Haukeland Universitetssykehus, Bergen

Battered Child Syndrome

Karen Rosendahl

Consultant Paediatric Radiologist,

Professor II, Department of Clinical Medicine, K1,

University of Bergen, Norway

The Battered-Child Syndrome

C. Henry Kempe, M.D.; Frederic N. Silverman, M.D.;

Brandt F. Steele, M.D.; William Droegemueller, M.D.;

Henry K. Silver, M.D.

JAMA. 1962;181(1):17-24.

Definition

• injuries sustained by a

child as a result of

physical abuse, usually

inflicted by an adult

caregiver

• shaken baby; shaken

baby syndrome; child

abuse; and non-

accidental trauma / injury

(NAT / NAI).

Incidence, age

• Incidence UK (Barlow et al. Lancet

2000)

– 2.5 per 10 000 children younger than

1 year (95% CI 14.9-38.5)

Clinical Presentation

• Unexpected soft tissue swelling

• Seizures/Collapse

• Irritability

• No history of a trauma…….

5 w old female, swelling left thigh for the last 1-2

days. ?infection

Imaging in non-accidental trauma

Imaging Clinical suspicion

Fractures

uncommonly seen

in accidental

injuries

discuss with the

Named and

Designated Doctor in

Child Protection for

your Institution

Recommended imaging in children

< 2-3yrs of age

• Head CT

• Skeletal survey (within 24 hrs, or asap)

• If findings on head CT, or if pos. neurology; add a MRI, including the spinal canal

• If positive MRI; repeat head CT on day 10, + FU MRI (after 2-3 months – 6-12 months)

• If abdominal trauma; abdominal CT

• In children older than 2-3yrs; individual imaging strategy

Refs.: 1) ESPR Task Force on Child Abuse: www.ESPR.org 2) Håndbok for helsepersonell ved mistanke om barnemishandling

http://www.nkvts.no/aktuelt/Sider/HandbokBarnemishandling.aspx

Head CT

Ref.: ESPR Task Force on Child Abuse: www.ESPR.org

3 months old girl

Skeletal survey

”Babygram”

Skeletal survey

• Skull (AP and lateral: Townes if ? occipital fracture)

• Spine (lateral views cervical, thoracic + lumbar)

• Chest (AP + oblique views both sets ribs)

• Abdomen, pelvis and hips (AP)

• Long bones (AP views both humeri, both rad/ulna, both femora and both tib/fib)

• Hands (DP)

• Feet (AP)

• Coned views of suspected abnormality d/w supervising Consultant Radiologist

Ref.: ESPR Task Force on Child Abuse: www.ESPR.org

Skeletal survey - standards

• Technical requirements for technique – small focal spot,

– suitable computed radiography systems (including standard resolution imaging plates) may be used for skeletal surveys if they have dedicated paediatric software

• Personnel requirements – Radiographers trained in paediatric radiography techniques

should perform skeletal surveys in children

– Appropriately trained radiographic staff must be available in all radiology departments where children are imaged

• Procedural standards

Ref.: ESPR Task Force on Child Abuse. www.ESPR.org

Additional, initial imaging

• CT chest if suspicion of rib fractures

Ref.: ESPR Task Force on Child Abuse: www.ESPR.org

Scintigraphy

• High sensitivity new rib fractures

• Low sensitivity skull fractures

Ref.: ESPR Task Force on Child Abuse: www.ESPR.org

MRI

• Low sensitivity for metaphyseal injury

and rib fractures

Kleinman et al. Whole body MRI in suspected infant abuse. AJR 2010

Ultrasound

Ref.: ESPR Task Force on Child Abuse: www.ESPR.org

Imaging- follow-up

• Repeat skeletal survey (except for skull,

pelvis, lateral spine) after 2 weeks

Ref.: Harper NS, Eddleman S, Lindberg DM et al. The Utility of Follow-

up Skeletal Surveys in Child Abuse. Pediatrics 2013; 131; 672-

The role of imaging is to answer the

following Q:

• Q1: Is there skeletal injury, and if so, are

there specific features suggestive of NAI?

• Q2: …….evidenced by?

• Q3: Most likely mechanisms – evidence?

• Q4: How old is the fracture - evidence?

• Q5: If the injury is suspicious of NAI – what

other options are there?

Skeletal injury in NAI

• Ribs (26%)

• Metaphysis (23%)

• Long bones (36%)

• Skull (15%)

Ref.: Carty H. Eur Radiol 1997; 7(9); 1365-1376

Skeletal injury; «specificity» for NAI

• High

– Methaphyseal lesions

– Rib fractures, particularly posterior

– Scapular, spinous process and sternal fractures

• Moderate

– Multiple fractures, especially bilateral

– Fractures of different ages

– Epiphyseal separations

– Vertebral body fractures and subluxations

– Digital fractures

– Complex skull fractures

Skeletal injury; «specificity» for NAI

• Low (but common)

– Subperiosteal new bone formation

– Clavicular fractures

– Linear skull fractures

Rib fractures

• costovertebral articulations

• costochondral junctions and anterior rib

ends, lateral fractures

• often multiple and bilateral

• may be clinically silent

Rib fractures

Issues

• Acute rib fractures difficult to diagnose:

– Use the best available XR technique

– Additional CT on the same day or repeat XR in 12-

14 days?

kV 64, mA 2.0 kV 62, mA 3.0 kV 60, mA 3.2

Radiographic technique

2 weeks later…

Male, 16 months

7th rt rib

8th rt rib

Classic metaphyseal lesion (CML)

• fracture along the primary

spongiosa of the metaph.

