Radiologic Contributions to the Investigation and Prosecution of Cases of Fatal Infant Abuse

In 1984 we started a two-year program in Worcester (Mass.) and Boston to provide additional radiologic data for the medical investigation of suspected fatal infant abuse. During that period the investigation of 12 cases of unexplained infant death included the review of complete radiographic skeletal surveys by a pediatric radiologist. Autopsies were supplemented with resection, high-detail radiography, and histologic study of all noncranial sites of suspected osseous injury. Thirty-four bony injuries were noted, including 12 acute and 16 healing fractures of the long-bone metaphyses and posterior-rib arcs in patterns indicative of infant abuse. The investigations determined that there were eight cases of abuse, two accidental deaths, and two natural deaths (sudden infant death syndrome). At this writing, the radiologic and osseous histologic studies appear to have influenced the determination of the manner of death in six of the eight cases of abuse and the criminal prosecution in four of the five convictions. These findings suggest that a thorough postmortem radiologic evaluation followed by selected histologic studies can have an impact on the investigation and prosecution of cases of fatal infant abuse. (N Engl J Med 1989; 320:507-11.) THE National Center on Child Abuse and Neglect estimates that between 2000 and 5000 children are fatally abused annually in the United States.¹ Since Caffey's classic report in 1946,² radiologists have become increasingly aware of a wide variety of osseous abnormalities that point specifically to child abuse.^{3 4 5 6 7 8} These lesions include fractures of the long-bone metaphyses, posterior ribs, spine, and sternum.^{9 10 11 12 13 14 15 16 17 18 19 20 21} Often, several of these axial and appendicular injuries coexist in infants who have been shaken, and most are explainable by severe torsional, tractional, and decelerational or accelerational forces delivered during such assaults.⁷ Although inflicted osseous injuries are often subtle and.