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The Child Abuse Referral and Education (CARE) Network

Content Development:
Gael J. Lonergan, MD LtCol USAF MC
Peer Review and WEB Implementation:
James G. Smirniotopoulos, M.D.

This is an Educational Website

A Project of the
Uniformed Services University of the Health Sciences
and the
Armed Forces Institute of Pathology

The opinions expressed herein are those of the author, and are not to be construed as representative of the University or the Department of Defense.

*  Please Read Disclaimer  *

NOTE: Child Abuse cannot be reported here.
Cases of suspected Child Abuse must be reported immediately to your local authorities.
This site is for educational purposes only!

Some Facts and Figures about Child Abuse

Child abuse is a relatively common problem in our society, and it takes many different forms. It can include physical abuse (broken bones, brain injury, bites, burns), sexual abuse, psychological abuse, and, most commonly, neglect. It is estimated that 4 million children a year are abused in some manner in the U.S., although probably less than half of all cases are reported. At least two thousand children die each year as a result of abuse (Council on Scientific Affairs: AMA diagnostic and treatment guidelines concerning child abuse and neglect. JAMA 1985; 254:1483-1486; US Dept of Health and Human Services , The Third National Incidence Study of Child Abuse and Neglect; 1996, Washington, US Government Printing Office).

Injuries seen in abuse are often distinctive because they are inflicted by adults (and may therefore be significantly more violent or purposeful than injuries sustained during normal childhood activities). The history given to explain the injury may hold the key to the abusive nature of the injury, especially if the injury and the given history seem implausible. For example, a 4 year old presenting with multiple cigaret burns is unlikely to have perpetrated this on himself (too painful), or to have allowed another similiar-age child to inflict the burns.  Consideration of the history is always inportant in any childhood injury. History must be correlated with the developmental stage of the infant or child. A two month old baby cannot, by himself, fall down stairs. This is not because he can't fall (he can), but rather because part of falling is getting oneself to the edge of the surface from which the fall occurred.  A 2month old isn't likely to crawl well enough (and for long enough) to get to the top of the stairs entirely under his own power. A baby could certainly unintentionally be dropped down the stairs, but a well-intentioned caretaker who accidentally drops his child will usually describe the accident as it happened ("I accidentally dropped him while I was carrying him downstairs"), whereas an abusive caretaker may give an evasive, inaccurate, and implausible history such as "she was at the top of the stairs and rolled down." When we consider this history, it becomes obvious how implausible it is (young age of the infant). Similarly, consider this reason cited for a 4 year old's skull fracture: an 18 month old sibling hit him with a baseball bat. Swinging a bat (even being able to lift it) forcibly enough to break a skull demonstrates considerable force and muscular coordination  - probably more than an 18 month old toddler can manage.

In addition to considering the history in childhood injuries, we should also consider the nature of the injury itself, for there are some injuries and injury patterns that are highly suggestive of abuse. If such injuries are discovered and acted upon, these children can be spared further trauma, as can their siblings. A thorough physical evaluation, including radiographs, is a critical part of the abuse evaluation, and may be what first identifies the child as a victim of abuse.

Injuries Worrisome for Child Physical Abuse

Skin and Soft Tissue Injury

*(A very rough guide)
There have been many attempts to correlate the color of a bruise with the chronology (timing) of the injury.  However, there continues to be controvery and debate about this subject.  One frequently quoted reference is:

Schwartz AJ, Ricci LR: "How accurately can bruises be aged in abused children? Literature review and synthesis." Pediatrics 1996 Feb;97(2):254-7.

Click here for a literature search.

Skeletal Injuries

Head Injuries

Abdominal Injuries

Signs of Neglect

Clues to child abuse in the history of the injury
(and the care sought to treat it):

Early motor milestones

4 mos raises head
5-6 mos  rolls over
8-9 mos  sits alone
15 mos  walks alone
18 mos  climbs stairs
22 mos  throws ball overhand
2-3 years  pedals tricycle
3 years  alternates feet up stairs
5 years  catches ball bounced

Suspicious Histories

Parental Behavior Patterns Seen in Abuse


Medical Evaluation of Suspected Physical Abuse

The abuse skeletal survey consists of individual frontal X-rays of the following body parts:

The Shaken Infant Syndrome ("shaken baby syndrome")

The term shaken infant syndrome describes a classic injury pattern seen in shaken infants and very young children. The victim is held around the chest by an adult's hands and violently shaken back and forth. This causes the extremities and the head to flail back and forth, in a whiplash movement. Violent shaking creates shearing forces on the extremities which may cause fractures of the growth plate (called metaphyseal, corner, or bucket-handle fractures). An example of one is shown below. Metaphyseal fractures are highly specific for abuse; these are some of the injuries sought on the skeletal survey.

