Introduction

Fractures are common in fatally abused infants and young children and imaging assessments of skeletal injuries have been an important focus of postmortem studies (1–21). Computed tomography (CT) and magnetic resonance imaging (MRI) have also been used to assess for skeletal, visceral, central nervous system, and soft tissue injuries (22–28). Although a thorough autopsy provides information regarding the presence of fractures of the skull, bony thorax, and other major skeletal injuries, a thorough gross autopsy may offer little evidence of other associated skeletal injuries described in depth in this text (see Chapters 2–6). Radiologic evaluation is most critical in the assessment of high-specificity indicators of abuse, such as the classic metaphyseal lesion (CML), and other subtle injuries involving the extremities, spine, and shoulder girdle. The diagnosis of abuse in infant fatalities, as in living infants, frequently rests on the existence of prior injuries, and the recognition of early signs of healing at postmortem assessment is critical. In the author’s study of 31 abused infant fatalities, 93% of infants with extracranial fractures showed evidence of healing injuries on postmortem skeletal studies (6).

Even when the gross autopsy provides initial information regarding the presence of fracture involving the cranial vault, radiologic evaluation of the skull is an important complement to direct inspection. It is also true that gross inspection gives information regarding acute rib fractures, but a thorough radiologic evaluation of the rib cage, with specimen radiography, may reveal additional fractures, particularly those near the costovertebral articulations (7, 29). Recent healing fractures are usually detected upon careful gross inspection, but mature fractures may be missed. Furthermore, the radiologic criteria for assessment of the age of healing rib fractures are more precise than what can be determined by direct inspection. The radiologic evaluation should be followed by histologic analysis, and the ultimate assessment of the injury should be based on a combination of the gross autopsy, radiologic study, and histologic examination. Conventional CT has value in the postmortem assessment, particularly with respect to rib injuries, but at this time it should be seen as a complement and not a substitute for radiography. It may also miss fractures noted at gross autopsy (28). High-resolution CT is, however, useful for the detailed assessment of individual fractures (see below) (27).