A child under the age of 18 who is intentionally harmed or mistreated is considered abused. Child abuse accounts for the majority of childhood morbidity and mortality causing the community and the victims’ families to lose a fortune. There are many different types of child abuse, which often occur all at once. A child may be abused through physical, sexual, emotional, and medical abuse, along with neglect. Children are often abused by someone they know and trust, usually a parent, family friend, or relative. The use of radiography and medical imaging nowadays plays a big part in identifying as well as evaluating child abuse. This essay will examine the role of radiography and its contribution to child abuse.
Whenever a child suspected of abuse is brought into the radiology department, members of the radiology team are required to follow specific protocols, and by utilizing these protocols it will be possible to determine the form of abuse that the child has been exposed to.
Types of child abuse
The first step is to identify the different types of abuse that a child can experience. Child abuse can take many forms such as:
Physical Abuse:
The term physical abuse is used broadly to describe any act of physical violence that is committed on a child, or anyone else associated with the child, by his or her parents, guardians, or anyone who has a responsibility to provide for that child. In addition to being the deadliest form of abuse, physical abuse is the first form of abuse that can be identified. Emotional Abuse:
In many cases, a child is subjected to emotional abuse when an adult ignores their needs. This is because the adult fails to provide psychological care, or permits a child to take drugs or drink alcohol. Moreover, children who experience domestic violence or who are raised by a sex offender can be categorized as having been abused emotionally. In other words, emotional abuse, which can sometimes be referred to as psychological abuse, is a form of aggression that negatively impacts a child's sense of self-worth and interferes with their psychological development in a negative manner
Sexual Abuse:
The act of sexual abuse occurs when an adult or another child forces a child to perform sexual acts. As a way to abuse the child, the abuser may use physical force, threats, or manipulation to gain an advantage of the child's limited understanding of sexuality. Child sexual abuse is often perpetrated by a trusted person, and not by a stranger. It is also possible to abuse children sexually by taking photographs of them or showing them pornography through magazines, movies, and the internet.
Neglect and Medical Neglect:
A child is said to be neglected when he or she is deprived of basic needs by a parent or other caregiver, which results in physical or psychological harm to the child. Neglect affects young children the most, and girls are more likely to suffer from it than boys. Apart from neglecting a child's emotional and psychological needs, neglect involves abandonment, lack of appropriate supervision, insufficient education, nutritional and medical care, shelter, and clothing. Medical neglect can be due to neglect and it is when a parent fails to provide suitable medical care to their child or children.
It is critical to acknowledge the fact that not all forms of child abuse can be seen radiographically. However, radiographs are of substantial help in indicating abnormal internal changes that may be a result of abuse. That is why child abuse radiology examination protocols were established. Another significant note is that even though the radiology department team is often the first to spot signs of child abuse, they are not responsible for filing an abuse case. Nevertheless, they are obligated to report the case to higher hospital authorities.
There are certain modalities that fit the type of injury that is caused by child abuse. When it comes to lesions and head injuries, CT is considered the most efficient modality. CT can also be used for spotting fractures. Furthermore, MRI is of great use in diagnosing subdural hematomas along with concussive, and shear injuries. Meanwhile, epidural hematomas are detected easily through both CT as well as MRI. Scintigraphy is also considered to be one of the most effective methods of detecting child abuse injuries. While it is more expensive than conventional radiography, it is extremely sensitive in diagnosing fractures, and approximately 10 percent of fractures can only be seen through scintigraphy. Nevertheless, scintigraphy is not a suitable option when it comes to skull fractures. Scintigraphy may be effective in detecting fractures. However, it has a higher radiation dose than Conventional radiography and requires experience in achieving proper positioning, and for the child to be sedated. In addition to conventional radiography being the more affordable as well as being and easily assessable option, it is the modality of choice when it comes to the musculoskeletal system. Ultrasonography is another modality that can be used in child abuse, it is used commonly for abdominal and retroperitoneal visceral injuries.
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A very critical step to assure that there are no lost findings in skeletal survey studies is to repeat the survey two weeks after the study has been evaluated. It has been found that around 27 percent of the time that a skeletal survey study follow-up is performed, it results in an increase in the number of definite fractures that are found.
