Variant 3: Child with one or more of the following: neurologic signs or symptoms, apnea, complex skull fracture, other fractures, or injuries highly suspicious for child abuse. Initial imaging evaluation. X-ray skeletal survey The skeletal survey is the primary examination for detecting fractures [11]. Fractures occur in up to 55% of physically abused children [29]; 80% of abused children with fractures are <18 months of age [4]. Thus, skeletal survey is recommended in all children <2 years of age in whom there is suspicion of abuse [51,52]. Tc-99m bone scan whole body Bone scintigraphy is a complementary/adjunctive examination for detecting bone injuries. It may aid by detecting bony injury that is occult, equivocal, or subtle on plain radiographs. Skull fractures and fractures near the growth plates, however, may be difficult to appreciate [31,32]. In children with skull fractures or clinical signs and symptoms of intracranial injury, an immediate noncontrast CT scan of the head should be performed. Contrast administration for the head CT examination is not indicated. If the CT scan does not detect significant lesions that require rapid neurosurgical intervention and the clinical presentation warrants further assessment, a MRI scan of the head should be performed. MRI head Additional diagnostic information will be found on MRI over CT in about 25% of patients [36], and MRI can also contribute to prognosis. In a child with an abnormal CT, additional assessment with MRI should be considered to further assess the extent of post-traumatic injury. Care should be taken in trying to determine the age of subdural hematomas by CT or MRI [67,68]. Although hyperdense blood products can be considered acute, collections of low or intermediate density do not indicate necessarily chronic blood products, as lacerations of the arachnoid may result in subdural hygromas or hematohygromas in the early or late post-traumatic periods.
Suspected Physical Abuse Child. Variant 3: Child with one or more of the following: neurologic signs or symptoms, apnea, complex skull fracture, other fractures, or injuries highly suspicious for child abuse. Initial imaging evaluation. X-ray skeletal survey The skeletal survey is the primary examination for detecting fractures [11]. Fractures occur in up to 55% of physically abused children [29]; 80% of abused children with fractures are <18 months of age [4]. Thus, skeletal survey is recommended in all children <2 years of age in whom there is suspicion of abuse [51,52]. Tc-99m bone scan whole body Bone scintigraphy is a complementary/adjunctive examination for detecting bone injuries. It may aid by detecting bony injury that is occult, equivocal, or subtle on plain radiographs. Skull fractures and fractures near the growth plates, however, may be difficult to appreciate [31,32]. In children with skull fractures or clinical signs and symptoms of intracranial injury, an immediate noncontrast CT scan of the head should be performed. Contrast administration for the head CT examination is not indicated. If the CT scan does not detect significant lesions that require rapid neurosurgical intervention and the clinical presentation warrants further assessment, a MRI scan of the head should be performed. MRI head Additional diagnostic information will be found on MRI over CT in about 25% of patients [36], and MRI can also contribute to prognosis. In a child with an abnormal CT, additional assessment with MRI should be considered to further assess the extent of post-traumatic injury. Care should be taken in trying to determine the age of subdural hematomas by CT or MRI [67,68]. Although hyperdense blood products can be considered acute, collections of low or intermediate density do not indicate necessarily chronic blood products, as lacerations of the arachnoid may result in subdural hygromas or hematohygromas in the early or late post-traumatic periods.