department, Pediatric ImagingSt Vincent de Paul HospitalParis Cedex 14France
  3. 3.Medico-Judicial UnitHôtel Dieu Hospital, AP-HPParisFrance

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