DiagnosticImagingofChildAbuse · 2015. 11. 16. · Section I – Skeletal trauma 1 The skeleton: structure, growth and development, and basis of skeletal injury 9 Andrew E. Rosenberg

Diagnostic Imaging of Child Abuse

Third Edition

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Cambridge University Press978-1-107-01053-6 - Diagnostic Imaging of Child Abuse: Third EditionEdited by Paul K. KleinmanFrontmatterMore information

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Diagnostic Imagingof Child AbuseThird Edition

Edited by

Paul K. Kleinman MD, FAAPDepartment of Radiology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA






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© Paul K. Kleinman 2015

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First published: 1987Second edition: 1998Third edition: 2015

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Library of Congress Cataloguing in Publication dataKleinman, Paul K., editor.Diagnostic imaging of child abuse / Paul K. Kleinman. – Third edition.

p. ; cm.Includes bibliographical references and index.ISBN 978-1-107-01053-6 (Hardback : alk. paper)I. Title.[DNLM: 1. Battered Child Syndrome–diagnosis. 2. Bone andBones–injuries. 3. Child Abuse. 4. Child. 5. DiagnosticImaging. 6. Infant. WA 325]RA1122.5617.100757–dc23 2014046556

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Every effort has been made in preparing this book to provideaccurate and up-to-date information which is in accord with acceptedstandards and practice at the time of publication. Although casehistories are drawn from actual cases, every effort has been made todisguise the identities of the individuals involved. Nevertheless, theauthors, editors, and publishers can make no warranties that theinformation contained herein is totally free from error, not leastbecause clinical standards are constantly changing through researchand regulation. The authors, editors, and publishers thereforedisclaim all liability for direct or consequential damages resultingfrom the use of material contained in this book. Readers are stronglyadvised to pay careful attention to information provided by themanufacturer of any drugs or equipment that they plan to use.






Dedicated to Sandy Marks











Contents

List of contributors ixEditor’s note on the Foreword to the third edition xiForeword to the third edition, Diego Jaramillo xiiForeword to the second edition, Clément J. Fauré xiiiForeword to the first edition, John A. Kirkpatrick, Jr. xvPreface xviiAcknowledgments xixList of acronyms xx

Introduction 1Paul K. Kleinman

Section I – Skeletal trauma1 The skeleton: structure, growth and development,

and basis of skeletal injury 9Andrew E. Rosenberg

2 Skeletal trauma: general considerations 23Paul K. Kleinman, Andrew E. Rosenberg, and Andy Tsai

3 Lower extremity trauma 53Paul K. Kleinman

4 Upper extremity trauma 121Paul K. Kleinman

5 Bony thoracic trauma 164Paul K. Kleinman

6 Dating fractures 208Paul K. Kleinman and Michele M. Walters

7 Differential diagnosis I: diseases, dysplasias,and syndromes 217Paul K. Kleinman and Paula W. Brill

8 Differential diagnosis II: disorders of calciumand phosphorus metabolism 240Ingrid Holm and Jeannette M. Perez-Rossello

9 Differential diagnosis III: osteogenesisimperfecta 254Deborah Krakow, Ralph S. Lachman, and PaulK. Kleinman

10 Differential diagnosis IV: accidental trauma 268Paul K. Kleinman

11 Differential diagnosis V: obstetric trauma 279Paul K. Kleinman

12 Differential diagnosis VI: normal variants 290Paul K. Kleinman

13 Evidence-based radiology and childabuse 309Christopher S. Greeley

14 Skeletal imaging strategies 324Paul K. Kleinman

15 Postmortem skeletal imaging 335Paul K. Kleinman

Section II – Abusive head and spinaltrauma

Editor’s note 343Paul K. Kleinman

16 Abusive head trauma: clinical, biomechanical,and imaging considerations 345Lori D. Frasier and Brittany Coats

17 Abusive head trauma: scalp, subscalp, andcranium 357Paul K. Kleinman, Brittany Coats, andV. Michelle Silvera

18 Abusive head trauma: extra-axial hemorrhageand nonhemic collections 394Gary L. Hedlund

19 Abusive head trauma: parenchymal injury 453P. Ellen Grant

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20 Abusive head trauma: intracranial imagingstrategies 487V. Michelle Silvera, P. Ellen Grant, Gary L. Hedlund,and Paul K. Kleinman

21 Abusive craniocervical junction and spinal trauma 494Paul K. Kleinman and V. Michelle Silvera

Section III – Visceral trauma and miscellaneousabuse and neglect

22 Visceral trauma 563Katherine Nimkin and Paul K. Kleinman

23 Miscellaneous forms of abuse and neglect 608Paul K. Kleinman

Section IV – Diagnostic imaging of abusein societal context

24 Psychosocial considerations 633Alice W. Newton and Amy C. Tishelman

25 Child abuse and the law I: general issues for theradiologist 638Sandeep K. Narang

26 Child abuse and the law II: the radiologist in courtand fundamental legal issues 645Martha Coakley

27 The radiologist’s response to child abuse 658Paul K. Kleinman

Section V – Technical considerationsand dosimetry

28 Radiologic image formation: physicalprinciples, technology, and radiation doseconsiderations 667Andrew Karellas and Srinivasan Vedantham

29 The physics and biology of magnetic resonanceimaging: medical miracle anyone? 688Robert V. Mulkern

30 Quality assurance and radiographic skeletal surveystandards 708Patricia L. Kleinman

Index 716

Contents

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Contributors

Paula W. Brill MD, FAAPChief of the Division of Pediatric Radiology at the New York-Presbyterian Hospital-Weill Cornell Center and Professor ofRadiology and Pediatrics at Weill Cornell Medical College,New York, New York, USA

