conclusive in all cases. Therefore, imaging techniquesincluding MRI were performed. The latter revealed therelevant findings for making the diagnosis of child abusein each case.
Case 1
A 3-week-old male newborn was admitted because hehad stopped moving his left arm after his father hadattempted to place him in a cloth designed for carryingbabies. His parents reported that for a moment, thefather had held his son solely in the left shoulder region.Clinically, the boy showed a paresis of the left armincluding the shoulder, elbow, and wrist. Movement ofthe fingers was unimpaired. The clinical diagnosis of aparesis of the upper neural brachial plexus was made.Otherwise, the examination finding was unremarkable.Laboratory analysis results including alkaline phosphataseand creatinine kinase were normal. There were no signs of aninfection. The radiograph finding of the left arm was normal;another radiograph of the thorax revealed a widened spacebetween the head of the humerus and the fossa glenoidalis,suggesting subluxation of the left shoulder (Figure 1A).Sonography results of the head, abdomen, and shoulderwere unremarkable, except for the presence of minor extrafluid in the shoulder joint. MRI revealed a significantedema located near the upper humerus in addition to an elevation of the periosteum from the cortical bone(Figure 1B, C). There were additional elevated signalintensities located in several ribs of the anterior chest, alllocated close to the sternum. The diagnosis of significanttraumatic lesions affecting the left shoulder and upperarm in addition to the anterior thorax was made. After 1week of follow-up, clinical symptoms resolved withoutremnants. After 4 weeks, the clinical status of the childwas still unremarkable.
In early childhood, clinical symptoms such as impairedmovements of extremities, joint or bone pain, andswelling of the extremities lead to a variety of differential
diagnoses. At first, traumatic causes have to be considered inaddition to inflammatory or malignant diseases. Physiciansneed to be aware that injuries in childhood possibly can becaused by child abuse. Regularly, the history in such casesis difficult to explore. Significant information about how thetrauma has happened is not reported by the parents. Thus,clinical examination is of major importance. However,sometimes it does not give important clues. Children whohave suffered from child abuse usually do not report thetrauma directly. Therefore, additional diagnostic methodshave to be performed to get a clear diagnostic picture.Magnetic resonance imaging (MRI) in this regard has majoradvantages. MRI can document bone and soft tissue lesions,whereas radiographs in early phases of bone trauma mightnot reveal relevant findings.1-3 In addition, forensic docu-mentation using imaging techniques including MRI can beof significant importance. In contrast to MRI, ultrasoundimaging does not evaluate bone tissue but may give addi-tional insights into soft tissue and periosteal disease.
Case Reports
We report on 4 children, all of whom presented with pain,limping, and swelling of their extremities. History was not
Original Article
Magnetic Resonance Imagingin Child AbuseThomas Eltermann, MD, Meinrad Beer, MD, and Hermann J. Girschick, MD
Magnetic resonance imaging is a particularly importantdiagnostic method when bone and soft tissue lesions ofinflammatory or malignant origin need to be analyzed.Traumatic lesions often are evaluated using standard radi-ographs or computed tomography. Both of these methodsevaluate fractures appropriately; however, bone bruise, bonebending, and soft tissue lesions might be underestimated.
Especially in the evaluation of suspected child abuse, mag-netic resonance imaging can contribute significantly tomaking the diagnosis, especially when the reported historyis not conclusive.
Keywords: magnetic resonance imaging; child abuse; mus-culoskeletal system
From the Children’s Hospital (TE, HJG) and the Section of PediatricRadiology, Department of Radiology (MB), University of Wuerzburg,Wuerzburg, Germany.
Address correspondence to: Hermann J. Girschick, MD, Children’s Hospital,University of Wuerzburg, Josef-Schneider-Str 2, 97090 Wuerzburg,Germany; e-mail: [email protected].
Eltermann T, Beer M, Girschick HJ. Magnetic resonance imaging inchild abuse. J Child Neurol. 2007;22:170-175.
