Visit https://ebookfinal.

com to download the full version and

explore more ebooks

Radiological Atlas of Child Abuse A Complete

Resource for MCQs v 1 1st Edition Amaka Offiah
(Author)

_____ Click the link below to download _____

https://ebookfinal.com/download/radiological-atlas-of-
child-abuse-a-complete-resource-for-mcqs-v-1-1st-
edition-amaka-offiah-author/

Explore and download more ebooks at ebookfinal.com

Here are some suggested products you might be interested in.
Click the link to download

An Atlas of Sarcoidosis 1 edition Edition Mihailovic-

Vucinic V. (Author)

https://ebookfinal.com/download/an-atlas-of-sarcoidosis-1-edition-
edition-mihailovic-vucinic-v-author/

Child Abuse Sourcebook Joyce Brennfleck Shannon

https://ebookfinal.com/download/child-abuse-sourcebook-joyce-
brennfleck-shannon/

Child Abuse and Neglect in Canada Lea Tufford

https://ebookfinal.com/download/child-abuse-and-neglect-in-canada-lea-
tufford/

Atlas of Breast Surgical Techniques A Volume in the

Surgical Techniques Atlas Series 1st Edition V. Suzanne
Klimberg
https://ebookfinal.com/download/atlas-of-breast-surgical-techniques-a-
volume-in-the-surgical-techniques-atlas-series-1st-edition-v-suzanne-
klimberg/
Internet Child Abuse Current Research and Policy 1st
Edition Julia Davidson

https://ebookfinal.com/download/internet-child-abuse-current-research-
and-policy-1st-edition-julia-davidson/

Child Abuse and Neglect Diagnosis Treatment and Evidence

1st Edition Carole Jenny

https://ebookfinal.com/download/child-abuse-and-neglect-diagnosis-
treatment-and-evidence-1st-edition-carole-jenny/

Child Abuse and Neglect 3rd Ed 3rd Edition Monica L. Mccoy

https://ebookfinal.com/download/child-abuse-and-neglect-3rd-ed-3rd-
edition-monica-l-mccoy/

Vagabond Vol 29 29 Inoue

https://ebookfinal.com/download/vagabond-vol-29-29-inoue/

100 Questions Answers About Your Child s Substance Abuse

1st Edition Romulo Aromin

https://ebookfinal.com/download/100-questions-answers-about-your-
child-s-substance-abuse-1st-edition-romulo-aromin/
Radiological Atlas of Child Abuse A Complete Resource
for MCQs v 1 1st Edition Amaka Offiah (Author) Digital
Instant Download
Author(s): Amaka Offiah (Author); Christine Hall (Author)
ISBN(s): 9781846190438, 1498790739
Edition: 1
File Details: PDF, 35.83 MB
Year: 2009
Language: english
RADIOLOGICAL ATLAS OF CHILD ABUSE
RADIOLOGICAL ATLAS OF
CHILD ABUSE

AMAKA C OFFIAH
Academic Consultant
Department of Radiology
Great Ormond Street Hospital for Children, London

and

CHRISTINE M HALL
Consultant Paediatric Radiologist
Department of Radiology
Great Ormond Street Hospital for Children, London

Foreword by

JOANNA FAIRHURST
Consultant Paediatric Radiologist
Southampton University Hospitals Trust

Radcliffe Publishing
Oxford • New York
Radcliffe Publishing Ltd
18 Marcham Road
Abingdon
Oxon OX14 1AA
United Kingdom

www.radcliffe-oxford.com
Electronic catalogue and worldwide online ordering facility.

© 2009 Amaka C Offi

fiah and Christine M Hall

Amaka C Offi fiah and Christine M Hall have asserted their right under the Copyright,
Designs and Patents Act 1998 to be identified
fi as the authors of this work.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior permission of the copyright owner.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.

ISBN-13: 978 1 84619 043 8

Typeset by Pindar NZ, Auckland, New Zealand

Printed and bound by TJI Digital, Padstow, Cornwall, UK
 Contents
Foreword vii
Preface viii
About the authors ix
Acknowledgement x

SECTION A
Image production, display and interpretation in child abuse

Chapter 1 Evidence-based radiology in child abuse 3

SECTION B
Skeletal injuries in child abuse

I Axial skeleton 17
Chapter 2 Skull 17
Chapter 3 Ribs 45
Chapter 4 Flat bones and spine 70
II Appendicular skeleton and viscera 81
Chapter 5 Diaphyseal fractures 81
Chapter 6 Classical metaphyseal lesions (CMLs) 106
Chapter 7 Visceral injuries 118
III Differential diagnoses 135
Chapter 8 Normal variants 135
Chapter 9 Pathological conditions 152
IV Dating fractures 180
Chapter 10 Fracture healing 180
V Examples 243
Chapter 11 Cases 244
VI References 347

