Imaging Evaluation of Head Injuries in Children Resulting from Negligence : The Saudi Journal of Forensic Medicine and Sciences

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Original Article

Imaging Evaluation of Head Injuries in Children Resulting from Negligence

Al Orf, Ali; Waheed, Khawaja Bilal; Oqailan, Ahmad Mohammad1; Zulfiqar, Farrukh2; Nassar, Mahdi Taha3; Alzahrani, Faisal Mohammad; Aljubair, Nawaf Nasser; Arulanantham, Zechariah Jebakumar4

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The Saudi Journal of Forensic Medicine and Sciences 2(2):p 36-40, May–Aug 2019. | DOI: 10.4103/sjfms.sjfms_4_20
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Child abuse comprises physical, sexual, and psychological abuse. Many children evaluated for child abuse have noninflicted injuries due to supervisory neglect.


The aim of this study is to evaluate the imaging findings in children with isolated head injuries due to neglect and to highlight the vulnerable age group.

Settings and Design: 

A retrospective case-based study in Radiology department at King Fahad Military Medical Complex (KFMMC) in the eastern region of Saudi Arabia from January 2017 to 2020.

Subjects and Methods: 

We retrospectively reviewed imaging findings of children (under 18 years) with head injuries related to negligence who were notified under Domestic Violence and Neglect Protection Prevention Program by the Medical Services Department at our KFMMC Hospital in Dhahran. Unconfirmed cases and those who lost follow-up were excluded. Skull radiographs and computed tomography of the brains were evaluated, and findings were labeled as “E” (extracranial, subgaleal hematoma, and scalp injury), “C” (cranial; fracture, and its location), and “I” (intracranial, extradural and subdural hematoma, brain contusion, etc.,). Imaging findings were documented in children aged under 5 years and between 5 and 18 years.

Statistical Analysis Used: 

The Chi-square test was used to determine the association. P < 0.05 was considered statistically significant.


Out of total 583 cases of notified child abuse cases, “neglect” accounted for 14.5% (n = 85) of cases, with a mean age of 33 months. Among 85 children with isolated head injuries, abnormal imaging findings were seen in more than half of children (n = 47, 55.2%). Children under 5 years were mostly affected with fractures (C) seen as common findings (n = 34, 72.3%), whereas 19 (40.4%) had intracranial (I) abnormalities (P = 0.89).


Head injuries resulting from negligence occur mostly in children under 5 years. Fractures account for more than two-thirds of injuries in children with abnormal imaging findings.


Nonaccidental injury (NAI), also known as child abuse or maltreatment, was first described by Tardieu in 1860.[1] Definition of child abuse is difficult as behaviors, and responses are perceived differently among different communities and cultures.[2] Child abuse comprises of physical abuse, sexual abuse, psychological abuse, and neglect.[3] Neglect occurs when a child's basic needs (i.e., food, clothing, housing, supervision, protection, health care, education, and nurturing) are not adequately met.[4] Various risk factors have been identified for physical abuse and neglect cases; therefore, a multidisciplinary approach is required for the identification of such affected cases. It is estimated that up to 16% of children are physically abused annually in developed countries, mostly victims of neglect, and that child abuse or neglect is leading cause of death in children under 4 years of ages.[5]

Many children evaluated for child abuse have noninflicted injuries due to supervisory neglect.?[6] Under-reporting of such cases is largely due to the lack of awareness and recognition of child maltreatment.[7] Victims often present to health-care systems for routine or emergency care. Clinically, medical history incongruent to clinical findings, discrepant histories, reluctance of parents/guardians to provide clinical information, distinctive patterns of burns or bruises, delay in seeking medical advice, history lacking details, and accident not compatible with injuries are few of alarming indications for NAI.[8] Imaging wise, skeletal surveys have highlighted several injuries and their specificities toward suspecting child abuse or neglect, for example, metaphyseal, scapular, rib, spinous process and sternal fractures have high specificity while multiple fractures, fractures of different ages, and complex skull fractures have moderate specificity for nonaccidental injuries.[9]

The detection of specific radiological or imaging findings mean that radiologists are often the primary physicians responsible for sounding the alarm in cases of abuse.[10] Therefore, we aim to evaluate the imaging findings of isolated head injuries that occurred as the consequences of neglect and to highlight the vulnerable age group.