Types of injuries caused by child abuse:
Skeletal Injuries:
There are multiple types of injuries that abuse can cause a child to have. Skeletal injuries can occur through the action of grabbing, shaking, and pulling of a child. Skeletal injuries are quite common and can range from 11 to 55 percent. It is frequently seen in infants and children under the age of 3.
Metaphyseal Lesion fracture:
It was recognized that the metaphyseal lesion resulting from child abuse is virtually pathognomonic. This injury happens mostly in locations such as the knee, lower leg, femur, and humerus. It is when a fracture spans transversely through the wide portion of the bone, where it separates a disk of bone from the primary spongiosa of the metaphysis. The edges of this disk are usually thicker than the center, and it may be seen as a transverse fracture line. The injury to the metaphyseal bone is rarely accompanied by periosteal reaction; vascular injury and obstructions to growth may also result in bowing of the extremity. Metaphyseal injuries are commonly seen in children who are not yet walking, and they are not caused by normal care, aggressive play, or accidental falls. Previously terms like 'Corner fracture' and 'Bucket handle fracture' were used to describe the metaphyseal lesion fracture patterns. The radiographic appearance of these patterns differs according to the fragment size, in addition to the X-ray beam's relation to the extremity's position. The Metaphyseal lesion can be difficult to detect on plain film at first, which is why it is critical to use proper techniques. In a tangential view, the fracture may resemble a corner fracture at the periphery where it extends toward the metaphysis. Radiographically, the metaphysis appears as a small corner separated from the metaphyseal border by very faint linear radiolucency. Nevertheless, the true nature of the fracture can only be seen when viewed with a slight cranial or caudal angulation. There is a slight curvilinear ossific density above the abscissa, which is partially detached from the metaphysis and separated by thin radiolucency, giving the impression of a classic bucket-handle fracture.
Long bone fractures:
Long bone fractures in children are unlikely to be caused by abuse, it is mostly seen in older children resulting from accidental trauma. However, it may be an abuse-related injury in infants. Fractures such as Spiral and transverse long bone fractures are usually seen in abused infants. To have a correct interpretation of the injury, it is necessary to understand the normal structure of the metaphysis in young children. The metaphysis widens gradually into the physis. Near the physis is a straightened bone ridge measuring about 1 to 2 mm in length. It represents a subperiosteal bone collar that encompasses the primary spongiosa and the physis. A groove of Ranvier is located at its epiphyseal end. This groove is responsible for the ossification of the bone bark, allowing the metaphysis to meet the width of the epiphysis. As the metaphysis expands to conform to the end of long bones, it produces an abrupt vertical interruption to the slope of the metaphysis. The collar is often visible at the distal radial metaphysis. The collar may result in a small spur surrounding the unossified physis, causing confusion. Spurs should not cause a periosteal reaction or linear lucency underneath the provisional calcification. in this case, oblique views can be very informative. There is focal cortical irregularity at the distal femoral metaphysis, which is usually associated with a small excrescence. From a lateral view, it may appear triangular and at times fragmented. Similar findings are seen at the medial proximal tibial metaphysis. Possibly caused by the normally bowlegged varus of toddlers' legs or asymmetric weight-bearing. A high level of bone turnover occurs at the medial proximal tibial and humeral metaphysis. A dynamic process of bone resorption and formation occurs at these bone-modeling sites, where the metaphysis flares dramatically towards the epiphysis. There can be a small concavity where the metaphysis meets the subperiosteal collar at the cutaway zone that resembles the shape of a small beak. The periosteal reaction usually highlights the fracture line. Furthermore, the subperiosteal reaction does not occur in areas where the fracture is intraarticular. Infants 1 to 5 months of age undergo physiologic subperiosteal bone formation. The most common sites are along the diaphysis of the humerus, femur, and tibia. It is usually bilateral, but not always, and is related to infant growth. The appearance of physiologic subperiosteal new bone formation usually progresses after 5 months. The subperiosteal new bone is characterized by the presence of a thin hazy area where there is an increase in density separated from the cortex by a thin lucence area.