The violent shaking causes similar shearing forces in and on the brain. This may cause large amounts of brain matter to tear (diffuse axonal injury) and can also cause bleeding to occur on the surface of the brain, where the brain abuts fixed structures during shaking (subdural hematoma and interhemispheric subdural hematoma). The brain often swells in response to this injury (edema or hyperemic swelling - "malignant brain edema"). With violent shaking, a significant amount of brain damage may occur; in fact, infants have been fatally abused by violent shaking alone.

The tight grasp around the chest that accompanies this shaking may also cause rib fractures (these are also highly specific for abuse). These rib fractures may be incidentally found on chest X-rays performed for other reasons, such as to evaluate for pneumonia.

Finally, the shaken infant syndrome may also include throwing the baby down or into a hard surface, like a wall or table. This will cause swelling at the point of impact and, if the head is the point of impact, may add to brain damage by causing local bleeding and swelling in and on the brain and scalp. This impact injury often accompanies shaking; this may be refered to as "the shaken-impact syndrome."

The Child Abuse Homicide

Abuse should be considered when any child dies unexpectedly.
The following should be performed on all unexplained childhood deaths: Pathologists and medical examiners do not routinely evaluate the long bones at autopsy; metaphyseal fractures will thus be missed. This is unfortunate, for metaphyseal fractures are some of the most specific injuries in abuse. Similarly, subtle, healing rib fractures (especially posterior rib fractures) may be missed on autopsy (Norman MG, Smialek JE, Newman DE, Horenbala EJ. The postmortem examination of the abused child. Pathological, radiographic, and legal aspects. Perspect Pediatr Pathol 1984; 8:313-343).

A full radiographic evaluation should be considered an integral part of a complete autopsy on a young child!


Teaching Cases

Click on Images to Enlarge

Case 1

HX: This 2 month old baby girl was brought into the local ER with scalp swelling.

DX: Multiple skull fractures (arrows), extremely worrisome for abuse

Discussion: Skull fractures are common child abuse injuries, but they are common in accidental trauma, too. Patterns of skull fracture that suggest child abuse are multiple ('eggshell') fractures (as in this case), those that are associated with neurologic symptoms such as drowsiness or seizure, occipital fractures, fractures crossing sutures, and any fracture that is inconsistent with the history. Depressed skull fractures are somewhat worrisome for abuse, but are dependent on history (Meservy CJ, Towbin R, McLaurin RL, Myers PA, Ball WS. Radiographic characteristics of skull fractures resulting from child abuse. AJNR 1987; 8:455-457).

When there is a simple linear fracture, correlation with history is important to determine if the fracture is worrisome for abuse. Again, we should keep in mind the developmental stage of the child as well as the likelihood the reported incident is to cause a fracture. Rolling off a sofa onto a carpeted floor is a very unlikely cause of a skull fracture, even a simple linear one. 

Case 2

HX: A 7 month old baby is brought to ER by mother, who came home from work and found him seizing.

DX: Right-sided cerebral edema (swelling of the right half of the brain). Notice how much darker grey the right cerebrum is relative to the left. This indicates edema. There is lack of grey-white distinction in the right cerebrum, another indicator of edema. There is also a posterior interhemispheric subdural hematoma (blood collection between the two cerebral hemispheres), as demonstrated by the irregular, thick white line between the two cerebral hemispheres(arrows). This white area is blood.

Discussion: Cerebral edema is the most common central nervous system injury in child abuse. Cerebral edema occurs in response to brain injury and is therefore an indicator of underlying brain injury. Sometimes the brain is injured so severely that it bleeds into itself (cerebral hematoma or contusion), but more commonly edema is all that is seen radiographically.

