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From the Archives of the AFIP

Child Abuse: Radiologic-Pathologic Correlation¹

¹ From the Department of Radiologic Pathology, Armed Forces Institute of Pathology, 14th and Alaska Sts NW, Bldg 54, Rm M-121, Washington, DC 20306-6000 (G.J.L.); Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (G.J.L.); Hennepin County Medical Examiner’s Office, Minneapolis, Minn (A.M.B., M.K.M.); and Armed Forces Center for Child Protection, National Naval Medical Center, Bethesda, Md (S.C.B.). Received February 10, 2003; revision requested March 24 and received March 31; accepted April 4. Address correspondence to G.J.L. (e-mail: glonergan@mac.com).

View larger version (71K): [in a new window]   Figure 1.  Violent shaking and squeezing of an infant may result in subdural hemorrhage (top right diagram) and shear-type brain injury, rib fracture (middle right diagram), and metaphyseal fracture (lower right diagram). These injuries are fully described and illustrated in subsequent sections.

View larger version (89K): [in a new window]   Figure 2.  Femoral shaft fracture in an abused 5-year-old boy. Frontal radiograph shows a transverse fracture of the diaphysis in femoral pin traction. The mother’s boyfriend confessed to pushing a television cabinet on top of the boy.

View larger version (49K): [in a new window]   Figure 3.  Diagram depicts the discoid metaphyseal fracture fragment (arrows).

View larger version (121K): [in a new window]   Figure 4a.  Acute CML in a fatally abused 2-month-old child. (a) Specimen radiograph of the proximal left humerus shows the subtle lucency of the CML (arrows). (b) Photomicrograph (unmagnified, hematoxylin-eosin stain) shows disruption of the calcified cartilage cores of the primary spongiosa (arrows). (Case courtesy of Paul K. Kleinman, MD, The Children’s Hospital, Boston, Mass.)

View larger version (137K): [in a new window]   Figure 4b.  Acute CML in a fatally abused 2-month-old child. (a) Specimen radiograph of the proximal left humerus shows the subtle lucency of the CML (arrows). (b) Photomicrograph (unmagnified, hematoxylin-eosin stain) shows disruption of the calcified cartilage cores of the primary spongiosa (arrows). (Case courtesy of Paul K. Kleinman, MD, The Children’s Hospital, Boston, Mass.)

View larger version (154K): [in a new window]   Figure 5a.  Subacute CML in a fatally abused 7-week-old boy. (a) Specimen radiograph of the distal femur (overlying soft tissue removed) shows irregular lucency of the medial femoral metaphysis (arrow). (b) Photograph of the fixed, bivalved femur shows physeal cartilage extension into the metaphysis (arrow). (c) High-power photomicrograph (original magnification, x100; hematoxylin-eosin stain) of the physis reveals hypertrophied chondrocytes (black arrow) growing into the metaphyseal fracture site (white arrows).

View larger version (156K): [in a new window]   Figure 5b.  Subacute CML in a fatally abused 7-week-old boy. (a) Specimen radiograph of the distal femur (overlying soft tissue removed) shows irregular lucency of the medial femoral metaphysis (arrow). (b) Photograph of the fixed, bivalved femur shows physeal cartilage extension into the metaphysis (arrow). (c) High-power photomicrograph (original magnification, x100; hematoxylin-eosin stain) of the physis reveals hypertrophied chondrocytes (black arrow) growing into the metaphyseal fracture site (white arrows).

View larger version (160K): [in a new window]   Figure 5c.  Subacute CML in a fatally abused 7-week-old boy. (a) Specimen radiograph of the distal femur (overlying soft tissue removed) shows irregular lucency of the medial femoral metaphysis (arrow). (b) Photograph of the fixed, bivalved femur shows physeal cartilage extension into the metaphysis (arrow). (c) High-power photomicrograph (original magnification, x100; hematoxylin-eosin stain) of the physis reveals hypertrophied chondrocytes (black arrow) growing into the metaphyseal fracture site (white arrows).

View larger version (166K): [in a new window]   Figure 6a.  CML in an abused 2-month-old girl. (a) Frontal radiograph of the ankle shows a rim of bone (arrow) separated from the tibial shaft by the metaphyseal fracture lucency, giving the appearance of a bucket handle. A CML of the distal fibula is also faintly seen (arrowhead). (b) Lateral radiograph depicts the tibial and fibular fractures as corner fractures (arrows).

View larger version (185K): [in a new window]   Figure 6b.  CML in an abused 2-month-old girl. (a) Frontal radiograph of the ankle shows a rim of bone (arrow) separated from the tibial shaft by the metaphyseal fracture lucency, giving the appearance of a bucket handle. A CML of the distal fibula is also faintly seen (arrowhead). (b) Lateral radiograph depicts the tibial and fibular fractures as corner fractures (arrows).