Martha Coakley JDFormer Attorney General of the Commonwealth ofMassachusetts, Boston, Massachusetts, USA

Brittany Coats PhDAssistant Professor of Mechanical Engineering and AdjunctAssistant Professor of Bioengineering at the University ofUtah, Salt Lake City, Utah, USA

Lori D. Frasier, MD, FAAPDivision Director, Center for the Protection ofChildren at Penn State Hershey Children’sHospital and Professor of Pediatrics at Penn StateHershey College of Medicine, Hershey, Pennsylvania, USA

P. Ellen Grant MD, MScDirector, Center on Fetal-Neonatal Neuroimaging andDevelopmental Science Center, Boston Children’s Hospitaland Associate Professor of Radiology at Harvard MedicalSchool, Boston, Massachusetts, USA

Christopher S. Greeley MD, FAAPProfessor of Pediatrics at the Center for Clinical Research andEvidence-Based Medicine, University of Texas Health ScienceCenter at Houston, Houston, Texas, USA

Gary L. Hedlund DOChief of Neuroimaging at the Primary Children’s MedicalCenter and Adjunct Professor of Radiology at the Universityof Utah, Salt Lake City, Utah, USA

Ingrid Holm MD, MPHDirector of the Phenotype Core of the Program in Genomics atBoston Children’s Hospital and Assistant Professor ofPediatrics at Harvard Medical School, Boston, Massachusetts,USA

Andrew Karellas PhD, FAAPM, FACRDirector of Radiological Physics at UMass Memorial HealthCare and Professor of Radiology at the University ofMassachusetts Medical School, Worcester, Massachusetts, USA

Patricia L. Kleinman MPH, RT(R)(QM)Radiologic Physics Technology Specialist, Department ofRadiology, Boston Children’s Hospital, Boston, Massachusetts,USA

Paul K. Kleinman MD, FAAPDivision Chief of Musculoskeletal Imaging at BostonChildren’s Hospital and Professor of Radiology at HarvardMedical School, Boston, Massachusetts, USA

Deborah Krakow MDProfessor of Orthopaedic Surgery, Human Genetics andObstetrics and Gynecology, David Geffen School of Medicineat UCLA, Los Angeles, California, USA

Ralph S. Lachman MDPediatric Radiologist at Harbor/UCLA Medical Center,International Skeletal Dysplasia Registry at Cedars-SinaiMedical Center and Professor of Radiology and Pediatrics atthe University of California, Los Angeles School of Medicine,Los Angeles, California, USA

Robert V. Mulkern PhDAssociate Physicist at the Department of Radiology, BostonChildren’s Hospital and Associate Professor of Radiology atHarvard Medical School, Boston, Massachusetts, USA

Sandeep K. Narang MD, JD, FAAPDirector, Child Abuse Fellowship at the Division of ChildProtection, Department of Pediatrics, CARE Center andAssistant Professor of Pediatrics, University of Texas HealthScience Center at Houston, Houston, Texas, USA

Alice W. Newton MD, FAAPMedical Director, Child Protection Program, MassachusettsGeneral Hospital and Assistant Professor of Pediatrics atHarvard Medical School, Boston, Massachusetts, USA

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Katherine Nimkin MDAssociate Director of Pediatric Imaging at the MassachusettsGeneral Hospital and Assistant Clinical Professor ofRadiology at Harvard Medical School, Boston,Massachusetts, USA

Jeannette M. Perez-Rossello MDStaff Pediatric Radiologist at Boston Children’s Hospital andAssistant Professor of Radiology at Harvard Medical School,Boston, Massachusetts, USA

Andrew E. Rosenberg MDDirector of Anatomic Pathology and Director of Bone and SoftTissue Pathology at the University of Miami Hospital andProfessor of Pathology at the University of Miami MillerSchool of Medicine, Miami, Florida, USA

V. Michelle Silvera MDStaff Pediatric Neuroradiologist at Boston Children’s Hospitaland Assistant Professor of Radiology at Harvard MedicalSchool, Boston, Massachusetts, USA

Amy C. Tishelman PhDResearch Director and Senior Psychologist, Child ProtectionProgram at the Massachusetts General Hospital, and AssistantProfessor of Psychology at Harvard Medical School, Boston,Massachusetts, USA

Andy Tsai MD, PhDStaff Pediatric Radiologist at Boston Children’s Hospital andInstructor in Radiology at Harvard Medical School, Boston,Massachusetts, USA

Srinivasan Vedantham PhDDepartment of Radiology at UMass Memorial Health Care andAssociate Professor of Radiology at the University ofMassachusetts Medical School, Worcester, Massachusetts,USA

Michele M. Walters MDStaff Pediatric Radiologist at Boston Children’s Hospital andInstructor in Radiology at Harvard Medical School, Boston,Massachusetts, USA

Contributors

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Editor’s note on the Foreword to the third edition

In the 1987 first edition of Diagnostic Imaging of Child Abuse,the Foreword was written by John Kirkpatrick, Radiologist-in-Chief at Boston Children’s Hospital and Professor of Radiologyat Harvard Medical School. For me, he was the consummatepediatric radiologist in intellect, spirit, and conduct.

A special relationship has existed between North Americanand European pediatric radiology, and for this reason I askedthe eminent French pediatric radiologist Professor ClémentFauré to write the Foreword to the second edition. This highlyrespected scholar and teacher had a long interest in the subjectof child maltreatment and made many significant contributionsto the field. I was privileged that this distinguished radiologistagreed to share his recollections and perspectives with us.

For the third edition, I sought a gifted and distinguishedpediatric radiologist, who like his predecessors garneredboth the respect and affections of the radiologic community.The choice was obvious – Diego Jaramillo. No radiologisthas contributed more to our understanding of normal bonegrowth and development. Our interests intersect in a varietyof planes, most notably in the response of the physis totraumatic injury. Diego shares many of the remarkable traitsof his predecessors in this task and I am in his debt fortaking the time from his busy schedule to contribute to thisvolume.