Also, blood collections can form on the surface of the brain (subdural hematomas) from abuse. This is from tearing of blood vessels serving the brain that are on the surface of the brain and are therefore relatively unprotected. This happens when there is a direct blow to the head (the force of the blow disrupts the blood vessels) and also when the head is shaken violently (this shaking creates shear forces that tear the blood vessels). Shaking is the typical cause of interhemispheric subdural hematomas; therefore, interhemispheric subdural hematomas are usually seen in the setting of the shaken infant syndrome (Zimmerman RA, Bilaniuk LT, Bruce D, Schut L, Uzzell B, Goldberg HI. Computed tomography of craniocerebral injury in the abused child. Radiology 1979; 130:687-690)

Case 3

HX: 1 year old child brought in by ambulance comatose.

DX: Diffuse cerebral edema. Notice how low in attenuation (dark grey) both cerebral hemispheres are. Also notice that the cerebellum, thalami, and basal ganglia (asterisk)  are actually brighter than the cerebral hemispheres. This is a good internal reference point on a brain CT scan - the cerebral hemispheres should be as bright as the cerebellum. If they are darker, they are edematous. This radiologic appearance has been called the reversal sign or the bright cerebellum sign. It indicates severe anoxic brain injury with resultant swelling. It may be seen in abuse as well as in accidental injury such as drowning (Han BK, Towbin RK, DeCourten-Myers G, McLaurin RL, Ball WS. Reversal sign on CT: effect of anoxic/ischemic cerebral injury in children. AJNR 1989; 10:1191-1198).

There is a faint wisp of white blood along the left edge of the tentorium cerebelli (white arrow); this is a small subdural hematoma between the left cerebral hemisphere and the cerebellum. Blood is also visible behind the cerebellum (black arrows); this is a posterior fossa subdural hematoma.

Discussion: This child was violently shaken, causing severe brain injury, evidenced by diffuse cerebral edema. The prognosis for diffuse cerebral edema is poor; this is usually a devastating brain injury with permanent impairment. This injury can be caused by shaking alone, but can also be caused by violent impact, or a combination of the two. It can also be caused by strangulation, drowning, and post-traumatic apnea. 

Case 4

HX: 15 month old child with seizure disorder for past 4 months and developmental delay, for evaluation by child neurologist.

DX: Bilateral subdural hematomas (arrows) of different ages and cerebral atrophy. This is a T1 weighted MRI scan. Blood products vary in appearance with age on MR, and different ages of blood collections will often show different shades of white - to - grey on an MR, with the older hematomas being whiter (until they approximate water, which is white on T2 MR but dark grey to black on T1 weighte MR) and the more recent hematomas being more grey. In this case, we can see 2 distinctly different signal intensities of fluid around the surface of the brain, brighter on the right than the left. It is difficult to accurately date the ages of these 2 hematomas, as blood product aging is very dependent on the patient's hematocrit and other variables. Hence we can say the collections are of two different ages, but usually cannot say the date of injury (Bradley WG. MR appearance of hemorrhage in the brain. Radiology 1993; 189:15-26). There is also enlargement of the ventricles, a sign of atrophy (loss of brain matter), most likely from abuse-related brain injury.

Discussion: The sequelae of repetitive brain injury may be the first indication of abuse, as in this child. Repetitive brain injury may manifest itself many ways: seizure disorder, decreased head circumference growth (falling off of growth chart), developmental delay, and others. The presence of the subdural hematoma in this case made it almost certain this child was a victim of abuse. 

Case 5

HX: 4 month old with cough, chest X-ray request says "rule out pneumonia."

DX: Posterior rib fracture of the left 7th rib (black arrow). This fracture is less than 14 days old as there is no visible callus. This is a case of child abuse incidentally found on CXR because of the detection of the rib fracture, which was unrelated to the child's presenting complaint (white arrows).

Discussion: Rib fractures are very common injuries in the young (less than 2 year old) abused child. Typically, this is part of violent shaking. The infant or young child is held very tightly around the chest and squeezed while being shaken. This compresses the ribs front to back and tends to break them next to their attachment to vertebrae and laterally where they are being literally almost folded in half. Therefore, lateral & posterior rib fractures are highly specific for abuse. CPR is rarely, if ever, a cause of such fractures (Spevak MR, Kleinman PK, Belanger PL, Primack C, Richmond JM. Cardiopulmonary resuscitation and rib fractures in infants. JAMA 1994; 272:617-618; Feldman KW, Brewer DK. Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics 1984; 73:339-342).  The extreme rarity of CPR-related rib fractures in infants and young children is quite different than their incidence in the adult population, in whom rib fractures are relatively common after CPR.

