Updated Summary: ACR Appropriateness Criteria® suspected physical abuse—child. [American College of Radiology]


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ACR Appropriateness Criteria®

Clinical Condition: Suspected Physical Abuse—Child

Variant 1: Suspected physical abuse. Child ≤24 months of age. Neurological or visceral injuries not clinically suspected. Initial imaging evaluation.

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 2: Suspected physical abuse. Child >24 months of age. Neurological or visceral injuries not clinically suspected. Initial imaging evaluation.

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

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.

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 4: Child. Suspected physical abuse. Suspected thoracic or abdominopelvic injuries (e.g., abdominal skin bruises, distension, tenderness, or elevated liver or pancreatic enzymes). Initial imaging evaluation.

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Variant 5: Child ≤24 months of age. High suspicion for abuse. Negative initial skeletal survey. Follow-up imaging evaluation.

Note: Abbreviations used in the tables are listed at the end of the “Major Recommendations” field.

Summary of Literature Review

Introduction/Background

Based on reports to child and protective service agencies, an estimated 3.2 million children were investigated for maltreatment (neglect, emotional abuse, sexual abuse, and physical abuse) in the United States in 2013, and an estimated 679,000 (9.1/1000 children) were victims of abuse. The youngest children are most vulnerable; children in their first year of life had the highest rate of victimization at 23.1/1000. An estimated 1520 children died from abuse, with three-fourths of these under 3 years of age. However, the full extent of child abuse is not known because of underreporting.

Eighteen percent of maltreated children were physically abused by being hit, shaken, thrown, poisoned, burned, scalded, drowned, and/or suffocated. Physically abused children may present with neurological injuries, hollow viscus and solid-organ injuries, superficial and deep soft-tissue injuries, thermal injuries, and/or fractures. Fractures highly suggestive of physical abuse include rib fractures, classic metaphyseal lesions, those unsuspected or inconsistent with the history or age of the child, multiple fractures involving more than 1 skeletal area, and fractures of differing ages. In some children, physical examination and history may clearly indicate that physical abuse has occurred. In other children, however, the diagnosis of abuse is not so straightforward and requires clinical, laboratory, imaging, pathological, and forensic evaluation and usually relies on the findings of a multidisciplinary team that includes physicians, social workers, and legal authorities. Imaging often plays a major role in the detection and documentation of physical injury. The type and extent of imaging performed in a child who is a suspected victim of abuse depends on the child’s age, signs, symptoms, and other social considerations, such as being the twin or sibling of a physically abused infant. Making the diagnosis of child abuse requires differentiation from anatomical and developmental variants and possible underlying metabolic and genetic conditions.

Overview of Imaging Modalities

X-ray Skeletal Survey

The radiographic skeletal survey is the primary imaging examination for detecting fractures. The skeletal survey should be composed of frontal and lateral views of the skull, lateral views of the cervical spine and thoracolumbosacral spine, and single frontal views of the long bones, hands, feet, chest, and abdomen. Oblique views of the ribs should be obtained to increase the accuracy of diagnosing rib fractures, which are strong positive predictors and may be the only skeletal manifestation of abuse.

The images should be obtained using high-detail imaging systems and coned to the specific area of interest for each of the body parts, with separate views of each arm, forearm, thigh, leg, hand, and foot to improve image quality and diagnostic accuracy (see Appendix 1 in the original guideline document). Fractures most often involve the long bones and ribs, with lesser involvement of the skull and clavicles and even less frequent involvement of the pelvis, spine, hands, and feet. It has therefore been questioned whether the radiation exposure outweighs the potential benefit of imaging the pelvis, spine, hands, and feet on initial skeletal survey. Although not part of American College of Radiology (ACR) or American Academy of Pediatrics guidelines, some add lateral radiographs of the long bones, which have been shown to increase detection of metaphyseal fractures by 50%. A repeat skeletal survey performed approximately 2 weeks after the initial examination can provide additional information on the presence and age of child abuse fractures in up to 12% of children and should be performed when abnormal or equivocal findings are found on the initial study and when abuse is suspected on clinical grounds. To limit radiation exposure, pelvis, spine, and skull radiographs can be omitted if no injury was initially seen in these regions. However, it is not possible to exactly date fractures by radiography.

