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Diagnostic Imaging of Child Abuse

C17. Diagnostic Imaging of Child Abuse. Navigation. Objectives. Medical imaging modalities: X-Ray Computed Tomography Magnetic Resonance Imaging Differentiate B enefits to CT and MRI in C hild A buse C ases Conclusion References. Child A buse F acts

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Diagnostic Imaging of Child Abuse

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  1. C17 Diagnostic Imaging of Child Abuse

  2. Navigation

  3. Objectives • Medical imaging modalities: • X-Ray • Computed Tomography • Magnetic Resonance Imaging • Differentiate Benefits to CT and MRI in Child Abuse Cases • Conclusion • References • Child Abuse Facts • Review the Definition of Child Abuse • Understand the Different Forms of Abuse • Identify Signs/Symptoms and Risk Factors

  4. Know the Facts • More than 4 children die from child abuse and neglect on a daily basis.1 • Over 70% of these children are below the age of 3.1 • Can occur in any cultural, ethnic, or income group.2 • 75% of child abuse victims die from neglect.2 • 41% of child abuse victims die from physical abuse.2 • Boys have a higher child mortality rate than girls (2.7 boys and 2 girls per 100,000).2 Figure 1: Chart demonstrates the ages that are more vulnerable to child abuse. 1

  5. What is Child Abuse? • Child Abuse or Child Maltreatment: the physical, sexual, and/or psychological maltreatment or neglect of a child or children, especially by a parent or other caregiver.3 • Child abuse may include any act or failure to act by a parent or other caregiver that results in actual or potential harm to a child, and can occur in a child's home, or in the organizations, schools or communities the child interacts with.3 Figure 2: Chart lists the factors and characteristics that place a child at risk for abuse and maltreatment. 2

  6. Shaken Baby Syndrome is one of the leading causes of death in child abuse cases within the US.5 Physical Abuse • Most common form of abuse • A non-accidental act that results in physical injury inflicted upon the child with cruel and/or malicious intent.4 • Causes: • The abuser is either angry or frustrated, causing them to beat, shake, or throw the victim.4 • Most prevalent form: • Shaken Baby Syndrome → arises when the baby violently gets shaken repeatedly, which can cause brain swelling, internal bleeding, mental retardation, or in extreme case death.6 Figure 3: Demonstrates effects of Shaken Baby Syndrome.3

  7. Emotional Abuse • The hardest form of abuse to identify; often a misunderstood form of trauma that can cause damage to a child’s developing brain. • Forms: • Threatening, insulting, and/or use of belittling words or actions to a child. • Extreme cases lead to: • Emotional Deprivation: syndrome that results from an extreme absence of affirmation and emotional attention in one’s life by primary caretakers.7

  8. Sexual Abuse • Occurs when a child is forced or persuaded to take part in sexual activities via contact or non-contact.8 • Contact: when the abuser touches the child; this form includes penetration.8 • Non-Contact: involves non-touching activities including grooming or exploitation.8 • Male and female offenders include trusted friends, neighbors, family, or strangers.8

  9. Sign/Symptoms3 • Physical: • Unexplained injuries including bruises,fractures, or burns that do not match the given explanation. • Emotional: • A change in a child’s self confidence, depression, loss of development skills, and avoidance of certain situations. • Sexual: • Pain and/or bleeding in genital area, abdominal pain, and any sexually transmitted diseases. Risk Factors9 • Individual: • Children under the age of 4 and special needs such as disabilities or mental health concerns. • Family: • Children socially isolated, negative interactions, and family violence. • Community: • Children living in disadvantaged areas with high poverty and unemployment rates.

  10. Importance of Medical Imaging10 • The assessment if child abuse is suspected relies heavily on the use of medical imaging. • Often in cases of abuse, history provided is either incomplete or can show misleading information. • Physical examinations do not always demonstrate injuries that can be involved in case of child abuse. • The information obtained is of the greatest value when high quality images are taken by trained staff and the images have been read out by a radiologist who is familiar with the findings seen in child abuse. • Imaging modalities not only help to identify the extent of injury, but it has the opportunity to point to a medical diagnosis when abuse is not present.

