A qualitative description of how Ghanaian radiographers identify suspected child physical abuse

IntroductionChild physical abuse is intentionally inflicted injury of a child and presents a challenging diagnosis to clinicians mostly as a result of doubts about whether the findings were perpetrated by carers of these children. Suspected child physical abuse cannot be reported without its initial identification, substantiation and reporting. Imaging findings is one way of providing evidence of abuse in court.MethodsA qualitative design was used to gather data. Twenty (20) radiographers were recruited using purposive criterion sampling to share their experiences of mode of identification of suspected child physical abuse. Semi-structured interviews were conducted to gain deeper insight into their experiences.ResultsRadiographers' suspicion or identification of child physical abuse was based on four (4) constructs: pre-radiographic observation; child's physical signs; caregiver secrecy and imaging findings. These observations provoked further investigations through questioning of the child (if of verbal age), parent or both. Their initial suspicion through assessment of cases was sometimes strengthened by the imaging findings.ConclusionRadiographers suspected child physical abuse using several approaches some of which were found to be unacceptable although it led to other important information, such as additional imaging performed by the radiographers without doctor consultation. However, being able to identify child physical abuse is important in child protection activities.Implication for practiceIdentification and reporting of suspected abuse to the appropriate child protection authorities are imperative for child protection. The possibility that some experienced radiographers may fail to deal with serious instances of child abuse exist. A radiographer's inability to identify such cases, could that the victim would miss the required protection from the professional.     

Imaging of head trauma in child abuse

This article reviews the imaging modalities used to evaluate head trauma received as a consequence of child abuse, signs most indicative of intentional injury, and methods use to data injury. Knowledge of neuroimaging features of child abuse is useful to radiologists who may encounter these children and may be in a position to raise the question of intentional injuries.     

Cranial imaging in child abuse

Serious head injury in children less than 2 years old is often the result of child abuse. The role of the different neuroimaging modalities in child abuse is reviewed. Skull X-ray and cranial CT are mandatory. Repeat or serial imaging may be necessary and brain MR imaging may contribute to the diagnostic work-up, particularly in the absence of characteristic CT findings. The radiologist plays an important role in accurately identifying non-accidental cranial trauma. The clinical presentation can be non-specific or misleading. The possibility should be considered of a combined mechanism, i.e., an underlying condition with superimposed trauma. In this context, the radiologist is in the front line to suggest the possibility of child abuse. It is therefore important to know the spectrum of, sometimes subtle, imaging findings one may encounter. Ophthalmological examination is of the greatest importance and is discussed here, because the combination of retinal hemorrhages and subdural hematoma is very suggestive of non-accidental cranial trauma.     

Head injury in child abuse: evaluation with MR imaging

To evaluate the usefulness of magnetic resonance (MR) imaging in the diagnosis of head injury in child abuse, the authors compared the findings at head MR imaging and computed tomography (CT) in 19 abused children. Subdural hematomas (15 cases), cortical contusions (six cases), and shearing injuries (five cases) were demonstrated to particular advantage with MR imaging. CT remained superior in the detection of subarachnoid hemorrhage. MR imaging appears to be valuable in the assessment of patients with suspected intracranial injury due to child abuse.     

Imaging of the central nervous system in child abuse: A computer-aided instructional program

This article describes a computer-aided instructional program dealing with diagnosis and classification of central nervous system injuries seen in child abuse. Cases were selected to demonstrate the spectrum of central nervous system injury seen in child abuse, with emphasis on features which can be used to help distinguish child abuse from accidental trauma. A review of the temporal changes of hematomas as seen by magnetic resonance imaging is also provided. Completion of the program requires 25–30 minutes. Free copies of the program may be obtained by contacting the authors.     

MR imaging of soft-tissue masses of the foot

As with other parts of the musculoskeletal system, the soft tissues of the foot can be affected by a wide variety of pathologic entities including trauma, congenital abnormalities, infections, and neoplastic disorders. While plain radiographs are usually the initial examination for evaluation of pathology, magnetic resonance imaging (MRI) is critical to evaluate for abnormalities within the ligaments, tendons, and other nonosseous structures within the foot. The constellation of clinical and MRI findings often allows a relatively specific diagnosis to be rendered. This article discusses both benign and malignant processes within the soft tissues of the foot and presents their characteristic imaging findings with MRI.     

Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine

Because of the controversy involving the determination of child abuse, or nonaccidental injury (NAI), radiologists must be familiar with the issues, literature, and principles of evidence-based medicine to understand the role of imaging. Children with suspected NAI must receive protective evaluation along with a timely and complete clinical and imaging work-up. Imaging findings cannot stand alone and must be correlated with clinical findings, laboratory testing, and pathologic and forensic examinations. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive clinical, imaging, biomechanical, or pathology findings.     

