- Rib fracture
- Classic metaphyseal lesion
- Femur fracture
- Skull fracture
- Subdural hematoma
- Diffuse cerebral edema
- Duodenal hematoma
- Hypoperfusion complex
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
Note:
- 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