ACR Appropriateness Criteria®
Clinical Condition: Suspected Physical Abuse — Child
Variant 1: Child 24 months of age or younger, no focal neurologic signs or symptoms.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray skeletal survey |
9 |
|
|
CT head without contrast |
7 |
Particularly for patients who are at "high risk" (e.g., with rib fractures, multiple fractures, facial injury, or less than 6 months of age). |
|
MRI head without contrast |
5 |
If further evaluation is indicated after CT examination. |
O |
MRI head without and with contrast |
5 |
If further evaluation is indicated after CT examination. Administration of contrast is suggested if indicated due to prior CT findings or findings on noncontrast portion of MRI. See statement regarding contrast in text under "Anticipated Exceptions." |
O |
Tc-99m bone scan whole body |
4 |
If skeletal survey is negative and high clinical suspicion remains. |
|
CT head without and with contrast |
1 |
|
|
CT head with contrast |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Child 24 months of age or younger, head trauma by history, no focal neurologic signs or symptoms, no evidence of visceral injury.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray skeletal survey |
9 |
|
|
CT head without contrast |
9 |
|
|
MRI head without contrast |
6 |
If further evaluation is indicated after CT examination. |
O |
MRI head without and with contrast |
6 |
If further evaluation is indicated after CT examination. Administration of contrast suggested if indicated due to prior CT findings or findings on noncontrast portion of MRI. See statement regarding contrast in text under "Anticipated Exceptions." |
O |
Tc-99m bone scan whole body |
4 |
If skeletal survey is negative and high clinical suspicion remains. |
|
CT head without and with contrast |
1 |
|
|
CT head with contrast |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Child 24 months of age or younger, with seizures or neurologic signs and symptoms, with or without physical findings.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray skeletal survey |
9 |
|
|
CT head without contrast |
9 |
|
|
MRI head without contrast |
8 |
Do not defer head CT to await MRI in symptomatic child. May be useful whether CT is positive or negative. |
O |
MRI head without and with contrast |
8 |
Do not defer head CT to await MRI in symptomatic child. May be useful whether CT is positive or negative. Administration of contrast suggested if indicated due to prior CT findings or findings on noncontrast portion of MRI. See statement regarding contrast in text under "Anticipated Exceptions." |
O |
Tc-99m bone scan whole body |
4 |
If skeletal survey is negative and high clinical suspicion remains. |
|
CT head without and with contrast |
1 |
|
|
CT head with contrast |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Child older than 24 months of age, with seizures or neurologic signs and symptoms, with or without physical findings.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CT head without contrast |
9 |
|
|
MRI head without contrast |
8 |
Do not defer head CT to await MRI in symptomatic child. May be useful whether CT is positive or negative. |
O |
MRI head without and with contrast |
8 |
Do not defer head CT to await MRI in symptomatic child. May be useful whether CT is positive or negative. Administration of contrast suggested if indicated due to prior CT findings or findings on noncontrast portion of MRI. See statement regarding contrast in text under "Anticipated Exceptions." |
O |
X-ray skeletal survey |
6 |
Value of survey is less as age rises. Radiographs should usually be tailored to the area(s) of suspected injury. |
|
Tc-99m bone scan whole body |
4 |
If skeletal survey is negative and high clinical suspicion remains. |
|
CT head without and with contrast |
1 |
|
|
CT head with contrast |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: Child 24 months of age or younger, with thoracic and/or abdominopelvic injuries, discrepancy with history.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray skeletal survey |
9 |
|
|
CT abdomen and pelvis with contrast |
9 |
|
|
CT head without contrast |
8 |
|
|
CT chest with contrast |
6 |
When indicated based on abnormal chest radiograph and/or patient's signs and symptoms. |
|
MRI head without contrast |
5 |
Do not defer head CT to await MRI in symptomatic child. May be useful whether CT is positive or negative. |
O |
MRI head without and with contrast |
5 |
If further evaluation is indicated after CT examination. Administration of contrast suggested if indicated due to prior CT findings or findings on noncontrast portion of MRI. See statement regarding contrast in text under "Anticipated Exceptions." |
O |
CT abdomen and pelvis without and with contrast |
1 |
|
|
CT abdomen and pelvis without contrast |
1 |
Should be considered only if there is an absolute contraindication to IV contrast administration. |
|
CT head without and with contrast |
1 |
|
|
CT head with contrast |
1 |
|
|
CT chest without and with contrast |
1 |
|
|
CT chest without contrast |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 6: Child older than 24 months of age, with thoracic and/or abdominopelvic injuries, discrepancy with history.
