Misattributing injuries can put children at risk for future abuse.
Radiologists can play a critical role in identifying victims of child abuse, but providers must be aware of the existing fringe beliefs that could result in missed diagnoses and further dangers for a child.
Annually, in the United States, 600,000 children are victims of maltreatment – one in five of whom are physically abused. However, according to a multi-institutional team of researchers, there are still some denialists – those who attribute injuries from abuse to other disorders or fabricated pathologies. In an article published in the American Journal of Roentgenology, the investigators outlined the 10 most common fringe beliefs.
“Injuries may be clinically occult and not apparent on physical exam, particularly in young children,” said the team led by Cory Pfeifer, M.D., MPH, assistant professor of radiology at the University of Texas Southwestern Medical Center. “Imaging, therefore, plays a critical role in identifying and documenting injuries that may be clinically and/or forensically significant.”
When faced with imaging findings suspicious of child abuse, the team said, a radiologist should alert the referring clinician about the specificity of the findings and expand a differential diagnosis when a medical predisposition to injury is clear in imaging. They should also offer up additional imaging evaluation whenever appropriate. In addition, radiologists must be prepared to offer accurate, unbiased, evidence-based medical expertise under oath in court.
According to the team’s analysis, the fringe beliefs most frequently presented by denialists fall into one of three categories: legitimate alternative diagnoses that should be considered, real disorders with actual findings that do not mimic child abuse, and fabricated pathologies.
Osteogenesis imperfecta (OI): This genetic disorder that affects bone formation is typically used as an alternative diagnosis for fractures resulting from child abuse. Clinical indicators for true OI cases include blue sclera, short stature, growth retardation, dentinogenesis imperfecta, and hearing impairment.
OI-related fractures include mid-shaft long bone fractures with subsequent bowing of the affected limbs, as well as pseudarthoses where healing occurs. In contrast, posterior rib fractures and classic metaphyseal lesions (CML), a result of torque being applied to an affected limb or whiplash from shaking, are commonly seen in children who have been abused.
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Ehlers-Danlos Syndrome (EDS): EDS is part of diverse family of connective tissue disorders. Hypermobile EDS, which results in joint laxity that can cause bruising and hemarthrosis, does not have a testable genetic mutation, so it can be a convenient alternative explanation for unexplained fractures, the team said.
Temporary Brittle Bone Disease (TBBD): According to the team, TBBD is a hypothetical disease that can lead to fractures during an infant’s first year of life. It is a suggested variant of OI due to a copper deficiency that can cause bone fragility that leads to fractures. However, copper deficiencies are rare and typically have justifiable causes, such as parenteral nutrition, severe malnutrition, or Menkes syndrome.
In addition, the team said, the Society for Pediatric Imaging (SPR) and the Society of European Pediatric Radiology (ESPR) have refuted the existence of TBBD.
Rickets or Vitamin D Deficiency: A Vitamin D deficiency has been offered as a cause for CML rather than trauma. However, extensive existing literature has refuted that claim.
In addition, the SPR has rejected any link with rickets of the high-specificity imaging findings of child abuse, the team said. Not only are fractures rare in children with rickets, but when they do appear they do not have the same pattern as with child abuse. Rickets-related fractures occur in the setting of osteopenia with radiographic evidence of rickets, and they generally are present in children who are old enough to generate enough force to cause a fracture on their own.
Birth Trauma: Clavicular fractures are known to happen during birth, and they can be corroborated by traumatic birthing complications. Other fractures, such as long bone and skull fractures are much less common, as are birth-related rib fractures. Such rib fractures are typically located in the mid-posterior, and they occur most in larger infants who experience other problems, such as shoulder dystocia, associated with difficult deliveries.
The team noted that multiple rib fractures identified in different stages of healing are suspicious.
“Given the high specificity of risk factors for abuse,” they said, “infants with rib fractures warrant a thorough evaluation for other injuries.”
Classic Metaphyseal Lesions & Posterior Rib Fracture: Providers searching for alternative child abuse diagnoses will frequently assert that CML and posterior-rib fractures are not highly specific for child abuse. However, these two, as well as scalpular fracture, spinous process fracture, and sternal fracture are frequently seen in suspicious cases.
In fact, the team said, radiologists are likely to see concurrent injuries in 60 percent of cases where a child under age 5 has a posterior rib fracture. According to one study, they said, a child who has suffered blunt or penetrating trauma has an increasing risk of death as the number of fractured ribs increases, they said.
Short Falls: Falls from short distances, such as off a couch, typically result in mild injuries rather than fractures. Still, these small falls are frequently reported in children with bone breaks. According to the team, this false history is so common that it shows up eight times more often with fatalities attributed to falls from 4 feet or less than with falls from between 10 feet-to-45 feet. Falls from the shorter distances were also accompanied by evidence of older fractures, trunk and extremity bruising, and head injury.
“Abuse should be considered in those patients presenting with unexpectedly severe injuries, persistent neurologic insult, or injuries that are inconsistent with the provided history,” the team said.
Small Subdural Hemorrhage from Birth Trauma: Small, clinically insignificant subdural hematomas are common in newborns, affecting between 26 percent-and 62 percent of infants. They are typically located posteriorly, resolve on their own within the first three months of life, do not progress to bleeding, and they are not associated with encephalopathy.
Hemorrhages associated with abusive head trauma are strongly associated with parenchymal edema and restricted diffusion, and they typically do progress to severe encephalomalacia.
Denialists, the team said, have argued that hypoxic ischemic injury (HIE) can result in a subdural hematoma, but existing research has shown there is no evidence of subdural hemorrhage with HIE.
“Triad”: The triad, including shaken baby syndrome, parent-infant traumatic stress syndrome, and batter child syndrome, has been used to describe head injury-associated with child abuse. These forces can cause retinal hemorrhages, subdural hematomas, and encephalopathy. However, the SPR and ESPR have issued reports opposing the assertion that shaking can cause these problems.
It is not always possible to determine the actual date of a hemorrhage, the team said, but brain imaging is crucial to assessing the extent of the traumatic brain injury. According to the results of one study, the team said, brain imaging shows a statistically significant association with intracranial pressure, seizures, coma, brain ischemia, subdural hematoma, and severe retinal hemorrhages in children who have been victims of abusive head trauma. Children who experienced accidents demonstrated more scalp swelling and skull fractures.
Benign Expansion of Extra-Axial Spaces: These expansions are common in the first year of life, the team said, with superficial and bridging veins being visualized in expanded subarachnoid space. These are rare when trauma has not occurred, the team said.
The team specifically noted that there has been no new science that has discounted or challenged the specificity of the diagnostic features of child abuse or that has questioned whether child abuse and the resulting head trauma actually happens.
It is incumbent upon medical journals to ensure that any published studies are vetted and reviewed appropriately because the continued proliferation of fringe beliefs in the literature and legal system will only cloud accepted clinical experience and expert consensus, they said, placing children at further risk for recurrent abuse.
“Radiologists must be cognizant of the findings of child abuse, the findings of the differential diagnoses, and the purported alternative diagnoses put forth by child abuse specialists,” they said. “Radiologists should also be aware of fringe beliefs and pseudoscience that seek to deny or distort an immense body of knowledge and literatures on the radiologic findings of child abuse.”
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