Index 351
 Foreword
Like it or not, as professionals who deal with the care of children, we cannot escape
involvement to some degree or other in the field of suspected child abuse. Whether that
involvement takes the form of reporting the radiographs of children attending the emer-
gency department or a pathologist called upon to examine a sudden infant death, we have
a responsibility to discharge our duty to that child to the best of our ability. To prepare
ourselves for this responsibility we need to be fully armed and fully informed. In practical
terms this often means accessing information from a variety of sources and using every
opportunity which presents itself to gain more experience in this field. The subtlety of the
radiological findings compounded by the wide variation in appearance of the developing
skeleton frequently leads to a lack of agreement between reporters. This in turn contributes
to the atmosphere of stress and uncertainty in what is already an emotionally challenging
area of practice.
Thankfully Professor Hall and Dr Offi fiah have used their extensive experience and
exhaustive study of the radiology of child abuse to produce a text which at last fills a sig-
nifi
ficant gap in this field. This volume addresses key issues facing the reporting radiologist
both acutely in making a diagnosis and thus identifying a child in need of protection, and
subsequently as part of the continued process of child protection proceedings.
The format of this text provides a comprehensive review of key areas such as image
production, differential diagnosis and fracture dating, and a detailed illustration of patterns
of injury. Each image is enhanced by pertinent learning points that help to consolidate the
messages conveyed by the text. It is these pointers, together with the breadth of images
and thorough contextual review, that make this atlas unique and ensure that it will provide
a lasting contribution to the literature in this fi
field. The atlas will be an invaluable source
of reference material that will act as a teaching resource for those new to this area, will
consolidate and confi firm practice for those professionals already familiar with this field, and
will stimulate research into questions which remain unanswered in this arena.
The authors’ approach and detailed image analysis make this comprehensive review
accessible to all who care for children. In presenting this atlas, Professor Hall and Dr Offiah
fi
have enhanced our understanding and provided a major tool with which to help our most
vulnerable young patients.

Joanna Fairhurst
Consultant Paediatric Radiologist
Southampton University Hospitals Trust
April 2009

vii
 Preface
Which is the lesser error – to make a wrongful diagnosis of physical abuse thus removing
an infant from loving carers, or to miss the diagnosis and return a baby to an environment
in which episodes of abuse may escalate, culminating in that baby’s death? Both scenarios
are distinct possibilities; the diffi
ficulty with making the diagnosis of abuse (particularly in
non-lethal cases) is that no external gold standard exists.
The situation is complicated by the fact that the radiological abnormalities associated
with suspected abuse can be extremely subtle. It is well recognised that acute rib fractures
are often missed, and there are several normal variants that may be mistaken for fractures.
It is therefore important that a paediatric radiologist with experience in dealing with such
cases reviews all radiographs obtained as part of a skeletal survey to exclude physical
abuse.
The purpose of this atlas is not to turn readers into immediate experts, but rather to offer
assistance with initial interpretation of what are often difficult
fi and subtle findings in the
emotionally charged environment that frequently exists when child abuse is suspected.
It is hoped that this atlas will be of particular use to radiologists (both in training and
at consultant level – specialist or with an interest in paediatric radiology). The atlas may
also be useful to those in other specialties including Histopathology and Accident and
Emergency.
We have tried to include as many examples of the sorts of difficult
fi cases/normal variants
that are encountered in day-to-day practice; however, if readers should come across par-
ticularly rare/interesting examples for inclusion in a future edition of this atlas, we should
welcome these with gratitude.
Finally, we acknowledge all those who have referred cases to us over the years – without
you this atlas would not have been possible.

Amaka C Offi fiah

Christine M Hall
April 2009

viii
 About the authors
Dr Amaka Offi fiah BSc, MBBS, MRCP, FRCR, PhD graduated from Ahmadu Bello University,
Zaria, Nigeria in 1990 and came to England in 1992 following house jobs and National
Youth Service. She trained as a radiologist in Sheffi field, and joined the Institute of Child
Health/Great Ormond Street Hospital in 2000 as a clinical research fellow. In 2005 she
was awarded a University of London PhD for her thesis ‘Optimisation of the digital
radiographic imaging of suspected non-accidental injury’. Her interest lies in the muscu-
loskeletal system, particularly physical child abuse and constitutional bone disorders. She
is Chairperson of the Great Ormond Street Child Abuse and Protection Group and serves
as an expert witness for the Courts. She is presently an Academic Consultant at Great
Ormond Street Hospital for Children, conducting research in the imaging of paediatric
musculoskeletal disorders.