Technetium-99 metastable (Tc-99m) Bone Scan Whole Body

In experienced hands, bone scintigraphy is a complementary/adjunctive examination for detecting bone injuries but is usually not considered an alternative to skeletal survey. It should be used when the radiographic skeletal survey is negative but clinical suspicion remains high and a search for further evidence of skeletal trauma is warranted. It may aid by detecting bony injury that is occult, equivocal, or subtle on plain radiographs, but it requires venipuncture and often requires sedation. In addition to standard images, the use of pinhole collimators and differential counts of the metaphyses may improve sensitivity. A bone scan is especially good for detecting periosteal reaction and rib, spine, pelvic, and acromion fractures. However, skull fractures and fractures near the growth plates, because of normally increased activity in the growth plate, may be difficult to appreciate. Bone scan is also not useful in dating of fractures, as the scan may be active for up to a year after injury.

CT Head without Contrast

Unenhanced computed tomography (CT) of the head is the examination of choice to evaluate children with suspected abusive head trauma (AHT). These include children who had skeletal survey for suspected child abuse, children with neurological changes, and children with facial injuries raising concern for abuse. Multiplanar reformations and 3-dimensional (3-D) volume rendering of the skull increase sensitivity for fracture and intracranial hemorrhage.

MRI Head without Contrast

Magnetic resonance imaging (MRI) is sensitive for the detection of small-volume extra-axial hemorrhage and for evolving parenchymal injury. In addition to standard sequences, diffusion-weighted imaging and susceptibility-weighted imaging increase sensitivity for detection of parenchymal ischemia, diffuse axonal injury, and microhemorrhage and can provide prognostic information in AHT. The addition of contrast-enhanced MRI sequences can be used in select cases to improve evaluation of extra-axial collections as it increases the sensitivity for the detection of membranes in subdural collections, a finding that indicates a chronic component. Care must be taken when attempting to date subdural collections, however, as the imaging appearance depends not just on the age of blood products but also on the potential presence of cerebrospinal fluid accumulation in the subdural space through an arachnoid laceration (hematohygroma). Thrombosis of bridging veins in the subdural space also suggest abusive trauma.

The MRI should include T1- and T2-weighted imaging as well as T2 FLAIR and T2* (gradient-echo or susceptibility-weighted imaging) sequences. Diffusion-weighted sequences are required to indicate whether acute cerebral injury is present. Susceptibility-weighted imaging may be useful in detection of blood products in the brain as well as retinal hemorrhages. MRI is a particularly good choice to image children at high risk for AHT in the nonemergent setting but is a lengthy scan often requiring sedation, so it is typically not utilized in the emergent setting.

MRI Spine

Recent evidence supports that spine injury is common in children with AHT. In recent retrospective studies, ligamentous injury at the craniocervical junction and spinal subdural hemorrhage (SDH) are reported in 36% to 78% and 44% to 63% of AHT cases, respectively. MRI of the cervical spine, including fat-suppressed fluid-sensitive sequences, a sagittal short tau inversion recovery or T2 fat-saturated sequence, should be performed in all cases where the skeletal survey demonstrates any fractures or when clinical concern for craniocervical junction or spinal injury is high. The prevalence of spine fracture is increased to almost 10% in the setting of a positive skeletal survey and is significantly associated with intracranial injury. The high incidence of cervical injuries in abused children with bilateral hypoxic-ischemic brain injuries suggests a causal relationship.

The value of routine screening of the whole spine in suspected AHT is still debated. In a subgroup of 38 children with AHT who underwent thoracolumbar spine imaging, 24 (63%) had thoracolumbar SDH, whereas only 1 of 70 patients with accidental trauma had spinal SDH in the same study. None of the children had spinal cord compression or long-term complications from the presence of the spinal SDH, and that imaging was performed mostly because of concern for thoracic or abdominal injury. Although not usually prompting change in management, detection of spinal SDH is significantly increased when imaging is extended through the thoracolumbar spine. The presence of thoracolumbar SDH does not imply direct trauma to the thoracolumbar spine and may be related to redistribution of blood products. Nevertheless, this finding has medicolegal implications as it may document otherwise undetected injury and may help distinguish between abusive and accidental injury.

