Neuroradiological findings in non accidental trauma. The first and overwhelming predominant forms of injury are the two related to hypoxic ischemic injury patterns. Radiologic imaging of inflicted injury in the child abuse syndrome. The term nonaccidental injury implies the physical abuse of a child by a person or persons usually adult in whose care that child is placed. Advanced imaging differs in younger and older pediatric. While a subdural hematoma sdh is the most common finding and is often enough to raise suspicion for abuse, no single injury is pathognomonic for abusive head trauma aht. In suspected physical abuse spa, skeletal surveys are performed because bone fractures are the most common presentation of spa, after soft tissue bruising and burns. Child abuse, non accidental trauma in children, nonaccidental trauma.
The vast majority of child abuse and neglect fatalities are less than 5 years old, and a significant number 41% are less than 1 year old. Nonaccidental injuries nai represent both ethical and legal challenges to treating physicians. Divided into three sections, the day will offer a thorough overview of this important topic. Radiographic imaging in deceased children is not easy, and yields significant artefacts, which. Non accidental trauma is a significant source of morbidity and mortality in the pediatric population. Radiographic skeletal survey was performed in this case but no other injury was seen. Appropriate use criteria, auc, child abuse, ct, mri, nonaccidental trauma, pediatric, shaken baby. Non accidental injury nai is common, and potentially lifethreatening.
Imaging of the central nervous system in suspected or. Describe the key imaging findings of male pelvic trauma and their role in management. Abusive head trauma aht is one of the most common subtypes of nonaccidental trauma and is a leading cause of traumatic brain injury in young children. The final diagnosis of nai is usually reached after considering the radiological findings in the light of the history provided and assessing findings from the physical examination. Non accidental injury nai remains the leading cause of morbidity and mortality in children. Radiologists may be the first clinical staff to suspect nonaccidental inju. Situations that evoke suspicion of non accidental injury in children include 15. The sidssudi skeletal survey must be carried out following the standards for radiological investigations of suspected non accidental injury and imaging department guidelines. Imaging nai 2015 update on imaging nonaccidental injury. Acr appropriateness criteria suspected physical abusechild. Comparison and optimization of imaging techniques in. Protocol for imaging non accidental injury nai in children communication all staff need to be aware that requests related to nai may not specify nai on the request. Although no single imaging finding is specific for abuse, no other medical condition fully mimics all the features of non accidental injury in infants and children. These abdominal injuries are non specific and could also be attributed to accidental injury.
Child abuse or child maltreatment is physical, sexual, andor psychological maltreatment or neglect of a child or children, especially by a parent or a caregiver. Compliance with skeletal surveys for child abuse in general. The primary objective of the presentation will be to outline the radiographers. The medical and imaging evidence, particularly when there is only central nervous system injury, cannot reliably diagnose intentional injury. Radiologists play a vital role in the detection of inflicted injuries. Discuss the most important differential diagnoses including non accidental injury. It is therefore clear that occult neurological injury cannot be excluded without routine cranial imaging. As discussed by hobbs and bilo, physical abuse of young children is a serious health problem. This practical day was an invaluable recap on nonaccidental imaging nai procedures and protocols and was led by a courtroom judge and an experienced expert witness. Recognition and nursing management of children with non. Nonaccidental trauma nat is a major cause of morbidity and. All children suspected of non accidental trauma will have a complete workup including a complete history and physical exam with a focus on injuries and explanation for the injuries. The mr imaging protocol should include t2weighted images, flair images, gradientecho images, t1weighted spin echo images in different planes and. There is an onus on all health professionals in medical imaging departments to respect and protect the rights of the child.