Professor Christine Hall MBBS, DMRD, FRCR, MD qualifi fied in 1968 from University
College, London. She trained in radiology between 1970 and 1975 at University College
Hospital and was appointed Consultant Paediatric Radiologist at Great Ormond Street
Hospital in 1975. She held this post until her retirement in March 2008. Her particular
interests have included the field of physical child abuse, in relation to which she has fre-
quently appeared as an expert witness to the Courts. She also has a specialist interest in
the radiological diagnosis of constitutional bone disorders. She has published almost 200
peer-reviewed papers in addition to many book chapters, two books and an electronic atlas
of malformation syndromes and skeletal dysplasias.

ix
 Acknowledgement
The authors should like to acknowledge the assistance of Mr Paul Barnard, Department
of Medical Illustration, Great Ormond Street Hospital, for his expertise in digitising and
annotating the radiographs.
Paul has worked in the Medical Illustration Department for 10 years. Previously he has
worked for the National Gallery and Sotheby’s and maintains a dedication for archival
documentation. In 2005 he gained a Higher National Diploma in Photography and Digital
Imaging.
Paul specialises in digitising and cataloguing extensive collections of original fl
flat material
including historic literature and early photographic plates, film and prints, and (of course)
radiological images. The end use of this material is invariably for online departmental
catalogues, on-screen presentations, publications (such as this atlas), and web access.
Paul has worked closely with the authors and the Radiology Department in general for
many years. Without his input this atlas would not have been possible. He maintained his
patience and humour throughout the production process – together we trawled through
hundreds of images (more than once) and yet have managed to remain on speaking
terms!
We thank him.

x
 SECTION A

Image production, display

and interpretation in
child abuse
 CHAPTER 1

Evidence-based radiology in
child abuse

BACKGROUND
Ambroise Tardieu, a physician in France, firstfi described the findings associated with
infl
flicted childhood injury, in 1860, 35 years before the discovery of X-rays by Wilhelm
Conrad Roentgen.1 However the ‘father’ of radiological imaging in child abuse must surely
be John Caffey, who in 1946 gave us the first radiological description of the findings.2 In
his seminal paper, Caffey described the association of multiple long bone fractures and
chronic subdural haematoma in infants. Since that time, the definition
fi of child abuse has
been expanded and refined,
fi such that the Child Abuse Prevention and Treatment Act (North
America) now states that

Child abuse and neglect means the physical or mental injury, sexual abuse, negligent
treatment, or maltreatment of a child under the age of 18 by a person who is respon-
sible for the child’s welfare under circumstances which indicate the child’s health or
welfare is harmed or threatened thereby.3

In summary, there are four major types of abuse: neglect, and physical, sexual and emo-
tional abuse.
The radiologist deals with physical abuse (commonly termed non-accidental injury, but
also variously known as the parent–infant traumatic stress or Caffey–Kempe syndrome,
infl
flicted/intentional injury, and the battered or shaken baby/babe syndrome).
Infants and young children are the most vulnerable in terms of fatal injuries resulting
from abuse with up to 90% of child abuse and neglect fatalities occurring in those less
than five years old, and 41% in those less than a year old.4 The majority of infants who die
following abuse have associated skeletal injuries, usually in the healing phase at the time
of their death.5 In both lethal and non-lethal cases, severe skeletal, neurological and organ
damage may exist in the absence of signifi ficant clinical/external signs and it is imperative
that high-quality radiographs of all bones are obtained.

IMAGING
There is scant evidence in the literature to support specifi
fic imaging modalities or views for
any given modality. Kemp, et al. have performed a systematic review addressing this very
issue.6 For the detection of skeletal injury they advocate a skeletal survey in combination
with a nuclear medicine bone scan. They recognise that prospective research is required
comparing skeletal surveys with oblique chest views; skeletal surveys with bone scans; skel-
etal survey plus repeat radiographs in two weeks; and bone scan plus skull and dedicated
views of epiphyses and metaphyses.

3
4 RADIOLOGICAL ATLAS OF CHILD ABUSE

SKELETAL SURVEY
The radiographs obtained in cases of suspected abuse are collectively known as the skeletal
survey. The skeletal survey is the primary investigation of choice for any child under the
age of two years where physical abuse is suspected, and once the suspicion has been raised,
the full skeletal survey MUST be performed.
In the past, there has been signifi
ficant variation in the individual radiographs obtained
by different Radiology Departments. Thus Offiah fi and Hall in 2003 showed that of 50
consecutive surveys received by them for a second opinion in suspected abuse, there were
37 different patterns of radiographs obtained.7 Furthermore, no survey concurred with the
British Society of Paediatric Radiologists’ (BSPR) guidelines.8 The study was repeated three
years later9 with more acceptable results (15% of surveys complying with the guidelines).
Some general rules apply.
 The imaging system should be of high quality.
 There should be tight collimation of each anatomical area.
 Additional views should be taken of any known sites of injury, of clinically suspicious
sites and of abnormal sites identifi fied on the radiographs. In one series, additional
radiographs following a two-week interval increased the detection rate of fractures by
27%.10 Additional (delayed) radiographs are also of benefi fit when attempting to date
fractures.