All cases of child abuse that were notified to Domestic Violence and Neglect Protection Prevention Program (DVANPPP) under Medical Services Department at King Fahad Military Medical Complex (KFMMC) Hospital in Dhahran, during a period of 3 years between January 2017 and 2020 were retrospectively reviewed. Cases of neglect were confirmed if proven by means of evidence (i.e., history, physical, and behavioral indicators) as addressed under hospital policy (Care of patients; COP-8009). All such affected children below the age of 18 years (as per DVANPPP and Hospital policy) with isolated head injuries were included. Unconfirmed or unproven cases and those who lost follow-up were excluded. The research study was approved by Hospital Ethic Committee (Reference No. 237, 2016) and Institutional Review Board (IRB Protocol No. AFHER-IRB-2020-019). The study was conducted in accordance with the Helsinki Declaration. All clinical and radiologic information were kept strictly confidential. Literature review was performed through electronic search (Google Scholar, PubMed). Clinical information and radiographic/imaging findings were acquired through patients' clinical notes/Hospital Information System and Radiology Information System/Picture Archiving and Communication System.

Demographic information about age and gender of all patients was collected. All imaging information about skull radiographs (X-rays), computed tomography (CT), and magnetic resonance imaging (MRI) of the brain (if performed) were recorded. Imaging findings were presented “Cranial” (C) i.e., presence and location of fractures (right or left; frontal, parietal, temporal, occipital, base of skull, orbital, and facial), “Intracranial” (I) i.e., extraaxial hemorrhages (including subdural, extradural, or subarachnoid hemorrhages), and parenchymal injuries (including contusions, laceration, hematoma, or intraventricular hemorrhages), “Extra-cranial” (E) i.e., sub-galeal hematoma, scalp laceration, or degloving injury. The absence of these findings was considered normal. Indications for CT included suspicion of fracture on skull radiograph or on clinical grounds (i.e., clinical condition of child or altered neurological status and behavior). Imaging findings were reviewed by two experienced general radiologists, and final documentation of findings was made by consensus reporting.

Imaging findings were compared among the two groups of children, those under 5 years and those between 5 and 18 years. The statistical analysis was carried out using the IBM SPSS version 22 (IBM Corp, Armonk, NY). The Chi-square test was used to determine the association, and P < 0.05 was considered statistically significant.


Out of total 583 cases of notified child abuse cases, “neglect” accounted for 14.5% (n = 85) of cases. The mean age of the affected group was 33 months (2.7 years). Thirty-eight (44.7%) were females, whereas remaining (n = 47, 55.3%) were males.

Out of 85 children with isolated head injuries related to neglect, children under 5 years were seen mostly affected with fractures (C) accounting majority of the abnormal findings (n = 34, 72.3%) while 19 (40.4%) had intracranial (I) abnormalities [Table 1 and Figure 1]. Thirty-eight had no detectable findings on imaging [Table 1]. The findings were not found statistically significant (2 = 2.33; P = 0.89). Abnormal imaging findings were seen in more than half of children (n = 47, 55.2%). Most of abnormal findings were on the left side (25/47, 53.2%), whereas 19 (40.4%) were on the right side and remaining 3 (6.4%) were bilateral. The findings were not found statistically significant (?2 = 2.40; P = 0.50).

Table 1:
Imaging findings in different age groups
Figure 1:
Bar chart demonstrating abnormal imaging findings in different age groups

Types of skull fractures (simple linear, branching or complex, and depressed) and associated findings (like underlying extra-axial or overlying subgaleal haematomas) were highlighted [Figures 2-5].

