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.

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.

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.

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.

This chapter, written by a team of radiologists, a pathologist and a child abuse pediatrician, focuses on extra-axial hemorrhage, i.e., epidural, subdural, subarachnoid and intraventricular hemorrhage, in relation to abusive head trauma. For each, an in-depth discussion of the hemorrhage and it’s clinical presentation in combination with imaging and neuropathological considerations is presented. In the section on subdural hematomas (SDHs), attention is also focused on birth-related SDHs and SDHs in children with benign enlargement of the subarachnoid space. Other types of subdural collections are presented, although with a more limited scope.

Given the relevance in child abuse investigations the authors also present data helpful in differentiating between accidental and nonaccidental causes of extra-axial hemorrhage and on the potential of imaging and neuropathologic examinations in dating the traumatic event leading to the extra-axial hemorrhage.

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.

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.

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.

Congenital uterine anomalies arise from an abnormality in the embryological development process. There can be defects in unification, canalisation or complete agenesis. Uterine anomalies are mnore common in those who experience miscaarriage compared with the general population. Patients with uterine anomalies are at higher risk of infertility, early and second trimester miscarriage, pre-term birth and malpresenatation at delivery.