Pediatric Imaging

What Imaging Is Best for Suspected Visceral Injury from Child Abuse Under Age 2?

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What Imaging Is Best for Suspected Visceral Injury from Child Abuse Under Age 2?

A 15-month-old child is brought to the emergency department late on a Tuesday night for evaluation of irritability and feeding refusal. On examination, you note faint, patterned bruising across the upper abdomen and tenderness to palpation. The caregiver’s explanation for the bruising is vague and inconsistent with the findings. You are concerned for non-accidental trauma, specifically an occult visceral injury. What is the appropriate initial imaging workup to assess for both the suspected abdominal injury and other potential signs of abuse? This is a high-stakes decision where choosing the right studies is critical for the child’s immediate safety and long-term protection.

For this specific clinical scenario, the American College of Radiology (ACR) Appropriateness Criteria rate both Radiography skeletal survey and CT abdomen and pelvis with IV contrast as Usually Appropriate. This article will detail the clinical workflow and rationale for this comprehensive initial evaluation.

## Who Fits This Clinical Scenario?
This guidance applies to a very specific and vulnerable patient population: children 24 months of age or younger who present for initial evaluation where physical abuse is suspected as the cause of potential internal injuries.

Inclusion criteria for this workflow are:

  • Age: 24 months or younger.
  • Clinical Suspicion: Concern for visceral injury based on physical exam findings such as abdominal pain, tenderness, guarding, or visible injuries to the trunk (e.g., bruising, hematomas, abrasions, or patterned skin marks on the chest or abdomen).
  • Timing: This is the initial imaging workup upon presentation.

It is crucial to distinguish this scenario from similar presentations that require a different diagnostic approach. This workflow does not apply if:

  • The child is older than 24 months: The patterns of injury and the diagnostic yield of certain imaging studies change in older children. This presentation in a 3-year-old routes to a different ACR variant.
  • The primary concern is for Central Nervous System (CNS) injury: If the child presents with neurological signs like seizures, altered mental status, or a bulging fontanelle, the imaging workup is prioritized differently, focusing on neuroimaging first.
  • This is a follow-up evaluation: If the child has already undergone a negative initial skeletal survey and head CT, subsequent imaging decisions follow a separate clinical pathway.

## What Diagnoses Are You Working Up in This Scenario?
When a young child presents with findings suggestive of abdominal trauma from physical abuse, the differential diagnosis is broad and includes several life-threatening conditions. The imaging strategy is designed to systematically evaluate for this entire spectrum of potential injuries.

Occult Skeletal Fractures: This is a primary target of the workup, even if the presenting sign is abdominal. Certain fractures, such as posterior rib fractures (from squeezing), classic metaphyseal lesions (from shaking or pulling limbs), and fractures of the sternum or scapula, are highly specific for non-accidental trauma. Identifying these occult injuries is often key to confirming the diagnosis of abuse.

Solid Organ Injury: Blunt force trauma to the abdomen can cause significant injury to internal organs. The most commonly injured solid organs in this context are the liver and spleen, which can suffer lacerations or hematomas. Adrenal hemorrhage and pancreatic injury (including contusion or transection) are also serious considerations.

Hollow Viscus Injury: These are less common but carry high morbidity and mortality. A direct blow to the abdomen can cause a duodenal hematoma, leading to gastric outlet obstruction. A more severe injury can cause perforation of the stomach or bowel, leading to peritonitis and sepsis.

Accidental Trauma: The clinical team must always consider whether the history provided could plausibly explain the injuries. A detailed history and a thorough physical exam, combined with imaging, help differentiate the injury patterns of accidental trauma (e.g., a simple fall) from those of abuse, which often involve multiple injuries in different stages of healing.

## Why Are Both a Skeletal Survey and Abdominal CT Recommended?
For a child under 24 months with suspected visceral injury from abuse, the ACR designates both a Radiography skeletal survey and a CT abdomen and pelvis with IV contrast as Usually Appropriate. These are not competing studies; they are complementary and essential components of a comprehensive evaluation. The skeletal survey seeks evidence of a pattern of abuse, while the CT directly assesses for life-threatening abdominal injuries.

The rationale for this dual approach is rooted in the nature of child abuse evaluations:

  • Skeletal Survey: Its primary role is to identify occult fractures that are highly specific for non-accidental trauma. In this age group, a child cannot provide a history, and caregivers may not be forthcoming. The objective evidence of fractures—especially posterior rib fractures, classic metaphyseal lesions, or multiple fractures in different stages of healing—can be the most definitive proof of abuse. This is critical for ensuring the child’s safety and initiating involvement from child protective services.
  • CT Abdomen and Pelvis with IV Contrast: This is the gold standard for evaluating the suspected visceral injury that prompted the workup. The presence of truncal bruising is a significant predictor of underlying organ damage. An IV contrast-enhanced CT is highly sensitive and specific for detecting liver and spleen lacerations, pancreatic transection, duodenal hematomas, and adrenal hemorrhage. Timely diagnosis of these injuries is essential for guiding immediate medical or surgical intervention.

### Why Lower-Rated Alternatives Are Not the First Choice

  • US abdomen (Usually Not Appropriate): While ultrasound avoids ionizing radiation, it is not sensitive enough for this indication. It is highly operator-dependent and performs poorly in detecting injuries to the retroperitoneum, including the pancreas, duodenum, and adrenal glands. It can also miss subtle solid organ lacerations and cannot reliably rule out bowel perforation.
  • Bone scan whole body (Usually Not Appropriate): A nuclear medicine bone scan is sometimes used in follow-up but is not the appropriate initial study. While sensitive for detecting subacute fractures, it is less specific for the classic metaphyseal lesions that are pathognomonic for abuse. It also delivers a higher pediatric radiation dose (ped_rrl=☢☢☢☢, 3-10 mSv) than a skeletal survey (ped_rrl=☢☢☢, 0.3-3 mSv) and takes significantly longer to acquire, delaying care in an acute setting.