Paul. K. Kleinman MD

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Foreword to the third edition

The only real voyage of discovery consists not in seeking newlandscapes, but in having new eyes.

Marcel Proust, In Search of Lost Time

Throughout history, humanity has tended either to turn a blindeye on the abuse of children or to deny its existence. Since 1962,when Kempe and Silverman wrote their landmark article on thebattered child, the scientific community has developed anincreasing awareness of the issue. In recent years, our under-standing of the imaging findings in battered children hasincreased substantially thanks to the two previous editions ofthe most authoritative book on the subject, Diagnostic Imagingof Child Abuse, by Dr. Paul Kleinman. The book is not just areview of findings in the literature; it is the summation ofdecades of outstanding research, deep thought and great teach-ing. In his journey to clarify the nature of the radiologicmanifestations of child abuse, Dr. Kleinman now looks at thesubject for a third time, with “new eyes.” With this thirdedition, Dr. Kleinman has taken a large step to increase thedepth and extent of what was included in the prior editions.

The new edition begins with a chapter about the structure,growth, and development of the skeleton by Professor AndrewRosenberg, a premier pathologist in the United States. The firsttwo chapters also deal with important concepts about thepathophysiology of skeletal injury, which are fundamental tothe understanding of the imaging manifestations of skeletaltrauma. The following chapters are divided regionally, dealingwith specific findings that are related to the particular bonethat is injured. Six chapters address the differential diagnosis ofabusive skeletal injury. At a time where there is discussionabout the etiology of many radiologic findings, particularlyin the metaphysis, this book provides a brilliant guide todifferentiating inflicted traumatic findings from many poten-tial mimickers. The chapters on the differentiation fromnormal variants and other sources of trauma reflect themeticulous research performed by Dr. Kleinman. The chapteron disorders of calcium and phosphorus metabolism,co-authored by Dr. Ingrid Holm, an expert in metabolic bonedisease, and Dr. Jeannette Perez-Rossello, who has studied thesubject in great depth, is particularly important. There is abalanced and very well-supported discussion of how the

radiologic manifestations of vitamin D deficiency and ricketsdiffer from those of inflicted trauma, which should bring lightto current “controversial” issues. Chapters on skeletal dyspla-sias and osteogenesis imperfecta are authored by some of thebest experts in the field. The chapter on evidence-based radi-ology provides useful information about how to judge theliterature and specifically analyze the soundness (or lackthereof) of the diagnosis of “temporary brittle bone disease.”

The second part of the book addresses the manifestations oftrauma to the head and spine. In multiple chapters by a group ofprominent experts in the pediatric central nervous system andbiomechanics, there are detailed descriptions of the imagingmanifestations of trauma to the scalp and cranium, and to theextra-axial and parenchymal structures. Imaging strategies arediscussed in a succinct, practical way, both for the head and thespine. The third part deals with visceral trauma and otherimportant manifestations of abuse and neglect.

Section IV is very useful for radiologists, as it clarifies thepsychosocial picture as well as the legal considerations and theobligations of the radiologists. The final part is dedicated totechnical considerations in radiography, CT, and MRI; andserves as an invaluable reference for the practicing radiologist.

In the foreword to the second edition of this book, ProfessorClement Fauré said, “Today, of course, the syndrome of theabused and neglected child is generally accepted.” This remainstrue, but now more than ever it is crucial to expand our know-ledge about mechanisms of injury and their manifestations.Those of us dealing with investigations of child abuse will dowell by heeding the advice of Hippocrates: “Leave nothing tochance. Overlook nothing. Combine contradictory observations.Allow yourself enough time.” We come closer to the truth byhaving more data, and by understanding it better. With thisinvaluable contribution of the third edition, Dr. Paul Kleinmanand his co-authors have done society a great service: they havebrought us closer to the truth in matters of child abuse.

Diego Jaramillo MD, MPH

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Foreword to the second edition

“It is not given to everyone to be an orphan,” deplores Poil deCarotte (Carrot Top), hero of a French novel most of us haveread. This wretched boy, our French counterpart to the Ameri-can Huckleberry Finn, was rejected, neglected, and battered bya mother who nonetheless loved her other children. We havealso learned that in past centuries, children were inflicted withsevere limb injuries to produce permanent deformities thatwould make them more efficient beggars. But society tendedto consider these facts a good subject for novels and did notappreciate their true frequency. Forgotten were the works ofAmbroise Tardieu, a French forensic physician, who in1860 described the injuries he found in infants or childrenwho died of inflicted trauma. Until the 1940s, these lesionsoften remained undiagnosed, and when a baby was founddead, the diagnosis of natural “sudden infant death” was com-monly accepted.

Radiology has been used in infants and children since itsorigins, but images were generally of poor quality, oftenblurred by patient movement. It was with the introductionof newer x-ray tubes enabling shorter exposure times thatpediatric radiology made a quantum leap. This improvedradiographic technology led to the discovery in 1946 of whatthe pediatric radiologist John Caffey MD recognized asinflicted trauma.

In France, it took years for this concept of “unrecognizedskeletal trauma” to be accepted. As a fellow in pediatricradiology at the Hôpital des Enfants Malades in Paris in theearly 1950s, I shared the difficulties encountered by my chief,Jacques Lefebvre, in convincing our clinicians of its occur-rence. Having as our bible Caffey’s Pediatric X-Ray Diagnosis,as well as other American publications in pediatric radiology,we were perfectly aware of the “battered child syndrome.”However, when we proposed this diagnosis to our colleagues,we were told we were wrong, mistaken by lesions due toscurvy, rickets, or hereditary (sic) syphilis. When a subduralhematoma was encountered without an associated skull frac-ture, trauma was unsuspected and the finding was often attrib-uted to pachymeningitis, or to cerebral collapse secondary tohypovolemic shock. Associated bone lesions of extremitieswere considered “neurotrophic,” related to central nervoussystem disorders. Even our great professor of pediatrics,

Robert Debré, who later popularized this entity as Silverman’ssyndrome, was reluctant at first to accept our conclusions.

