The Spectrum of Non-accidental Injuries (Child Abuse) and Its Imitators

  • Paul K. Kleinman


Skeletal injuries are the most common findings noted on imaging studies in cases of child abuse. In infants (<1 year), they result from manual assault that may include shaking. In contrast to central nervous system and other visceral injuries, they are rarely life-threatening. However, documentation of skeletal trauma is often central to the diagnosis of abuse. In infants, certain lesions are sufficiently characteristic to point strongly to the diagnosis of inflicted trauma (Table 1). Other fractures are less specific for abuse, but when correlated with other imaging findings and clinical information their presence may add strong support for the diagnosis.
Table 1

Specificity of raddiologic findings


Cage Leukemia Pneumonia Brittle Neuroblastoma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Caffey J (1946) Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. AJR Am J Roentgenol 56:163–173Google Scholar
  2. 2.
    Caffey J (1957) Some traumatic lesions in growing bones other than fractures and dislocations: clinical and radiological features. Br J Radiol 30:225–238CrossRefPubMedGoogle Scholar
  3. 3.
    Kleinman P (1998) Diagnostic imaging of child abuse, 2nd edn. Mosby-Year Book, St. Louis, MOGoogle Scholar
  4. 4.
    Kleinman PK (2008) Problems in the diagnosis of metaphyseal fractures. Pediatr Radiol 38(Suppl 3):S388–S394CrossRefPubMedGoogle Scholar
  5. 5.
    Grayev A, Boal D, Wallach D et al (2001) Metaphyseal fractures mimicking abuse during treatment for clubfoot. Pediatr Radiol 31:559–563CrossRefPubMedGoogle Scholar
  6. 6.
    Gordon CM, Feldman HA, Sinclair L et al (2008) Prevalence of vitamin D deficiency among healthy infants and toddlers. Arch Pediatr Adolesc Med 162:505–512CrossRefPubMedGoogle Scholar
  7. 7.
    Keller KA, Barnes PD (2008) Rickets vs. abuse: a national and international epidemic. Pediatr Radiol 38:1210–1216CrossRefPubMedGoogle Scholar
  8. 8.
    Jenny C (2008) Rickets or abuse? Pediatr Radiol 38:1219–1220CrossRefPubMedGoogle Scholar
  9. 9.
    Slovis TL, Chapman S (2008) Evaluating the data concerning vitamin D insufficiency/deficiency and child abuse. Pediatr Radiol 38:1221–1224CrossRefPubMedGoogle Scholar
  10. 10.
    Ekengren K, Bergdahl S, Ekstrom G (1978) Birth injuries to the epiphyseal cartilage. Acta Radiol Diagn (Stockh) 19:197–204Google Scholar
  11. 11.
    Snedecor S, Wilson H (1949) Some obstetrical injuries to the long bones. J Bone Joint Surg 31A:378–384PubMedGoogle Scholar
  12. 12.
    O’Connell AM, Donoghue VB (2008) Classic metaphyseal lesions follow uncomplicated caesarean section NOT brittle bone disease. Pediatr Radiol 38:600CrossRefGoogle Scholar
  13. 13.
    Taybi H, Lachman R (1996) Radiology of syndromes, metabolic disorders arid skeletal dysplasias, 4th edn. Mosby-Year Book, St. Louis, MOGoogle Scholar
  14. 14.
    Paterson CR, Burns J, McAllion S J (1993) Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form. Am J Med Genet 45:187–192CrossRefPubMedGoogle Scholar
  15. 15.
    Ablin DS, Sane SM (1997) Non-accidental injury: confusion with temporary brittle bone disease and mild osteogenesis imperfecta. Pediatr Radiol 27:111–113CrossRefPubMedGoogle Scholar
  16. 16.
    Chapman S, Hall CM (1997) Non-accidental injury or brittle bones. Pediatr Radiol 27:106–110CrossRefPubMedGoogle Scholar
  17. 17.
    Miller M, Hangartner TN (1999) Temporary brittle bone disease: associated with decreased fetal movement and osteopenia. Calcif Tissue hit 64:137–143CrossRefGoogle Scholar
  18. 18.
    Miller ME (1999) Temporary brittle bone disease: a true entity? Semin Perinatol 23:174–182CrossRefPubMedGoogle Scholar
  19. 19.
    Spivack B (2000) Contributing editor’s note. Child Abuse Quarterly Medical Update 8:20Google Scholar
  20. 20.
    Barsness KA, Cha ES, Bensard DD et al (2003) The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma 54:1107–1110CrossRefPubMedGoogle Scholar
  21. 21.
    Bulloch B, Schubert CJ, Brophy PD et al (2000) Cause and clinical characteristics of rib fractures in infants. Pediatrics 105:E48CrossRefPubMedGoogle Scholar
  22. 22.
    van Rijn RR, Bilo RA, Robben SG (2009) Birth-related midposterior rib fractures in neonates: a report of three cases (and a possible fourth case) and a review of the literature. Pediatr Radiol 39:30–34CrossRefPubMedGoogle Scholar