CT Chest without Contrast

CT of the chest is more sensitive than chest radiography in detection of rib fractures; chest radiography defines only about 60% of the fractures that are detected by CT. Anterior and posterior fractures are better seen by CT, as are bilateral fractures. However, the need for sedation in noncooperative children makes this test a useful adjunct rather than a first-line test in the imaging workup of nonaccidental trauma (NAT). A reduced-dose chest CT may detect rib fractures in infants with high suspicion for NAT and a normal initial 4-view chest, with a submillisievert radiation dose equaling twice that of a 4-view chest. Multiplanar reformatted images may aid in rib fracture detection. In addition, chest CT may detect scapular and spine fractures not evident on skeletal survey.

CT Chest with Contrast

A CT scan of the chest with intravenous (IV) contrast is reserved for children with clinical suspicion of intrathoracic traumatic injury. IV contrast allows for detection of vascular injuries.

CT Abdomen and Pelvis with Contrast

CT of the abdomen and pelvis with IV contrast is utilized for children with suspected intra-abdominal and/or intrapelvic injury. Portal venous phase imaging is most helpful for detecting solid-organ injury. Delayed excretory-phase imaging may be useful in a few selected cases when imaging findings suggest disruption of the genitourinary tract. Noncontrast abdominal CT is not recommended. The need for oral contrast is at the discretion of the radiologist, and its use may be considered when there is concern for duodenal hematoma.

Discussion of Imaging Modalities by Variant

Variant 1: Suspected Physical Abuse. Child ≤24 Months of Age. Neurological or Visceral Injuries Not Clinically Suspected. Initial Imaging Evaluation

X-ray Skeletal Survey

Children <6 months of age with bruising raising the possibility of NAT have a high incidence of additional injuries. Radiographic skeletal surveys are the initial imaging modality of choice as fractures occur in up to 55% of physically abused children. The majority of skeletal surveys that are positive for fractures are performed in children <1 year of age, and 80% of abused children with fractures are <18 months of age. Thus, skeletal survey is recommended in all children <2 years of age in whom there is suspicion of abuse. Eleven percent to 20% of infants undergoing evaluation for abuse have an unsuspected fracture detected by skeletal survey. Fractures that are highly specific for NAT in the normal child include those involving the posterior ribs, classic metaphyseal lesions or epiphyseal separation injuries, and avulsive fractures of the acromion process. Rib fractures may be the only skeletal abnormality in about 30% of physically abused infants.

Highly suggestive skeletal injuries include fractures that are unsuspected or inconsistent with the provided history or age of the child, multiple fractures involving >1 skeletal area, fractures of differing ages, and a combination of skeletal and nonskeletal injuries. In addition, fractures of the radius, ulna, tibia, fibula, or femur that occur in children <1 year of age and midshaft or metaphyseal humeral fractures should be considered suspicious for abuse. The child’s motor developmental level is a key discriminator for abuse in certain fractures. In particular, femoral fractures in a child who is not yet walking and unexplained humeral fractures in children <15 months of age should be considered suspicious for abuse. Multiple fractures in any location without overt trauma are strongly associated with abusive injury. Pediatric contacts of abused children may also need to be screened by skeletal survey, especially twins.

Tc-99m Bone Scan Whole Body

Bone scintigraphy is a complementary/adjunctive examination for detecting bone injuries but is usually not considered an alternative to skeletal survey. It should be used when the radiographic skeletal survey is negative but clinical suspicion remains high and search for further evidence of skeletal trauma is warranted. It may aid by detecting bony injury that is occult, equivocal, or subtle on plain radiographs, but it requires venipuncture and often requires sedation.