  11. In children older than 5, a skeletal survey is of little value in screening for injuries because they are less reliable the older the age.6 Diagnostic X-Rays Skeletal Survey: focuses on the entire bony skeleton • Have the abilities to help identify abnormal injuries such as a metaphyseal lesion, that occurs in long bones and posterior rib fractures that are highly suggestive that abuse has transpired.6 General Skeletal Survey Protocol: • Skull Series (AP, Townes,& both Laterals) • AP and Oblique Ribs • AP + Lateral T and L spine • Long Bone Survey: • AP Humerus, Forearms, Femurs, & Tibia/Fibula • Coned down AP views of: • Knees, Feet, Ankles, Elbows, Hands, & Wrists Figure 4: Demonstrates images from a Skeletal Survey.4

  12. Indications for Obtaining a Skeletal Survey Figure 52

  13. Case Study #1 • Figure 611: • An abused child of unknown age and sex • (a) Initial AP view of the chest shows three acute left lateral rib fractures (arrows). • (b) Follow-up radiograph 6 weeks later shows four additional rib fractures not previously seen (arrows) • Findings: • Younger children have higher plasticity of their ribcage; the ribs deform before they fracture. • The presence of rib fractures in infants (less than 1 year of age) is highly specific for abuse • Fractures of the first rib appear to require even greater force than other rib fractures, and strongly suggest abuse • In 62 children, a total of 316 rib fractures were identified. In 51 children (82%) the fractures were due to abuse. In children less than 3 years of age the PPV of rib fractures for abuse was 95%. Figure 611

  14. Case Study #2 • Figure 711 • A 3-week-old abused girl brought to the emergency room after an apnoeic episode (Disorder where breathing stops and starts again repeatedly). • Initial images of the lower extremity show: • (a) no abnormality of the right distal femur • (b) a left distal femur classic metaphyseal lesion (CML) (arrow) and no abnormality in the proximal right and left tibia. • Follow-up radiographs 2 weeks later reveal: • (c) a healing right distal femur CML (arrow) and • (d) bilateral proximal tibia CMLs (arrows) Figure 711

  15. Abusive head trauma is one of the main leading causes of death in children under the age of 2 years old.6 Computed Tomography (CT) • Most effective and sensitive imaging technique for identifying injuries of the lungs, pleura, and abdominal organs.6 • Characteristic findings provided: • Pancreatic injury • Duodenal hematomas • A CT scan of the head is the imaging modality of choice when evaluating a child with acute neurological findings or retinal hemorrhage based on physical examination.12

  16. Case Study #3 • Figure 811 • Shaken Baby Syndrome has increased the importance of a detailed evaluation of the skeleton in cases of suspected inflicted neurotrauma • 4 month-old abused girl • (a) AP view of the chest reveals a healing posterolateral fracture of the right 6th rib (black arrows) • (b) The axial CT image to the left demonstrates a left frontal subdural haematoma (white arrows) Figure 811

  17. Magnetic Resonance Imaging (MRI) • MRI remains to be the best imaging modality to fully determine any injuries within the skull:13 • Collections of fluid within the skull, but outside the brain parenchyma • Bleeding within the parenchyma • Contusions • Shear injuries • Brain swelling and Edema • “MRI offers the highest sensitivity and specificity for diagnosing subacute and chronic injury and should be considered whenever typical skeletal injuries associated with shaking or impact are identified.”6 “Abused infants may not demonstrate neurologic signs and symptoms, despite significant central nervous system injury.”6

  18. Case Study #4 • Figure 911 • A 1-year-old girl who was abused and beaten repeatedly in the head. The images on the left: • (a) demonstrates a skull x-ray showing a wide fracture with smooth margins (arrows) • (b) shows an axial T2 weighted MRI image of the brain that displays adural tear and herniation of cerebrospinal fluid and brain tissue (arrow) Figure 911

  19. Advantages of CT6 • Quick and efficient scan time (5 to 15 minutes). • More readily available due to short scan times. • Two-thirds less than the cost of MRI. • Better for imaging of bone and better detection of subarachnoid hemorrhages. Advantages of MRI6 • Increase contrast resolution that allows visual impact of an MRI scan to lead to greater indications of the findings of abuse. • Does not use ionizing radiation, it used gradient coils and magnetic field to collect needed sequences. • Multi-planar imaging without reformats and moving patients.