Figure 2:
A left posterior parietal linear fracture is seen in a child as depicted on (a and c) (axial bone window and three-dimensional image, respectively, pointing arrows), associated with minimal underlying extra-axial haematoma (vertical arrow) and overlying subgaleal hematoma (horizontal arrow) as seen on image (b) (soft-tissue brain window)
Figure 3:
A left posterior parietal branching fracture is seen in a child as depicted on (a and c) (axial bone window and three-dimensional image, respectively, pointing arrows), associated with minimal underlying extra-axial blood and overlying subgaleal hematoma as seen in middle (b) (axial soft-tissue brain window)
Figure 4:
A left posterior parietal depressed Ping-Pong configuration fracture is seen on (a) (skull radiograph), (b) (axial bone window computed tomography image), (c) (axial soft-tissue brain window computed tomography image) and (d) (three-dimensional reconstruction reformatted computed tomography image)
Figure 5:
A linear frontoparietal fracture is seen (vertical arrows) crossing the coronal suture (horizontal arrows) as seen on (a) (skull lateral radiograph) and (b) (three-dimensional reconstruction reformatted computed tomography image)


Child abuse or NAI is a worldwide concern,[11] and Saudi Arabia is not an exception. Despite its widespread prevalence, affected cases are often under-looked and underreported probably because of lack of awareness, variable cultures, and behavior of societies.[12] Doctors can play a vital role in the identification and early reporting of such cases for timely treatment of affected children and to prevent further similar events. Particular attention should be paid to discrepancies between the patterns of injuries and the reported clinical histories.[13] Making the diagnosis of child abuse also requires differentiation from anatomical and developmental variants and possible underlying metabolic and genetic conditions.[14] Our study highlighted the important radiological aspects of head injuries in cases of neglect that constitute a considerable number of notified child abuse cases in this region.

In our study, neglect accounted for nearly 15% of child abuse cases notified to the hospital local body. This figure is quite low when compared to an earlier study by Jawadi et al. in 2019 that was conducted in Riyadh.[15] They analyzed 6 years' data of nonaccidental cases registered at National Family Safety Program Registry at King Abdulaziz Medical City in Riyadh and found that neglect was more common than physical abuse (52% vs. 45%), history of fall accounted for about 55%, and skull the most common site of fracture (40%). The low figures in our study might be related to differences in education and perception of the regional population at the Eastern Province. We found head injuries in more than half of abnormal imaging studies performed in cases of neglect, that seems correlating with the results of Notrica etal. in 2020 that found neglect-injuries to be associated with direct hospital presentations with more than 60% cases of isolated head injuries.[6] They also classified the types of supervisory neglect while retrospectively evaluating 553 patients and found interrupted supervision to be accounting for more than half (53%) of such injuries followed by rough handling (32%). Head injuries can also be fatal.[16] Although we did not find death or mortality in our study amongst affected children probably due to short and limited duration study. However, Delaplain etal. in 2019 reviewed the data of nearly 15,000 infants and found that the incidence of mortality was higher in nonaccidental trauma infants than accidental trauma (41.6% vs. 13.9%; P < 0.0001), and those were more likely to have traumatic brain injury (TBI) (63.1% vs. 50.6%; P < 0.001).[17]

We also found in our study that youngest children (under 5 years) were most vulnerable. Skeletal survey is the universal screening examination in children under 2 years of age having clinical suspicion of NAI.[18] Fractures occur in over half of abused children.[19] Selection of additional imaging for pediatric patients of suspected abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of torso injuries, and social considerations. Unenhanced CT of the head is the initial study for suspected intracranial injury. Clinically, occult abusive head trauma can occur, especially in young infants.[20] Therefore, head CT should be performed in selected neurologically asymptomatic physical abuse patients.[21] It is worth stating that although CT is the first neuroimaging option in NAI, MRI of the head can better characterize the lesions seen on CT and can help to estimate the age of the lesions,[22] and also can be used for follow-up to document the effects of traumatic injury. Lindberg etal. in 2019 found that fast MRI (T2-weighted, fluid attenuated inversion recovery, and diffusion-weighted imaging) was more feasible and accurate relative to CT in clinically stable children with concern for TBI (skull fracture, intracranial hemorrhage, or parenchymal injury).[23]

