Skeletal surveys to determine child abuse

Skeletal surveys to determine child abuse

In medico-legal jargon the term “non-accidental injury” (NAI) is a euphemism for physical abuse resulting in an injury. A large proportion of the victims of abuse are children, many of them under the age of four. In April this year the Aunt Minnie Radiology website featured an article that reported on shocking statistics at an inner-city hospital in Boston, USA, stating that a quarter of the children evaluated were found to be victims of abuse.

The injuries to the skeleton are often occult, i.e., not visible during an external examination. Many children, especially infants, are unable to articulate what happened to them and can thus not provide evidence in cases of abuse.

A radiographic skeletal survey is a useful tool for imaging the skeleton to reveal fresh fracture, as well as older fractures that may have healed and are visible because of the callus that forms at the injury site. Typical injuries include rib fractures, in particular posteriorly at the costo-vertebral junction (as a result of chest compression and shaking), classic metaphyseal fractures of the long bones (as a result of violent pulling or twisting of a limb), sternal fractures (as a result of blunt force applied to the chest), fractures of the spinal processes (as a result of being thrown down), as well as fractures of the scapula, clavicle and skull.

Not all hospitals have a protocol for conducting a skeletal survey. There is also quite a variation in protocols when they are available. One group of researchers examined various protocol and studies, and has proposed a new protocol for use in New Zealand, offering it for other sites to consider implementing. However, even when there is a documented procedure in place, it could be a fairly lengthy process to acquire all the radiographic views of the head, chest, pelvis, long bones, hands and feet that are required for a skeletal survey. In addition, it may be difficult to keep the child calm throughout the imaging. And finally, the downside of multiple X-ray images is the increased ionising radiation dose the patient will receive.

Part or the armament in a trauma centre for dealing with child abuse – or physical abuse in general – could well be a Lodox full-body X-ray scanner. The scanner serves as a screening tool, providing full-body AP and lateral images of the patient at about 10% of the dose of a conventional X-ray system, and in a fraction of the time. Dedicated views are also possible with the Lodox scanner should the attending physician require a more detailed image of a region of interest.

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