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Question 10 - Battered Child Syndrome (Non-Accidental Injury / NAI)
Diagnosis
This is a classic case of Battered Child Syndrome (also called Non-Accidental Injury / NAI, Shaken Baby Syndrome, or Inflicted Injury).
The key red flags in this scenario are:
- An infant brought by his mother (caregiver)
- Lacerated injury to the right shoulder
- Multiple injuries in different parts of the body
- An inadequate or implausible explanation - the mother's account does not match the pattern
Battered Child Syndrome was first described by Kempe et al. in 1962, who defined it as "inadequately explained injuries" in children at the hands of their caregiver(s). Infants and young children are at greatest risk - up to 80% of cases involve children under 5 years of age, and up to 50% involve infants under 1 year.
- Grainger & Allison's Diagnostic Radiology, p.1933
- Miller's Review of Orthopaedics 9th Ed, p.930
What Investigations / Workup to Order ("What will you get from it?")
A full skeletal survey is the cornerstone investigation:
| Investigation | Purpose |
|---|---|
| Skeletal survey (whole-body X-ray series) | Reveals fractures in multiple sites at different stages of healing |
| CT head | Detect subdural haematoma, retinal haemorrhage, cerebral oedema (Abusive Head Trauma is the #1 NAI cause of death) |
| MRI brain | More sensitive for diffuse axonal injury, SDH, cord oedema |
| Ophthalmology (fundoscopy) | Retinal haemorrhages - hallmark of shaken baby syndrome |
| Full blood count, coagulation screen | Rule out bleeding disorder (important differential) |
| Bone profile, Vitamin D, alkaline phosphatase | Rule out rickets, metabolic bone disease |
| Social work assessment + paediatric review | Mandatory; all states/jurisdictions require reporting of suspected abuse |
| Photography of all external injuries | Medico-legal documentation |
Fracture Dating - How to Differentiate "Injuries of Different Ages"
This is the KEY forensic tool for proving repeated abuse. Radiological dating of fractures uses the following staging:
| Stage | Radiological Feature | Approximate Timeframe |
|---|---|---|
| Acute | Soft-tissue swelling only | < 1 week |
| Recent | Periosteal reaction begins | 4 days - 2 weeks (present in >50% by 2 weeks) |
| Recent-subacute | Soft callus formation | 8-35 days |
| Old/Healing | Hard callus, bridging | ≥36 days |
| Remote | Remodelling | Peaks at 8 weeks; may persist >1 year |
So on a single skeletal survey, finding fractures with periosteal reaction but no callus (recent, days old) alongside fractures with hard callus or remodelling (weeks-months old) in different bones proves that the injuries occurred at different times, making accidental single-event trauma impossible - and strongly indicating repeated abuse.
- Grainger & Allison's Diagnostic Radiology, p.1941
Fracture Patterns Most Suspicious for Abuse
The following fracture patterns should immediately raise concern:
- Corner (bucket-handle) fractures at the metaphysis - considered pathognomonic for abuse (caused by gripping/yanking limbs)
- Posterior rib fractures - pathognomonic; result from squeezing the thorax
- Spiral humeral fractures and distal humeral physeal separations - highly suggestive
- Spiral femoral fractures in a non-ambulatory child
- Fractures in children <1 year - abuse accounts for 50% of all fractures in this age group
Differential Diagnoses to Rule Out
| Condition | Distinguishing Feature |
|---|---|
| Accidental trauma | Single injury, plausible history, single time point |
| Birth trauma | Affects clavicle/femur/humerus; absence of callus >11 days after birth excludes it |
| Osteogenesis imperfecta | Blue sclerae, family history, abnormal bone density, genetic testing |
| Rickets / metabolic bone disease | Low Vit D, low phosphate, cupped/frayed metaphyses on X-ray |
| Copper deficiency (Menkes syndrome) | Metaphyseal changes + neurological features |
Medicolegal Obligation
All clinicians are mandated reporters. If this child is not diagnosed and reported, there is a 30-50% chance of repeat abuse and a 5-10% chance of death from subsequent injury. Immediate referral to child protection services and involvement of a paediatric radiologist experienced in NAI is required.
- Miller's Review of Orthopaedics 9th Ed, p.930
- Grainger & Allison's Diagnostic Radiology, p.1934-1935
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