Radiographs should be obtained according to the BSPR guidelines8 (these differ slightly
from those of the American College of Radiology (ACR) Standards11).
In brief the BSPR guidelines advise the following:
 anteroposterior and left and right oblique radiographs of the chest
 anteroposterior and lateral skull
 anteroposterior limbs (or individual long bones)
 posteroanterior hands
 dorso-plantar feet
 lateral spine including cervical spine
 anteroposterior abdomen to include the pelvis and lower ribs.
A radiologist with paediatric radiology experience, who will be providing a report, should
review the skeletal survey for appropriate quality of the images. Double reporting is
recommended.
Additional radiographs may be required on an individual basis.
 Coned views of metaphyses.
 Lateral long bone radiographs when a shaft fracture is identified, to evaluate
displacement.
 Towne’s view of the skull if an occipital injury is suspected either clinically or from the
initial radiographs.
 Delayed (limited) skeletal survey (1–2 weeks following the initial survey): to identify
additional fractures not initially apparent. These are usually earlier acute rib fractures
that may only become apparent once callus develops. Delayed images may also help in
the evaluation of the healing process and in dating fractures.
 A skeletal survey on children under the age of two years with the same carers will
identify or exclude fractures not apparent on clinical examination.
 EVIDENCE-BASED RADIOLOGY IN CHILD ABUSE 5

RADIONUCLIDE BONE SCAN

A bone scan is sometimes advocated as an adjunct to the initial skeletal survey, or as a
delayed investigation, to help to identify fractures missed on the radiographic skeletal
survey. Until results of a well-designed prospective study are known, the bone scan should
not replace an initial skeletal survey. However it may identify missed rib and spinal frac-
tures and sometimes, old virtually healed fractures. Whether or not a radionuclide bone
scan is performed will depend on local expertise in performing high quality studies in this
diffi
ficult age group.

PITFALLS OF A RADIONUCLIDE BONE SCAN

 A scan typically takes of the order of 15 minutes to perform and any movement or
incorrect positioning during this time results in poor image quality and the potential
for misinterpretation.
 As a consequence of the previous point, it may be necessary to sedate the child.
 Skull fractures do not show increased uptake of isotope.
 All the rapidly growing physes and adjacent metaphyses show increased uptake of
isotope. This may give rise to false positives (over-reporting of metaphyseal fractures)
or false negatives (under-reporting of metaphyseal fractures).
 Dating fractures is not possible.

CT SCAN
HEAD CT
Because head injury may be occult, it is recommended that computed tomography (CT) of
the head is also routinely performed in any child under the age of two with a suspicion of
physical abuse.12 It should be performed on soft tissue and bone window settings. If frac-
tures are identifi
fied, reconstruction of images on bony windows may be helpful for court
purposes. The head CT should not replace the skull radiographs performed as part of the
skeletal survey. It is possible for skull fractures to be missed on CT when they are in the
same plane as the tomographic cut. In addition, the width of a skull fracture is traditionally
evaluated from the digital/analogue radiographs.

INTRA-ABDOMINAL TRAUMA
Abdominal trauma may be suspected when a child presents with an acute abdomen and
other evidence of trauma. Anterior (costochondral) rib fractures (particularly of the lower
ribs) may be the result of a direct blow to the epigastrium and have a high association
with intra-abdominal injury.13 Appropriate investigations include ultrasound and CT of
the chest and abdomen.

ULTRASOUND/MRI
These other modalities do not form a routine part of the investigation of physical child
abuse other than in patient management and in particular, in serious head injuries. In indi-
vidual cases, soft tissue injuries and periosteal damage may be identified
fi on ultrasound, and
magnetic resonance imaging (MRI) has a role in some joint and soft tissue injuries.

POST-MORTEM INVESTIGATIONS
Post-mortem radiographs form an important part of a full forensic investigation into the
cause of death of either a sudden unexpected death in infancy (SUDI) or an obvious case
of physical abuse of an infant or child. It is recommended that a full skeletal survey as
detailed above be undertaken before the start of the post-mortem examination. A forensic
6 RADIOLOGICAL ATLAS OF CHILD ABUSE

pathologist – preferably a paediatric pathologist – should perform the post-mortem accord-

ing to published guidelines.14 Selected areas of the skeleton thought to show evidence of
injury from the skeletal survey and post-mortem examination may then be resected and
decalcifified for further specimen radiography and histology. This is the most rigorous
approach to identifying and dating individual injuries. Fracture dating cannot be precise
with either a radiological or pathological approach alone. Both disciplines should be
regarded as complementary to each other. In general, histology gives more precise dating
in the first week following a fracture, but radiographic evaluation is more reliable after
that time.

