This case is described of an eleven-month-old infant with lower limbs swelling and the left elbow skeletal malformation following a fall. The radionuclide bone scan was performed to exclude bone infection or congenital skeletal anomaly. The images unexpectedly showed multiple increased radioactive foci throughout the whole body. It was a strong probability of child abuse. All lesions are readily apparent on the following plain film radiographs and MRI.
The battered child syndrome consists of a constellation of signs that may be either apparent or covert. Many patterns of injury have been described in the child abuse syndrome. Bone scintigraphy is a valuable imaging modality in the examination of the battered child. It is often used to evaluate skeletal trauma and identify fractures which previously would have been ignored [
An eleven-month-old infant weighted 1780 g with a premature birth age of 34 weeks was in the intensive care for seizure attack, aspiration pneumonia, and subdural and subarachnoid hemorrhage. He developed progressive lower limbs swelling and his left elbow skeletal malformation following a fall. To protect the privacy of our patients, their full transcripts are not openly available. The radionuclide bone scan with 185 MBq (5 mCi) Tc-99m MDP was performed for an evaluation of suspicious malunion fracture, bone infection, or preexisting medical conditions because metabolic disorders and bone diseases may make a child’s bones more vulnerable to fracture [
Bone scan: multiple increased radioactive foci throughout the whole body (arrows) were accidentally found. There was a strong probability of child abuse.
X-ray: a series of plain film radiographs demonstrated calvarial fracture lines at left temporoparietal region, bony anomaly of the spine, multiple old fractures with callus formation involving posterior aspect of left 10, 11th ribs, right proximal humerus, bilateral proximal femurs, and metaphyses of tibias (arrows). Adjacent soft tissue swelling is evident. The above findings were consistent with child abuse.
Adjacent soft tissue swelling was evident. The above findings were also consistent with child abuse. Radiographic skeletal survey and radionuclide images are complementary procedures for diagnosis and documenting this type of injury (Figure
MRI of both lower legs: the T2-weighted coronal images show metaphyseal fractures involving distal left femur and proximal bilateral tibias with extensive periosteal hemorrhage or edema, favored child abuse.
X-ray: the previous multiple bony fractures with callus formation are not prominent on the following plain film radiograph 6 months later.
The estimated incidence of reported child abuse has increased from 3% in 1985 to 4.5% in 1992 [
Bone scintigraphy is a valuable imaging modality in the examination of these young children, especially in detecting injury in ribs, costovertebral junctions, hands, feet, spine, and diaphyses of long bones [
The combination of bone scan and X-ray with experienced hands can reduce the false-negative rate from 12.3% to 0.8%. Although the bone scan may be positive as early as 7 hours after injury, the child is usually brought to a hospital so late that the bone healing has begun [
The image modalities play a key role in the investigation and documentation of the battered child syndrome. The primary diagnostic imaging study in suspected child abuse is either a bone scan and X-ray series or a complete radiographic skeletal survey by X-ray series in babies and infants [
The authors declare they have no conflicts of interest in publishing this case study.
Ya-Wen Chuang and Chin-Chuan Chang contributed equally to this work.
This work was supported by the Ministry of Science and Technology (Research Grants MOST 103-2320-B-037-025), Kaohsiung Medical University (KMU-TP105E12, KMU-TP105PR06, KMU-M106029, 105KMUOR02, and KMU-O104003), and NSYSU-KMU Research Project, Taiwan (NSYSUKMU106-P011).