Unfall oder Misshandlung? Radiologische Befunde beim nichtakzidentiellen Trauma

The focus of this review article is on child abuse and the radiographic pattern of X?ray findings. The radiologist should be able to recognize typical injuries resulting from child abuse. In some cases the findings are highly specific for abuse and these include metaphyseal corner fractures of the long bones in children aged up to 24 months. In other cases the fractures are not specific but highly indicative of child abuse: rib fractures, for example can be associated with child abuse in more than 50?% of the cases; however, maltreatment is difficult to diagnose without taking the entire pattern of skeletal findings into consideration so that a radiological screening of the entire skeleton is often necessary. The concept of sentinel injuries might be helpful for deciding in which cases a complete skeletal screening should be performed. In the age group up to 24 months old a complete skeletal status (with some exceptions) is recommended if one of the three sentinel injuries of rib fractures, intracranial bleeding and abdominal trauma is present.     

MRI of the pelvis: a guide to incidental findings for musculoskeletal radiologists

Patients undergoing magnetic resonance imaging (MRI) of the pelvis for presumed musculoskeletal disease are commonly found to have abnormal imaging findings in the incidentally imaged pelvic viscera. Such incidental findings can be problematic for the musculoskeletal imager, both in terms of assigning clinical significance and determining the appropriate workup for a given abnormality. In this article we discuss the normal MRI appearance of the various pelvic organ systems as well as normal variants, emphasizing those that can mimic pathological processes. We then discuss the MRI appearance of common pathological entities encountered in these organ systems and the key imaging findings that should warrant a recommendation for further radiologic and/or clinical evaluation.     

Bone scintigraphy in the evaluation of extraskeletal injuries from child abuse

Bone scintigraphy is a valuable imaging modality in the examination of the battered child. It is often used to evaluate skeletal trauma. However, bone scans may also reveal subtle and unusual scintigraphic findings that, if recognized, can lead to the diagnosis of intracranial, visceral, and soft-tissue injury. Several cases of child abuse in which bone scan findings suggested the presence of injuries other than skeletal trauma are presented.     

Musculoskeletal interventional ultrasound

Ultrasound is a nonionizing, low-cost, portable imaging technique for the evaluation of tendons, muscles, joints, soft tissue masses, and cysts, especially in patients unable to tolerate computed tomography or magnetic resonance imaging. These advantages make ultrasound an ideal modality for guiding musculoskeletal interventions. Its real-time capabilities allow continuous observation of needle placement into the targeted area and direct visualization of interventions such as injection of medication while avoiding other soft tissue structures or nearby neurovascular bundles. After a brief overview of the technical factors involved in performing ultrasound-guided musculoskeletal interventions, this article reviews commonly performed percutaneous procedures in the musculoskeletal system.     

Anterior chest pain: musculoskeletal considerations

The clinical symptom of anterior chest pain generally elicits a long list of diagnoses. When cardiac and pleural conditions are excluded, conditions that affect the musculoskeletal system become important considerations. Many of these conditions have characteristic imaging features that allow accurate diagnosis. In others, the imaging findings can be instrumental in directing the appropriate course of action. This article reviews the imaging features of a number of musculoskeletal entities that present with anterior chest pain including traumatic, rheumatologic, inflammatory, infectious, and neoplastic conditions.     

Non-accidental trauma: the role of radiology

Non-accidental trauma is a significant source of morbidity and mortality in the pediatric population. Given the vulnerable state of the child, the radiologist can often provide valuable diagnostic information in the setting of suspected abuse. This review focuses on common findings of abusive trauma and serves as a guide to aid in clinical decision-making for providers of emergency medicine and pediatrics. Amid this discussion is an assessment of modern controversies regarding reported mimicking pathologies, recapitulation of the current state of evidence with respect to radiologic findings of abuse, and examination of the contribution that spine imaging may add to the diagnosis of possible abusive head trauma in the acutely injured child. Recommendations for avoiding pitfalls regarding the dating of intracranial injuries are discussed, and illustrated depictions of perpetrator-induced pathology are provided to aid in the understanding of these injuries. Through the use of the appropriate approach to imaging and evidence-based guidelines regarding radiologic findings, the role of radiology is to provide fundamental clues to diagnose and prevent recurrence of abusive injury in patients who cannot speak for themselves.     

Musculoskeletal injuries related to yoga: imaging observations

OBJECTIVE: The purpose of this article is to describe the imaging appearances of musculoskeletal injuries related to yoga. We performed an automated search in the database of a large tertiary care center and conducted a retrospective analysis of the imaging findings in 38 patients over a 9-year period. CONCLUSION: The most frequently encountered musculoskeletal injuries were tendinous lesions, including tears of the supraspinatus, Achilles, and peroneus brevis tendons and fibrocartilaginous tears involving the medial meniscus, acetabular labrum, glenoid labrum, and lumbar disk with extrusion.     