For further details including technical parameters of the imaging system and qualifications
fi
of involved personnel, the interested reader is referred to the British Society of Paediatric
Radiologists’ standard for skeletal surveys in suspected abuse8 and the American College
of Radiology practice guidelines for skeletal surveys in children.11

COMPUTED/DIGITAL VS ANALOGUE RADIOGRAPHY

Computed radiography (CR), also known as storage phosphor radiography was fi first intro-
duced in the early 1980s.15 It is a form of digital imaging increasing in popularity because
of advances in technology (picture archiving and communication systems – PACS) allowing
for ‘fifilmless’ departments. The system consists of two major components: (1) a reusable
laser-stimulated luminescent phosphor imaging plate and (2) a scanning and recording
mechanism.16 The phosphor plate is sensitive to X-rays but relatively insensitive to light.
While expensive, it can be reused several thousand times.17
Digital radiography (DR) systems (whether direct or indirect) have no need for an imag-
ing plate as images are sent directly to a computer for processing. Image quality is better
than that obtained with CR or traditional film/screen systems.18
The techniques have several practical advantages over conventional film-screen radiog-
raphy, including economic and ergonomic.19 In terms of technical effi ficacy, there is reduced
spatial, but increased contrast resolution.20 These differences are detectable clinically as
reduced visibility of cortex and trabecular markings (spatial resolution) and increased vis-
ibility of soft tissues (contrast resolution) when interpreting CR compared to fi film screen
radiographs of the paediatric lateral spine.21
CR systems have the ability to produce radiographs of almost constant density regard-
less of exposure parameters.20 There is therefore potential for dose reduction. However,
although film density remains constant, in clinical practice dose reduction is limited by an
increase in quantum mottle. This may have signifi ficant (not as yet quantifified) effects on the
observer’s ability to visualise the subtle fractures of abuse.
Digital systems allow (limited) post processing. When used optimally post processing
improves visualisation of pathology, and allows both bone and soft tissue detail (for exam-
ple) to be clearly visualised on the same radiograph. Techniques include magnification, fi
grey-scale, contrast, brightness, non-linear grey-scale enhancement, non-linear unsharp
masking (edge-enhancement) and single or dual exposure energy subtraction.
In the case of physical abuse, it has been shown that neither post processing parameters
(magnifi fication and edge enhancement) nor method of digital image display (i.e., whether
radiographs were printed or viewed from a monitor) affect the diagnostic accuracy of
individual observers.22 Furthermore there is signifi ficant variability in diagnostic accuracy
between observers.
To conclude, with digital radiography systems, emphasis should be placed on observer
training and experience rather than image display and post processing techniques.
 EVIDENCE-BASED RADIOLOGY IN CHILD ABUSE 7

INDIVIDUAL INJURIES
Depending on the age of the study population, an estimated 10% to 70% of physically
abused children manifest some form of skeletal trauma.23–6 Furthermore, fractures are sec-
ond only to soft tissue injury as the commonest presentation of physical child abuse.27

SOFT TISSUE INJURY

Although multiple bruising is the commonest presenting feature in (physically) abused
children,27 it is also a common finding in the normal non-abused infant and child. In one
study of accidental fractures, Mathew, et al. found that 91% of children had no associated
bruising at presentation, and most (72%) remained without evidence of bruising in the fi first
week after their injury.28 Carpenter examined 177 six to twelve month old babies present-
ing routinely to child health clinics, and found a prevalence rate of 12% for (presumed)
accidental bruises.29 This is comparable to the prevalence of 12.5% observed by Roberton,
et al. in a study on 62 babies aged three to nine months old.30 Accidental bruising is most
often found on the face and head, on the front of the trunk and over bony prominences.
All accidental lower limb bruising occurs in mobile children. The incidence of bruising
in children increases signifi ficantly with increasing mobility.29 In contrast, multiple bruises
of different ages, bruises over soft sites (e.g., the cheeks), and lower limb bruising in a
non-mobile infant are all suggestive of abuse.29,31 Some soft tissue injuries are obviously
non-accidental, e.g., cigarette burns and bite marks.
Even minor injury to the soft tissues results in haemorrhage and infl flammatory exudate.
This manifests on radiographs as obliteration of the normal radiolucency of the superficial fi
and deep soft tissue planes. There may also be displacement of the fat planes around the site
of injury.32 Bruising may or may not be associated with underlying bony injury.33 Conversely
severe skeletal injuries involving acceleration-deceleration forces alone may occur in the
absence of visible signs of injury.34 This means that when physical abuse is suspected, the
entire skeletal survey must be performed regardless of the presence or absence of bruising.
Closer scrutiny and a lower threshold for repeating dedicated views of bones underlying
clinical bruising may increase the detection rate of skeletal injury.
Generally speaking, bruising is not a radiological diagnosis, although reports exist
describing radiological features such as calcified fi haematomas in older children,35 as well
as a case of so called ‘necklace calcifi fication’ in the soft tissues of the neck presumed due
to fat necrosis following strangulation.36 The major benefi fit in recognising the radiological
features of soft tissue injury is that they help to determine the age of the fracture particu-
larly those affecting the shafts of the long bones. There is a gradual increase in the size
of swelling overlying the site of the fracture over the course of the first three to four days
after a fracture has been sustained. This is accompanied by loss of definition fi of the soft
tissue planes, initially at the site of the fracture, but over the course of the four days after
a fracture, this extends up and down the limb away from the fracture site. Thereafter the
swelling gradually subsides and generally has resolved by seven to ten days after the fracture
has occurred. These changes in the soft tissues are seen before there is evidence of bony
healing.