Radiologic Procedure |
Rating |
Comments |
RRL* |
CT abdomen and pelvis with contrast |
9 |
|
|
CT head without contrast |
8 |
|
|
X-ray skeletal survey |
6 |
Value of survey is less as age rises. Radiographs should usually be tailored to the area(s) of suspected injury. |
|
CT chest with contrast |
6 |
When indicated based on abnormal chest radiograph and/or patient's signs and symptoms. |
|
MRI head without contrast |
5 |
If further evaluation is indicated after CT examination. |
O |
MRI head without and with contrast |
5 |
If further evaluation is indicated after CT examination. Administration of contrast suggested if indicated due to prior CT findings or findings on noncontrast portion of MRI. See statement regarding contrast in text under "Anticipated Exceptions." |
O |
CT abdomen and pelvis without and with contrast |
1 |
|
|
CT abdomen and pelvis without contrast |
1 |
Should be considered only if there is an absolute contraindication to IV contrast administration. |
|
CT head without and with contrast |
1 |
|
|
CT head with contrast |
1 |
|
|
CT chest without and with contrast |
1 |
|
|
CT chest without contrast |
1 |
|
|
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Summary of Literature Review
Introduction/Background
In 2009, based on reports to child and protective service agencies, an estimated 702,000 children were victims of maltreatment (neglect, emotional abuse, sexual abuse, and physical abuse) in the United States. Of these children, 17.8% were victims of physical abuse and an estimated 1,770 children died from abuse or neglect. As high as these numbers are, the extent of the problem is actually much greater, as officially reported cases grossly understate the true incidence of abuse.
In some children, physical examination and history may clearly indicate that physical abuse has occurred. In other children, however, the diagnosis of physical abuse is not so straightforward. It requires consideration of possible underlying metabolic and genetic conditions and usually relies on the findings of a multidisciplinary team that includes physicians, social workers, and legal authorities. Imaging often plays a major role in the detection and documentation of physical injury. The type and extent of imaging performed in a child who is a suspected victim of abuse depend on the child's age, signs, symptoms, and other social considerations such as being the twin of a physically abused infant.
Child abuse injuries can involve any site in the human body. Physically abused children may present with hollow viscus and solid-organ injuries, superficial and deep soft-tissue injuries, thermal injuries, and/or fractures. Fractures occur in up to 55% of child abuse victims. Fractures most often involve the long bones and ribs, with lesser involvement of the skull, clavicles, pelvis, and other bones.
Fractures that are highly specific for nonaccidental trauma in the normal child include those involving the ribs, metaphyseal or epiphyseal injuries, and avulsive fractures acromium process. Highly suggestive skeletal injuries include fractures that are unsuspected or inconsistent with the provided history or age of the child; multiple fractures involving more than one skeletal area; fractures of differing ages; and a combination of skeletal and nonskeletal injuries. In addition, fractures of the radius, ulna, tibia, fibula, or femur that occur in children younger than 1 year of age and midshaft or metaphyseal humeral fractures should be considered suspicious for abuse. A recent systematic review of the literature on fractures and child abuse found the child's motor developmental level to be a key discriminator for abuse in certain fractures. In particular, femoral fractures in a child who is not yet walking and unexplained humeral fractures in children younger than 15 months of age should be considered suspicious for abuse. This review also found that multiple rib fractures in any location without overt trauma were strongly associated with abusive injury, but that the posterior location of a rib fracture was not a discriminator for abuse.
Radiographic Skeletal Survey
The radiographic skeletal survey is the primary imaging examination for detecting fractures. Compared with bone scintigraphy, the radiographic skeletal survey is more sensitive for detecting skull and metaphyseal long-bone fractures. The skeletal survey should be composed of frontal and lateral views of the skull, lateral views of the cervical spine (if not included on the lateral skull view) and thoracolumbosacral spine, and single frontal views of the long bones, chest, and abdomen. Oblique views of the ribs should be obtained to increase the accuracy of diagnosing rib fractures, which as previously noted are strong positive predictors and may be the only skeletal manifestation of abuse. The images should be obtained using high-detail imaging systems and coned to the specific area of interest for each of the body parts, with separate views of each arm, forearm, thigh, leg, hand, and foot to improve image quality and diagnostic accuracy (see Appendix 1 in the original guideline document).