Magnetic Resonance Imaging in Child Abuse / Eltermann et al 171
Case 2
A 6-week-old male infant was admitted because his parentshad noticed painful movement of the left leg that had per-sisted for 3 days. The parents reported that while lying in astroller and kicking with his legs, the boy had squeezed hisleft leg between the stroller’s handle and a metal bar. Therewas significant swelling of the left upper leg with a painfulflexed position. Mobility of the left foot and toes was withoutlimitations. Further examination findings were unremark-able. Laboratory analysis including creatinine kinase andalkaline phosphatase showed normal values. There were nosigns of an infection. The radiograph finding of the left femurwas unremarkable, as were radiograph results of the cra-nium, thorax, and extremities. However, MRI revealed an elevated T2 signal of the left femur with an elevation of the periosteum (Figure 2A). A marked lesion of the sur-rounding soft tissue was noted, which showed a significantsignal enhancement after gadolinium diethylenetriaminepen-taacetic acid. These results were consistent with a significanttraumatic injury of the femur. The minor trauma reported bythe parents did not seem to be appropriate for such a lesion.Fourteen days later, another radiograph of the left femur wasperformed. At this time, an elevation of the periosteum waspresent (Figure 2B). In consideration of the clinical pictureplus diagnostic imaging studies, abuse had to be considered.However, the course of events leading to the described lesionremained unclear. After 7 days, swelling and impairment ofmovement gradually declined. Four weeks later, a follow-upvisit revealed an unremarkable condition.
Case 3
A 1-year-old boy was admitted because he refused towalk. His parents reported that limping started after a 7-year-old relative had taken him out of a wheelbarrow.Walking was painful, and movement of his right leg wasimpaired in a flexion contracture. Clinically, swelling ofthe right leg was apparent. There were no skin lesions.The patient’s body temperature was slightly elevated(38°C). Laboratory analysis showed leukocytosis (whiteblood cell count of 13 090/µL) and thrombocytosis (plateletcount of 536 000/µL). Markers for bone and muscularlesions including creatinine kinase and alkaline phos-phatase, in addition to inflammatory parameters, wereunremarkable. A radiograph result of the right lower limbwas unremarkable. An MRI scan showed a bone lesionwith intraosseous edema. The surrounding soft tissue ofthe right tibia was also affected. These findings wereinterpreted to be consistent with osteomyelitis or trauma(Figure 3A). A bone scan showed an increased uptake oftechnetium in the right metaphyseal tibia consistent withosteomyelitis or trauma (Figure 3B). Another radiographof the right leg was made 14 days later, which showed aperiosteal elevation of the bone, suggesting a traumaticcause of the lesion (Figure 3C). Therefore, the parentsagain were confronted with the recent diagnostic find-
Figure 1. Imaging studies of patient 1. A 3-week-old male newbornhad stopped moving his left arm after his father had attempted to placehim in a cloth designed for carrying babies. The parents reported that fora short period of time, the father had held his son solely in the left shoul-der region. Clinically, the diagnosis of a paresis of the upper brachialplexus was made. Conventional radiograph (A) revealed a widened spacebetween the humerus and the fossa glenoidalis (arrow). A gadoliniumcontrast dye-enhanced T1-weighted magnetic resonance image showedsignificant gadolinium uptake around the upper humerus (B, arrow). Inaddition, a T2-weighted magnetic resonance image using fat suppressiontechnique (TIRM/STIR) revealed edema around the upper humerus andan elevation of the periosteum (arrow) from the cortical bone (C).
172 Journal of Child Neurology / Vol. 22, No. 2, February 2007
Figure 2. Imaging studies of patient 2. A 6-week-old male infant was admitted because his parents had noticed painful movement of his left leg.The boy showed significant swelling of the left upper leg with a painful flexed position. A T2-weighted magnetic resonance image using fat suppres-sion technique (TIRM/STIR) revealed a significant edema (arrow) located around the femur in addition to an elevation of the periosteum (A).Fourteen days later, the radiograph of the left femur revealed an elevation of the periosteum (B, arrow).
Magnetic Resonance Imaging in Child Abuse / Eltermann et al 173
ings. The father then admitted that he had slipped andfallen to the ground while holding his child in his arms.He stated that during this accident, he had roughlygripped the boy’s right leg. One month after the patient’sdischarge, the movement of his leg was normal.