Why Silverman’s syndrome and not Caffey’s or Kempe’s?I can relate the story. Robert Debré was a great friend ofGeorge M. Guest MD, Professor of Pediatrics in Cincinnati.Each time the two met, whether in Paris or Cincinnati, therewas an opportunity for case presentations. Professor Debréalso sent some of his best pupils each year for residencytraining in Guest’s department. During one of Debré’s visitsto Cincinnati in the early 1950s, Fred N. Silverman MD, at thattime the hospital’s pediatric radiologist, presented a case of a“battered child.” After the presentation, Debré told one of hisresidents who had attended the meeting that he was reluctantto accept Silverman’s diagnosis.

One year later in France, at a weekly gathering of ProfessorDebré and his assistants and pupils, that same resident pre-sented a compelling case of child abuse. After the presentation,Debré’s comment was “But of course, this is a case of Silver-man’s syndrome!” remembering the syndrome Fred Silvermanhad presented in Cincinnati. Hearing this, the audience askedto learn more of Silverman’s “discovery” from their respectedteacher. Since that day, child abuse has been known as Silver-man’s syndrome in French medical literature. What we hadtried to make evident for two or three years was now suddenlyaccepted. As the French saying goes, “On ne prête qu’auxriches” (Only to the rich is money lent).

Where are we in France at the end of the century? Today,of course, the syndrome of the abused and neglected child isgenerally accepted. It is taught to our medical students, andthen more completely explored with our residents in pediat-rics, radiology, and orthopedic surgery. But we still face somedifficulties – when bone lesions are not evident at first glanceand even more so when a diagnosis appears to some observersto contradict the “social status” of the caretakers.

By this long preamble I wish to highlight the generalassistance that American pediatric radiology has brought itsFrench and other European counterparts. And in this field ofchild abuse, Paul Kleinman’s book Diagnostic Imaging of ChildAbuse will continue to improve our fund of knowledge.A major contribution from the author is the radiologic andpathologic descriptions of the subtle lesion he calls the “classic

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metaphyseal lesion” (CML). To familiarize our eyes to itsappearance, the book offers a large display of CMLs in severallocations and in different stages of evolution. In a similarmanner, the chapter devoted to bony thoracic trauma injuryis particularly informative, explaining the location of rib frac-tures according to their mechanisms of injury. This can help inquestioning the caretaker about the origin of the rib fracturesnoted radiographically. This chapter, as well as the others,offers a rich iconography.

All the classic bone lesions of the abused child are thor-oughly described and illustrated. Bone scintigraphy plays animportant role in the early detection of skeletal lesions that areinitially undetected radiographically and revealed only by thedevelopment of callus some weeks later. Initial scintigraphicdata can prevent a defendant’s attorney from convincing thejury that the fractures noted were sustained during thepatient’s hospitalization and were therefore due to underlyingbone fragility; we have found ourselves involved in such a case.The book also provides an in-depth description of the diseasessimulating abuse, particularly osteogenesis imperfecta. Thegreat contribution of cross-sectional imaging modalities is

evident when we evaluate craniocephalic or visceral lesions.Indeed, this book covers all that is known regarding theimaging of child abuse at the turn of the century.

The last chapters of the book are of paramount interest.They share information about child abuse and the law.Readers will appreciate, as I have, all the pertinent adviceoffered to the radiologist involved in civil or criminal casesas an expert witness. In such cases, the radiologist is calledupon to use his or her expertise to determine whether lesionsdiscovered by imaging can be attributed to a pre-existingdisease or clearly point to inflicted trauma. The radiologistis not a judge, however; his or her main concern is the child’ssafety. In cases where the child survives, the best we can hopefor is the child’s placement in a safe and loving home. Whatpunishment should be given to the abuser is beyond ourmission. When the maltreatment results in death, determin-ing whether it is due to the ignorance, irritability, stupidity,or perversity of the caretakers is the domain of social workersand the courts.

Clément J. Fauré

Foreword to the second edition

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Foreword to the first edition

The concept of willful assault upon children by their caretakersis almost incomprehensible. Sometimes the physician needsreassurance that what is seen by physical examination ofradiography can be believed. The chapters on the radiologicaspects of child abuse, 2 through 9, present in exquisite detail,with gross microscopic pathologic correlation, the many radio-graphic findings caused by willful injury to the skeleton andsolid organs. The discussion of the incidence and patterns ofinjury reminds us of the underestimation of the incidence ofskeletal injury and that the overall concept of child abuse hasbeen expanded. The discussion of the skeletal survey and thescintigraphic examination of the skeleton shows that each hasvalue – they are more complementary than supplementary.

The chapter dealing with the radiologic dating of fracturesis important in the diagnosis of the abused child and also haseveryday applicability. The pathophysiology of fracture healingis lucidly presented, as is its modification by repetitive trauma.The discussion of trauma to solid viscera and the centralnervous system includes the use of computed tomographyand mechanisms of injury; for example, mesenteric injurycan result from blunt trauma or sudden deceleration. Involve-ment of the distal colon and rectum is most often caused bysexual abuse. Inflicted abuse seldom injures the spleen, thekidneys, or the lower urinary tract.