View larger version (154K): [in a new window]   Figure 7a.  Tibial CML in an abused 10-week-old girl. (a) Frontal radiograph demonstrates a CML, which has a corner fracture appearance (arrowhead). There is subtle periosteal new bone along the medial tibial shaft (arrow). (b) Tc-MDP scan of the lower extremities demonstrates increased uptake along the right tibial shaft (straight arrow) and metaphysis (curved arrow).

View larger version (104K): [in a new window]   Figure 7b.  Tibial CML in an abused 10-week-old girl. (a) Frontal radiograph demonstrates a CML, which has a corner fracture appearance (arrowhead). There is subtle periosteal new bone along the medial tibial shaft (arrow). (b) Tc-MDP scan of the lower extremities demonstrates increased uptake along the right tibial shaft (straight arrow) and metaphysis (curved arrow).

View larger version (80K): [in a new window]   Figure 8.  Rib fracture mechanism in tight squeezing. Diagram of the midthorax during tight squeezing reveals anteroposterior compression, which causes compression and fracture of the ribs laterally (arrow). There is hyperextension of the posterior rib ends over the transverse process, with fracture of the ventral cortex (black arrowhead). Anteriorly, the chest wall compression leads to inward bending of the anterior ribs and fracture (white arrowhead).

View larger version (90K): [in a new window]   Figure 9a.  Acute posterior rib fracture in a fatally abused 7-month-old boy. (a) Autopsy photograph of the ventral surfaces of the right posterior ribs, after the pleura has been removed, clearly shows the acute rib fractures (arrows). (b) Axial specimen radiograph of one of the injured ribs with its vertebral articulations intact shows that the fracture (arrow) is limited to the ventral cortex. (The anomaly of the vertebral arch is an artifact incurred during autopsy resection.) (c) In an axial photomicrograph (unmagnified, hematoxylin-eosin stain) of one of the injured ribs with its vertebral articulations intact, the fracture is clearly visible (arrow), as is the cartilage of the rib head (*) and rib tubercle ().

View larger version (61K): [in a new window]   Figure 9b.  Acute posterior rib fracture in a fatally abused 7-month-old boy. (a) Autopsy photograph of the ventral surfaces of the right posterior ribs, after the pleura has been removed, clearly shows the acute rib fractures (arrows). (b) Axial specimen radiograph of one of the injured ribs with its vertebral articulations intact shows that the fracture (arrow) is limited to the ventral cortex. (The anomaly of the vertebral arch is an artifact incurred during autopsy resection.) (c) In an axial photomicrograph (unmagnified, hematoxylin-eosin stain) of one of the injured ribs with its vertebral articulations intact, the fracture is clearly visible (arrow), as is the cartilage of the rib head (*) and rib tubercle ().

View larger version (83K): [in a new window]   Figure 9c.  Acute posterior rib fracture in a fatally abused 7-month-old boy. (a) Autopsy photograph of the ventral surfaces of the right posterior ribs, after the pleura has been removed, clearly shows the acute rib fractures (arrows). (b) Axial specimen radiograph of one of the injured ribs with its vertebral articulations intact shows that the fracture (arrow) is limited to the ventral cortex. (The anomaly of the vertebral arch is an artifact incurred during autopsy resection.) (c) In an axial photomicrograph (unmagnified, hematoxylin-eosin stain) of one of the injured ribs with its vertebral articulations intact, the fracture is clearly visible (arrow), as is the cartilage of the rib head (*) and rib tubercle ().

View larger version (153K): [in a new window]   Figure 10a.  Acute lateral and healing posterior rib fractures in a fatally smothered 7-week-old boy. (a) Frontal chest radiograph of the deceased infant reveals widening of the posterior right third through eighth ribs (arrows). (b) Magnified view of the lower lateral left chest wall reveals fractures of the lateral left seventh and eighth ribs, without callus (arrows). (c) Specimen radiograph of the anterolateral part of the left eighth rib reveals a fracture of the inner cortex (arrow). (d) Autopsy photograph of the resected chest cage shows the healing posterior rib fractures (arrows), which are subtle but distinctly larger and more bulbous than the contralateral normal posterior ribs. (e) Axial specimen radiograph of the right sixth posterior rib clearly shows the fracture callus (arrow). The vertebral articulations and the contralateral left sixth rib in the specimen are intact. (f) Axial photomicrograph (unmagnified, hematoxylin-eosin stain) of the rib fracture depicted in e shows mineralized callus (arrow).

