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224 Injuries from Child Abuse

cases of physical abuse involve skeletal injury. Two-thirds of fractures
involve the long bones, and the fractures can be spiral or transverse.
Certain fractures are almost pathognomonic for child abuse, such as
a chip fracture (corner or bucket handle fracture) of the long bones
(Figure 34.4). This injury occurs due to avulsion of the corner of the
metaphysis from the periosteum during wrenching injuries to the long
bones. Approximately 10 days after the injury, calcification of the
subperiosteal bleeding will give rise to the classical double cortex line.
In all children with suspected child abuse, a skeletal survey
should be obtained. The skeletal survey comprises a combination of
x-rays of the chest, skull, and extremities only in the anteroposterior
(AP) direction. Repeated abuse may manifest as old rib fractures
with callous formation in different phases of healing (Figure 34.5).
A radionuclear bone scan is a more sensitive method to pick up old Source:-Pressel-DM.-Evaluation-of-physical-abuse-in-children.-The-American-Family-Physician.
injuries, but is unreliable under the age of 1 year. (http://www.aafp.org/afp/20000515/3057.html).-Reproduced-with-permission.
Differential Diagnosis Figure 34.3: Retinal haemorrhages (arrows) in a patient with shaken-baby
syndrome
Child abuse is common in Africa; however, a number of other condi-
tions may be mistaken for abuse (and vice versa), including the fol-
lowing:
• Birth trauma: should be evident from the birth history.
• Congenital syphilis: chronic periosteal reaction combined with
metaphyseal widening and positive blood tests.
• Osteogenesis imperfecta: multiple fractures, blue sclerae, osteopaenia.

(A) (B)
Figure 34.1: Severe brain atrophy in an infant due to physical abuse. Source:-Courtesy-of-Brian-Coley-MD,-Nationwide-Children’s-Hospital,-Columbus,-Ohio,-USA.
Figure 34.4: Classic metaphyseal lesion. (A) Lateral radiograph of the left tibia
shows a distal metaphyseal corner fracture (arrow). (B) Frontal radiograph of
the same left tibia shows that with a different obliquity the metaphyseal fracture
appears as a crescentic fragment (arrows), the “bucket-handle” fracture.

Source:-Courtesy-of-Brian-Coley-MD,-Nationwide-Children’s-Hospital,-
Columbus,-Ohio,-USA.- (A) (B)
Figure 34.2: Noncontrast CT scan of the brain. There is diffuse cerebral Source:-Courtesy-of-Brian-Coley-MD,-Nationwide-Children’s-Hospital,-Columbus,-Ohio,-USA.
oedema with loss of normal grey-white matter differentiation and abnormal Figure 34.5: Rib fractures from physical abuse. (A) Frontal chest radiograph
hypodensity in the posterior parietal lobes, indicating early infarction. There is shows healing fractures of the right posterior 8th, 10th, and 11th ribs (arrows).
bilateral intraventricular haemorrhage (arrowheads) and a parafalcine acute (B) Frontal chest radiograph shows healing fractures of the right posterior 5th,
subdural haematoma (arrow). 6th, 7th, and 8th ribs (arrows).