Dr. Kleinman has had a long and fruitful relationship withhis colleagues in pathology. The material derived from autop-sies is of interest to both disciplines. The value of postmortemradiographic study and of its correlation to the actual

pathologic anatomy is persuasively presented. The differentialdiagnosis of inflicted skeletal injury is discussed in Chapter 11,followed by a chapter dealing with the legal aspects ofchild abuse.

In the chapter dealing with legal issues, it is stated that“sensitive management of family violence cases requires bothmedical and legal input.” The radiologist has a role in deter-mining the nature and degree of inflicted injury – informationthat often can be obtained in no other way. Of further interestto the radiologist is the discussion concerned with legal con-sent, medical records, reporting statutes, and procedures rela-tive to service as a witness or expert witness. This is followedby a chapter on psychological considerations associated withabuse that includes the role of the radiologist in the initialdetection of skeletal injury, its documentation, and the subse-quent support provided for psychological or legal intervention.

The last chapter reviews technical considerations in dosim-etry and includes a discussion of radiation risks entailed in theexamination as well as methods for the reduction of exposurethrough appropriate selection of equipment, techniques, andthe application of clinical judgment.

All in all, one can be enthusiastic about this work andthankful to Dr. Kleinman and his co-authors for presenting acogent examination of the radiologic aspects of child abuse.The radiologist may be the first to note the possibility of anunfortunately common occurrence.

John A. Kirkpatrick, Jr. MD

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Preface

The origins of my interest in the subject of child abuse rest inpart with a bizarre incident that occurred during my pediatricresidency. The episode began with a middle-of-the-night phonecall from a woman who introduced herself as only “Clara.” Shespoke in an authoritative and well-polished manner andquickly drew me from my groggy state. Without any apologyfor waking me, she said my court testimony was required in achild custody trial set to take place the following day. Thematter entailed a dispute between estranged parents who wereeach seeking to gain custody of their children, one of whomwas allegedly abused. She indicated that the child had been seenin our acute care clinic by a physician who was not available totestify and so, as I had been assigned to the same clinic, mytestimony was required to validate the clinical record of thevisit. Because I did not recall seeing the patient and the exam-ining physician was unfamiliar to me, I suggested she seek theassistance of the director of the clinic where the child was seen.She would not relent and explained in further detail the abusiveassaults perpetrated by the mother and the vital importance ofplacing the children with the father. The conversation drew to aclose only after I pressed her to explain her special interest inthe case. I soon fell back to sleep, and the following morningI wondered if I had dreamt the entire incident.

Shortly after morning rounds, I was summoned to theoffice of the chief of staff and was escorted into a statelywood-paneled board room. Seated around a huge imposingtable were the chief of staff, the director of the pediatric clinic,a lawyer, and a number of other unfamiliar individuals. Theyasked if I had been contacted by anyone requesting my testi-mony in a current child custody case. I shared with them whatI could recall from the prior evening’s telephone conversationand asked them to explain what was going on.

They provided me with the details of a custody casepresently in court in which child abuse had been alleged andin which the validity of the medical record was being con-tested. The clinic director held a copy of a page taken from thechild’s medical record that detailed the physical, laboratory,and radiologic findings of one of the children in the custodydispute. The clinical findings read like a page out of Helferand Kempe’s textbook, The Battered Child Syndrome. Theradiologic descriptions could have been taken directly from

Caffey’s Pediatric X-Ray Diagnosis and included terms such as“corner fractures” and “bucket handle” lesions. Althoughmuch of the terminology was appropriate, the organizationof the note, the use of language, and the flow of the narrativeclearly indicated that the note had not been written by aphysician. The bogus nature of the record was confirmed whenit was determined that none of the laboratory studies andx-rays referred to in the note had been performed.

As the various elements of the story were pieced together,it became clear that someone had doctored the medical recordto support an allegation of maternal child abuse. This wasachieved simply by securing hospital progress note forms,entering the false historical, physical, and laboratory data,and bolstering the account with suitable language from appro-priate textbook discussions on the subject of child abuse. Thepapers were then forwarded to the record room and dutifullyadded to the patient’s existing chart. The true identity of themidnight caller remains a question to this day. However, thefather in this case was described to me as a major figure in highNew York circles with many important friends, and I suspectthe caller was one of them.

My scientific interests in the field of child abuse grew fromsimple intellectual curiosity. In my early years as a pediatricradiologist, I was struck by the unique character of certainskeletal injuries found in cases of abuse, particularly thoseencountered in young children. One infant had sustained afatal head injury and also manifested the classic metaphyseallesions described by one of the fathers of pediatric radiology,John Caffey. Caffey speculated regarding the basic morphologicalterations and their significance, but provided no pathologicbasis for his views. When the infant in question died, I calledmy friend and colleague, Brian Blackbourne, then the ChiefMedical Examiner of the Commonwealth of Massachusetts,and asked him if he would be willing to remove the injuredbones so that we might examine them further. He resected theinjured metaphyseal regions and we subsequently subjected thespecimens to high-detail radiography performed by radiologictechnologist Patricia Belanger, with the help of physicistAndrew Karellas. To assist in the analysis of the histologicmaterial, we sought the aid of anatomist Sandy Marks,an expert in bone structure, growth, and repair. The

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radiologic–histopathologic correlations that grew from thesecollaborative efforts over the ensuing years have increased ourunderstanding of both the fundamental structural alterationsof skeletal injury and the mechanical factors involved in theirproduction. From these studies, our interest expanded toencompass the wide array of inflicted injuries involving theentire skeleton, the viscera, and the central nervous system.