The recommendations for use of skeletal surveys vary with the child's age and type of presentation. A majority of skeletal surveys that are positive for fractures are performed in children younger than 1 year of age, and 80% of children with fractures due to child abuse are younger than 18 months of age. Radiographic skeletal survey is recommended in all children younger than 2 years of age in whom there is suspicion of abuse. In children 2 to 5 years of age, performance of skeletal survey should be based on the presence of other clinical findings and the need to document the presence or absence of injuries. In this older group of children, however, skeletal imaging should be strongly considered in a child who has unexplained craniocerebral or abdominal injuries or fractures that are suspicious for abuse. In addition, a repeat skeletal survey performed approximately 2 weeks after the initial examination can provide additional information on the presence and age of child abuse fractures and should be performed when abnormal or equivocal findings are found on the initial study and when abuse is suspected on clinical grounds. These follow-up studies should include all the images except the skull radiographs that were included in the initial skeletal survey. Skull radiographs can be omitted since new findings would not be expected on these images.
Bone Scintigraphy
Bone scintigraphy is a complementary examination for detecting bone injuries. It should be used when the radiographic skeletal survey is negative but clinical suspicion remains high and a search for further evidence of skeletal trauma is still necessary. To increase sensitivity, the bone scan should include the use of pinhole collimators and differential counts of the metaphyses. A bone scan is especially good for detecting periosteal trauma and rib, spine, pelvic, and acromion fractures.
Head Trauma
Though less frequent than skeletal injuries, most child abuse fatalities are the result of head trauma, and head injury due to child abuse is the principal cause of death in children younger than 2 years of age. Subdural hematoma is the most commonly seen intracranial abnormality. Additional craniocerebral injuries include cerebral contusion, epidural hematoma, cerebral edema, subarachnoid hemorrhage, and unilateral hypoxic-ischemic injury.
Imaging the head in children with suspected abuse depends on the child's age and type of presentation. In children with skull fractures or clinical signs and symptoms of intracranial injury, an immediate noncontrast computed tomography (CT) scan of the head should be performed. If the CT scan does not detect significant lesions that require rapid neurosurgical intervention and the clinical presentation warrants further assessment, a magnetic resonance imaging (MRI) scan of the head should be performed. The MRI should include T1- and T2-weighted sequences with proton density or inversion recovery and gradient echo sequences. In addition, diffusion-weighted sequences are suggested to indicate whether acute cerebral injury is present. In a child with an abnormal CT, additional assessment with MRI should be considered to further assess the extent of post-traumatic injury.
There are varying opinions on how to image children who are suspected abuse victims and show no objective evidence suggesting intracranial injury. Children, especially those younger than 12 months of age, may have significant intracranial injury without signs or symptoms of head injury. Findings of physical examination, in particular the absence of retinal hemorrhages, should not be used to determine the need for imaging, as intracranial injury may occur in the absence of retinal hemorrhages. Skull radiographs are also unreliable. Though skull radiographs may detect fractures associated with intracranial pathology, they do not provide adequate screening, since significant traumatic intracranial pathology may occur in the absence of skull fractures.
In one study 37% of children younger than 2 years of age with "high-risk" criteria (defined as rib fractures, multiple fractures, facial injury, or younger than 6 months of age) and without overt signs of head injury who underwent head CT or MRI had occult head injury. In this study, 18 of the 19 children with occult head injury were younger than 1 year of age. Another study of 51 children younger than 4 years of age with no signs of intracranial injury who underwent skeletal survey for abuse found that 29% of those who underwent neuroimaging had evidence of intracranial injury that included subdural hematoma, epidural hematoma, or cerebral edema. Given these studies, clinicians should have a relatively low threshold for performing either CT or MRI of the head in children with suspected abuse. MRI avoids the radiation of CT and is a particularly good choice in the nonemergent setting to image these "high-risk" children without overt neurologic signs or symptoms.
