Acting as an effective expert witness in suspected cases of child abuse can represent a major challenge for clinicians because they tend to see things in multiple shades of grey, whereas lawyers want responses in black-and-white, according to a U.K. expert.

It can be difficult, if not impossible, for a clinician to testify only “Yes” or “No” when asked in court on a child abuse case, ‘Could the femoral fracture have been caused during a nappy change?’.

“Lawyers fail to understand that clinicians are trained to provide an integrated approach to dealing with uncertainty in an imperfect world, where they work within a resource-limited system designed towards maximising the number of patients treated in the most efficient way,” said Dr. Amaka Offiah, reader in paediatric musculoskeletal imaging and honorary consultant paediatric radiologist at the Academic Unit of Child Health, Sheffield Children’s NHS Foundation Trust.

A six-month-old baby presented to the radiology department after blunt head trauma. Following an x-ray (A), a 3-D CT reconstruction of the skull (B) showed an impression fracture in keeping with blunt force trauma (provided by Prof. Rick van Rijn).

Seeking to discredit an individual radiologist witness based on the imperfect system in which they work is not constructive, and detracts from the real matter in hand, she added. Although being an expert witness is challenging on many levels, not least because of the amount of written reports and information that often runs into thousands of pages and hundreds of emails, overall it is rewarding and satisfying.

Her advice to ECR 2020 delegates is that although the prospect of expert witness work may appear daunting, she would definitely recommend it because “you learn a lot and you make a difference to the positive work of protecting children.”

One-month-old baby presented with a bruise on the face. The chest radiograph showed multiple healing bilateral rib fractures (provided by Prof. Rick van Rijn).

“Protecting children is one of the driving forces for doing the work I do,” said fellow speaker Prof. Rick van Rijn, PhD, a paediatric radiologist at the Emma Children’s Hospital, Amsterdam, the Netherlands. “Child abuse unfortunately is common in the Netherlands, where between 100,000 and 160,000 children annually are the victim of some form of abuse, yet there is hardly any funding available to do research in this field – this actually holds true for forensic medicine in general.”

Although there may be no definitive signs of child abuse, it is likely there will be some findings in the clinical history or on imaging that are suggestive of abuse, particularly bruising in a non-ambulatory child and recurrent trauma, he continued.

Van Rijn explained that the diagnosis of child abuse is based on a full work-up of the case from a team led by paediatricians and child advocacy teams. Close collaboration and interprofessional working have an essential role in cases of suspected child abuse. He said investigations should consist of a thorough clinical history, physical examination, and proper laboratory testing. Ideally, imaging should also include a follow-up exam, but this is not always possible because the child may be placed elsewhere for their protection.

“Child abuse is real, and radiologists may be the first to raise suspicion of child abuse and that way start proper analysis of the case so correct help for the child and his parents/caregivers can be given,” he said, adding that the radiologist may be the first clinician to see isolated bruises, so it is important for him or her to be aware of the signs of abuse and the value of skeletal imaging exams.

Metaphyseal corner fracture: five-month-old child with bilateral subdural hematomas. Radiograph of the ankle shows a metaphyseal corner fracture of the distal tibia (arrow) (provided by Prof. Rick van Rijn).

Conventional radiography and CT are complementary techniques that enable the radiologist in their diagnosis of suspected child abuse. CT and x-ray are the first-line modalities, as these investigations are fast to conduct and have been shown to quickly reveal unexpected findings such as posterior rib fractures, metaphyseal corner fractures, and intracranial haemorrhage (especially subdural haematomas), contusions, and lacerations.

Van Rijn noted that in a case with abnormal findings or if the child continues to show neurological abnormalities, MRI should be performed, and it is important to image the whole spine on MRI.

Support from colleagues is absolutely crucial because this is emotionally stressful and challenging work, he explained. It is vital to create a team around you in which you feel safe, because you are presented with difficult, confronting cases that provoke emotions in you, and tears are often shed in private in the difficult cases, he pointed out.

Working as an expert witness requires specific knowledge of the legal system in which you work and awareness of the clinical knowledge gap of others working on the case, including police officers, district attorneys, lawyers, and judges, according to van Rijn. The Netherlands has a national expertise centre, the Dutch Expertise Centre for Child Abuse (DECCA), which is available 24/7 to give evidence-based guidance to clinicians who are faced with a possible case of child abuse. He finds this particularly useful as it can be difficult to find an expert in the field to collaborate with or to have as a source of support or point of referral.

LIVE
Special Focus Session, Saturday, July 18, 14:30–15:30
SF 13 The abused child: the key role of imaging

  • Chairperson’s introduction
    Karl J. Johnson; Birmingham/UK
  • Skeletal injury: should we use radiography or CT?
    Rick R. van Rijn; Amsterdam/NL
  • Head injury CT and/or MRI?
    Arabinda Choudhary; Little Rock, AR/US
  • Inflicted abdominal injury
    Maria Raissaki; Iraklion/GR
  • Testimony in court
    Amaka C. Offiah; Sheffield/UK
  • Live Q&A: Imaging in non-accidental injury: the role of the paediatric radiologist

FURTHER READING

Hahnemann ML, Kinner S, Schweiger B et al (2015) Imaging of bridging vein thrombosis in infants with abusive head trauma: the ‘Tadpole Sign’. Eur Radiol. 25(2):299-305: european-radiology.org/3443

Fadell M, Miller A, Trefan L et al (2017) Radiological features of healing in newborn clavicular fractures. Eur Radiol. 27(5):2180-2187: european-radiology.org/4569

Planells Alduvin MC, Mankad K (2019) Neuroimaging findings in children with abusive head trauma.
ECR 2019 / C-3147: myESR.org/193147

Bomer J, Holscher H (2018) Extrapleural density on oblique chest radiographs in non-accidental injury. ECR 2018 / C-0030: myESR.org/1830

Salinas E, Prieto D, Montoya R, Moreno A (2016) Pearls and pitfalls of suspected child abuse. Findings not to miss. ECR 2016 / C-1004: myESR.org/161004