Case 6

HX: 4 month old with failure to thrive.

DX: Healing multiple left and right-sided lateral rib fractures. Look closely at the lateral aspects of the ribs as they curve around the chest wall. In the lateral asepct of left 3rd thru 5th and right 3rd thru 5th ribs (arrows) there are rounded areas of ill-defined increased bone density, representing callus, and cortical discontinuity, representing the fractures. The fractures themselves are not well seen because of their lateral location and subacute age. The presence of callus tells us the fractures are at least 7 days old.

Discussion: Callus generally forms no earlier than 7 days after a fracture, but will usually form by 14 days. Thus, fractures without visible callus may be up to 14 days old, and fractures which have callus are at least 7 days old (O'Connor JF, Cohen J. Dating fractures. In: Kleinman PK. Diagnostic Imaging of Child Abuse, 2nd ed. St. Louis, Mosby, Inc. 1998, 168-177). This is another case of incidentally found child abuse. 

Case 7

HX: 3 month old brought in for abdominal pain and vomiting.

DX: Healing right posterior 5th-7th and 9th rib fractures, as well as multiple healing right lateral rib fractures (arrows).

Discussion: Posterior rib fractures are much harder to see than lateral rib fractures, as they often occur near the joints the ribs make with various parts of the vertebrae (the bodies and transverse processes). They may be undetectable by CXR acutely; they become visible as callus forms (Kleinman PK, Marks SC, Adams, VI, Blackbourne BD. Factors affecting the visualization of posterior rib fractures in abused infants. Am J Roentgenol 1988; 150:635-638).  Because the prodcution of callus renders the healing opsterior fraactures more visible,it's recommended to repeat a CXR in a suspicious case a week after the initial skeletal survey, to see if any healing posterior rib fractures have formed callus and are now visible. Alternatively, a bone scan (nuclear medicine scintigram) may also show the rib fractures, as in case 11 (Conway JJ, Collins M, Tanz RR, et al. The role of bone scintigraphy in detecting child abuse. Semin Nucl Med 1993; 23:321-333).

Case 8

HX: 4 month old baby with brain injury suspicious for child abuse. Skeletal survey performed to evaluate for other injuries of abuse.

DX: There is a corner fracture of the distal femur (arrow).

Discussion: This corner fracture (also known as a metaphyseal or bucket handle fracture) is highly specific for abuse (Kleinman PK, Marks SC, Blackbourne B. The metaphyseal lesion in abused infants: a radiologic-histopathologic study. Am J Roentgenol 1986; 146:895-905). It occurs when a child is violently shaken, or other forms of torsional stress and shear are applied to a limb (such as severe twisting or wrenching of the limb). When this occurs from shaking, the shaking causes the arms and legs to flail violently, and shear forces (whiplash forces) are exerted on the distal ends of long bones. Fractures occur through the most immature (weakest) part of the growing bone, which is immediately adjacent to the physis or growth plate. This fracture shears off a disc of bone at the end of the shaft; this fracture fragment may resemble a "corner" of bone or a bucket handle (see case 9), depending on the orientation of the fracture site to the X-ray film. Notice how subtle this fracture is. Visualizing these fractures is very dependent on high detail radiography.

Case 9

HX: 3 month old younger sibling of an older abused child, to evaluate for possible abuse.

DX: Bucket handle metaphyseal fracture of the distal tibia (arrows).

Discussion: A bucket handle fracture is a corner fracture seen "en face". The disc of bone that is the fracture fragment, when tilted slightly, can be seen as a disc or bucket handle. This fracture, as discussed, in case 8, is highly specific for abuse. NOTE: metaphyseal fractures do not typically heal with easily visible callus, so dating of metaphyseal fractures is often difficult (Kleinman PK. Diagnostic Imaging of Child Abuse, 2nd ed. St. Louis, Mosby, Inc. 1998; p. 22).

Case 10

HX: 3 month old deceased sibling of a child who is found to have rib and metaphyseal injuries indicative of abuse. Cause of death of the abused infants sibling (1992) listed by coroner's office as "bacterial peritonitis" from an unknown cause; death ruled "natural" (meaning it was neither a homicide nor an accident). Body exhumed for reevaluation when younger sibling presented with abuse injuries.

DX: Metaphyseal corner fracture (arrow) of tibia, virtually diagnostic for abuse.