CT Head and MRI Head

There are varying opinions on how to image suspected abuse victims who show no evidence suggesting intracranial injury. Although skull radiographs may detect fractures associated with intracranial pathology, they do not provide adequate screening, since significant traumatic intracranial pathology may occur in the absence of skull fractures. Children, especially those <12 months of age, may have significant intracranial injury without signs or symptoms of head injury or retinal hemorrhage. Unenhanced CT of the head is the examination of choice for initial evaluation for intracranial injury in child abuse. MRI is a good choice to image children for abusive head injury in the nonemergent setting.

A study of abused children without clinical suspicion of intracranial injury showed that 11 (29%) of the 51 children had positive neuroimaging including subdural hematoma, epidural hematoma, or cerebral edema; most of them had negative skeletal surveys and no retinal hemorrhage. Eight of the 11 children were <12 months of age. In another prospective study of infants <6 months of age evaluated for possible physical abuse, the presence of apparently isolated bruises (seen in 146 children) at presentation correlated with new injury on neuroimaging in 40 children (27%). In yet another study, 37% of children <2 years of age with high-risk criteria (defined as rib fractures, multiple fractures, facial injury, or <6 months of age) and without overt signs of head injury who underwent head CT or MRI had occult head injury; nearly all with occult head injury were <1 year of age. Intracranial injury is also associated with spinal trauma seen on skeletal survey. Given these studies, clinicians should have a relatively low threshold for performing either CT (emergent setting and more sensitive for detection of nondisplaced fractures) or MRI of the head in children with suspected abuse.

In summary, there is no strong evidence to recommend universal screening with neuroimaging. However, clinicians should have low threshold for performing head CT or MRI in young children with suspected child abuse.

Variant 2: Suspected Physical Abuse. Child >24 Months of Age. Neurological or Visceral Injuries Not Clinically Suspected. Initial Imaging Evaluation

X-ray Area of Interest

Children >2 years of age are often able to verbalize the area(s) of injury or pain during clinical examination. Thus, initial imaging should focus on the areas of clinical concern.

X-ray Skeletal Survey

In children >2 years of age, performance of skeletal survey is usually not done but may be performed based on clinical findings and the need to document the presence or absence of injuries. In this older group of children, skeletal imaging should be strongly considered in a child who has unexplained craniocerebral or abdominal injuries or fractures that are suspicious for abuse. Multiple areas of fracture and unusual fractures should raise one’s suspicion for child abuse; the common accidental fractures in children of this age group are distal humeral and distal radius/ulna after a short fall.

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, but the study requires venipuncture and often requires sedation.

CT Head and MRI Head

Unenhanced CT of the head is the examination of choice for acute evaluation for intracranial injury in child abuse. However, there is no strong evidence to recommend universal screening with neuroimaging in the absence of clinical suspicion for AHT. This is particularly true in older children where the neurological examination is typically more reliable, except for children with chronic disabilities.

MRI is a good choice to image children for abusive head injury in the nonemergent setting. MRI is useful in the detection of small-volume extra-axial hemorrhage and for evolving parenchymal injury. Diffusion-weighted imaging and susceptibility-weighted imaging increase the sensitivity for detection of parenchymal ischemia, diffuse axonal injury, and microhemorrhage. The addition of contrast-enhanced MRI sequences can be utilized in select cases to improve evaluation of extra-axial fluid collections.

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. Fractures occur in up to 55% of physically abused children; 80% of abused children with fractures are <18 months of age. Thus, skeletal survey is recommended in all children <2 years of age in whom there is suspicion of abuse.

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.

CT Head

Although less frequent than skeletal injuries, most child abuse fatalities are the result of head trauma, and head injury due to child abuse is the principal cause of death in children <2 years of age. AHT is responsible for the majority of severe traumatic brain injury in children <2 years of age, with case fatality rates above 20%. Subdural hematoma is the most commonly seen intracranial abnormality (multiple, convexity, interhemispheric, posterior fossa). Additional craniocerebral injuries include cerebral contusion, epidural hematoma, cerebral edema, subarachnoid hemorrhage, and unilateral hypoxic/ischemic injury. Imaging the head in children with suspected abuse depends on the child’s age and type of presentation.

