Educational paper

Abstract

Fractures are reported to be the second most common findings in child abuse, after skin lesions such as bruises and contusions. This makes careful interpretation of childhood fractures in relation to the provided clinical history important. In this literature review, we address imaging techniques and the prevailing protocols as well as fractures, frequently seen in child abuse, and the differential diagnosis of these fractures. The use of a standardised protocol in radiological imaging is stressed, as adherence to the international guidelines has been consistently poor. As fractures are a relatively common finding in childhood and interpretation is sometimes difficult, involvement of a paediatric radiologist is important if not essential. Adherence to international guidelines necessitates review by experts and is therefore mandatory. As in all clinical differential diagnoses, liaison between paediatricians and paediatric radiologists in order to obtain additional clinical information or even better having joint review of radiological studies will improve diagnostic accuracy. It is fundamental to keep in mind that the diagnosis of child abuse can never be solely based on radiological imaging but always on a combination of clinical, investigative and social findings. The quality and interpretation, preferably by a paediatric radiologist, of radiographs is essential in reaching a correct diagnosis in cases of suspected child abuse.

Controversial aspects of imaging in child abuse: a second roundtable discussion from the ESPR child abuse taskforce

“…Radiologists play a vital role in the detection and assessment of physical abuse. Fractures are the second most common injury after bruising in children who have suffered physical abuse [ 3 ] and have been recorded in as many as 55% of these children, with 18% having sustained multiple fractures [ 4 ]. Fractures due to abuse may be clinically occult and are most common in infants under 18 months of age.…”

Prevalence and distribution of occult fractures on skeletal surveys in children with suspected non-accidental trauma imaged or reviewed in a tertiary Dutch hospital

“…In addition, the bone scan cannot help with the dating of injuries, it can highlight areas of suspicion but further imaging is necessary to confirm whether there are any fractures [ 28 ]. Van Rijn and Sieswerda stated in their educational paper that another drawback of the bone scan is that there is a lack of experience in children, of which the consequence is a limited applicability because reading these studies will be insufficient [ 29 ]. On top of that the bone scan involves a high radiation dose compared to the skeletal survey (3 mSv versus 0.16 mSv effective dose) [ 5 ].…”

Optimizing bone surveys performed for suspected non-accidental trauma with attention to maximizing diagnostic yield while minimizing radiation exposure: utility of pelvic and lateral radiographs

“…Fractures are the second most common finding in NAT after skin bruising and contusions [9]. Thus, most children with suspected NAT have a skeletal survey as a primary step toward diagnosis.…”

“…Previous studies have established that limiting the evaluations in follow-up skeletal surveys, including eliminating pelvic and spinal radiographs, allows decreased radiation exposure without reducing diagnostic efficacy [9, 10, 13]. Other authors have postulated a multimodality approach to imaging NAT, which is particularly useful for neurological injury [14] and injuries to the axial skeleton.…”