ACR Appropriateness Criteria®
Clinical Condition: Suspected Physical Abuse - Child
Variant 1: Child 2 years or less, no facial signs or symptoms.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| X-ray, skeletal survey |
9 |
Includes at least 2 views of the skull. |
| MRI, brain |
5 |
For evidentiary purposes only. |
| NUC, bone scan |
4 |
May be useful in selected cases. For evidentiary purposes only. |
| CT, brain |
2 |
|
| US, abdomen |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Child 2 years or less, head trauma by history, no focal findings, no neurologic abnormality.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| X-ray, skeletal survey |
9 |
Includes at least 2 views of the skull. |
| MRI, brain |
7 |
|
| CT, brain |
6 |
|
| NUC, bone scan |
4 |
May be useful in selected cases. For evidentiary purposes only. |
| US, abdomen |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Child up to age 5, seizures or neurologic signs and symptoms, with or without physical findings.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| X-ray, skeletal survey |
9 |
Includes at least 2 views of the skull. |
| CT, brain |
9 |
|
| MRI, brain |
8 |
May be appropriate as alternative to CT or following CT. |
| NUC, bone scan |
4 |
May be useful in selected cases. For evidentiary purposes only. |
| US, cranial |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Child of any age, visceral injuries, discrepancy with history, physical and laboratory examinations inconclusive.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| X-ray, skeletal survey |
9 |
Includes at least 2 views of the skull. |
| CT, abdomen and pelvis, with contrast |
9 |
|
| US, abdomen and pelvis |
2 |
|
| MRI, abdomen and pelvis |
2 |
|
| CT, abdomen and pelvis, without contrast |
2 |
|
| CT, brain |
2 |
|
| MRI, brain |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
The kind of imaging necessary in a child suspected of abuse depends on the child's age, signs, and symptoms. Therefore, the suffering child may enter this algorithmic sequence at several points.
Entry point one: Child 2 years of age or younger with a clinical suspicion of abuse but no focal signs or symptoms.
The most basic imaging examination is the skeletal survey, composed of frontal and lateral views of the skull and single frontal views of the long bones, lateral spine, frontal chest, and abdomen. Since rib fracture may be the only skeletal manifestation of abuse, oblique radiographs of the ribs are included in the initial skeletal survey. The goal is to detect fractures for documentation of abuse.
When results of this survey are negative but a clinical suspicion remains high and documentation is still necessary, a bone scan is obtained with meticulous attention to position and technique (pin-hole collimators and differential counts of the metaphysics), and with the understanding that skull fractures will usually not have increased uptake of the radioisotope. A bone scan is especially good for diagnosing rib, spine, pelvic, and acromion fractures.
Entry point two: Child 2 years of age or younger with a history of head trauma but no focal findings or neurologic abnormality. A clinical suspicion of abuse is present.
A skeletal survey, as described above, is obtained. A cross-sectional image procedure of the brain in a child with a normal neurological exam doesn't alter the nature of medical treatment nor the child's clinical course. When the skeletal survey is negative but a strong clinical suspicion of abuse exists, a full skull series and MRI can be obtained for legal documentation of abuse. MRI has a far greater sensitivity for detecting and dating intracranial injury than CT and avoids unnecessary radiation (see MRI sequences, diffusion-weighted imaging (DWI), etc., in entry point 3 below).
If the skeletal survey is negative but a clinical suspicion remains high and documentation is still necessary, a bone scan may be subsequently obtained.
Entry point three: Child up to 5 years of age with neurologic signs and symptoms, and suspicion of abuse with or without other physical findings.
The child needs a careful clinical assessment. If the child is critically ill with serious signs of neurologic injury an immediate noncontrast CT scan of the brain should be performed. If this scan does not detect significant lesions needing rapid neurosurgical intervention, the child should be stabilized and an urgent MR study of the brain performed with a minimum of diffusion imaging, susceptibility imaging, T1, T2, and inversion recovery sequences.
If the child is clinically stable with neurologic symptoms (transient loss of consciousness, seizure, altered mental status, confirmed presence of retinal hemorrhages) MR may be used for the initial neurologic imaging evaluation. Sequences for susceptibility, T1, T2, and inversion recovery should be used. Diffusion imaging may be used depending on the severity of the child's illness.
In either case, if the child is less than 2 years of age, a skeletal survey as defined in entry point one should be performed, and should include a full skull series if fracture is not otherwise documented by CT.
Entry point four: A child of any age with visceral injury that is discrepant with the history, and either the physical examination or the laboratory studies or both do not provide a satisfactory explanation. The visceral injuries would include:
- pancreatic pseudocyst
- adrenal hemorrhage
- free air (bowel perforation) after blunt trauma
- contusion or laceration of viscera
- traumatic bladder perforation
In this setting, all of these injuries (a-e) should be considered signs of abuse. If the patient is less than 2 years of age, skeletal survey should be done.
In all probability, the child would already have had the injury detected by contrast-enhanced CT (CECT) with oral or intravenous contrast. If a CT was not obtained, it would be the first imaging test. Follow-up imaging relates to the disease process, not abuse. Some authorities prefer not to use oral contrast for this CT study; however, there is not a clear documentation of the superiority of either technique; therefore, the issue of oral contrast should be left to the discretion of the radiologist.
It is of interest that of all the cases of bowel perforation after blunt trauma (incidence 1 to 5%), most of them (65%) are found in abused children.
Abbreviations
- CT, computed tomography
- MRI, magnetic resonance imaging
- NUC, nuclear medicine
- US, ultrasound
