This chapter reviews the normal anatomy, fractures and challenges of the upper extremity frequently encountered in child abuse imaging. Specifically, fracture types of the humerus, the elbow and the forearm are examined with attention to imaging techniques and protocols, particularly radiography and ultrasound.

Facial and orbital trauma are frequently seen in cases of child abuse, with certain patterns, such as specific types of retinal haemorrhage, being highly indicative of abusive head trauma. These injuries can be subtle on imaging and often lack a clear history. While some abusive injuries may resemble accidental ones, particular injury patterns or combinations of injuries, alongside additional clinical findings, raise concerns for abuse. Radiologists play a critical role in diagnosing these injuries by obtaining a thorough history and utilizing advanced imaging techniques like MRI and CT with three-dimensional reconstructions, which provide detailed views of soft tissue and bone. Recognizing subtle signs of trauma and correlating them with the clinical context is essential for accurate diagnosis and the child’s protection. Early detection and precise diagnosis by the radiologist enable the multidisciplinary team to intervene appropriately, ensuring the safety and well-being of vulnerable children.

Fractures from accidental trauma to the extremities or ribs in young infants are rare. Towards the end of the first year, when infants begin to gain mobility, accident fractures become more common and are quite prevalent in toddlers. All patterns of accidental fractures may also occur due to abuse; however, presentation and clinical and associated physical examination and imaging findings may suggest abuse. Fractures similar to high specificity abusive fractures may rarely occur from accidental mechanisms.

Iatrogenic fractures are rare in infants and young children. Careful review of the purported mechanism and for underlying bone disease is necessary. Radiographic findings may overlap with abusive fractures, suggesting mechanistic similarities.

The differential diagnosis for multiple fractures in infants and young children includes disorders of calcium and phosphorus metabolism. Conditions such as nutritional vitamin D deficiency rickets, metabolic bone disease of prematurity and congenital rickets may present with metaphyseal changes and fractures, but these typically differ from those seen in abusive trauma. Specialized laboratory studies and imaging tests, as well as potential consultations with endocrinologists, are essential to differentiate between metabolic bone diseases and abuse.

The lower extremities are common sites of abusive skeletal injuries, with fractures often serving as the initial clue to raise suspicion of abuse, and prompt further clinical and imaging investigation. This chapter examines the fracture types, histologic characteristics and imaging findings of skeletal injuries in the femur, tibia and fibula. Notably, the classic metaphyseal lesion, a highly specific indicator of infant abuse, is prevalent in the lower extremities. Detecting these subtle injuries requires rigorous imaging and meticulous inspection of the initial skeletal survey images. The chapter also reviews advanced imaging with ultrasound, CT, MRI and scintigraphy for characterization of complex injuries.

Child maltreatment is prevalent, with 7.7 out of 1,000 children involved in substantiated cases of maltreatment in the United States during 2022. This chapter is intended to provide deeper understanding of the psychosocial issues in cases of suspected child maltreatment, guidance about how radiology staff can interface with these patients and their families and recommendations for support and education to inform best practice and mitigate secondary trauma and implicit biases.

Visceral injuries are important manifestations of child abuse. This chapter reviews mechanisms, clinical presentation and imaging of inflicted injuries involving the neck, thorax, abdomen and pelvis. Because most visceral injuries can be plausibly explained as accidental, the significance of the injuries noted radiologically must be assessed in conjunction with the clinical context, including age and ambulatory status of the child, and other imaging findings, particularly skeletal findings that may be more specific for abuse.

The goal of this chapter is to provide the reader with broad guidance on the many points of intersection between child abuse, diagnostic imaging, the legal system and the radiologist.

The radiologist’s involvement begins before the report in setting up department protocols and supervising the acquisition of images. Communication of important and unexpected findings should occur before finalization of a report. The radiology report is a medicolegal document – the report should be correct, complete, conclusive, cogent and clean. Issues related to reporting are addressed in detail.

Radiologists have a duty to educate other members of the healthcare team and trainees about the diagnostic imaging of child abuse and its differential diagnoses.

Child abuse cases produce an uncomfortable intersection of medicine and the law for the involved radiologist. This chapter provides guidance on all aspects of preparation for possible court testimony. The importance of preparation cannot be understated. In court, the role of testifying radiologists is to provide reputable information and to educate the court.

A thorough understanding of the fundamental aspects of radiologic image formation is key to assessing the appropriateness, advantages, limitations and potential risks in the imaging evaluation of child abuse. This chapter reviews two of the most frequently used imaging modalities that utilize ionizing radiation; planar digital radiography and CT. It is accompanied by a summary of the lesser-used techniques of x-ray fluoroscopy and nuclear medicine (planar gamma camera imaging, single photon emission CT, positron emission tomography). The purpose of this work is to offer the reader, whether radiologist, nonradiologist physician or allied health provider (medical radiation technologist, nurse, etc.) a sufficient accounting of the physical principles, technology and radiation dose considerations of these imaging choices to supplement their clinical expertise in making imaging decisions for their patients. Special attention will be allotted to core concepts of radiation dose and its practical and contextual considerations. Familiarity with typical dose estimates across relevant patient size and age is essential for planning and relative risk assessment. Communicating radiation risk in the context of benefit remains a core responsibility of all associated with medical imaging, one that should be embraced, and not feared, by the clinical team.