METAPHYSEAL FRACTURES
The reported incidence of metaphyseal fractures in physical abuse ranges from 11% to
53%.23,37–9 Although less common than diaphyseal fractures,38,40,41 metaphyseal fractures
fic single sign of physical abuse.40,42,43 They occur most commonly in the
are the most specifi
lower limbs around the knees and ankles,31 but are also seen around the other joints of the
upper and lower limbs.44
8 RADIOLOGICAL ATLAS OF CHILD ABUSE

Metaphyseal fractures are variously known as metaphyseal infractions, avulsion frac-

tures and metaphyseal spurs. Kleinman suggests they be referred to as classical metaphyseal
lesions (CML).45 For the sake of consistency, the term ‘CML’ has been adopted in the
remainder of this text.
The CML was originally thought to represent an avulsion injury of the periphery of the
metaphysis.46 However, Kleinman, et al.8,47–51 have characterised these lesions histologi-
cally, and thus explained their radiological appearances and likely mechanism of injury. In
brief, the CML is a series of planar microfractures through the most immature portion of
the metaphyseal primary spongiosa. The fracture line extends in a planar fashion towards
the periphery (cortex) of the bone. As it does so, it veers away from the physis (growth
plate) undercutting a bony peripheral segment that encompasses the subperiosteal bone
collar. As a consequence, the peripheral bony fragment(s) will be thicker than the central
portion.
Traditionally the CML has been divided into two types based on radiological appear-
ance; namely ‘corner’ and ‘bucket-handle’ fractures.40 However these are in fact the same
lesion. The radiological appearance depends on the radiographic projection.45 When imaged
with the beam at 90° to the long axis of the diaphysis (in the same plane as the physis),
the CML has a corner fracture confi figuration. The relatively thick peripheral portion of
the fracture is seen end-on as a somewhat discrete triangular fragment. A bucket-handle
appearance of the fracture results from imaging the same lesion with beam angulation
(more or less than 90°). In this instance, beam angulation throws the fractured metaphysis
off the diaphysis, and it is seen as a curvilinear radiodensity.
Metaphyseal lesions occur as a result of direct shearing or twisting forces, and are also
said to occur during shaking when indirect acceleration-deceleration forces are applied to
the infant’s limbs.31,41,45

DIAPHYSEAL FRACTURES
Although less specifi fic for abuse, diaphyseal fractures are four times commoner than the
CML of physical abuse.38,40 Multiple fractures of the shafts of the long bones are highly
suspicious.52 Apart from bruising, the most common initial presentation of abuse is an
isolated diaphyseal fracture.38,53,54 Of the fracture types, transverse fractures are the com-
monest.31,55 The middle (50%) and distal third (41%) locations are the most prominent
sites of long bone fracture.53 Extremity fractures have been shown to occur at a younger
age than skull fractures in a cohort of patients under a year old.56
The most commonly fractured bone varies from series to series, with the tibia, femur
and humerus being variously cited.23,25–7,38,53,57 In the most recent series,39 the commonest
site of an isolated long bone fracture was the humerus (including one metaphyseal fracture)
followed by the femur (including two metaphyseal fractures).
Humerus In young children, a humeral shaft fracture rarely occurs in accidental injury
and has a high association with abuse.27,37,53 Physical abuse should be considered in all
children less than 15 months old with humeral fractures, including those children with
supracondylar fractures.58
Tibia A tibial shaft fracture in a non-ambulatory child is highly suspicious of abuse, par-
ticularly when an inappropriate history is given.52 Although Loder and Bookout38 reported
the tibia as the commonest long bone to be fractured in abuse, it must be emphasised that
two-thirds of these tibial fractures were in fact metaphyseal and not diaphyseal. Toddler’s
fractures (hairline spiral fractures of the tibial shaft) occur in the ambulant child. Their
recognition is important to avoid the over-diagnosis of physical abuse.31
Femur Like tibial fractures, femoral fractures in the non-ambulant child are highly
 EVIDENCE-BASED RADIOLOGY IN CHILD ABUSE 9