Read imaging of nonaccidental head injury, pediatric radiology on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at. Cervical spine imaging for young children with inflicted trauma. Suspected physical abuse previously termed nonaccidental injury, nai in infants and young children represent both ethical and legal challenges to treating physicians. It is recommended as best practice that, whenever possible, two radiographers perform the skeletal survey and at least one radiographer should be trained in paediatric. Imaging in nai remains a controversial issue with little agreement concerning how, when and what imaging. A reenactment of a dramatic courtroom scene was the highlight of update on nonaccidental injury imaging held in london last month. Diagnostic imaging pathways paediatric, injury non. Non accidental injuries may be difficult to recognize since caretakers rarely disclose maltreatment, some children cannot provide a history, and signs and symptoms of. Concerning information during history taking is if the injury is not well explained, the severity does not match with the history, or the injury is inconsistent with the. Non accidental trauma nat screening and management guideline inpatient and outpatient red flag history of present injury no history or inconsistent hx changing history unwitnessed injury delay in seeking care prior ed visit domestic violence in home premature infant imaging in non accidental trauma nat has been geared towards assessment of intracranial and musculoskeletal injuries, as abdominal and pelvic injuries were considered to be less common.
The radiologist therefore plays a crucial role in the diagnosis of non accidental injury. It exists in different forms emotional, neglect, sexual and physical. Skeletal imaging of child abuse nonaccidental injury. Suitable computed radiography systems including standard resolution imaging plates may be used for skeletal surveys if they have dedicated paediatric software. In this issue of the journal, sundgren et al in michigan examine the roles of two imaging modalitiescomputed. Offiah a1, van rijn rr, perezrossello jm, kleinman pk. Acrspr practice parameter for skeletal surveys in children. In the 33 patients with non accidental brain trauma in this series, the patterns of brain injury on dwi indicate one major type of injury having two different levels of magnitude and several other less frequent forms of injury. The nai skeletal survey must be carried out following the standards for radiological investigations of suspected non accidental injury and imaging department guidelines and protocols. I n a clinical setting where musculoskeletal injury is the chief complaint, it is imperative to maintain a threshold of suspicion for physical abuse as the primary cause of an injury. Fractures that are specific for non accidental injury eg rib fractures in young children and metaphyseal, corner, or bucket handle fractures. Observational study of skeletal surveys in suspected nonaccidental injury. The key imaging modality in suspected cases is plain radiography in. The role of imaging in cases of suspected abuse is not only to identify the extent.
Imaging plays an important role in the evaluation of trauma. The consultant radiologist should decide this, at the time of checking the films with the radiographers. Child abuse is relatively common and recent studies suggest the incidence is rising 1. Rather, the combination of imaging and physical findings and the clinical presentation help. A survey of nonaccidental injury imaging in england. In fact, imaging cannot reliably distinguish non accidental injury from accidental injury or from predisposing or complicating medical conditions, period.
Nonaccidental injury nai remains the leading cause of morbidity and mortality in children. Research scholars program for the opportunity to spend two years studying and. Subdural hematoma in infants without accidental or nonaccidental injury partha s. A unique pattern of findings on imaging is widely recognized to be associated with abuserelated head injury in infants and young children. Post mortem imaging pmi utilizing crosssectional modalities is a rapidly emerging field.
Suspected physical abuse radiology reference article. Physical child abuse is synonymous to nonaccidental injury nai or. Pediatric nonaccidental injury causes considerable morbidity and mortality that can often be prevented by early. Child abusenonaccidental injury nai and abusive head. Standardizing the evaluation of nonaccidental trauma in a large pediatric emergency department. Radiologists may be the first clinical staff to suspect nonaccidental injuries when confronted with a particular injury pattern. We aim to formulate evidencebased recommendations to assist physicians decisionmaking in the assessment and management of children younger than 16 years presenting to the emergency department ed following a blunt head trauma with no suspicion of non accidental injury. I moved back to london, to great ormond street hospital and the institute of child health, where i obtained a phd for my thesis, optimisation of the digital radiographic imaging of suspected nonaccidental injury. Nai is an important cause of paediatric major trauma.
