1. Skeletal survey. Radiographs of the entire skeleton, including views of chest, skull, spine, pelvis, and extremities, should be obtained to look for occult fractures in all children younger than 2 years of age with suspected physical abuse. A single x-ray of the entire body ("babygram") is not adequate. X-rays should be the primary screening test for skeletal trauma. Routine skeletal x-rays in children older than 2 years are considered on a caseto-case basis.
a. Fractures highly associated with abuse include rib fractures, metaphyseal "corner" or bucket-handle fractures, and fractures of sternum, scapula, or vertebral spinous processes.
b. Suspicious fractures include multiple fractures, especially when bilateral or at different stages of healing, and complex skull fractures.
c. Any fracture in a nonambulatory infant and all fractures when there is no history of trauma or the history is inconsistent with the injury should raise concerns of abuse.
d. Repeat skeletal survey is often recommended 2 weeks after initial x-rays to help identify healing fractures that may not have been seen on initial films.
2. Nuclear medicine bone scan. Can pick up minor fractures before they are seen on x-rays and may remain positive after complete healing is seen on x-rays. Not useful for diagnosis of acute skull fractures or acute metaphyseal fractures of long bones. Should not be primary screening test for skeletal trauma.
3. CT scan of head. The primary screening test for acute inflicted head trauma. Essential for evaluation of children with suspected head trauma but should be considered in all young infants with any signs of inflicted injury.
a. Subdural hematomas with or without skull fractures and associated with bilateral retinal hemorrhages are classic findings for inflicted head trauma.
b. Subarachnoid hemorrhages, brain contusions, and focal or diffuse brain edema may be seen in some cases of inflicted head injury.
4. MRI scan of head. Useful in delineating small subdural hematomas and lesions of brain parenchyma.
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