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, an 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, 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. 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. MR venography utilizing unenhanced 2-dimensional time-of-flight technique can be used to assess patency of the dural venous sinuses and deep venous system.

Neuroimaging should not be performed as a screening examination in all children but should be used for further evaluation of all abnormal initial examinations and in cases of clinical suspicion. The clinician should have a relatively low threshold for performing either CT (emergent setting) or MRI of the head (nonemergent setting), especially in children under 1 year of age.

MRI Cervical Spine

MRI of the cervical spine should be strongly considered at the time of MRI brain imaging, as unsuspected spinal injuries may be demonstrated in >36% of cases. Cervical spine injury, particularly at the craniocervical junction, is highly associated with bilateral hypoxic-ischemic injury. Most cervical spine injury detected by MRI in abused infants is ligamentous.

MRI Complete Spine

MRI of the entire spine may show thoracolumbar SDH, most commonly from redistribution of blood products; however, it rarely results in cord compression or alters clinical management. An MRI of the total spine should be reserved for cases where the distinction between abusive and accidental trauma is not clear, since thoracolumbar SDH is more commonly seen with abusive trauma.

Variant 4: Child. Suspected Physical Abuse. Suspected Thoracic or Abdominopelvic Injuries (e.g., Abdominal Skin Bruises, Distension, Tenderness, or Elevated Liver or Pancreatic Enzymes). Initial Imaging Evaluation

X-ray Skeletal Survey

As most children with thoracic or abdominopelvic injury from child abuse have polytrauma, skeletal survey is recommended in all children 24 months of age or younger and should be considered in older children.

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.

CT Head and MRI Head

CT or MRI of the head should also be performed in children with neurologic symptoms or risk factors for intracranial injuries (see Variant 3).

CT of the Abdomen and Pelvis

Nonskeletal injuries to the chest, abdomen, and pelvis can occur as the result of child abuse. Child abuse should be considered in any child with thoracoabdominal injuries that are not consistent with the provided history.

Up to 10% of abused children have intra-abdominal injury; 15% of children aged 0 to 4 years hospitalized for abdominal injury are victims of child abuse. Victims of nonaccidental abdominal trauma tend to be younger and have a more delayed presentation than those who experience accidental trauma. Clinical findings of abdominal pain, abdominal distension, vomiting, abdominal wall bruising, and hypoactive or absent bowel sounds may suggest intra-abdominal injury. Abnormal liver transaminases and pancreatic enzymes may be seen with occult abdominal trauma.

One series suggested that nearly half of abused children with abdominal injury require surgical intervention. In addition, independent of concomitant injury, blunt trauma due to child abuse is associated with a 6-fold increase in odds of death compared to children whose injuries resulted from accidental trauma. Nonskeletal abdominopelvic injuries include pancreatitis, pancreatic pseudocysts, and lacerations and contusions of the liver, adrenal gland, spleen, kidneys, and bowel (especially duodenum). Bowel injuries and pancreatic injuries are seen disproportionately more often in child abuse compared to accidental trauma. Contrast-enhanced CT of the abdomen is indicated in acute evaluation of the child with suspected abdominopelvic injuries. The use of ultrasound in the acute setting is limited, as both focused abdominal scan in trauma and standard abdominopelvic ultrasound are less sensitive than CT in detection of hemoperitoneum and solid-organ injuries. Noncontrast CT of the abdomen is not adequately sensitive in detection of intrathoracic or intra-abdominal trauma. Routine CT scan screening for abdominal or chest injury is not recommended.

CT of the Chest

Injuries to the chest (other than the ribs) are uncommon and include hemopericardium, cardiac contusions and lacerations, pleural effusion, and lung contusions. Contrast-enhanced CT of the chest is indicated in acute evaluation of the child with these types of suspected nonskeletal intrathoracic injury; noncontrast CT of the chest is not adequately sensitive. Routine CT scan screening for chest injury is not recommended.