The first edition of Diagnostic Imaging of Child Abuse wasan attempt to collect these imaging observations in a singledetailed resource that also addressed various related technical,social, and legal issues designed to assist in the imaging evalu-ation of suspected child abuse. In the second edition, publishedin 1998, additional imaging patterns of abuse and neglect weredescribed. The evolution of cross-sectional imaging techniquesoffered new perspectives on familiar physical injuries andrevealed additional unusual manifestations of child maltreat-ment. Perhaps the most stunning insights were gained by theapplication of magnetic resonance imaging to inflicted centralnervous system injuries.

The broadening of the imaging spectrum and the advancesin our understanding of inflicted injuries are reflected in thesubstantial growth of the core imaging chapters in this thirdedition. The incorporation of color imagery has enhancedAndrew Rosenberg’s new discussion of the structure, growth,and development of bone as well as the pathologic basis ofskeletal injury. Color photomicrographs are also liberallyemployed in the following chapters complementing theimaging features of various fracture patterns.

The first edition contained a single chapter devoted todifferential diagnosis. The second expanded the array to fourchapters. The differential diagnosis of abuse has gained evengreater importance in the medical and legal environments, andthe discussion has been expanded to six chapters, with specialattention given to metabolic bone disease. Given the advancesin our understanding and imaging complexities of abusivehead and spinal trauma, an entire section of six chapters hasbeen devoted to the clinical, biomechanical, and imagingfeatures of these often devastating injuries.

The imaging of child abuse draws the members of theRadiology team into the larger societal realm in ways thatcan pose unique challenges for even the most seasoned profes-sional. Alice Newton, a Child Abuse Pediatrician and AmyTishelman, a child psychologist working with our Child Pro-tection Team offer special information and advice to imagingprofessionals on dealing with possible victims of abuse/neglectand their families.

In the first of three legal chapters, Sandeep K. Narang MD,JD covers the principal legal requirements in the area of child

abuse, with an emphasis on those materials relevant to radi-ologists. In a revised chapter Martha Coakley JD, former Chiefof the Middlesex County Child Abuse Prosecution Unit andAttorney General of the Commonwealth of Massachusetts,familiarizes the reader with the US court system, providingguidance to physicians in negotiating their way through thepotentially daunting task of testifying to the details of imagingfindings in court. In this edition, I have again offered mypersonal perspective on the role that radiologists play inassisting investigative and other legal authorities in resolvingcases of suspected abuse. Although there is no substitute foractual personal experience, it is hoped that some of my ownobservations and recommendations may give the reader anidea of how to deal with the judicial system.

Finally, Andrew Karellas PhD, Srinivasan Vedantham PhD,and Robert V. Mulkern PhD, provide technical discussions toaid in understanding modern diagnostic imaging examin-ations. Patricia Kleinman MPH, RT, then defines the role ofquality assurance in diagnostic radiology and details the stand-ard skeletal survey examination for suspected child abuse.

Because this volume is directed toward a radiologic audi-ence, the reader can be assured that every effort has been madeto provide a comprehensive and reliable discussion of the bodyof knowledge in this specialized field. It is hoped that col-leagues in pediatrics, orthopedics, surgery, and other primarycare disciplines caring for children may find this text useful intheir practices. Professionals in the fields of child protection,law enforcement, and the legal community should also findthis work an authoritative resource.

As the spectrum of imaging alterations expands, so do thecomplex issues entailed in the differentiation of child abusefrom its imitators. Although a great deal has been learned sinceCaffey’s original description, there is still much to be dis-covered, particularly with respect to the biomechanics ofinflicted injury. Physicians and other professionals practicingin this field may seek to simplify matters, taking extremepositions that reflect either an overly zealous approach todiagnosing abuse or an unwillingness to consider abuse in allbut the most flagrant cases. The most effective approach todiagnosis is one based on thoughtful and measured acquisitionof data that are carefully analyzed in light of one’s knowledgeand experience. With the third edition of Diagnostic Imaging ofChild Abuse, I have tried to provide a thorough review of thesubject and, with the assistance of my esteemed co-authors,equip the reader with the tools to serve the best interests ofchildren.

Paul K. Kleinman MD

Preface

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Acknowledgments

Many fine individuals contributed to the first and second edi-tions of Diagnostic Imaging of Child Abuse, and their effortswere acknowledged in those volumes. As with all scientific textsthat focus on conditions that we do not fully understand, it is awork-in-progress. Each volume builds upon its predecessor,and thus any expression of gratitude for the current editionmust also include those who helped bring the earlier editions tolife. I have expressed those appreciations in the prior editions,but wish to again give special praise to my former assistantKathy Delongchamp, who provided extraordinary clerical andadministrative support for both the first and second editions.

These exercises take their toll on the family life and test thestrength of the bonds that connect us. This project has takenover four years to complete and without the guidance, support,and profound understanding provided by my dear wife Patricia,this most daunting and frustrating of tasks might well have beenabandoned long ago. The work not only invaded our home life:the dreaded laptop was with us on the beach, at all our get-aways, and on all forms of transportation – including the sail-boat. Her commitment to the care and well-being of children,ever-present in her own distinguished career, has fostered hersupport, informal and formal (see Chapter 30), for this text.

Another strong woman who has shepherded this workfrom inception to completion is my current administrativeassistant, Susan Ivey. Her intellect and unrelenting personalcommitment to the goals of this enterprise have ensured thatall the material included in the 3rd edition will be of thehighest quality. Putting together and maintaining the integrityof the raw materials of this text – reams of pages, thousands ofimages with countless annotations, innumerable references –as well as keeping track of all the materials submitted by ouresteemed, but often idiosyncratic, contributors, is a trulyremarkable accomplishment. She shares the credit for anygood that comes from this monumental effort.

More than ever, I have depended on my contributors toguarantee that we have delved into all the facets and nuances ofthe problem – from the microscopic skeletal alterationsthrough the diagnostic imaging of abuse and its mimics –and into the broader societal context with all the vagaries ofcurrent medico-legal proceedings. In an environment wherewe are all more connected to our work and personal time is inshort supply, the contributors to this edition have poured theirprecious time and effort into this project, and to them I alsosay thank you.