Bastin,1 david daviespayne,1 diana browne,1 helen l. Pdf postmortem skeletal surveys in suspected nonaccidental injury. Inflicted head injury is a major cause of mortality and morbidity in young children 5, 711, 15, 19, 22. Nonaccidental injury imaging british institute of radiology. Apr 02, 2020 now in its eighth year, this study day embraces current developments in the field of suspected non accidental injury suspected physical abuse imaging and joint publication by the society and college of radiographers and royal college of radiologists. Given the vulnerable state of the child, the radiologist can often provide valuable diagnostic information in the setting of suspected abuse. Retinal haemorrhages are seen in 53% of cases of non accidental head trauma. Mr imaging is always indicated when non accidental intracranial trauma is suspected and the head ct is negative as mri can detect the more subtle signs of child abuse such as dai 15, 16, 17. Problem with reporting software not easy to document 2nd radiologists presence on the radiology information system. In general most cases of suspected non accidental injury will initially have a skeletal survey followed by a bone scan if there is still diagnostic uncertainty and ongoing high suspicion.
Responsibilities of the radiographer in non accidental injury sherril spencer, associate professor, faculty of health, social care and education, kingston university and st georges university of london and education, training and research officer, international association of forensic radiographers iafr. Performance of computed tomography of the head to evaluate for skull fractures in infants with suspected non accidental trauma. Imaging often plays a major role in the detection and documentation of physical injury. In children suspected of nonaccidental injuries but with negative or equivocal ss, sampling of the anterior and posterior end of ribs 58 and the bones around the knee for histological. The american college of radiology, with more than 30,000 members, is the. Diagnostic imaging pathways paediatric, injury nonaccidental. Clinical radiology is published by elsevier on behalf of the royal college of radiologists. The radiologists task is to detect findings that are suggestive of abuse, to distinguish abuse from other pathologies and normal variants, and to provide reasonable estimates of fracture age and mechanism of injury.
Only the child protection investigation may provide the basis for in. In recent years there has been a worldwide increased awareness that children are physically abused by their carers. Guidance torn frenulum and non accidental injury in children. Ghosh, md and debabrata ghosh, md clinical pediatrics 2011 50. Diagnostic imaging of child abuse american academy of pediatrics. Diagnostic imaging plays an important role in the early diagnosis of abuse. Some advocate that all children with suspected non accidental injury should have both a skeletal survey and bone scan 9. Update on imaging nonaccidental injury british association. The role of skeletal survey in identifying nonaccidental trauma in. Issues and controversies in the era of evidencebased medicine january 2011 radiologic clinics of north america 491.
The many normal variants found in the developing skeleton provide numerous pitfalls to the diagnosis. Imaging and reporting considerations for suspected physical abuse non accidental injury in infants and young children. To identify the difference in injury patterns of children with suspected nai versus accidentally injured children. Standard for skeletal surveys in suspected nonaccidental injury nai.
Pitfalls congenital infections birth related injuries e. These images are a random sampling from a bing search on the term child abuse. Is a difficult diagnostic problem with both missing the diagnosis and misdiagnosis very important concerns 1. Pediatric central nervous system imaging of nonaccidental. Imaging the brain in nonaccidental head trauma deepdyve.
Child abuse may include any act or failure to act by a parent or a caregiver that results in actual or potential harm to a child, and can occur in a childs home, or in the organizations, schools or communities the child interacts with. The key imaging modality in suspected cases is plain radiography in the form of a skeletal survey. Imaging of nonaccidental head injury, pediatric radiology. Implementation of a comprehensive program to improve child. Xray lateral spiral fracture of any long bone in a nonmobile infant is always worrying for nonaccidental injury child abuse. Assertive guidelines to call nat to avoid cognitive errors 6. Adherence to the alarp and irmer principles are paramount in all paediatric radiography. Department of health western australia diagnostic imaging pathways 01 july 2014 this pathway provides guidance on imaging a child suspected at risk of non accidental injury. The authors found that patients with minor head injury could be classified into two levels of risk.