suspicious of physical abuse. Of course ambulant children may also be abused, hence
the importance of a detailed history.59–61 Many practitioners believe spiral fractures to be
pathognomonic of physical abuse.55 This is not the case, as no single type or site of fracture
ficantly more associated with or characteristic of physical abuse.31 Beals and Tufts60
is signifi
suggest that subtrochanteric femoral fractures are more common in non-accidental than
accidental injury in children. This opinion is not supported by the work of Scherl, et al.55
In fact these authors concluded that because spiral fractures are viewed as particularly
suspicious, care must be taken not to miss cases of physical abuse in children with trans-
verse fractures.
Radius/Ulna Although they are fractured commonly in accidental trauma, the radius
and ulna are the least fractured long bones in child physical abuse.25–7,38,53,57
Findings suggestive of physical abuse were summarised by Leventhal, et al.,62 and
include:
 fractures in children whose carers give a history of behavioural change in the child, but
no accidental event, or a minor fall not consistent with the severity of the sustained
injury
 fractures of the radius and ulna, tibia and fibula, or femur in children less than a year
old
 mid shaft or metaphyseal fractures of the humerus.
Mechanisms of injury include direct trauma (in an older child attempting to fend off a
blow), inappropriate pulling (causing the bone to fracture under the weight of the sus-
pended struggling child (infant), an awkward fall (as the child (infant) is thrown or pushed
away), or a twisting force.11,31,41 By their nature, spiral fractures imply a twisting force, and
are therefore highly suggestive of abuse.37,41 Care must be taken when attributing a spiral
fracture to physical abuse – history, patient age and development, fracture age, and the
presence of other injuries must all be taken into consideration to reduce the risk of over
or under diagnosis.63

SKULL FRACTURES
Skull fractures are the commonest38,62 or second most common52 skeletal injury in cases
of physical abuse, depending on case selection. They are said to be more frequent in non-
accidental than in accidental injury.43 This is particularly true of the younger child – 3% of
skull fractures in one series of patients less than 13 years of age were due to child physical
abuse,64 compared to 33% in a group of children less than two years of age.65 In another
study of 189 battered children, skull fractures were the only fracture type more likely to
be present in children aged less than a year compared to older children.53
A fall out of bed is a rare cause of skull fracture.66,67 Simple linear fractures occur from
a height of three to five and a half feet (i.e., from domestic falls), while more complex
(accidental) fractures occur from a height of six or more feet.68 The majority of stairway
injuries are relatively insignifi
ficant (because they consist of a series of low height, low impact
falls). Although falls may be associated with severe injury,69 the presence of multiple sites of
injury following an alleged fall down a flight of stairs should be viewed with more suspicion
than should a solitary skull fracture.70
Most skull fractures occurring in cases of physical abuse cannot on their own be differ-
entiated from those occurring in accidental trauma, and there is no single appearance that
is pathognomonic of abuse.35 There are some features however which favour a diagnosis
of physical abuse, these include non-parietal fractures; complex fractures (especially if both
sides are affected); multiple fractures; fractures equal to or greater than 4 mm in width;
10 RADIOLOGICAL ATLAS OF CHILD ABUSE

growing fractures; depressed fractures (especially occipital); and fractures associated with
intracranial injury.64,65
It must be remembered that a skull fracture crossing a suture to involve more than
one bone may be the result of a single blow with the fracture line radiating in both direc-
tions from the single impact site.63 This occurrence is most frequent in the parietal bones,
although occasionally the occiput may be involved.
The absence of a skull fracture does not exclude signifi ficant intracranial injury.31 It has
been recommended that following blunt trauma, skull radiography should be performed
in children older than two years of age only if physical abuse is suspected. It may also
be performed to confi firm the presence of a depressed fracture. On the other hand, skull
radiography should be performed in all children less than two years old because of the
higher likelihood of abuse in this group.71 In suspected physical abuse, even in the absence
of neurological signs, intracranial injury should be excluded by cross-sectional imaging
whenever the radiograph confirms fi a skull fracture.72 It has recently been advocated that
cross-sectional neurological imaging be performed routinely in cases of suspected physi-
cal abuse,12 and it is now part of the routine protocol in many departments in the United
Kingdom.

