Patricia L. Belanger

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 non-cranial 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.

The Tailored Low Dose Fluoroscopic Voiding Cystogram for Familial Reflux Screening

PURPOSE Radionuclide voiding cystography is generally advocated as a screening study to detect familial reflux. We assessed the efficacy of tailored low dose fluoroscopic voiding cystography for this purpose. MATERIALS AND METHODS We evaluated 10 boys and 10 girls 9 months to 10 years old (mean age 5 years) who were siblings of patients known to have reflux. The technique used a low dose fluoroscopic system. A tailored voiding cystographic protocol was designed to minimize gonadal radiation dose. RESULTS Absence of reflux was confirmed in 10 patients. Mean fluoroscopy time was 19 seconds (range 14 to 22), resulting in mean gonadal radiation exposure of less than 1.5 mrad., which is comparable to the lowest reported doses with the radionuclide technique. After reflux was demonstrated in 10 patients the study was immediately converted to a standard fluoroscopic imaging technique to define lower tract anatomy and quantitate reflux, avoiding a second study. CONCLUSIONS Tailored low dose fluoroscopic voiding cystography appears to be a practical approach for the assessment of familial reflux.

Detection of rib fractures in an abused infant using digital radiography: A laboratory study

Abstract Purpose. To assess the diagnostic performance of digital radiography using charge-coupled device (CCD) technology in the detection of rib fracture in infant abuse. Materials and methods. Four fractured posterior rib arcs and eight normal ribs removed at autopsy from a 10-month-old abused infant were radiographed using a CCD prototype, four clinical film-screen systems, and direct-exposure film. Each rib was viewed with these six systems in nine different projections. The resultant 648 images were assessed for probability of fracture (0–100%) by four pediatric radiologists. The calculated area under the resultant ROC curves (Az) for the CCD was compared with those obtained with direct-exposure, high-detail, medium and fast film-screen radiographic systems. Results. The mean Az for the CCD (0.937) fell within the range of the high-detail systems (0.934–0.940) and was significantly higher (p<0.05) than the medium and fast system (0.861 and 0.858, respectively). Despite a lower spatial resolution than direct-exposure film (7 line pairs per millimeter vs. >20 line pairs per millimeter) the CCD performance was comparable (Az=0.944 vs. 0.937). The similar performance can be explained by the higher contrast resolution of the digital technology. Conclusion. This study indicates that in the ex vivo setting, digital radiology can perform comparably to high-detail film-screen imaging. The findings suggest that digital radiography has the potential to replace film-screen imaging in the evaluation of inflicted skeletal injury in infants.