This chapter reviews the most common clinical presentations of abusive head trauma (AHT) and associated indications for imaging. The presentation of AHT is highly variable, and may include a history of accidental trauma, acute neurologic or constitutional symptoms, sentinel non-central nervous system (CNS) injuries, macrocephaly or chronic neurologic dysfunction or asymptomatic high-risk contacts of a child abuse victim. The indications for screening neuroimaging depend on clinical presentation and level of concern. Some patients warrant evaluation based on acute neurological presentation. In others the clinical history, physical examination, laboratory and non-CNS radiologic findings indicate the need for screening. This chapter reviews the available evidence and outlines an approach to screening neuroimaging followed by diagnostic evaluation. Cranial ultrasound, CT or MRI are used depending on presentation and clinical setting. If screening neuroimaging is suspicious for AHT then full diagnostic neuroimaging evaluation with brain and often spine MRI is essential. Strengths and limitations of the modalities used are discussed.

Basic semen examination is the cornerstone for initially evaluating the male fertility potential. The latest World Health Organization (WHO) sixth edition of semen analysis (SA) manual includes a detailed description of basic SA procedures and is considered a valuable guide for laboratory technicians. However, the interpretation of the results of basic SA in the context of male infertility management is not clear. This chapter will review the limits linked to the basic SA, detailing the macroscopic and microscopic parameters evaluated during the seminal fluid examination. Additionally, the management of the patients who show alterations in the macroscopic parameters of the seminal fluid will be explored in depth.

Osteogenesis imperfecta (OI), colloquially known as “brittle bone disease,” must be routinely considered in all children presenting with recurrent or unexplained fractures. Proper medical work-up includes careful consideration of the history of present illness, review of growth patterns including length/ height, past medical history, family history, physical examination, radiographic and laboratory findings. For decades, OI was described as four major types categorized largely based on clinical features, but in the modern era of genomics, there is more expanded molecular diagnosis and nomenclature. In general, OI can be clinically categorized into mild, moderate, and severe forms. In unexplained fractures in infants, mild forms of OI present an important differential diagnosis to child abuse; more moderate and severe types are usually readily diagnosed based on clinical and radiographical presentation. There is a role for judicious use of genetic testing in cases where OI is a possibility. Ehlers-Danlos syndrome has been purported to cause fractures and mimic child abuse in infants and young children, but this is a flawed explanation largely manufactured for courtroom purposes. By understanding the natural history of OI versus other connective tissue disorders, and by adopting appropriate clinical strategies and evidence-based practices, multidisciplinary clinical teams enhance diagnostic accuracy and improve clinical outcomes for children in our care.

A fundamental dilemma in both the radiology reading room as well as the courtroom is whether a potential abusive head or spinal injury may be mistaken for other entities – both pathological processes and also normal anatomical or physiological variants.

A number of differential diagnoses, or mimics, for abusive head trauma may be apparent radiologically, but many may not be. Striving to achieve a medical “diagnosis” of an abusive injury requires the interplay between the radiologist and numerous other clinical specialties. The wide differentials which we discuss include accidental trauma, coagulopathies – both congenital and acquired, metabolic disorders, sepsis and vascular malformations, with all needing to be excluded before reaching a conclusion of nonaccidental trauma.

The experienced radiologist and clinician working in the challenging field of child protection also recognises that it is not always possible to reach a clear-cut decision and learning to communicate levels of uncertainty is essential. Part of this process is to always be alert to diagnostic mimics that may mislead the inexperienced and unwary.

The extended examination chapter of the sixth edition of the WHO manual presents additional tests that include: indices of multiple defects, sperm DNA fragmentation (SDF) test, sperm aneuploidy test, tests related to immunology, assessment of interleukins, anti-Spermatozoa-antibody coating of spermatozoa, assessment of immature germ cells, biochemical assays for accessory gland function, and assessment of sequence of ejaculation. Of note, some of these exams were already included in previous versions of the textbook and have simply been revised, while others are an absolute novelty in the new edition.

Although these tests present some limitations (e.g. lack of standardization, unclear cut-offs, cost-effectiveness) that preclude their use for routine semen examination, they may be useful in selected circumstances, either for diagnostic or research purposes. The present chapter is structured to give to the clinician a practical guide on physiological principles of the tests, as well as suggest situations in which they might be useful and how to interpret the results.

This chapter provides a comprehensive framework for pediatric and other radiologists serving as witnesses in criminal and civil child abuse cases around the world. The authors clearly and explain key concepts including understanding expert witness qualifications, participating in discovery and pretrial preparation, developing courtroom communication skills and techniques, and effectively anticipating cross-examination. The chapter critically examines the role of evidence-based medicine in the courtroom, highlighting the increasing importance of legitimate peer-reviewed research, consensus statements and statements defining ethical testimony issued by medical professional associations. It also explores contemporary problems, such as courts’ misunderstanding and misuse of unwarranted and medically unsupported alternative explanations for abusive infant and child injuries.

Overall, the chapter aims to equip radiologists with the knowledge and skills to provide accurate, effective, and ethical courtroom testimony. The authors’ overarching goal is to facilitate evidence-based legal decision-making in civil and criminal child abuse cases. The chapter contributes to the growing body of literature on medicolegal collaboration, arguing that radiologists play a crucial role in ensuring fair and accurate judicial outcomes in child abuse cases. It also advances the view that effective expert testimony not only serves individual cases but supports a better public understanding of science and medicine and enhances public health initiatives focused on child abuse prevention and education.

Child abuse can occur in many varied and overlapping forms. Beyond physical abuse, neglect and sexual abuse constitute most reports of child maltreatment, and along with a variety of miscellaneous forms of child maltreatment, they may be accompanied by subtle and occasionally striking abnormalities on diagnostic imaging. Furthermore, some children with real or factitious signs and symptoms suggesting somatic disorders may undergo radiologic examinations that can obscure, rather than clarify, the true nature of the process. The radiologist must be familiar with both the clinical complexities as well as the unusual imaging manifestations of these assorted forms of child maltreatment and may be the first medical professional to suggest the correct diagnosis.

Abusive head trauma (AHT) is a leading cause of traumatic death in infants, often resulting in severe brain injuries with lifelong consequences. It can cause cognitive, sensory and behavioral impairments, which may not fully emerge until later in childhood. AHT injuries are typically classified as primary (direct mechanical damage, such as contusions and lacerations) or secondary (indirect effects like hypoxic-ischemic injury and cerebral edema).

Infants are particularly vulnerable due to factors like poor neck control, larger head size and incomplete brain development. Neuroimaging, especially MRI and diffusion-weighted imaging, is essential for diagnosing these injuries and tracking their evolution, as some manifestations develop over days or weeks. Mechanisms of cell death, including necrosis, apoptosis and autophagy, play a key role in the progression of brain damage.

Differentiating AHT from accidental trauma is challenging. Certain patterns, such as subdural hemorrhages with ischemic injury, strongly suggest abuse. Comprehensive imaging, clinical evaluation and follow-up are crucial for documenting injury progression and understanding its impact on the developing brain.