  23. 23.
    Kleinman PK, Schlesinger AE (1997) Mechanical factors associated with posterior rib fractures: laboratory and case studies. Pediatr Radiol 27:87–91CrossRefPubMedGoogle Scholar
  24. 24.
    Chalumeau M, Foix-L’Helias L, Scheinmann P et al (2002) Rib fractures after chest physiotherapy for bronchiolitis or pneumonia in infants. Pediatr Radiol 32:644–647CrossRefPubMedGoogle Scholar
  25. 25.
    Hymel KP, Jenny C (1996) Abusive spiral fractures of the humerus: a videotaped exception. Arch Pediatr Adolesc Med 150:226–227PubMedGoogle Scholar
  26. 26.
    Dunbar J, Owen H, Nogrady M et al (1964) Obscure tibial fracture of infants — the toddler’s fracture. J Can Assoc Radiol 15:136–144PubMedGoogle Scholar
  27. 27.
    Belfer RA, Klein BL, Orr L (2001) Use of the skeletal survey in the evaluation of child maltreatment. Am J Emerg Med 19:122–124CrossRefPubMedGoogle Scholar
  28. 28.
    Kemp AM, Butler A, Morris S et al (2006) Which radiological investigations should be performed to identify fractures in suspected child abuse? Clin Radiol 61:723–736CrossRefPubMedGoogle Scholar
  29. 29.
    Kleinman PL, Kleinman PK, Savageau JA (2004) Suspected infant abuse: radiographic skeletal survey practices in pediatric health care facilities. Radiology 233:477–485CrossRefPubMedGoogle Scholar
  30. 30.
    Offiah AC, Hall CM (2003) Observational study of skeletal surveys in suspected non-accidental injury. Clin Radiol 58:702–705CrossRefPubMedGoogle Scholar
  31. 31.
    Schmit P (2007) Inflicted injuries in children: variability of imaging practice among pediatric radiologists. Pediatr Radiol 37:S49Google Scholar
  32. 32.
    Slovis TL, Smith W, Kushner DC et al (2000) Imaging the child with suspected physical abuse. American College of Radiology. ACR Appropriateness Criteria. Radiology (215 Suppl):805–809Google Scholar
  33. 33.
    Anonymous (2006) ACR Practice Guideline for Skeletal Surveys in Children (Res. 47, 17, 35) In: American College of Radiology: ACR Standards. American College of Radiology, Reston, VA, pp 145–149Google Scholar
  34. 34.
    The British Society of Paediatric Radiology (2008) Standard for skeletal surveys in suspected non-accidental injury (NAI) in children. Retrieved February 25, 2008 from Scholar
  35. 35.
    Kleinman PL, Zurakowski D, Strauss KJ et al (2008) Detection of simulated inflicted metaphyseal fractures in a fetal pig model: image optimization and dose reduction with computed radiography. Radiology 247:381–390PubMedGoogle Scholar
  36. 36.
    Hansen KK, Prince JS, Nixon GW (2008) Oblique chest views as a routine part of skeletal surveys performed for possible physical abuse — is this practice worthwhile? Child Abuse Negl 32:155–159PubMedGoogle Scholar
  37. 37.
    Ingram J, Connell J, Hay T et al (2000) Oblique radiographs of the chest in nonaccidental trauma. Emerg Radiol 7:42–46CrossRefGoogle Scholar
  38. 38.
    Renton J, Kincaid S, Ehrlich PF (2003) Should helical CT scanning of the thoracic cavity replace the conventional chest x-ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis. J Pediatr Surg 38:793–797CrossRefPubMedGoogle Scholar
  39. 39.
    Traub M, Stevenson M, McEvoy S et al (2007) The use of chest computed tomography versus chest X-ray in patients with major blunt trauma. Injury 38:43–47CrossRefPubMedGoogle Scholar
  40. 40.
    Kleinman PK, Nimkin K, Spevak MR et al (1996) Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol 167:893–896PubMedGoogle Scholar
  41. 41.
    Zimmerman S, Makoroff K, Care M, et al (2005) Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl 29:1075–1083CrossRefPubMedGoogle Scholar
  42. 42.
    Drubach LA, Sapp MV, Laffin S et al (2008) Fluorine-18 NaF PET imaging of child abuse. Pediatr Radiol 38:776–779CrossRefPubMedGoogle Scholar
  43. 43.
    Mandelstam SA, Cook D, Fitzgerald M et al (2003) Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child 88:387–390; discussion 387–390CrossRefPubMedGoogle Scholar
  44. 44.
    Block RW, Palusci VJ (2006) Child abuse pediatrics: a new pediatric subspecialty. J Pediatr 148:711–712CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia 2009

Authors and Affiliations

  • Paul K. Kleinman
    • 1
  1. 1.Department of RadiologyChildren’s Hospital BostonBostonUSA

Personalised recommendations