Rib Fractures:
Rib fractures occur a lot more than long bone fractures. This type of fracture is difficult to see at first but becomes easy to spot when it heals. Posterior rib fractures are the type of fractures that can be seen in abused children, it occurs as a result of compression to the chest. Rib fractures that are seen laterally are caused by front-to-back compression. It should be taken into account that posteromedial rib fractures do not occur when the back is laid flat because it helps rule out that the fracture is posterior. In rib fractures, the fracture always begins on the outside rather than on the inside. Radiographs of an acute rib fracture can identify a linear lucency in the bone. The degree of lucency varies with the angle of the fracture relative to the beam, fracture age, and the amount of displacement. It can be difficult to acutely diagnose a rib fracture if it is nondisplaced or only mildly displaced. In the healing process, callus forms and identifies the fracture as a narrowing segment of fusiform underneath the rib contour. As a fracture heals, the linear lucency of the fracture becomes less evident. Furthermore, there may be subtle linear sclerosis. Radiographically evident radiolucency around a healing fracture can be explained by medullary trabecular resorption about the fracture. Because ribs are curved, the rib neck is posteromedially hidden behind the denser mediastinum. Oblique views of the chest are therefore very helpful in diagnosing rib fractures. Rib fractures can be easily detected using scintigraphy and it can be easily spotted in CT scanning with all its soft tissue changes. In addition to a standard skeletal survey, multidetector-row CT is a valuable modality, and it is often prescribed after large soft tissue injuries have occurred in infants in the thorax or abdomen.
Skull and Intracranial injuries:
Skull fractures:
The consequences of accidental head injuries in children are rarely severe. In most cases, linear fractures from baby chairs, tables, and sofas do not result in intracranial damage. It is common for children less than 2 years old to suffer serious head injuries as a result of abuse. It is mandatory to obtain a cranial CT and a skull X-ray in this situation. If there were no CT findings found, an MRI of the brain may be needed to aid the diagnosis. It is the radiologists' responsibility to accurately identify non-accidental cranial trauma.
Intracranial injuries:
A major component of abusive head trauma is intracranial injury, which includes subarachnoid and subdural hemorrhage, intracerebral and intracerebellar hemorrhage, and massive edema. Naturally, there can be combinations. Separate consideration should be made for any case involving a complex skull fracture and any neurologic finding in an infant or child after a fall from a height believed to be 90 cm or less to be considered incidental abuse. The presence of a severe or complex skull fracture that is clearly indicated by radiography should be followed up with a CT or MRI immediately. Even without a skull fracture, a CT or MRI should be ordered if other findings strongly suggest child abuse.
Shaking injuries:
Shaken Baby Syndrome:
A serious brain injury caused by shaking an infant or toddler too violently is referred to as shaken baby syndrome. Which is also recognized as abusive head trauma, shaken impact syndrome inflicted head injury, and whiplash shake syndrome. This is a form of child abuse where it causes a child's brain to be deprived of enough oxygen and is subject to brain cell death. A child who is subjected to this type of abuse can suffer permanent brain damage and even die as a result. When it comes to Shaken Baby Syndrome It can be challenging to make a correct diagnosis. An X-ray of the entire body can be performed to highlight new fractures or those that have consolidated. To investigate the involvement of the Central Nervous System (CNS) in infants with suspected Shaken Baby Syndrome, computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain and spine are required. Due to its high sensitivity in investigating bone tissue, CT is decisive in detecting fractures as well as ischemic areas, brain edema, and blood collections. However, MRI offers a better understanding of brain parenchyma than CT scanning and is recommended for those who have Shaken baby syndrome with no CT findings. Children with neurological impairment should have an initial CT scan with 3-D reformatted images of the calvarium followed by a full series of MRIs of the brain and spine as soon as possible. Children with neurologic intactness should undergo their first MRI immediately. It is often recommended to repeat an MRI because timing parenchymal and extra-axial injuries can be tricky.
In conclusion, it is known that whenever someone mentions investigating child abuse, not many will think that radiography has a hand and a role in evaluating the injuries that are caused by it. Therefore, learning how each injury can be identified using different medical imaging modalities will let others understand the big part that radiography plays in child abuse. It is also crucial to keep in mind that radiography will assist in not only diagnosing the injury but will also aid in recognizing the form of abuse that caused it.
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