Of necessity, the case material illustrated in this book hasbeen drawn from many sources. As with the earlier editions, Ihave attempted to acknowledge these important contributors;again, special thanks to Mike Thomason for his many interest-ing and elegantly imaged cases. He is the consummate scholar /clinical radiologist.

In an era of bottom-line-driven publishing, a monographon a subject of great public health importance, but with afocused audience, may not receive attention from publishinghouses that is commensurate with the book’s potential value tothe community. I wish to thank Deborah Russell, formerly ofCambridge University Press, for believing in this text, and forfostering our collaboration. I also thank the Cambridge Uni-versity Press in-house team and all their affiliates for theirefforts throughout this long journey.

This book has been written during my tenure at BostonChildren’s Hospital and I thank all my radiology colleagues fortheir encouragement and support, especially during those cha-otic deadline-driven periods. This precious work has beenfostered at this remarkable institution and I cannot think of amore suitable place at which to write a text dedicated to thehealth and well-being of all children.

Paul K. Kleinman MD

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List of acronyms

Acronym Description

1,25D2 1,25-dihydroxyvitamin D, active formof vitamin D

18F-NaF PET Fluorine 18-labeled sodiumfluoride PET

25(OH)D-1-alpha-hydroxylase

25-HydroxyvitaminD-1-alpha-hydroxylase

25D 25-Hydroxyvitamin D2D Two dimensional2D-FT 2D Fourier transform3D Three dimensional3D-FT 3D Fourier transform99mTc MDP Technetium-99m methylene

diphosphonateAAP American Academy of PediatricsAAPM American Association of Physicists in

MedicineAccT Accidental head traumaACR American College of RadiologyACTH Adrenocorticotropic hormoneADC Apparent diffusion coefficientAEC Automatic exposure controlAHIMA American Health Information

Management AssociationAHT Abusive head traumaAJR American Journal of RoentgenologyALL Acute lymphoblastic leukemiaALL Anterior longitudinal ligamentALT Alanine aminotransferaseALTE Apparent life-threatening eventAML Acute myelogenous leukemiaAP AnteroposterioraSDH Acute SDHASL Arterial spin labelingAST Aspartate aminotransferaseATP Adenosine triphosphateAVF Arteriovenous fistulaAVM Arteriovenous malformationBBB Blood brain barrierBESSI Benign enlargement of the

subarachnoid spaces in infancy

BMC Bone mineral contentBMD Bone mineral densityBMI Body mass indexBO Magnetic field strengthBW BandwidthCAP Child Abuse PediatricianCARES Child Abuse Reporting

Experience StudyCaSR Calcium-sensing receptorCAT Computed axial tomographyCCJ Costochondral junctionCDC Centers for Disease ControlCECT Contrast-enhanced computed

tomographyCF Capital femurCHESS Chemical shift selective suppressionCHH Cartilage hair hypoplasiaCI Confidence intervalCML Classic metaphyseal lesionCNS Central nervous systemCOJ Chondro-osseous junctionCPR Cardiopulmonary resuscitationCPS Child Protective ServicesCPT Child Protection TeamCR Computed radiographyCR/DR Computed radiography/digital

radiographycSDH Chronic subdural hematomaCSF Cerebrospinal fluidCSVT Cerebral sinovenous thrombosisCT Computed tomographyCTA CT angiographyCTDI CT dose indexCTDIvol Volume CTDICTV CT venographyD2 Vitamin D2 (ergocalciferol)D3 Vitamin D3 (cholecalciferol)DAI Diffuse axonal injuryDBCL Dural border cell layerDCE Dynamic contrast-enhanced

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DDH Developmental dysplasia of the hipDeff Effective DoseDI Dentinogenesis imperfectaDIR Double inversion recoveryDLP Dose length productDNA Deoxyribonucleic acidDP Dural venous plexusDQE Detective quantum efficiencyDR Digital radiographyDSA Digital subtraction angiographyDT Digital tomosynthesisDTI Diffusion tensor imagingDTPA Diethyl-triamine-penta-acetic acidDTT Diffusion tensor tractographyDWI Diffusion-weighted imagingDXA Dual-energy X-ray absorptiometryEBM Evidence-based medicineEBR Evidence-based radiologyECG ElectrocardiogramECMO Extracorporeal membrane oxygenationED Emergency departmentEDH Epidural hemorrhage or hematomaEI Exposure indicatorEMR Electronic medical recordEMS Emergency Medical ServicesEPI Echo planar imagingER Emergency roomETE Effective echo time18F Radioactive fluorine-18F-FDG 2-deoxy-2-fluoro-D-glucoseFA Fractional anisotropyFAST Focused assessment with sonography

for traumaFE Finite elementFIESTA Fast imaging employing steady state

acquisitionFIRES Febrile infection-related epilepsy

syndromeFLAIR Fluid-attenuated inversion recoveryfMRI Functional MRIF-PET or 18F-PET or18F-NaF PET

Fluorine 18-labeled sodiumfluoride PET

fps Frames per secondFS Fat staturatedFSE Fast spin echoFSEIR Fast SE with inversion recoveryFT Fourier transformFTT Failure to thriveGA1 Glutaric Aciduria Type 1GCS Glasgow Coma ScoreGE Gradient echoGI GastrointestinalGM-CFU Granulocytic-macrophage colony-

forming unit

GRE Gradient recalled echoGT Greater trochanterGy Gray1H-MRS Hydrogen-1 MR spectroscopyHC Head circumferenceHLH Hemophagocytic lymphohistiocytosisHIE Hypoxic ischemic encephalopathyHII Hypoxic ischemic injuryHIPAA Health Insurance Portability and