View larger version (96K): [in a new window]   Figure 10b.  Acute lateral and healing posterior rib fractures in a fatally smothered 7-week-old boy. (a) Frontal chest radiograph of the deceased infant reveals widening of the posterior right third through eighth ribs (arrows). (b) Magnified view of the lower lateral left chest wall reveals fractures of the lateral left seventh and eighth ribs, without callus (arrows). (c) Specimen radiograph of the anterolateral part of the left eighth rib reveals a fracture of the inner cortex (arrow). (d) Autopsy photograph of the resected chest cage shows the healing posterior rib fractures (arrows), which are subtle but distinctly larger and more bulbous than the contralateral normal posterior ribs. (e) Axial specimen radiograph of the right sixth posterior rib clearly shows the fracture callus (arrow). The vertebral articulations and the contralateral left sixth rib in the specimen are intact. (f) Axial photomicrograph (unmagnified, hematoxylin-eosin stain) of the rib fracture depicted in e shows mineralized callus (arrow).

View larger version (45K): [in a new window]   Figure 10c.  Acute lateral and healing posterior rib fractures in a fatally smothered 7-week-old boy. (a) Frontal chest radiograph of the deceased infant reveals widening of the posterior right third through eighth ribs (arrows). (b) Magnified view of the lower lateral left chest wall reveals fractures of the lateral left seventh and eighth ribs, without callus (arrows). (c) Specimen radiograph of the anterolateral part of the left eighth rib reveals a fracture of the inner cortex (arrow). (d) Autopsy photograph of the resected chest cage shows the healing posterior rib fractures (arrows), which are subtle but distinctly larger and more bulbous than the contralateral normal posterior ribs. (e) Axial specimen radiograph of the right sixth posterior rib clearly shows the fracture callus (arrow). The vertebral articulations and the contralateral left sixth rib in the specimen are intact. (f) Axial photomicrograph (unmagnified, hematoxylin-eosin stain) of the rib fracture depicted in e shows mineralized callus (arrow).

View larger version (154K): [in a new window]   Figure 10d.  Acute lateral and healing posterior rib fractures in a fatally smothered 7-week-old boy. (a) Frontal chest radiograph of the deceased infant reveals widening of the posterior right third through eighth ribs (arrows). (b) Magnified view of the lower lateral left chest wall reveals fractures of the lateral left seventh and eighth ribs, without callus (arrows). (c) Specimen radiograph of the anterolateral part of the left eighth rib reveals a fracture of the inner cortex (arrow). (d) Autopsy photograph of the resected chest cage shows the healing posterior rib fractures (arrows), which are subtle but distinctly larger and more bulbous than the contralateral normal posterior ribs. (e) Axial specimen radiograph of the right sixth posterior rib clearly shows the fracture callus (arrow). The vertebral articulations and the contralateral left sixth rib in the specimen are intact. (f) Axial photomicrograph (unmagnified, hematoxylin-eosin stain) of the rib fracture depicted in e shows mineralized callus (arrow).

View larger version (71K): [in a new window]   Figure 10e.  Acute lateral and healing posterior rib fractures in a fatally smothered 7-week-old boy. (a) Frontal chest radiograph of the deceased infant reveals widening of the posterior right third through eighth ribs (arrows). (b) Magnified view of the lower lateral left chest wall reveals fractures of the lateral left seventh and eighth ribs, without callus (arrows). (c) Specimen radiograph of the anterolateral part of the left eighth rib reveals a fracture of the inner cortex (arrow). (d) Autopsy photograph of the resected chest cage shows the healing posterior rib fractures (arrows), which are subtle but distinctly larger and more bulbous than the contralateral normal posterior ribs. (e) Axial specimen radiograph of the right sixth posterior rib clearly shows the fracture callus (arrow). The vertebral articulations and the contralateral left sixth rib in the specimen are intact. (f) Axial photomicrograph (unmagnified, hematoxylin-eosin stain) of the rib fracture depicted in e shows mineralized callus (arrow).

View larger version (80K): [in a new window]   Figure 10f.  Acute lateral and healing posterior rib fractures in a fatally smothered 7-week-old boy. (a) Frontal chest radiograph of the deceased infant reveals widening of the posterior right third through eighth ribs (arrows). (b) Magnified view of the lower lateral left chest wall reveals fractures of the lateral left seventh and eighth ribs, without callus (arrows). (c) Specimen radiograph of the anterolateral part of the left eighth rib reveals a fracture of the inner cortex (arrow). (d) Autopsy photograph of the resected chest cage shows the healing posterior rib fractures (arrows), which are subtle but distinctly larger and more bulbous than the contralateral normal posterior ribs. (e) Axial specimen radiograph of the right sixth posterior rib clearly shows the fracture callus (arrow). The vertebral articulations and the contralateral left sixth rib in the specimen are intact. (f) Axial photomicrograph (unmagnified, hematoxylin-eosin stain) of the rib fracture depicted in e shows mineralized callus (arrow).

