THERE are few situations as heart-rending as child abuse. Children may be abused physically, sexually or emotionally. The problem of child abuse is an international one that thrives when good people ignore the signs that are often all around us.

In Jamaica, a survey commissioned by the Office of the Children’s Registry (OCR) and United Nations Children’s Fund (UNICEF) in 2014 revealed that only one in 10 Jamaicans report abuse, despite having knowledge of it. The survey found that while 76 per cent of professionals who work closely with children have reported cases of abuse, only 30 per cent of children and 11 per cent of adults interviewed have ever made reports. This is despite the fact that most of the people surveyed claimed to have either experienced abuse, or knew of a child who has been abused in the past three months.

The radiologist plays a crucial role in documenting serious cases of known physical child abuse. There are also circumstances where a radiologist can help to expose previously hidden cases of child physical abuse based on unique radiological findings. As with other complex medical issues, collaboration between all the doctors involved is of vital importance. Knowing the social history of a child, the developmental history and the delay involved in seeking medical attention are all pieces of the puzzle which show the picture of child abuse when combined.

SKELETAL INJURY

Skeletal injury is the most common abuse-related injury (excluding pure soft tissue injuries such as bruising).

Virtually every type and location of fracture has been documented in abused children; however, children less than 18 months of age sustain unusual injuries because of their immature skeletons and unique mechanisms of injury. Metaphyseal and rib fractures, when found in infants, are highly specific for abuse.

METAPHYSEAL FRACTURE

Metaphyseal fractures are virtually specific for abuse. The term classic metaphyseal lesion (CML) was coined to describe a series of microfractures across the metaphysis, which is a part of the bone close to the growth plate. The growth plates are often found near the ends of long bones.

CMLs commonly occur near the knee (end of the femur or beginning of the tibia), near the ankle (end of the tibia) or near the shoulder (beginning of the humerus). They are seen almost exclusively in children less than two years old. The orientation of the fractures perpendicular to the long axis of the bone reveals that the mechanism is a shearing injury across the bone end.

Holding and shaking an infant by the hands or feet or shaking the infant while he is held around the chest with the limbs, whiplashing back and forth, produces this injury.

RIB FRACTURES

Rib fractures occur in older children and adults as a result of trauma, such as falls and motor vehicle accidents. In infants without metabolic bone disease, however, these injuries are non-accidental.

The young child’s skeleton deforms rather than breaks when subjected to trauma, until a threshold is reached. Rib fractures in infants are highly specific for abuse because the mechanism that causes the fracture is relatively specific. A very tight hold around the chest by adult hands may result in fractures of the anterior, lateral and posterior aspects of the rib. Fractures of the first rib are considered virtually diagnostic of abuse. In rare cases, rib fractures may be produced by birth trauma.

Fractures in the acute setting may be difficult to see on X-rays therefore, follow up X-rays several weeks after the incident are important because healing fractures are more visible.

CENTRAL NERVOUS SYSTEM

In children under one-year-old, 95 per cent of all serious head injury and 64 per cent of all head injuries result from abuse. The outcome of infants suffering non-accidental head injury is worse than for those of the same age who have sustained accidental injury. Mental retardation and disability are common in those children who survive.

INTERHEMISPHERIC EXTRA AXIAL HAEMORRHAGE

Subdural haemorrhage (SDH) and subarachnoid haemorrhage (SAH) are common abusive injuries. They refer to bleeding in spaces below different membranes that cover the brain.

Neither is specific for abuse, since SDH may result from birth and SAH may occur from accidental injury.

Both types of bleeds occur because veins in the brain that travel across the subdural and subarachnoid spaces are subjected to a shearing force. In child abuse, violent shaking of the child causes a to and fro head motion which tears the midline veins. Computed tomography (CT) scan usually detects SAH and SDH in the emergency setting.

VISCERAL INJURIES

The most commonly injured abdominal organ in child abuse is the small bowel.

Bleeding, tears, blood vessel injury and post-traumatic narrowing have all been reported. The duodenum and jejunum, because of their rich blood supply and relatively fixed position, are most commonly injured. Plain X-rays, barium studies, ultrasound, and CT are all used to diagnose the sequelae of abdominal trauma.

Any bone or organ may be injured by child abuse. The examples above represent the most specific injuries related to child abuse, particularly in the infant. A team approach is required to combat this tragedy. We are all responsible for taking care of the most vulnerable among us. Every responsible citizen should do his or her part to be the other’s keeper.

Dr Duane Chambers is a consultant radiologist and founding partner of Imaging and Intervention Associates located at shops 58 and 59 Kingston Mall, 8 Ocean Boulevard. He may be contacted through the office numbers 618-4346 or 967-7748.