Accountability ActHSAN Hereditary sensory and autonomic

neuropathiesHSV Herpes simplex virusHU Hounsfield unitHUS Head ultrasoundHVL Half-value layerhZPC Histologic ZPCICI Intracranial injuryICRP International Commission on

Radiological ProtectionICU Intensive care unitIDH Intradural hematomaIOS Interoccipital synchondrosisIPV Intimate partner violenceIQ Intelligence quotientISOD Isolated sulfite oxidase deficiencyITP Immune thrombocytopenic purpuraIU International unitsIV IntravenousIVC Inferior vena cavaIVH Intraventricular hemorrhageIVP Intravenous pyelogramJCAHO Joint Commission for the

Accreditation of HospitalOrganizations

J/kg Joules per kilogramkeV Kilo electron voltskVp Peak kilovoltageLCH Langerhans cell histiocytosisLDH Lactate dehydrogenaseLP Lumbar puncturelp/mm Line pairs per millimeterLPO Left posterior obliqueLSDI Line scan diffusion imagingLT LeftmA MilliampsM-CFU Macrophage colony-forming unitsMD Mean diffusivityMD Metaphyseal dysplasiasMDCT Multi-detector CTMDP Methylene diphosphonateMELAS Myopathy encephalopathy lactic

acidosis and stroke-like episodesMHE Multiple hereditary exostoses

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List of acronyms






MIM Mendelian Inheritance in ManMIP Maximum intensity projectionMIP Multiplanar reconstructionMPGR Multiplanar gradient recalledMPR Multiplanar reformationMR Magnetic resonanceMRA MR angiographyMRI Magnetic resonance imagingMRS MR spectroscopyMRV MR venogramMSBP Munchausen syndrome by proxyMTF Modulation transfer functionMVA Motor vehicle accidentNAA N-acetylaspartateNECT Noncontrast-enhanced CTNEX Number of excitationsNF1 Neurofibromatosis type 1NIH National Institutes of HealthNMDA N-methyl-D-aspartateNMR Nuclear magnetic resonanceOI Osteogenesis imperfectaOMIM Online Mendelian Inheritance in ManOPG OsteoprotegerinOR Odds ratioOSH Outside hospitalPA PosteroanteriorPASL Pulsed arterial spin labelingPCASL Pseudo-continuous arterial spin

labelingPCD Programmed cell deathPCPCS Pediatric Cerebral Performance

Category ScalePD Proton densityPET Positron emission tomographyPHI Protected health informationPITS Parent–infant traumatic stress

syndromePMMA Polymethyl-methacrylatePNET Primitive neuroectodermal tumorPO Intake by mouthPPV Positive predictive valuePTH Parathyroid hormonePTHrP Placental parathyroid-related proteinQA Quality assuranceQALY Quality-adjusted life yearsQC Quality controlQCT Quantitative CTrad Radiation absorbed doseRANK Receptor activator for nuclear

factor κβRANKL RANK ligandRBC Red blood cellRCT Randomized controlled trialRF Radio-frequency

RH Retinal hemorrhageRMRP RNA component of mitochondrial

RNA processing endoribonucleaseRPO Right posterior obliquerZPC Radiologic ZPCSAH Subarachnoid hemorrhageSAS Subarachnoid spaceSBS Shaken baby syndromeSCALP Skin, Connective subcutaneous tissue,

Aponeurotica, Loose avascularconnective tissue between theaponeurotica and the pericranium,Pericranium

SCIWORA Spinal cord injury withoutradiographic abnormality

SD SubduralSD Standard deviationSDH Subdural hematomaSDH Subdural hemorrhageSDHy Subdural hygromaSE Spin echoSH Salter–HarrisSH Subperiosteal hemorrhageSID Source-to-image distanceSIDS Sudden infant death syndromeSIS Second impact syndromeSMD Spondylometaphyseal dysplasiasSMPTE Society for Motion Picture and

Television EngineersSNR Signal-to-noise ratioSPACE 3DT2 turbo spin echowith variable flip

angle (Sampling Perfection withApplication optimized Contrasts)

SPBC Subperiosteal bone collarSPECT Single photon emission CTSPGR Spoiled gradient recalled echoSPGR FS Spoiled gradient recalled echo fat-

saturatedSPGR MR Spoiled gradient recalled echo MRSPNB Subperiostial new boneSPNBF Subperiosteal new bone formationSPR Society for Pediatric RadiologySPR Superior pubic ramusSS Skeletal surveySSDE Size-Specific Dose EstimatesSSDHI Spontaneous subdural hemorrhage in

infantsSSFSE Single-shot fast spin echoSTIR Short tau inversion recoverySUID Sudden unexpected infant deathSv Sieverts, a unit designating the

equivalent doseSWI Susceptibility-weighted imagingT1WI T1-weighted image

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List of acronyms






T2WI T2-weighted image“TBBD” “Temporary brittle bone disease”TBI Traumatic brain injuryTE Echo timeTFT Thin-film transistorTI Inversion timeTNF Tumor necrosis factorTOF Time of flightTR Repetition timeTrueFISP True fast imaging with steady state

free precession

TSE Turbo spin echoUGI Upper gastrointestinalUS UltrasoundVDR Vitamin D receptorVKDB Vitamin K deficient bleedingVL Ventral lateralVSD Ventricular septal defectVWD Von Willebrand diseaseWB-MRI Whole-body MRIWI Weighted imageZPC Zone of provisional calcification

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List of acronyms






Documents

DiagnosticImagingofChildAbuse · 2015. 11. 16. · Section I – Skeletal trauma 1 The skeleton: structure, growth and development, and basis of skeletal injury 9 Andrew E. Rosenberg