Pelvic fractures in children resulting from abuse are rare but strong indicators of severe trauma. These injuries, especially in infants, are subtle and usually involve the superior pubic rami. In older children, they often occur in cases of significant blunt trauma or sexual abuse. Pelvic fractures are frequently associated with other signs of abuse, particularly other fractures around the hips. The anteroposterior view of the pelvis in the initial skeletal survey should be examined with care. Due to the rarity of pelvic fractures, it is reasonable to exclude the frontal view of the pelvis in the follow-up skeletal survey. Cross-sectional imaging may be beneficial in selected cases.

Rib fractures are the most common fracture by number in the abused child. While posterior rib fractures bear the highest specificity for child abuse, rib fractures are rare in infants and young children from accidental trauma. In the absence of overt underlying bone disease or reliably witnessed trauma, any rib fracture in an infant or young child is worrisome and indicates the need for further evaluation.

Normal rib anatomy is presented. Rib fractures may occur at any location in the rib from rib head proximally to costochondral junction distally. Abusive rib fractures may be acute or, more commonly, in the healing state at presentation. Rib fractures are commonly accompanied by other abusive injuries. Lower rib fractures are not infrequently seen when there is abusive visceral trauma.

Cardiopulmonary resuscitation in infants may cause rib fractures; however, such fractures are characteristically buckle fractures of the anterior or anterolateral upper and middle ribs and show no evidence of healing at presentation.

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.

Consideration of possible alternatives to child abuse as an explanation for skeletal abnormalities during a child abuse investigation is an essential element of due diligence by all healthcare professionals involved in these cases, including and, in particular, radiologists.

Conditions which may have features resembling sequelae of child abuse include bone fragility states, conditions with metaphyseal abnormalities resembling classical metaphyseal lesions and conditions featuring subperiosteal new bone formation. Further suspicion for child abuse may be raised when there are associated extraskeletal mimics of abuse, such as skin lesions.

This chapter explores a range of genetic, nutritional and other acquired disorders which may present in this fashion.

This chapter reviews the principles of evidence-based medicine and evidence-based radiology as they apply to child maltreatment clinical care and research. Common pitfalls and the rise of “predatory publishing” are discussed as important challenges to rigorous medical literature appraisal and its application to clinical care and research. An approach to critical appraisal is given, to help you determine whether a study is of high quality or not. A detailed discussion of the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) report is included as a particular example of the misuse of evidence-based edicine principles.

Compared to the ribs, long bones and skull, injuries to the hands and feet are less common findings in child abuse. Particularly in infants, these fractures carry a strong association with inflicted injury and should be sought in all imaging evaluations for suspected abuse. Meticulous attention to technique assures optimal display of hand and foot fractures. In the hand, abusive fractures most commonly involve the metacarpals, to a lesser extent the proximal phalanges, and are rarely distal. In the foot, the metatarsals are most commonly involved, particularly the first metatarsal. Most fractures of the metacarpals, metatarsals and phalanges are buckle fractures. Other fracture patterns (transverse, physeal, corner fracture) are less common. Fractures of the hands and feet usually accompany other fractures of abuse; however, they are occasionally the skeletal injury. Radiography is the chief mode of imaging abusive hand and foot fractures, though fractures may be evident with other imaging modalities.

Medical providers involved in child abuse cases will encounter a variety of issues with legal implications, including informed consent, appropriate documentation, confidentiality, mandated reporting and potential liability. Consequently, all medical providers who may become involved in child abuse cases should have a fundamental understanding of child maltreatment laws in their jurisdiction. While informed consent is a well-established medicolegal doctrine in many countries, there are often jurisdiction-specific variations in cases of suspected child maltreatment. Complete, accurate and objective medical documentation is also imperative, as medical reports are frequently submitted in legal proceedings. Care should be taken, however, to ensure appropriate release and retention of medical records in accordance with country-specific legislation (e.g., Health Insurance Portability and Accountability Act and 21st Century Cures Act in the United States). Finally, medical providers should understand their responsibility to report to the appropriate protective services agency if there is reasonable suspicion that child maltreatment has occurred. A practitioner’s failure to adhere to statutory requirements may result in negative actions against the provider.

Fractures are common in physically abused infants and young children, and they are often central to the diagnosis of maltreatment. Given the anatomic and biologic framework provided in the preceding chapter, the discussion now moves on to the specific features of these important and frequently distinctive osseous injuries. The authors begin with a review of the epidemiology, anatomic distribution and specificity of fractures noted in abused infants and children. The discussion then proceeds to systematically describe the specific osseous alterations, providing radiologic correlations with histopathology to enhance the reader’s understanding of the various patterns of bony injury and repair. These correlations also help to elucidate the proposed mechanisms underlying these important indicators of abusive injury. Although this discussion of the imaging features focuses on fractures of the long bones, the principles presented here should serve as a background for subsequent chapters dealing with injuries of the axial skeleton.