Sonography of the musculoskeletal system

Improved technology and the development of high-resolution transducers have made sonography of the structures of the musculoskeletal system possible. The vast majority of scientific reports on the value of sonography for imaging musculoskeletal abnormalities have been written only in the last decade. Sonography has several inherent advantages: it is relatively inexpensive, allows comparison with the opposite normal side, uses no radiation, and can be performed at bedside or in the operating room if necessary. The advent of MR imaging has revolutionized musculoskeletal imaging and may be used in many instances rather than sonography for evaluating the same abnormalities or anatomic structures. It is important, however, to keep in perspective what the different imaging techniques have to offer, and, if one is just as efficacious as the other, the least invasive and least expensive should be chosen whenever possible. The goal of this article is to review the applications of sonography to the evaluation of musculoskeletal disorders including tendon disease, soft-tissue masses, identification of foreign bodies, osteomyelitis, cellulitis, and certain joint abnormalities.     

Role of radiography in the diagnosis of battered children

Radiological imaging plays an important role in diagnosis of the child abuse syndrome. The radiologist must identify specific foci of injury and document that such injuries are the result of abuse. The capacity to identify abuse-related injuries (sensitivity) has been greatly enhanced by technological advances in radiological imaging including radionuclide scintigraphy (skeletal injury); cranial computed tomography (craniocerebral injuries); and body computed tomography/ultrasonography (abdominal injury). This increased sensitivity has resulted in a greater appreciation of the magnitude of abuse related injuries. Specificity, differentiation between accidental and non-accidental injuries, depends on knowledge of the radiologic characteristics and pattern of abuse-related trauma. Specific injuries must be viewed in light of known pathologic response of anatomic structures to mechanical forces, and determination of the chronology of trauma.     

Applications of Doppler imaging in the musculoskeletal system

Pathological conditions affecting the musculoskeletal system often result in alterations of regional blood flow. The assessment of a Doppler signal in inflammatory or infective processes complements the grayscale findings, helping to evaluate the severity of disease. Doppler imaging can also be used to determine therapeutic response or help guide injections. In addition, Doppler interrogation enables vascular characterization of solid masses. The presence of a Doppler signal can also help differentiate solid from cystic lesions. This article reviews the wide range of applications for Doppler imaging of the musculoskeletal system.     

The ultrasonographic characterization of tendons

Ultrasonography has not been utilized in the diagnosis of musculoskeletal disorders. However, the superficial location of tendons and ligaments lend themselves to evaluation by this modality. The ultrasonographic characteristics of the normal Achilles tendon are described in both the rabbit and man. The characteristic ultrasonographic findings after injury to the Achilles tendon are also determined. This imaging technique provides a sharp definition of the tendon and surrounding structures and easily demonstrates abnormalities. The superficially located quadriceps tendon is also well visualized by ultrasound and representative examples are shown. Ultrasound should be considered as another useful method for evaluation of these superficial musculoskeletal structures.     

Bildgebende Diagnostik der Kindesmisshandlung

Diagnostic imaging in child abuse plays an important role and includes the depiction of skeletal injuries, soft tissue lesions, visceral injuries in “battered child syndrome” and brain injuries in “shaken baby syndrome”. The use of appropriate imaging modalities allows specific fractures to be detected, skeletal lesions to be dated and the underlying mechanism of the lesion to be described. The imaging results must be taken into account when assessing the clinical history, clinical findings and differential diagnoses. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations must be performed in order to detect lesions of the central nervous system (CNS) immediately. CT is necessary in the initial diagnosis to delineate oedema and haemorrhages. Early detection of brain injuries in children with severe neurological symptoms can prevent serious late sequelae. MRI is performed in follow-up investigations and is used to describe residual lesions, including parenchymal findings.     

Diagnostic imaging in child abuse

Diagnostic imaging in child abuse plays an important role and includes the depiction of skeletal injuries, soft tissue lesions, visceral injuries in "battered child syndrome" and brain injuries in "shaken baby syndrome". The use of appropriate imaging modalities allows specific fractures to be detected, skeletal lesions to be dated and the underlying mechanism of the lesion to be described. The imaging results must be taken into account when assessing the clinical history, clinical findings and differential diagnoses. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations must be performed in order to detect lesions of the central nervous system (CNS) immediately. CT is necessary in the initial diagnosis to delineate oedema and haemorrhages. Early detection of brain injuries in children with severe neurological symptoms can prevent serious late sequelae. MRI is performed in follow-up investigations and is used to describe residual lesions, including parenchymal findings.