Nonskeletal Chest, Abdomen, and Pelvic Injuries
Nonskeletal injuries to the chest, abdomen, and pelvis can occur as the result of child abuse. Injuries to the chest are rare, but may include hemopericardium, cardiac contusions and lacerations, pleural effusion, lung contusions, and chylothorax. Nonskeletal injuries to the abdomen and pelvis include pancreatitis, pancreatic pseudocysts, and lacerations and contusions of the liver, adrenal gland, spleen, and kidneys as well as injury and rupture of the bladder and bowel. Clinical findings of abdominal pain, abdominal distension, vomiting, abdominal wall bruising, and hypoactive or absent bowel sounds may be seen in children with intra-abdominal injury. Abnormal liver transaminases and pancreatic enzymes suggest the presence of occult abdominal trauma. Victims of nonaccidental abdominal trauma tend to be younger and have a more delayed presentation than those who experience accidental trauma. The delay in presentation may be related to the caretaker's delay in bringing the patient to medical attention, inconsistent history, or the vagueness of symptoms that may accompany the injuries. In addition, independent of concomitant injury, blunt trauma due to child abuse is associated with a six-fold increase in odds of death compared to children whose injuries resulted from other mechanisms.
In most cases, imaging for assessing these injuries will be directed by the patient's clinical presentation or concerning findings on conventional radiographs and consists of a CT scan of the involved body part. CT scan of the chest should generally be performed with intravenous (IV) contrast to detect vascular injuries. CT scan for suspected intra-abdominal injury should include both the abdomen and pelvis and should be performed with IV contrast. The need for oral contrast is at the discretion of the radiologist, and its use should be strongly considered when there is concern for duodenal hematoma. Parenchymal or late arterial phase imaging is most helpful for detecting solid-organ injury. Delayed, excretory phase imaging is recommended if imaging findings suggest disruption of the genitourinary tract. In patients with spinal injury, either CT or MRI should be performed, depending on the severity of the patient's signs and symptoms. CT scan is recommended to assess fractures. MRI is the preferred imaging examination to assess the spinal cord in the presence of neurologic deficits.
Child abuse should be considered in any age child with thoracoabdominal injuries that are not consistent with the provided history. A skeletal survey can be helpful by detecting the presence of other injuries and may confirm the diagnosis of abuse. As a result, skeletal survey is recommended in children 24 months of age or younger when an apparently isolated thoracoabdominal injury is found and raises the possibility of physical abuse. In addition, a skeletal survey should be strongly considered in older patients in the same clinical setting.
Summary
- The appropriate imaging of pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and whether the child's injuries are discrepant with the clinical history.
- An x-ray skeletal survey is always indicated in a child 24 months of age, or younger. In older children, a skeletal survey can be performed, but it is often more appropriate to tailor the radiographs to the area(s) of suspected injury.
- CT scan of the head without contrast is always indicated in a patient with seizures or neurologic signs and symptoms and when there is a history of head trauma.
- CT scan of the head should be strongly considered in "high-risk" children (rib fractures, multiple fractures, facial injury, or are 6 months of age, or younger) and children with thoracic and/or abdominopelvic injuries and a discrepant clinical history.
- MRI of the head may be needed for further assessment after a head CT and may be useful whether the head CT is positive or negative. When the child is symptomatic, however, the head CT should not be delayed if an MRI is to be obtained.
- Whole-body Technetium (Tc)-99m bone scan may be helpful if the x-ray skeletal survey is negative and a high clinical suspicion remains.
- CT scans of the chest, abdomen, and/or pelvis are indicated if there are signs and symptoms of abuse or if abnormal findings are seen on conventional radiography, particularly when there is a discrepancy with clinical history.
- CT scan of the abdomen and pelvis should always be performed with IV contrast unless the patient has an absolute contraindication to it.
Anticipated Exceptions
Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (i.e., <30 mL/min/1.73 m2), and almost never in other patients. There is growing literature regarding NSF. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73 m2. For more information, please see the American College of Radiology (ACR) Manual on Contrast Media (see the "Availability of Companion Documents" field).
Abbreviations
- CT, computed tomography
- IV, intravenous
- MRI, magnetic resonance imaging
- Tc, technetium
Relative Radiation Level Designations
Relative Radiation Level* |
Adult Effective Dose Estimate Range |
Pediatric Effective Dose Estimate Range |
O |
0 mSv |
0 mSv |
|
<0.1 mSv |
<0.03 mSv |
|
0.1-1 mSv |
0.03-0.3 mSv |
|
1-10 mSv |
0.3-3 mSv |
|
10-30 mSv |
3-10 mSv |
|
30-100 mSv |
10-30 mSv |
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.” |