View larger version (160K): [in a new window]   Figure 11.  Posterior rib fractures in an abused 3-month-old girl. Frontal chest radiograph reveals fractures without visible callus (white arrows) of the posterior eighth through tenth ribs. The posterior left fourth through seventh ribs are slightly thicker and more opaque than the opposite, normal right posterior ribs, indicating healing posterior rib fractures (black arrows).

View larger version (132K): [in a new window]   Figure 12a.  Increased rib fracture conspicuity over time in an abused 5-month-old boy. (a) Frontal chest radiograph obtained at presentation with seizure reveals right lateral sixth rib fracture with callus (arrow) and possibly fractures of the right lateral fourth, fifth, and seventh ribs. (b) Frontal chest radiograph obtained 2 weeks later depicts healing right lateral fourth through seventh rib fractures (white arrows). New from comparison is callus of the posterior left seventh through tenth ribs (black arrows). Also noted are fractures of the anterior left fourth through sixth ribs (arrowheads).

View larger version (143K): [in a new window]   Figure 12b.  Increased rib fracture conspicuity over time in an abused 5-month-old boy. (a) Frontal chest radiograph obtained at presentation with seizure reveals right lateral sixth rib fracture with callus (arrow) and possibly fractures of the right lateral fourth, fifth, and seventh ribs. (b) Frontal chest radiograph obtained 2 weeks later depicts healing right lateral fourth through seventh rib fractures (white arrows). New from comparison is callus of the posterior left seventh through tenth ribs (black arrows). Also noted are fractures of the anterior left fourth through sixth ribs (arrowheads).

View larger version (117K): [in a new window]   Figure 13a.  Radiographically occult posterior rib fractures detected at bone scintigraphy in an abused 1-month-old boy. (a) Frontal chest radiograph reveals subtle increased width of the posterior sixth and seventh ribs (arrows). (b) Posterior Tc-99m MDP scan obtained the same day demonstrates increased uptake in multiple adjacent posterior left ribs. Incidentally noted is increased uptake of both proximal humeri, determined at skeletal survey to be secondary to a CML of the left proximal humerus (arrowhead) and periostitis of the right proximal humerus (*).

View larger version (140K): [in a new window]   Figure 13b.  Radiographically occult posterior rib fractures detected at bone scintigraphy in an abused 1-month-old boy. (a) Frontal chest radiograph reveals subtle increased width of the posterior sixth and seventh ribs (arrows). (b) Posterior Tc-99m MDP scan obtained the same day demonstrates increased uptake in multiple adjacent posterior left ribs. Incidentally noted is increased uptake of both proximal humeri, determined at skeletal survey to be secondary to a CML of the left proximal humerus (arrowhead) and periostitis of the right proximal humerus (*).

View larger version (141K): [in a new window]   Figure 14a.  Healing posterior rib fracture in an abused 2-month-old girl. (a) Frontal chest radiograph shows focal widening of the posterior left ninth rib (arrow). (b) Axial CT scan of the chest windowed for bone detail shows the posterior rib fracture with callus (arrow).

View larger version (92K): [in a new window]   Figure 14b.  Healing posterior rib fracture in an abused 2-month-old girl. (a) Frontal chest radiograph shows focal widening of the posterior left ninth rib (arrow). (b) Axial CT scan of the chest windowed for bone detail shows the posterior rib fracture with callus (arrow).

View larger version (117K): [in a new window]   Figure 15.  Sacral fracture dislocation in an abused 2-month-old girl. Lateral radiograph depicts a fracture between the fourth and fifth vertebrae, through the intervertebral disk space. The fifth sacral vertebra and coccyx (arrows) are anteriorly displaced. The injury was originally explained as resulting from a changing table fall; the mother’s boyfriend later confessed to slamming the child down in a sitting position.

View larger version (154K): [in a new window]   Figure 16.  Spiral femoral fracture in an abused 3-month-old boy. Lateral radiograph shows a displaced, spiral fracture of the femur.

View larger version (94K): [in a new window]   Figure 17.  Vertebral body compression fracture in a shaken 3-month-old boy. Lateral radiograph of the lower thoracic and upper lumbar spine reveals anterior wedging of the second lumbar vertebra (arrow).

View larger version (148K): [in a new window]   Figure 18a.  Linear parietal skull fracture secondary to abuse. (a) Frontal skull radiograph depicts a linear, right parietal skull fracture (arrow). (b) Lateral TC-MDP scan of the head appears normal.

View larger version (130K): [in a new window]   Figure 18b.  Linear parietal skull fracture secondary to abuse. (a) Frontal skull radiograph depicts a linear, right parietal skull fracture (arrow). (b) Lateral TC-MDP scan of the head appears normal.