Spiral fracture of any long bone in a non mobile infant is always worrying for non accidental injury child abuse. This practical day was an invaluable recap on non accidental imaging nai procedures and protocols and was led by a. This event will provide a vital update on nonaccidental injury nai imaging. Neuroimaging evaluation of nonaccidental head trauma with. A followup skeletal survey may be indicated in the setting of nonaccidental injury. Subdural hematoma in infants without accidental or. The royal college of radiologists rcr and the society and college of radiographers scor issue jointly this additional guidance in response to specific questions regarding the use of anatomical markers in imaging for suspected non accidental injury examinations of living children and the correct course of action to be taken if the marker is absent from the image. The expert must fairly balance the need to protect the child against just treatment of the carers. Imaging for nonaccidental injury the sor and rcr have issued joint additional guidance on the use of anatomical markers in imaging for suspected nonaccidental injury examinations of living children and the correct course of action to be taken if the marker is absent from the image. Clinical and neuroradiolgical findings of non accidental trauma nat 3.
Click on the image or right click to open the source website in a new browser window. Diagnostic imaging pathways suspected stable angina diagnostic imaging pathways suspected stable angina. Imaging in nai remains a controversial issue with little agreement concerning how, when and what imaging modalities should be used in the investigation of suspected cases. In recent years there has been a worldwide increased awareness. In many jurisdictions, radiologists and radiographers will also have legal responsibilities related to the reporting of suspected physical abuse of childrensuspected non accidental injury. This pathway provides guidance on imaging a child suspected at risk of non accidental injury. Diagnostic imaging pathways suspected stable angina. Professor amaka offiah bsc, mbbs, mrcp, frcr, phd, frcpch. The type and extent of imaging performed in a child who is a suspected victim of abuse depends on the childs age, signs, symptoms, and other social considerations, such as being the twin or sibling of a physically abused infant. I obtained my mbbs while working at oldchurch hospital, essex and then trained as a radiologist in sheffield.
The radiological investigation of suspected physical abuse in children. It also discusses more severe conditions, including septic arthritis, osteomyelitis, slipped upper femoral epiphysis, perthes disease, malignancies and non accidental injury. Responsibilities of the radiographer in non accidental injury. Diagnostic imaging therefore plays a crucial role in identifying potential patterns of abuse. Radiographic skeletal survey for nonaccidental injury. It can present with musculoskeletal problems, such as pain, swelling or limping, and all healthcare professionals who have contact with children should be alert to the possibility of abuse. We found in our study a high incidence of spinal subdural hemorrhage in abusive head trauma in cases where the thoracolumbar spine was imaged. Select the most appropriate imaging modality and summarize protocol optimization. Only the social investigation may provide the basis for inflicted injury in the context of supportive medical, imaging, or. Bird,1 susan craw,2 david duncan,1 philippa depree,3 alina leigh,4 andrew mclaughlin,1,5 russell metcalfe,1 jean murdoch,6.
The radiology of nonaccidental injury nai requires meticulous attention to detail. So you have to look for other more specific skeletal injuries in these children. Management and prognosis of these conditions are discussed in the context of guidance from the national institute for health and care excellence. This is an important finding that may help to distinguish between abusive and accidental injury and to understand the mechanism of injury with further studies. The medical and imaging evidence, particularly when there is only cns injury, cannot accurately diagnose presumed intentional injury. Bone scan however revealed focal increased uptake in the right 4th to 7th ribs posteriorly consistent with fractures. An approach to nonaccidental injuries learn pediatrics. However in most of these cases of child abuse, there is a history that does not correlate well with the injuries, that are found. Skeletal imaging of child abuse non accidental injury. The vast majority of child abuse and neglect fatalities are less than 5 years old, and a. The canadian ct head rule cchr was prospectively derived on 3121 patients who had a minor head injury, defined as a gcs of or greater with witnessed loss of consciousness, disorientation or definite amnesia 3, 20, 21.
Now in its eighth year, this study day embraces current developments in the field of suspected nonaccidental injury suspected physical abuse imaging and joint publication by the society and college of radiographers and royal college of radiologists. Fractures are the second most common findings of nai, after cutaneous lesions such as bruises and contusions. Imaging for nonaccidental injury society of radiographers. Protocol for imaging nonaccidental injury nai in children.
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