Discussion: This is a specimen radiograph of the dissected limb of the exhumed body (the limb has been removed and cleared of all overlying soft tissue such as muscle and skin). Notice the exquisite detail. A forensic autopsy does not evaluate the limbs well (especially the metaphyses), and therefore metaphyseal fractures will often be missed. A skeletal survey should be performed on all unexplained childhood deaths to look for evidence of abuse. In this case, the child did die of bacterial peritonitis from an abuse-related traumatic bowel perforation. 

Case 11

HX: 11 month old female with possible right-sided posterior rib fractures at recent skeletal survey.

DX: Bone scan (nuclear medicine scintigram) shows focal increased uptake along multiple posterior right ribs (arrows), the left humeral shaft (arrow head), and both humeral heads (asterisk).

Discussion: Bone scans are exquisitely sensitive for many bone injuries and can help decide if an equivocal finding on a skeletal survey is real or not. Areas of increased uptake on bone scan signify metabolic increased activity of that bone; as such, bone scans are non-specific as to the cause of the increased metabolic activity. It may be from trauma, infection, tumor, etc.  Therefore, plain X-rays of the skeleton (in the areas of abnormality identified at bone scan) are almost always still needed to evaluate for the exact nature of the abnormality. Reserve the use of bone scans for when there is an equivocal finding or there is high clinical suspicion but the plain X-rays are normal. Bone scans will detect those difficult to see posterior rib fractures, as in this case. The pattern of rib uptake (in a veritically-oriented row) is essentially diagnostic of rib fracture. No other entitiy (infection, metastatic disease) will be so linearly displayed in multiple bones. The increased uptake int he left humeral shaft was due to a spiral fracture, and there were metaphyseal fractures of both humeral heads, explaining the increased uptake in these regions.

Case 12

HX: 3 month old child with vertebral abnormality noted on chest X-ray.

DX:Compression injury to the body of L1. Notice the angulation of L1 relative to T12 above it and the defect in the anterior superior margin of the body of L1 (arrow).

Discussion: Injuries to the thoracolumbar junction are relatively common in abuse, especially in shaken infant syndrome. Shaking by holding the infant around the chest makes the thoracolumbar junction a fulcrum. Violent shaking can thus create strong compression forces on vertebral bodies at this area of the spine (very much like the "lapbelt" injuries in motor vehicle accidents). Compression fractures can occur, and there can even be rupture of intervertebral ligaments and disc herniations, too. This patient's angulation at T12 - L1 indicates the posterior spinal ligaments have been torn, allowing angulation. There is loss of the T12 - L1 disc height, too, indicating herniation of this disc. Fortunately, neurologic symptoms are unusual in this injury, although the injury to the bony and ligamentous elements is permanent. This is one of the injuries we are looking for on a lateral T & L spine done on infants. 

Case 13

HX: 3 1/2 year old with 4 day history persistent vomiting after eating and abdominal pain.

DX: Upper GI shows a mass in the wall of the descending duodenum (arrow). This is consistent with a duodenal hematoma.

Discussion: This is the classic presenting symptom complex of a duodenal hematoma, which is a hematoma (blood collection) in the wall of the bowel. This is, in children, almost always the result of direct trauma (assault, bicycle handlebar injury, etc.). It is a relatively common injury in abuse and is typically seen in older children who are punched or kicked in the abdomen (intentionally or accidentally). It is an unusual injury in very young children (less than 2 years old). Of note, abdominal injury, such as this duodenal hematoma, is the leading cause of morbidity and mortality in the older abused child. Because abdominal injuries are usually seen in older children, who ar often quite active, identifying the injury as abuse-related is mroe difficult. Correlation with history and other evidence of abuse suggest the diagnosis.

Case 14

HX: 20 month old female admitted for evaluation of low hematocrit.

DX: Abdominal CT shows a left adrenal hematoma (arrow) and retroperitoneal ascites.

Discussion: Children can sustain a variety of abdominal injuries from abuse. The mechanism may be shaking (which is relatively uncommon) or direct blows (more commonly). Organs frequently injured include the adrenal in the very young, and the liver, pancreas, bowel, spleen, kidneys, and bladder.

NOTE: Child Abuse cannot be reported here.
Cases of suspected Child Abuse must be reported immediately to your local authorities.
This site is for educational purposes only!


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