A child is brought to the emergency room by his parents, who
maintain that he fell down a flight of stairs. They also describe
easy bruisability. Frontal radiographs of the skull (figure
1), right shoulder (figure 2), and left wrist (figure 3) are
shown, along with a posterior gamma camera view from a radionuclide
bone scan (figure 4). What is the most likely diagnosis?
The proper workup of a child suspected of having been physically
abused includes a radiographic survey of all of the long bones, the
pelvis, the spine, the ribs, and the skull. Scintigraphy with
bone-seeking pharmaceutical agents also may be a useful adjunct to
the roentgenographic examination, although false-negative
radionuclide studies have been noted and these examinations are
more invasive and time-consuming than conventional radiography.
Roentgenographic findings include single or multiple fractures,
especially in the ribs though these also may involve, in order of
descending frequency, the humerus, the femur, the tibia, the small
bones of the hand and foot, and the skull. Diaphyseal or
metaphyseal fractures can be seen in various stages of healing.
Metaphyseal infractions may be quite subtle, requiring multiple
projections for adequate visualization. "Unusual" fractures, such
as those of the sternum, the lateral aspect of the clavicle, the
scapula, and the vertebral bodies and posterior osseous elements,
should arouse suspicion of abuse. Other clues to this diagnosis
include overabundant callus formations, bilateral acute fractures,
and fractures in the lower extremities in infants and young
children who are not walking. Rib fractures that are bilateral and
paravertebral and those that conform in distribution to the size of
an adult's fist are suggestive of child abuse. Injury of the spinal
cord may accompany vertebral trauma.
Subperiosteal bone formation may be apparent in a period of 7 to
14 days following the injury. This can vary in appearance from
focal, thin periosteal deposits to massive bone formation.
Periostitis with intramedullary foci of necrosis also may represent
the sequela of traumatically-induced pancreatitis in the abused
child. Late skeletal findings include metaphyseal cupping, growth
disturbances, subluxation, and diaphyseal widening due to
Extraosseous alterations may include cutaneous lesions,
myositis, malnutrition with decrease in subcutaneous fat, pulmonary
contusion and laceration with pneumothorax, gastrointestinal
hemorrhage with mass formation and obstruction, pancreatitis,
hepatic and renal injuries, mucosal alterations in the mouth and
palate, ocular lesions such as retinal detachment, and intracranial
and subdural hematomas.
Disorders that must be differentiated from this syndrome are the
normal periostitis of infancy, osteogenesis imperfecta, types of
congenital insensitivity to pain, and infantile cortical
hyperostosis. Metaphyseal avulsion fractures also may accompany
abnormal copper metabolism in "kinky hair" syndrome (Menkes'
syndrome). Metaphyseal changes in a variety of other congenital
disorders, and of scurvy also may resemble those in the abused
Several other points of the differential diagnosis should be
mentioned. The typical age range of children with nonaccidental
trauma is from one to four years; after this age, children
generally are able to escape the abusing parent or, at the very
least, can verbalize what has occurred. Common accidental injuries
in the young child are torus fractures of the distal portion of the
radius, spiral fractures of the tibia (toddler's fractures), and
clavicular and skull fractures. Accidental fractures of tubular
bones require that the child be able to accelerate himself or
herself; thus, an infant alone cannot break a humerus and a
crawling child cannot break a femur. Rarely, passive exercise or
physical therapy in premature children can result in injuries that
simulate those of child abuse.
1. Resnick D, Niwayama G: Diagnosis of bone and joint disorders,
ed 2. Philadelphia, WB Saunders, 1986.
This series of diagnostic challenges is prepared by David J.
Sartoris, MD, Professor, Department of Radiology, University of
California School of Medicine, San Diego, CA.