View larger version (159K): [in a new window]   Figure 19.  Complex skull fractures in an abused 3-month-old girl. Lateral skull radiograph reveals multiple skull fractures (arrows).

View larger version (87K): [in a new window]   Figure 20.  Subdural hemorrhage. Diagram of a coronal view through the brain depicts blood subjacent to the inner dura mater along the left cerebral convexity and adjacent to the interhemispheric falx.

View larger version (131K): [in a new window]   Figure 21.  Dura from an abused 3-month-old infant who sustained a head injury. Low-power photomicrograph (original magnification, x20; hematoxylin-eosin stain) shows that the subdural membrane (within the brackets) is composed of organizing granulation tissue, indicating prior hemorrhage. The normal dura (*) is at the bottom of the image. Hemosiderin-filled macrophages (arrows) are plentiful.

View larger version (133K): [in a new window]   Figure 22a.  Extraaxial hemorrhage and edema in a fatally abused 3-year-old boy. (a) Axial unenhanced CT scan, obtained through the cerebral hemispheres at the level of the lateral ventricular atria, reveals diffuse left hemispheric edema, manifest as parenchymal low attenuation (*), sulcal effacement, and left lateral ventricular effacement. There is high-attenuation blood in the posterior interhemispheric fissure, extending to the left of the superior sagittal sinus (arrows) and along the left convexity (arrowheads). (b) Axial CT scan obtained at the level of the mesencephalon reveals high-attenuation extraaxial blood along the left tentorium cerebelli (arrow) and left hemispheric edema. (c) Autopsy photograph of the brain (vertex view, with the skull removed, patient’s left on the left) reveals blood in the interhemispheric fissure (arrow), extending as thin layers of SAH and SDH over both convexities, left greater than right.

View larger version (135K): [in a new window]   Figure 22b.  Extraaxial hemorrhage and edema in a fatally abused 3-year-old boy. (a) Axial unenhanced CT scan, obtained through the cerebral hemispheres at the level of the lateral ventricular atria, reveals diffuse left hemispheric edema, manifest as parenchymal low attenuation (*), sulcal effacement, and left lateral ventricular effacement. There is high-attenuation blood in the posterior interhemispheric fissure, extending to the left of the superior sagittal sinus (arrows) and along the left convexity (arrowheads). (b) Axial CT scan obtained at the level of the mesencephalon reveals high-attenuation extraaxial blood along the left tentorium cerebelli (arrow) and left hemispheric edema. (c) Autopsy photograph of the brain (vertex view, with the skull removed, patient’s left on the left) reveals blood in the interhemispheric fissure (arrow), extending as thin layers of SAH and SDH over both convexities, left greater than right.

View larger version (156K): [in a new window]   Figure 22c.  Extraaxial hemorrhage and edema in a fatally abused 3-year-old boy. (a) Axial unenhanced CT scan, obtained through the cerebral hemispheres at the level of the lateral ventricular atria, reveals diffuse left hemispheric edema, manifest as parenchymal low attenuation (*), sulcal effacement, and left lateral ventricular effacement. There is high-attenuation blood in the posterior interhemispheric fissure, extending to the left of the superior sagittal sinus (arrows) and along the left convexity (arrowheads). (b) Axial CT scan obtained at the level of the mesencephalon reveals high-attenuation extraaxial blood along the left tentorium cerebelli (arrow) and left hemispheric edema. (c) Autopsy photograph of the brain (vertex view, with the skull removed, patient’s left on the left) reveals blood in the interhemispheric fissure (arrow), extending as thin layers of SAH and SDH over both convexities, left greater than right.

View larger version (122K): [in a new window]   Figure 23.  Mixed attenuation SDH and cerebral edema in an abused 8-month-old infant. Axial unenhanced CT scan obtained at the level of the lateral ventricles depicts a mixed attenuation SDH along the left convexity (arrows). There is also a thin interhemispheric extraaxial hemorrhage (arrowheads) and left cerebral edema.

View larger version (119K): [in a new window]   Figure 24a.  Multiple SDHs in a head-injured 4-month-old boy. (a) Axial unenhanced CT scan of the brain obtained at the level of the frontal horns reveals subtle increased attenuation of the extraaxial fluid over both convexities (arrows). (b) Coronal MR image (repetition time msec/echo time msec = 9,002/162; inversion time, 2,200 msec) of the brain taken 4 days later reveals intermediate- to high-signal-intensity SDH over the left convexity and high-signal-intensity SDH over the right (white arrows). Both of these fluid collections are brighter than the intraventricular cerebrospinal fluid. Small, high-signal-intensity SDHs are visible in the posterior fossa (arrowheads), and there is high signal intensity in the right hemispheric parenchyma, indicating edema (black arrows).