The radiation dose from the CT abdomen and pelvis (ped_rrl=☢☢☢☢, 3-10 mSv) is a valid consideration. However, the risk of missing a life-threatening visceral injury in a symptomatic or high-risk child far outweighs the long-term risk from this medically necessary radiation exposure.

Once you’ve decided on the skeletal survey, our protocol guide covers the specific views, technique, and reading principles. You can find it here: Skeletal Survey.

## What’s Next After Imaging? Downstream Workflow
The results of the skeletal survey and abdominal CT will dictate the immediate next steps in both the medical management and the child protection investigation.

  • If the Skeletal Survey is Positive: The identification of fractures with high specificity for abuse (e.g., posterior ribs, metaphyseal lesions) confirms the diagnosis of non-accidental trauma. This requires immediate reporting to child protective services and consultation with the hospital’s multidisciplinary child abuse team. The findings of the abdominal CT will determine if surgical intervention or intensive care monitoring is needed for any associated visceral injuries.
  • If the Skeletal Survey is Negative but the Abdominal CT is Positive: The visceral injury (e.g., liver laceration, duodenal hematoma) becomes the primary focus of medical or surgical management. A negative skeletal survey does not rule out abuse, as abdominal injuries can occur in isolation. The nature of the visceral injury itself, in the context of an implausible history, is often sufficient to proceed with a child protection evaluation.
  • If Both Studies are Negative: If the child is clinically well and both the skeletal survey and abdominal CT are negative, the likelihood of a significant occult injury is low. However, a negative workup does not definitively exclude abuse. The decision for discharge or admission for observation depends on the overall clinical picture, the nature of the initial presenting signs (e.g., the bruising), and the safety of the child’s home environment, often determined in consultation with social work and child protective services.

## Pitfalls to Avoid (and When to Get Help)
Navigating a suspected child abuse case is clinically and emotionally challenging. Avoiding common pitfalls is essential for the child’s well-being.

  • Pitfall 1: Not performing a skeletal survey. Focusing only on the abdominal injury and ordering only a CT means you may miss the classic fracture patterns that are often the most definitive evidence of abuse.
  • Pitfall 2: Ordering an abdominal CT without IV contrast. A non-contrast CT is inadequate for evaluating solid organ parenchyma, vascular injury, or the enhancement pattern of the bowel wall. It is rated Usually Not Appropriate.
  • Pitfall 3: Attributing all findings to a single event. Physical abuse is often repetitive. Be vigilant for injuries in different stages of healing on the skeletal survey, which strongly suggests an ongoing pattern of harm.
  • Pitfall 4: Delaying the workup. If there is a high suspicion of visceral injury, imaging should be performed emergently. Delays in diagnosing a bowel perforation or a bleeding solid organ can be catastrophic.

If you are uncertain about the imaging findings or the clinical management, escalate immediately. This involves a consultation with a pediatric radiologist, a pediatric surgeon, and your institution’s child abuse pediatrician or team.

## Related ACR Topics and Tools
For a comprehensive overview of imaging in all scenarios related to suspected child abuse, or to explore the technical details of the recommended studies, the following resources are available:

Frequently Asked Questions

Why is a skeletal survey necessary if my main concern is an abdominal injury?

A skeletal survey is crucial because in children under 2, physical abuse often involves multiple injuries. Even with a presenting sign like abdominal bruising, there is a high likelihood of co-existing occult fractures. Finding classic fractures (like posterior rib or metaphyseal lesions) provides powerful, objective evidence of non-accidental trauma, which is essential for diagnosis and child protection.

Can I just order an abdominal ultrasound to avoid radiation?

No, an abdominal ultrasound is rated ‘Usually Not Appropriate’ by the ACR for this initial workup. It lacks the sensitivity to reliably detect or rule out serious injuries, especially in the retroperitoneum (pancreas, duodenum) and subtle solid organ lacerations. In the setting of suspected visceral injury, a contrast-enhanced CT is the necessary diagnostic standard despite the radiation.

What if the abdominal CT is positive for an injury but the skeletal survey is negative?

A negative skeletal survey does not rule out abuse. A significant visceral injury, such as a liver laceration or duodenal hematoma, without a plausible history of major accidental trauma is itself a very strong indicator of abuse. The case would still require immediate reporting to child protective services and management by a multidisciplinary team.

Is a ‘babygram’ (a single radiograph of the whole body) an acceptable substitute for a formal skeletal survey?

No, a single ‘babygram’ is not an acceptable substitute. A formal skeletal survey consists of a series of 20+ specific, coned-down, high-detail views of the entire skeleton. This technique is required to achieve the diagnostic sensitivity needed to detect subtle but highly specific fractures, which would be missed on a single, lower-quality overview image.

If the initial skeletal survey is negative, is any follow-up imaging needed?

Yes, in many cases. Some fractures, particularly of the ribs and metaphyses, may not be visible on initial radiographs. A follow-up skeletal survey in approximately two weeks is often recommended, as healing callus formation can make previously occult fractures visible. This decision is typically made in consultation with the child abuse team.

Reviewed by Pouyan Golshani, MD, Interventional Radiologist — May 30, 2026