Injuries to the scalp and cranium are often encountered in children who suffer abusive head trauma. Various imaging modalities, such as radiography, CT and MRI, contribute to accurately diagnosing these injuries and reliably differentiating them from normal variants. A significant challenge in both radiographic and clinical evaluations of skull fractures and extracranial soft tissue injuries is the resemblance between accidental and nonaccidental injuries. Thus, a comprehensive approach that combines imaging findings with the patient’s history, physical examination and laboratory results is essential in each case. This chapter presents vital information on the developmental anatomy of the cranium and scalp and how these relate to traumatic injuries. It also reviews the imaging features of typical abusive injuries, their association with specific mechanisms of trauma and the appropriateness of various imaging modalities.

This chapter provides a summary of longstanding and updated research for the accurate diagnosis of fractures of the clavicle, sternum and scapula in the setting of suspected physical abuse of infants and young children. Findings key to diagnosing fractures by radiographic skeletal survey, computed tomography, ultrasound and magnetic resonance imaging are demonstrated with numerous representative examples. A section for each of these anatomical regions includes a detailed review of anatomy and injury mechanisms in addition to characteristic imaging features. Considerations for differential diagnosis and pitfalls in interpretation are presented specific to each anatomic area. Attention to imaging technique and careful evaluation of findings are emphasized to promote proper diagnosis.

Abusive spinal injury is important to understand and recognize as it may be the only manifestation of child physical abuse and may result in significant morbidity and mortality if undetected. In this chapter, we review historical literature about spinal trauma in the era of radiography and skeletal surveys as well as the expanding literature, epidemiology and understanding of this manifestation of inflicted injury in the era of increased CT and MRI utilization. We highlight key anatomic considerations of developing infants and young children, which make them susceptible to specific types of inflicted spine trauma with emphasis placed on the craniocervical junction, which is particularly susceptible to injury. We provide many imaging case examples to help the reader understand and recognize the myriad and specific types of injuries that occur. Considering our increased understanding of abusive spinal trauma, we discuss implications to imaging evaluation, technique and screening if inflicted spinal injury is detected or suspected.

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.

This chapter presents a scheme for best estimating the age of a fracture in a young child. It describes the features of healing fractures in children. It presents the current literature, addressing rates of healing, factors that may affect healing and how the radiographic findings change during phases of healing. In addition, the authors emphasize the role a radiologist plays in the establishment of an injury timeline. By understanding the contemporary literature, a reader will be able to estimate the age of fractures using the healing features depicted on a radiograph or series of radiographs.

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.

Post-mortem imaging is an indispensable tool in the investigation of suspicious childhood deaths, particularly for identifying fractures and intracranial hemorrhages. It offers significant logistical advantages over traditional autopsies, including cost-effectiveness and rapid image acquisition. However, its application requires close collaboration between radiologists, pathologists and forensic experts, and is rarely used as a standalone approach. This chapter delves into the role of post-mortem imaging, with a primary focus on post-mortem CT and some coverage of post-mortem MRI and novel techniques of micro-CT and linear slot scanning.

The chapter discusses key medicolegal considerations, imaging protocols, common findings and interpretation challenges and the importance of maintaining strict chain-of-custody protocols. As post-mortem imaging continues to gain traction, we underscore the need for standardized imaging protocols and enhanced support for multidisciplinary teams to safeguard the well-being of professionals conducting these sensitive examinations.

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 discusses skeletal injuries associated with obstetric trauma during the birth process. The prevalence of obstetric injuries has decreased with modern obstetric techniques, but major injuries still occur, providing valuable insights into the mechanisms involved in similar lesions seen in abuse cases.

This chapter highlights specific types of injuries, such as clavicular fractures, long bone injuries (including subperiosteal new bone formation and fractures) and rib fractures. Clavicular fractures are the most common site of obstetric fracture, often occurring with relatively uneventful vaginal births of large babies. Long bone injuries include subperiosteal new bone formation and fractures, which may present similarly to abuse-related injuries. Radiographs and sonography play a crucial role in characterizing the extent and nature of these injuries.

This chapter emphasizes the importance of understanding and differentiating obstetric injuries from abuse-related injuries, as well as providing valuable information about the biomechanics, natural history and imaging characteristics of inflicted skeletal injuries during birth.

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.

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.

Abstract: The Conclusion argues that the state of nature remains central to understanding the fractured condition of modern Western thought, particularly in the fields of colonialism, secularism, and ecology. It highlights the continuing relevance of the notion for interpreting the fragmented imaginaries of Western modernity.

• Severe crush injury can result in sequelae such as significant bony fractures, rhabdomyolysis, extremity compartment syndrome or crush syndrome. Crush syndrome comprises the systemic manifestations that arise as a result of a crush injury followed by reperfusion. From the rupture of muscle cells, substances such as myoglobin, potassium, phosphorus and creatinine phosphokinase are released into the bloodstream. The patient can subsequently develop hyperkalemia, hypocalcemia, hypovolemia, shock, compartment syndrome, lactic acidosis or renal failure from traumatic rhabdomyolysis (seen in up to 40% of patients with crush injury).

The chapter commences with a description of various observations of time-dependent fractures in ice. In the medium scale tests, slow loading resulted in very large flaws, whereas fast loading resulted in many small fractures and spalls in the vicinity of the load application. Then, a summary of fracture toughness measurements on ice are summarized. The question of stress singularity at crack tips is raised, and to deal with this, Barenblatt’s analysis is introduced, based on linear elasticity. Schapery’s linear viscoelastic solution for this method is described, using the elastic-viscoelastic correspondence principle. The J integral forms the basis of the application to fracture, using the correspondence principle noted. A set of experiments on ice samples, beams with 4-point loading, was conducted. Tests with a range of loading rates, as well as constant-load tests, were conducted. Comparison of the results with theory was made. The results of Liu and Miller using the compact tension set-up were also considered. Good agreement with theory was found in all cases. Nonlinear viscoelastic theory of Schapery is also outlined.

Recent observations are summarized, in which it has been found that in compressive ice failure, zones of high-pressure form with pressures locally as high as 70 MPa. Various aspects of ice behaviour are summarized: creep, fracture, recrystallization, and the development of microstructurally modified layers of ice. Pressure melting is described, whereby the melting temperature decreases with accompanying hydrostatic pressure. The importance of fracture and spalling in the development of high-pressure zones is emphasized. The use of mechanics in analysis of ice failure is discussed.