- The history does not correlate with the child's injuries.
- There are multiple fractures involving the metaphysis of the extremities and rib fractures.
Because of the adversarial nature of civil and criminal cases involving alleged child abuse, the documentation, identification, and dating of skeletal injuries are important factors in the ultimate disposition of cases of suspected abuse and radiographic findings are often used in care and protection cases and in criminal proceedings.
Pediatric films are often difficult to evaluate even when normal. If one suspects child abuse the films should be evaluated by a radiologist, preferably a pediatric radiologist. The radiologist who interprets imaging studies in cases of suspected abuse should be willing to assume the role of advocate for the welfare of the child, which includes providing the child protection and criminal justice authorities with appropriate radiologic documentation of the extent of injuries.
Over 50 percent of fractures due to abuse involve the ribs, including the costovertebral articulations, and costochondral junctions, which are particularly difficult to identify. The distribution and location of rib fractures are often very strong indicators of abuse. It is generally agreed that most rib fractures in abused infants (generally three months and younger) are the consequence of thoracic compression. Anterior compression of the thorax tends to cause rib fractures, which tend to be impacted along the inner rib margin, with an outer margin that shows bowing or a distracted fracture site. The most common mechanism of injury is when the infant is held facing the assailant with the palms at the infant's side, the fingers at the back, and the thumbs near the midline. The infant is squeezed in the anteroposterior plane and may be shaken. The assailant's anteriorly positioned thumbs depress the sternum and costal cartilages.
The other common region of fracture is the metaphysis of a long bone in the extremities. This involves fracture of the growth plate which is generally caused by the infant or child being lifted up by an arm or leg. This metaphyseal injury is caused by the abrupt twisting and pulling of the extremity. Identifying these metaphyseal fractures are very difficult and require very high detail radiography. If one suspects these types of fractures, referral to a well-equipped radiology department would be an excellent way of confirming and documenting the skeletal injuries.
The diagnostic criteria for child abuse vary depending on the specific context in which the diagnosis is considered; findings supporting a medical diagnosis of abuse may not satisfy the standards prescribed by civil and criminal law. Depending on the legal forum, a diagnosis of abuse may require a preponderance of evidence (>50 percent chance), a reasonable medical probability, or a reasonable medical certainty (beyond a reasonable doubt). Previous legal studies confirm the crucial role that radiologic evaluation of the fractures and documentation of the age of the injuries play in the prosecution of child abuse.
When child abuse is suspected, every precaution should be taken to obtain the best documentation and expert evaluation possible, and as quickly as possible. You must be willing to assume the role of advocate for the welfare of the child, which may include a great deal of perseverance and fortitude. To save just one child from this terrible experience is well worth the effort.
Deborah Pate, DC, DACBR
London, England
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