  20. Conclusion • Abuse comes in a multitude of forms (physical, emotional, and sexual), each of which affects an individual in various way. • Diagnostic imaging plays and important role in the representation of skeletal, tissue, and brain injuries. • The assessment of suspected child abuse relies greatly on the use of diagnostic imaging. • Although each modality is somewhat restricted, they each have certain qualities that are critical in determining whether abuse has transpired and the appropriate next steps. • Ultimately, the modalities have the ability to detect the first indications of child abuse. • It is essential to include imaging modalities when child abuse is suspected to ensure proper diagnosis and treatment to the child and a chance to live a normal life.

  21. References • National child abuse statistics. Americanspcc.org. Available at: https://americanspcc.org/child-abuse-statistics. Accessed March 8, 2019 • Christian CW. The evaluation of suspected child physical abuse. American Academy of Pediatrics Clinical Report. 2015;135(5):1337-1354. • Child abuse. Psychologytoday.com. Available at: https://www.psychologytoday.com/us/conditions/child-abuse. Accessed March 8, 2019. • MedicineNet. Definition of Physical child abuse. Available at: https://www.medicinenet.com/script/main/art.asp?articlekey=8360. Accessed January 7 2019. • Kidshealth.org. Child Abuse (for Parents). Available at: https://kidshealth.org/en/parents/child-abuse.html. Accessed January 17, 2019. • Ncjrs.gov. Available at: https://www.ncjrs.gov/pdffiles1/ojjdp/161235.pdf. Accessed January 7, 2019. • Webb J. Emotional neglect and emotional deprivation are not the same. https://drjonicewebb.com/emotional-neglect-and-emotional-deprivation-are-not-the-same. Accessed January 17, 2019. • NSPCC. (2019). Sexual abuse. Available at: https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/child-sexual-abuse. Accessed January 17, 2019. • Cdc.gov. (2019). Risk and protective factors|Child abuse and neglect|Violence prevention|Injury center. CDC. Available at: https://www.cdc.gov/violenceprevention/childabuseandneglect/riskprotectivefactors.html. Accessed January 7 2019. • Jain N. The role of diagnostic imaging in the evaluation of child abuse. BC Medical Journal. 2015; 57(8): 336-340. • Offiah A, Van Rijn RR, Perez-Rossello JM, et al. Skeletal imaging of child abuse (non-accidental injury). Pediatric Radiology. 2009;39(5):461-470. • Nita Jain, P. and Nita Jain, P. The role of diagnostic imaging in the evaluation of child abuse. British Columbia Medical Journal. Bcmj.org. Available at: https://www.bcmj.org/articles/role-diagnostic-imaging-evaluation-child-abuse. Accessed January 7, 2019. • Di Pietro MA. Diagnostic imaging of child abuse. American Academy of Pediatrics. 2009; 123(5). Available at: http://pediatrics.aappublications.org/content/123/5/1430. Accessed January 17, 2019.

  22. Figures Figure 1: National child abuse statistics. Americanspcc.org. https://americanspcc.org/child-abuse-statistics. Accessed March 8, 2019 Figure 2: Christian CW. The evaluation of suspected child physical abuse. American Academy of Pediatrics Clinical Report. 2015;135(5):1337-1354. Figure 3: Ncjrs.gov. Available at: https://www.ncjrs.gov/pdffiles1/ojjdp/161235.pdf. Accessed January 7, 2019. Figure 4:Ijnm.in. Available at: http://www.ijnm.in/viewimage.asp?img=IndianJNuclMed_2011_26_2_112_90267_f1.jpg. Accessed February 1, 2019. Figure 5: Christian CW. The evaluation of suspected child physical abuse. American Academy of Pediatrics Clinical Report. 2015;135(5):1337-1354. Figures 6-9: Offiah A, Van Rijn RR, Perez-Rossello JM, et al. Skeletal imaging of child abuse (non-accidental injury). Pediatric Radiology. 2009;39(5):461-470.

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