View larger version (190K): [in a new window]   Figure 24b.  Multiple SDHs in a head-injured 4-month-old boy. (a) Axial unenhanced CT scan of the brain obtained at the level of the frontal horns reveals subtle increased attenuation of the extraaxial fluid over both convexities (arrows). (b) Coronal MR image (repetition time msec/echo time msec = 9,002/162; inversion time, 2,200 msec) of the brain taken 4 days later reveals intermediate- to high-signal-intensity SDH over the left convexity and high-signal-intensity SDH over the right (white arrows). Both of these fluid collections are brighter than the intraventricular cerebrospinal fluid. Small, high-signal-intensity SDHs are visible in the posterior fossa (arrowheads), and there is high signal intensity in the right hemispheric parenchyma, indicating edema (black arrows).

View larger version (151K): [in a new window]   Figure 25a.  SDH in an abused 3-month-old girl. (a) Coronal T2-weighted (2,000/105) MR image reveals a high-signal-intensity SDH over the right convexity, extending into the interhemispheric (parafalcine) region (arrows). (b) Magnified coronal sonogram of the brain vertex obtained with a linear 7.5-MHz transducer shows the echogenic fluid over the right convexity and in the parafalcine subdural space (arrows). The lateral ventricles are filled with anechoic cerebrospinal fluid (*). Normal, prominent subarachnoid cerebrospinal fluid is visible over the left convexity (arrowhead).

View larger version (95K): [in a new window]   Figure 25b.  SDH in an abused 3-month-old girl. (a) Coronal T2-weighted (2,000/105) MR image reveals a high-signal-intensity SDH over the right convexity, extending into the interhemispheric (parafalcine) region (arrows). (b) Magnified coronal sonogram of the brain vertex obtained with a linear 7.5-MHz transducer shows the echogenic fluid over the right convexity and in the parafalcine subdural space (arrows). The lateral ventricles are filled with anechoic cerebrospinal fluid (*). Normal, prominent subarachnoid cerebrospinal fluid is visible over the left convexity (arrowhead).

View larger version (112K): [in a new window]   Figure 26a.  White matter tear in a fatally abused 7-week-old boy. (a) Axial CT scan of the brain shows a fluid-filled cavity in the left frontal white matter, with blood layering posteriorly (arrow). (b) Autopsy photograph of the fixed and sectioned brain shows the collapsed tear (arrow) in the left frontal lobe.

View larger version (155K): [in a new window]   Figure 26b.  White matter tear in a fatally abused 7-week-old boy. (a) Axial CT scan of the brain shows a fluid-filled cavity in the left frontal white matter, with blood layering posteriorly (arrow). (b) Autopsy photograph of the fixed and sectioned brain shows the collapsed tear (arrow) in the left frontal lobe.

View larger version (173K): [in a new window]   Figure 27a.  Axonal spheroids in shear-type NAHI. (a) High-power photomicrograph (original magnification x400; hematoxylin-eosin stain) of the medullary corticospinal tract from a 3-month-old infant reveals axonal injury as axonal enlargements or spheroids (arrows). (b) High-power photomicrograph (original magnification, x400; ßAPP with hematoxylin stain) of a pontine corticospinal tract from a 2-year-old child clearly shows axonal spheroids (arrows).

View larger version (187K): [in a new window]   Figure 27b.  Axonal spheroids in shear-type NAHI. (a) High-power photomicrograph (original magnification x400; hematoxylin-eosin stain) of the medullary corticospinal tract from a 3-month-old infant reveals axonal injury as axonal enlargements or spheroids (arrows). (b) High-power photomicrograph (original magnification, x400; ßAPP with hematoxylin stain) of a pontine corticospinal tract from a 2-year-old child clearly shows axonal spheroids (arrows).

View larger version (136K): [in a new window]   Figure 28a.  Occipital contusion in a fatally abused 2-month-old girl. (a) Axial unenhanced CT scan shows interhemispheric hemorrhage (black arrow) and a small area of high attenuation in the right occipital lobe (white arrow). (b) Axial T1-weighted (600/15) MR image shows areas of high signal intensity in both occipital lobes (black arrows), as well as interhemispheric and left convexity extraaxial hemorrhage (white arrow). (c) T2-weighted (2,200/115) MR image reveals these areas of parenchymal contusion (arrows) as slightly larger than those seen with T1-weighted imaging and of high signal intensity, compatible with hemorrhage and edema. (d) Autopsy photograph of the fixed brain shows the hemorrhagic nature (brown pigmentation) of the right occipital contusion (arrow). Scale is in centimeters.

