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The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.


  • Of 540 studies reviewed, 16 studies addressed this issue 1-16
  • Study design:
    • 13 case series 1-3,6-12,14-16
    • 3 case studies 4,5,13
  • Age range: 0 – 8 years
  • Gender: data not analysed by gender
  • No study addressed radiological investigations of disabled children
  • No study addressed the influence of ethnicity and socio-economic group


Details of included studies

Computerised Tomography (CT)

  • Older studies suggested that Computerised tomography scan (CT) will miss skull fractures 1,12,14. However, use of 3D reconstruction is a valuable asset in interpreting skull fractures 10
  • CT of chest may show rib fractures missed on two view chest radiography 16 or on four view chest radiographs 11

Magnetic Resonance Imaging (MRI)

  • MRI may be valuable additional investigations for physeal or epiphyseal injures 8
  • MRI may identify trauma where plain films are equivocal 3
  • Whole body MRI (WB-MRI) was compared to initial and repeat skeletal survey combined.  WB-MRI had a high specificity (95%) but low sensitivity (40%) for detecting fractures.  It was poor at identifying rib and metaphyseal fractures in particular 9

Ultrasound (U/S)

  • U/S may show metaphyseal fractures around the knee 6,8,13
  • U/S highlighted periosteal haematoma of the tibia, later confirmed as a fracture, and also a femoral fracture 15
  • U/S of the elbow may help to identify distal humeral epiphysiolysis 4
  • U/S may be useful in the diagnosis of costo-chondral dislocation of the lower ribs 6,13
  • U/S of chest may show acute rib fractures not apparent on plain film, including oblique views 5

Other imaging modalities

  • Plain films may miss physeal or epiphyseal injuries of the humerus which may be seen on Radionuclide imaging 7 or MRI 8
  • The use of (18F-NaF) positron emission tomography (PET) was compared to initial SS in 22 children (follow-up in 14) less than two years of age. PET versus SS had a sensitivity of 85% versus 72% for detecting all fractures, 92% versus 68% for thoracic fractures, and 67% versus 80%  for detecting classic metaphyseal lesions 2
  • PET identified three spinal fractures in one child missed on SS and confirmed on MRI 2

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  1. Cohen RA, Kaufman RA, Myers PA, Towbin RB. Cranial computed tomography in the abused child with head injury. American Journal of Roentgenology. 1986;146(1):97-102 [Pubmed]
  2. Drubach LA, Johnston PR, Newton AW, Perez-Rossello JM, Grant FD, Kleinman PK. Skeletal trauma in child abuse: detection with 18F-NaF PET. Radiology. 2010;255(1):173-181 [Pubmed]

  3. Eltermann T, Beer M, Girschick HJ. Magnetic resonance imaging in child abuse. Journal of Child Neurology. 2007;22(2):170-175 [Pubmed]
  4. Hansen M, Weltzien A, Blum J, Botterill NJ, Rommens PM. Complete distal humeral epiphyseal separation indicating a battered child syndrome: a case report. Archives of Orthopaedic and Trauma Surgery. 2008;128(9):967-972 [Pubmed]
  5. Kelloff J, Hulett R, Spivey M. Acute rib fracture diagnosis in an infant by US: a matter of child protection. Pediatric Radiology. 2009;39(1):70-72 [Pubmed]
  6. Markowitz RI, Hubbard AM, Harty MP, Bellah RD, Kessler A, Meyer JS. Sonography of the knee in normal and abused infants. Pediatric Radiology. 1993;23(4):264-267 [Pubmed]
  7. Merten DF, Kirks DR, Ruderman RJ. Occult humeral epiphyseal fracture in battered infants. Pediatric Radiology. 1981;10(3):151-154 [Pubmed]
  8. Nimkin K, Kleinman PK, Teeger S, Spevak MR. Distal humeral physeal injuries in child abuse: MR imaging and ultrasonography findings. Pediatric Radiology. 1995;25(7):562-565 [Pubmed]
  9. Perez-Rossello JM, Connolly SA, Newton AW, Thomason M, Jenny C, Sugar NF, Kleinman PK. Pubic ramus radiolucencies in infants: the good, the bad, and the indeterminate. American Journal of Roentgenology. 2008;190(6):1481-1486 [Pubmed]
  10. Prabhu SJ, Newton AW. Three-dimensional skull models as a problem-solving tool in suspected child abuse. Paediatric Radiology. 2013;43(5):575-581. [Pubmed]

  11. Sanchez TR, Lee JS, Coulter KP, Seibert JA, Stein-Wexler R. CT of the chest in suspected child abuse using submillisievert radiation dose. Pediatric Radiology. 2015;45(7):1072-1076 [Pubmed]

  12. Saulsbury FT, Alford BA. Intracranial bleeding from child abuse: the value of skull radiographs. Pediatric Radiology. 1982;12(4):175-178 [Pubmed]
  13. Smeets AJ, Robben SG, Meradji M. Sonographically detected costo-chondral dislocation in an abused child. A new sonographic sign to the radiological spectrum of child abuse. Pediatric Radiology. 1990;20(7):566-567 [Pubmed]
  14. Tsai FY, Zee CS, Apthorp JS, Dixon GH. Computed tomography in child abuse head trauma. Journal of Computed Tomography 1980;4(4):227-286 [Pubmed]
  15. Warkentine FH, Horowitz R, Pierce MC. The use of ultrasound to detect occult or unsuspected fractures in child abuse. Pediatric Emergency Care. 2014;30(1):43-6. [Pubmed]

  16. Wootton-Gorges SL, Stein-Wexler R, Walton JW, Rosas AJ, Coulter KP, Rogers KK. Comparison of computed tomography and chest radiography in the detection of rib fractures in abused infants. Child Abuse and Neglect. 2008;32(6):659-663 [Pubmed]


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