Differential diagnosis of child abuse injuries

Approach to the differential diagnosis of child abuse injuries:

  • Rib fracture – especially posteromedial has high specificity for abuse
  • Classic metaphyseal lesion – has high specificity for abuse
  • Femur fracture – in < 3 years old without a good history is suspicious for abuse
  • Skull fracture – if complex has moderate specificity for abuse
  • Subdural hematoma – determining its age can be challenging
  • Diffuse cerebral edema – is not specific for abuse
  • Duodenal hematoma – suspect this in abused child who is vomiting with feeding
  • Hypoperfusion complex – is marker of hypovolemic shock


  • Skeletal survey should be repeated after 2 weeks in < 2 years old as rib fractures + classic metaphyseal lesions can be initially subtle and only seen on later imaging
  • When a high specificity fracture for abuse is seen (posterior rib fracture, classic metaphyseal lesion) you must ensure the referring clinician begins an investigation for child abuse as radiologist is a mandatory reporter
  • Ensure skeletal survey is done with meticulous attention to detail, fractures are described as acute / subacute / chronic, radiology report is precise and correct
  • Recommend head CT without contrast to look for intracranial injury along with possibly brain MRI without contrast, have high index of suspicion for GI blunt abdominal trauma injury
  • The radiologist is but one member of a multidisciplinary child protection team
  • Proving that abuse occurred and who did it are two separate things