• tibiae, distal femur and

proximal humerus often

bilateral

• minimal or no periosteal

reaction

• heal without callus

formation

• may be clinically silent

Ref.: Kleinman et al.

Reformatted coronal micro-CT scan

shows transmetaphyseal extent of

fracture

9 months old infant

Classic methaphyseal lesion

• rotation / traction

Issues

• Positioning!

• Differentiation between injury and

physiological irregularities

– additional views, high-res.

– repeat x-ray in 10-12 days, or 4-6

weeks

at presentation

2 days later

9 days after

presentation

follow-up 4 weeks later

3 mo old,

died from

his head

injury

25.5.07 3.7.07 6.9.07

Male, 8 months, subdural haematoma

Long bones

• Femur and humerus most common

– femur

• midshaft

• transverse / spiral / oblique

• (no differences between NAI and accidental)

– humerus

• midshaft, but also supracondylar

Long bones

• spiral fracture = twisting

force

• oblique fracture =

levering (e.g. lifting a

child by a limb)

• transverse fracture may

be the result of a direct

impact, a greenstick or

buckle fracture will be

caused by

compression, e.g. a fall

Issues

• ”physiological” periosteal reaction

– < 3-4 months of age

– most often symmetrical

– <2mm

Skull fractures (15%)

Skull fractures

“the shaken infant – (impact) syndrome” (Caffey)

Skull Fractures

Accidental

• Simple linear

“hair-line”

unilateral parietal

Non-Accidental

• Wide (> 5mm)

• Fissured

• Non-Parietal

• Crossing Sutures

• Affecting + one

bone

• Depressed

• Growing

Reference: Hobbs C. J. (1984). Skull fracture

and the diagnosis of abuse; Arch. Dis. Child. 59:246-252.

Fracture healing - dating

• Dating of fractures is of medico legal

importance

• Most radiologists date fractures based on

their personal clinical experience

• Few studies

1) A timetable for the radiologic features of fracture healing in young children. Prosser I,

Lawson Z, Evans A, Harrison S, Morris S, Maguire S, Kemp AM. AJR Am J Roentgenol.

2012 May;198(5):1014-20.

2) How old is this fracture? Radiologic datin gof fractures in children: a systematic review.

Prosser I, Maguire S, Harrison SK, Mann M, Sibert JR, Kemp AM.

AJR Am J Roentgenol. 2005 Apr;184(4):1282-6. Review.

Fracture healing

• SPNBF

– Early: 4-10 d

– Top: 10-14 d

– Late: 14-21 d

Fracture healing

• Endosteal callus

formation

– Soft

• 10-14 d (early)

• 14-21 d (peak)

– Hard

• 14-21d (early)

• 21-42d (peak)

• 42-90 d (late)

14/08/2006 7/9/2006

Table 1. Chronology (in days) of radiographic changes during fracture healing.

Kleinman 1998.

Fracture healing

• fractures in young children may be dated as

acute (< 1 week), recent (8-35 days), or old (≥

36 days) on the basis of the presence of six

key radiologic features in combination

• good interobserver agreement suggests

these results are reproducible

A timetable for the radiologic features of fracture healing in young

children. Prosser I, Lawson Z, Evans A, Harrison S, Morris S,

Maguire S, Kemp AM. AJR Am J Roentgenol. 2012

May;198(5):1014-20.

Differentials

1. Birth trauma (most common clavicle,

femur and humerus). The absence of

callus 11 days or more after birth

excludes a birth-related injury

2. Accident

3. Bone disorder

Literature

• Kemp A et al. patterns of skeletal fractures in child abuse: systematic review. BMJ 2008;337:1518-

• Kleinman, P.K. Diagnostic imaging of child abuse, 3.ed. Mosby, 2016

• Tatantino et al. Short vertical falls in infants. Pediatr Emerg Care 1999;15:5-8

• Barkovich AJ. Pediatric neuroimaging. 4th ed. 2005.

• Carty H, Brunelle F, Stringer D, Kao CS. Imaging Children.2nd ed. Elsevier 2005.

• Chapman S. Non-accidental injury. Imaging (2004) 16, 161-173.

• Carty H, Pierce A. Non-accidental injury: a retrospective analysis of a large cohort. Eur Radiol 2002;12:2919–25.

• Jaspan et al. Neuroimaging for Non-Accidental Head Injury in Childhood: A Proposed Protocol. Clinical Radiology 2003:58;44-53.

• The British Society of Paediatric Radiology. Standard for skeletal surveys in suspected non-

accidental injury (NAI) in children.

• Flaherty, E. G., Perez-Rossello, J. M., Levine, M. A., Hennrikus, W. L., American Academy

of Pediatrics Committee on Child, A., Neglect, Society for Pediatric, R. (2014). Evaluating

children with fractures for child physical abuse. Pediatrics, 133(2), e477-489.

doi:10.1542/peds.2013-3793

• Harper NS, Eddleman S, Lindberg DM et al. The Utility of Follow-up Skeletal Surveys in

Child Abuse. Pediatrics 2013; 131; e672.

• Ashwal S, Wycliffe ND, Holshouser BA. Advanced neuroimaging in children with

nonaccidental trauma. Developmental neuroscience 2010;32(5-6):343-60.

• Choudhary AK, Ishak R, Zacharia TT, Dias MS. Imaging of spinal injury in abusive head

trauma: a retrospective study. Pediatric Radiology. 2014;44(9):1130-1140

Acknowledgements

• Professor Christine Hall

• Dr Amaka Offiah

• Superintendent Radiographer Jenny Grehan

• Dep. Cons. Frank Marshall