View larger version (152K): [in a new window]   Figure 28b.  Occipital contusion in a fatally abused 2-month-old girl. (a) Axial unenhanced CT scan shows interhemispheric hemorrhage (black arrow) and a small area of high attenuation in the right occipital lobe (white arrow). (b) Axial T1-weighted (600/15) MR image shows areas of high signal intensity in both occipital lobes (black arrows), as well as interhemispheric and left convexity extraaxial hemorrhage (white arrow). (c) T2-weighted (2,200/115) MR image reveals these areas of parenchymal contusion (arrows) as slightly larger than those seen with T1-weighted imaging and of high signal intensity, compatible with hemorrhage and edema. (d) Autopsy photograph of the fixed brain shows the hemorrhagic nature (brown pigmentation) of the right occipital contusion (arrow). Scale is in centimeters.

View larger version (133K): [in a new window]   Figure 28c.  Occipital contusion in a fatally abused 2-month-old girl. (a) Axial unenhanced CT scan shows interhemispheric hemorrhage (black arrow) and a small area of high attenuation in the right occipital lobe (white arrow). (b) Axial T1-weighted (600/15) MR image shows areas of high signal intensity in both occipital lobes (black arrows), as well as interhemispheric and left convexity extraaxial hemorrhage (white arrow). (c) T2-weighted (2,200/115) MR image reveals these areas of parenchymal contusion (arrows) as slightly larger than those seen with T1-weighted imaging and of high signal intensity, compatible with hemorrhage and edema. (d) Autopsy photograph of the fixed brain shows the hemorrhagic nature (brown pigmentation) of the right occipital contusion (arrow). Scale is in centimeters.

View larger version (142K): [in a new window]   Figure 28d.  Occipital contusion in a fatally abused 2-month-old girl. (a) Axial unenhanced CT scan shows interhemispheric hemorrhage (black arrow) and a small area of high attenuation in the right occipital lobe (white arrow). (b) Axial T1-weighted (600/15) MR image shows areas of high signal intensity in both occipital lobes (black arrows), as well as interhemispheric and left convexity extraaxial hemorrhage (white arrow). (c) T2-weighted (2,200/115) MR image reveals these areas of parenchymal contusion (arrows) as slightly larger than those seen with T1-weighted imaging and of high signal intensity, compatible with hemorrhage and edema. (d) Autopsy photograph of the fixed brain shows the hemorrhagic nature (brown pigmentation) of the right occipital contusion (arrow). Scale is in centimeters.

View larger version (157K): [in a new window]   Figure 29a.  Reversal sign in a 3-month-old boy with abusive head injury. (a) Axial unenhanced CT scan depicts low attenuation, with loss of gray-white matter differentiation, throughout both hemispheres. There is relative high attenuation of the basal ganglia and thalami (white arrows). Also seen is low-attenuation SDH bilaterally (*) and interhemispheric and tentorial hemorrhage (black arrows). (b) Axial unenhanced CT scan obtained 18 days later reveals generalized cerebral atrophy and large bilateral low-attenuation SDH (*), likely enlarged by the rapid atrophy with resultant tension on the bridging veins.

View larger version (152K): [in a new window]   Figure 29b.  Reversal sign in a 3-month-old boy with abusive head injury. (a) Axial unenhanced CT scan depicts low attenuation, with loss of gray-white matter differentiation, throughout both hemispheres. There is relative high attenuation of the basal ganglia and thalami (white arrows). Also seen is low-attenuation SDH bilaterally (*) and interhemispheric and tentorial hemorrhage (black arrows). (b) Axial unenhanced CT scan obtained 18 days later reveals generalized cerebral atrophy and large bilateral low-attenuation SDH (*), likely enlarged by the rapid atrophy with resultant tension on the bridging veins.

View larger version (131K): [in a new window]   Figure 30a.  Diffusion-weighted MR imaging in a 9-month-old girl with abusive head injury. (a) Axial unenhanced CT scan obtained on the day the child presented with seizure shows right hemispheric sulcal effacement, loss of gray-white matter differentiation, and a thin rim of extraaxial blood along the right convexity and in the interhemispheric region (arrows). (b) Axial T1-weighted (516/12) MR image obtained the same day as the CT scan reveals low signal intensity of the right temporal and occipital lobes (white arrows) and high-signal-intensity SDH over the convexities, in the posterior interhemispheric region, and in the tentorial incisura (black arrows). (c) Axial T2-weighted (3,200/99) MR image at the same level and from the same day reveals increased signal intensity of the right temporal and occipital lobes (black arrows) and high-signal-intensity SDH over the convexities bilaterally (white arrows). (d) Diffusion-weighted (9,999/96) MR image obtained the same day reveals marked elevated signal intensity throughout the right hemisphere compatible with restricted free water diffusion.