Variant 5: Child ≤24 Months of Age. High Suspicion for Abuse. Negative Initial Skeletal Survey. Follow-up Imaging Evaluation

X-ray Skeletal Survey

Additional imaging may be useful in children suspected of nonaccidental injury whose initial skeletal survey is negative. A negative initial skeletal survey has a true negative rate of about 90%, so with high clinical suspicion, it is very appropriate to perform further imaging such as follow-up skeletal survey, bone scan, and/or noncontrast low-dose CT of the chest.

In children <24 months of age, a repeat skeletal survey performed approximately 2 weeks after the initial examination can detect fractures not seen on initial skeletal survey, can clarify equivocal findings, and can provide information on the age of child abuse fractures. Nine to 12% of infants have healing fractures on follow-up survey after a negative initial survey, and up to one-third of follow-up surveys yield new information. Half to three-fourths of these newly detected fractures are rib fractures; classic metaphyseal lesions are the second most common. As such, many authors have suggested a more limited follow-up skeletal survey, as described above. However, it is not possible to exactly date fractures by radiography.

Tc-99m Bone Scan Whole Body

In selected cases, when it is not possible to wait 2 weeks for a follow-up skeletal survey radiograph, a bone scan can be considered. Bone scan is sensitive in detecting radiographically occult fractures. It is particularly useful in detection of fractures of the ribs, scapula, spine, and pelvis. It is not sensitive, however, in the detection of skull fractures. Metaphyseal injury may be difficult to see because of the adjacent normal metabolically active physis. Radiation exposure is higher than a skeletal survey. If used in follow-up, radiographs of areas of abnormal uptake should also be performed.

CT Chest

Low-dose noncontrast CT of the chest also offers a time advantage over repeat skeletal survey. It is useful in the detection of rib, scapula, and thoracic spine fractures not seen on skeletal survey. Anterior and posterior rib fractures are detected more often by CT than by skeletal survey. Fractures may also be dated as acute, subacute, or chronic. It would not replace contrast-enhanced chest CT in initial evaluation of nonskeletal thoracic injuries, such as hemopericardium, cardiac contusions and lacerations, pleural effusion, and lung contusions.

CT Head and MRI Head

Follow-up neuroimaging is usually not indicated in the setting of a negative skeletal survey and absence of clinical suspicion of AHT. If there is suspicion for injury after the initial evaluation, neuroimaging should be considered. Noncontrast CT is useful in the evaluation of healing skull fractures, whereas MRI is the method of choice to evaluate the intracranial compartment.

Summary of Recommendations

  • The appropriate imaging of pediatric patients being evaluated for suspected physical abuse depends upon the age of the child, the presence of neurological signs and symptoms, and evidence of visceral thoracic or abdominopelvic injuries.
  • A skeletal survey is indicated in the initial imaging evaluation of a child 24 months of age or younger. In older children, it is usually appropriate to target imaging to the area(s) of suspected injury.
  • Skeletal survey and CT head without contrast are indicated in the emergent/initial imaging evaluation of a child with neurologic signs and symptoms, complex skull fracture, apnea, multiple fractures, spine trauma, or facial injury. These examinations are not indicated for general screening.
  • MRI head may provide additional diagnostic information to head CT in about 25% of children.
  • MRI of the cervical spine should be considered at the time of head MRI, as unsuspected injury (usually ligamentous) may be present in over 33% of children with intracranial injury.
  • Skeletal survey and CT chest/abdomen/pelvis with IV contrast are indicated if there are signs or symptoms of intrathoracic or intra-abdominal visceral injury (abdominal pain/distension/bruising, abnormal liver, or pancreatic enzymes, etc.).
  • In children 24 months of age or younger with equivocal skeletal survey or with a high clinical suspicion for abuse and a negative initial skeletal survey, a repeat limited/focused skeletal survey performed at 2 weeks may add diagnostic information.

Abbreviations

  • CT, computed tomography
  • IV, intravenous
  • MRI, magnetic resonance imaging
  • Tc-99m, technetium-99 metastable

Relative Radiation Level Designations