It should be noted that studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse.[20] Our study results also indicate intracranial injuries in nearly half of abnormal imaging findings [Figure 1] particularly in affected children under 5 years. Although statistically not significant, however, findings are believed to be clinically important as this group of children is vulnerable and dependent. Brain injury in this group may interfere with the motor development and life-long consequences. American College of Radiology recommends that clinicians should have a low threshold to obtain neuroimaging in these patients.[21] Boehnke etal. in 2018 found a high prevalence of occult head injury in patients <2 years old with suspected physical abuse in 1143 children under 2 years.[20] Although unilateral linear skull fractures with histories of fall have low specificity for abuse [Figure 2]. However, complex, depressed configuration require further workup to look for NAI-related body imaging regardless of age [Figures 3 and 4].[24] Furthermore, fractures that cross sutures [Figure 5] (as well as widening of 3 mm) and bilateral fractures are more likely related to abuse.[25] Epidural hemorrhages are common with accidental injuries. However, extra-dural and subarachnoid haemorrhages are more common in nonaccidental injuries.[26] It is best to do CT and MRI at initial evaluation. It is worth mentioning that spinal injuries may accompany head traumas related to abuse, for example, whiplash injuries related to shaken baby syndrome (triad of retinal bleed, subdural hematoma, and brain swelling in the absence of recent car accident or other clear explanation for injuries),[27] and even spinal cord injury without radiographic abnormality and need to be clinically looked carefully to advice further investigation.

Effective screening programs may help to identify sentinel injuries (previous injury reported in medical history that was suspicious for abuse and minor injuries with major significance) in suspected cases of nonaccidental injuries.[28] Earlier detection and psychosocial interventions are needed to avoid recurrent events or severe abuse which confer a higher mortality rate.[17] Even the life-long consequence of child abuse is profound. Maltreated children exhibit high rates of physical, developmental, and mental health deficits during childhood and their future lives. Victims of maltreatment are more likely to develop behavioral problems, insecurities, and poor health and are more vulnerable to attempt suicides.[29] Any doctor treating children should always be aware of the possibility of child abuse and neglect in children with injuries, especially in young and nonmobile children presenting with an unknown trauma mechanism and occurrence of specific imaging findings. If a suspicion of child abuse or neglect arises, a thorough diagnostic work-up should be performed, including a full skeletal survey according to the guidelines.[19] Further tools should be incorporated in health-care systems that include education sessions for health-care providers to identify NAI, automated notes or checklists within the electronic medical record to prompt specialty referrals, and a multidisciplinary team of experts that can address the needs of these children in the acute care setting.[7242830]

Study limitations

Authors of the study consider retrospective, single center, and small sample size to be few important study limitations. Consideration of isolated head injuries in our study may underestimate true extent or pattern of findings if would have been compared to neglect cases of head injuries combined with other regional body injuries (including cervical, chest, abdominal, and pelvic injuries). Furthermore, neglect injuries related to indoor or outdoor events were not categorized.


Head injuries related to negligence occur mostly in children under 5 years. Fractures are found in more than two-thirds of affected children with abnormal imaging findings, whereas intracranial abnormalities are seen in nearly half of these children.

All clinicians must be vigilant to screen patients and families, recognize signs and symptoms of abuse and neglect, and find time to advocate for home visits, early intervention programs, and education on this important issue.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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Child abuse; head trauma; neglect; nonaccidental injury

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