View larger version (155K): [in a new window]   Figure 30b.  Diffusion-weighted MR imaging in a 9-month-old girl with abusive head injury. (a) Axial unenhanced CT scan obtained on the day the child presented with seizure shows right hemispheric sulcal effacement, loss of gray-white matter differentiation, and a thin rim of extraaxial blood along the right convexity and in the interhemispheric region (arrows). (b) Axial T1-weighted (516/12) MR image obtained the same day as the CT scan reveals low signal intensity of the right temporal and occipital lobes (white arrows) and high-signal-intensity SDH over the convexities, in the posterior interhemispheric region, and in the tentorial incisura (black arrows). (c) Axial T2-weighted (3,200/99) MR image at the same level and from the same day reveals increased signal intensity of the right temporal and occipital lobes (black arrows) and high-signal-intensity SDH over the convexities bilaterally (white arrows). (d) Diffusion-weighted (9,999/96) MR image obtained the same day reveals marked elevated signal intensity throughout the right hemisphere compatible with restricted free water diffusion.

View larger version (153K): [in a new window]   Figure 30c.  Diffusion-weighted MR imaging in a 9-month-old girl with abusive head injury. (a) Axial unenhanced CT scan obtained on the day the child presented with seizure shows right hemispheric sulcal effacement, loss of gray-white matter differentiation, and a thin rim of extraaxial blood along the right convexity and in the interhemispheric region (arrows). (b) Axial T1-weighted (516/12) MR image obtained the same day as the CT scan reveals low signal intensity of the right temporal and occipital lobes (white arrows) and high-signal-intensity SDH over the convexities, in the posterior interhemispheric region, and in the tentorial incisura (black arrows). (c) Axial T2-weighted (3,200/99) MR image at the same level and from the same day reveals increased signal intensity of the right temporal and occipital lobes (black arrows) and high-signal-intensity SDH over the convexities bilaterally (white arrows). (d) Diffusion-weighted (9,999/96) MR image obtained the same day reveals marked elevated signal intensity throughout the right hemisphere compatible with restricted free water diffusion.

View larger version (142K): [in a new window]   Figure 30d.  Diffusion-weighted MR imaging in a 9-month-old girl with abusive head injury. (a) Axial unenhanced CT scan obtained on the day the child presented with seizure shows right hemispheric sulcal effacement, loss of gray-white matter differentiation, and a thin rim of extraaxial blood along the right convexity and in the interhemispheric region (arrows). (b) Axial T1-weighted (516/12) MR image obtained the same day as the CT scan reveals low signal intensity of the right temporal and occipital lobes (white arrows) and high-signal-intensity SDH over the convexities, in the posterior interhemispheric region, and in the tentorial incisura (black arrows). (c) Axial T2-weighted (3,200/99) MR image at the same level and from the same day reveals increased signal intensity of the right temporal and occipital lobes (black arrows) and high-signal-intensity SDH over the convexities bilaterally (white arrows). (d) Diffusion-weighted (9,999/96) MR image obtained the same day reveals marked elevated signal intensity throughout the right hemisphere compatible with restricted free water diffusion.

View larger version (155K): [in a new window]   Figure 31.  Bowel injury and perforation in an 18-month-old boy who was beaten. Axial CT scan through the midabdomen, obtained after oral and intravenous administration of contrast material, demonstrates ascites (*), free intraperitoneal air (arrow), and thick-walled bowel (arrowhead).

View larger version (128K): [in a new window]   Figure 32.  Duodenal hematoma in a 6-year-old boy who was beaten by a caretaker. Image from a barium study of the stomach and duodenum reveals a mass (arrow) in the lateral wall of the descending duodenum.

View larger version (111K): [in a new window]   Figure 33.  Pancreatic laceration in a 2-year-old girl who was beaten by a caretaker. Axial CT scan of the upper abdomen, obtained after intravenous administration of contrast material, reveals a linear defect (arrow) in the ventral body of the pancreas and generalized abdominal and retroperitoneal ascites.

View larger version (116K): [in a new window]   Figure 34a.  Liver lacerations in abused children. (a) Axial CT scan of the liver, obtained with intravenous contrast material, in an abused 14-month-old boy demonstrates a large irregular area of low attenuation in the right lobe of the liver, representing a liver laceration. (b) Photograph of an axially sectioned liver from a fatally abused 8-month-old boy shows a large central laceration (arrows).

View larger version (94K): [in a new window]   Figure 34b.  Liver lacerations in abused children. (a) Axial CT scan of the liver, obtained with intravenous contrast material, in an abused 14-month-old boy demonstrates a large irregular area of low attenuation in the right lobe of the liver, representing a liver laceration. (b) Photograph of an axially sectioned liver from a fatally abused 8-month-old boy shows a large central laceration (arrows).