Case 4
A 6-week-old boy was admitted because his parents hadnoted a swelling of his right lower leg that had persistedfor 3 days. Clinically, swelling of the right calf, right ankle
joint, and right foot were noted. The motion of the rightknee joint was limited and painful. Laboratory analysisresults were normal. A radiograph finding at admissionwas normal. MRI showed massive edema of almost all legmuscles. The tibia and fibula showed bone edema (Figure4A-D). A traumatic lesion was considered, but the parentsdenied several times that a trauma had occurred. Inflam-matory parameter results were repetitively negative. Noinfectious agent could be isolated from the blood culture.A biopsy was planned to further clarify the lesion but wasrefused by the parents. Finally, a presumptive diagnosis ofmyositis plus osteomyelitis was made, and an intravenousantibiotic therapy was administered for 3 weeks. After 6weeks, the boy was discharged in an unremarkable condi-tion. Three months later, the boy was admitted to anotherhospital suffering from intracranial bleeding, from whichhe did not survive. At this time, the parents admitted thatthey had beaten the child. The radiograph of the leg wasthen repeated, and it showed a periosteal elevation in theright femur and tibia. Thus, the initial diagnosis of a pre-sumed bacterial osteomyelitis was revised to batteredchild.
Discussion
All described children had swelling, pain, or limitedmovement of a limb on clinical examination. The parents’history in each case was misguiding. Initial radiographand laboratory analysis were not conclusive at all. In con-trast, MRI documented a significant trauma in eachchild. Therefore, child abuse had to be suspected.
Characteristic signs in diagnostic imaging such as sub-dural hematoma, brain contusion, and multiple skeletalinjuries, in part of different age, can uncover childabuse.4 For the assessment of conventional radiograph,knowledge about radiological symptoms in addition todevelopmental variants in childhood is necessary.5 Ifresults are inconclusive, further imaging techniquesincluding MRI have been suggested.6 Oestreich1 reportedon the broad spectrum of diseases in childhood, in whichMRI is helpful. MRI is advantageous in the assessmentof muscular or soft tissue lesions.1 However, in an emer-gency situation, the availability of MRI might be limited.Furthermore, in the very young child, it requires seda-tion. In addition, the duration of this diagnostic proce-dure is significant.7 The differential diagnosis of childabuse lesions seen in MRI includes inflammatoryprocesses such as osteomyelitis, tumor, and trauma. Softtissue lesions documented by MRI sometimes appearmore impressive than suspected by the clinical examina-tion. Previously, the role of MRI in diagnosing intracra-nial lesions in shaken baby syndrome has beendocumented.8-10 However, the role of MRI in document-ing lesions of the extremities and the trunk resultingfrom abuse has not been elucidated in detail. Thus, the
Figure 3. Imaging studies of patient 3. A 1-year-old boy was admittedbecause he refused to walk. The parents reported that limping startedafter a 7-year-old relative had taken him out of a wheelbarrow. Walkingwas painful, and movement of his right leg was impaired in a flexioncontracture. Clinically, there was apparent swelling of the right leg. AT2-weighted magnetic resonance image using fat suppression technique(TIRM/STIR) revealed a significant edema (A, arrow) located inside andaround the tibia in addition to an elevation of the periosteum. A bonescan showed an increased uptake of technetium in the right metaphy-seal tibia (B, arrow). Fourteen days later, the radiograph of the tibiarevealed an elevation of the periosteum (C, arrow).
174 Journal of Child Neurology / Vol. 22, No. 2, February 2007
radiologist’s knowledge of the type of lesions documentedby MRI might be limited. Misdiagnosis prevents the instal-lation of protective measures to avoid future life-threatening
abuse. Careful investigations including MRI can be thebasis for further diagnostic procedures and eventuallylegal measures.11
Figure 4. Imaging studies of patient 4. A 6-week-old boy was admitted because his parents had noted swelling of his right lower leg that persisted for 3days. Clinically, swelling of the right calf, right ankle joint, and right foot were noted. The motion of the right knee joint was limited and painful. A T1-weighted magnetic resonance image (A) did not reveal relevant anatomical changes; however, a gadolinium-enhanced T1-weighted magnetic resonanceimage showed a significant gadolinium uptake of the periosteum and especially of the calf muscles (B, arrow). A T2-weighted magnetic resonance imageusing fat suppression technique (TIRM/STIR) revealed a significant edema located in the muscles and subcutaneous tissue around the femur and tibia (C, D; arrow). (D) This panel (TIRM/STIR) shows the whole extent of the lesion affecting the leg almost completely. The arrow points to the calf muscles.
Magnetic Resonance Imaging in Child Abuse / Eltermann et al 175
Conclusion
MRI is an important tool to uncover even limited traumaticlesions resulting from child abuse. In addition, MRI canreveal the full dimension of the lesions, which might beunderestimated clinically. Other diagnostic imaging tools,especially radiographs and bone scan, are not as sensitiveas MRI. It is important that both the radiologist and thephysician are aware of characteristic MRI findings.
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