RIB FRACTURES
Ninety per cent of abuse-related rib fractures occur in children less than two years of age.40
The presence of multiple rib injuries adds considerably to the radiologist’s confidence
fi in
making a diagnosis of abuse. They were not mentioned in Caffey’s original description
of the association between long bone fractures and subdural haematomas,2 but with
the expansion of the radiological phenotype of child abuse, their importance was soon
recognised.73,74
The ribs of infants and young children are relatively pliable, and therefore with normal
day-to-day handling of the child, fractures at this site should be uncommon.68 Any of
the 12 ribs may be fractured, and individual ribs may fracture anywhere along their arc
depending on the mechanism of the infl flicted injury. A compressive squeezing force in the
anteroposterior (front-to-back) direction results in lateral rib fractures, and in the lateral
(side-to-side) direction produces anterior or posterior fractures. Rib fractures in this age
group may also occur as a result of accidental trauma (following notable trauma such as a
road traffi fic accident), occasionally following cardiopulmonary resuscitation (CPR), bone
fragility, birth trauma, chest physiotherapy and severe coughing.75–8 However the occur-
rence of rib fractures due to these causes in infants is very uncommon.
Thomas79 reviewed 10 000 infants, and found rib fractures (from any cause, includ-
ing some cases of abuse) in only 25. Others80 have failed to demonstrate rib fractures in
a large cohort (greater than 13 000) of live births. Furthermore post-mortem radiological
and histological examination failed to demonstrate a single rib fracture in a cohort of 91
patients under a year old after failed cardiopulmonary resuscitation.81
In summary, child physical abuse must always be considered in an infant found to have
rib fractures.
The reported incidence of rib fractures in physical abuse ranges from 5% to 29%.25,37–9,53
It has been said that these figures probably represent an underestimate68 with 80% of rib
fractures being occult.40 There are at least two reasons for the diffi ficulties in radiographic
identifification of rib fractures. Firstly the X-ray beam may not align with the fracture line.
Furthermore overlapping structures may easily obscure the fracture line (particularly in the
acute phase).41 Kleinman, et al.82 reported that of 84 rib fractures demonstrated on post-
mortem histopathology studies, only 30 (36%) were visible on the original skeletal survey. It
 EVIDENCE-BASED RADIOLOGY IN CHILD ABUSE 11

is also known that high-detail post-mortem radiography of dissected ribs allows visualisation
of fractures not visible on pre-dissection radiographs. This is illustrated in Plates 3.12 and
3.13. These disturbing findings perhaps explain the advice given by the BSPR8 to routinely
perform left and right oblique projections of the rib cage in addition to the anteroposterior
chest radiograph as part of the skeletal survey in suspected physical abuse.
Ng and Hall13 reported a relationship between fractures of the anterior ends (costo-
chondral junctions) of the lower ribs (6th–9th) and intra-abdominal visceral injury. These
fractures were diffificult to visualise, were equated to the ‘bucket handle’ CML, and were
associated with major abdominal visceral trauma.
Boal has published results on her analysis of 910 cases referred over 13 years. Of 1463
rib fractures in abused children, 12% occurred at the costochondral junction, 0% in chil-
dren thought not to have been abused and 15% in those in whom a definite fi distinction
between abuse and other cause could not be made.63

SUBPERIOSTEAL NEW BONE FORMATION

Subperiosteal new bone formation (SPNBF) may be seen in physical abuse in two
contexts:
 as a normal response to fracture healing
 in the absence of a fracture, as a radiological feature of abuse (periosteal trauma).
The radiological evidence of healing fractures is dealt with later, while isolated SPNBF as
a feature of abuse is discussed below.
Caffey2 described the finding in his seminal paper, and it has since been demonstrated
to be relatively common in abused children.54
The pathological finding is haemorrhage causing the osteogenic layer of periosteum to
be stripped from the underlying cortex. The osteogenic layer of periosteum adheres tightly
to the metaphyses and epiphyses, and more loosely to the diaphyses of bones. As a result,
collections of subperiosteal blood are of maximum diameter along the shafts and taper
towards the ends (except in the case of massive haemorrhage or repetitive trauma).45,52,68
Tractional and torsional forces on the periosteum as a result of rough gripping and
twisting or pulling of an extremity, was initially felt to be the mechanism of causation of
SPNBF. Some workers also feel that SPNBF can occur following acceleration-deceleration
forces.31,45,68
SPNBF is not specifi fic to physical abuse. It may be seen as a result of infectious, trau-
matic, metabolic and neoplastic disease and Caffey’s disease. Another important differential
diagnosis to consider is benign periosteal reaction, which occurs physiologically and was
initially described in infants between the ages of six weeks and six months.31 It has since
been shown that physiological SPNBF most frequently involves the femur or tibia, is usu-
ally symmetrical, never extends to the metaphysis, is very rarely greater than 2 mm thick,
and is commonest between the ages of one and four months.83
As with many other fractures in physical abuse, there may or may not be soft tissue
evidence of injury. Radiologically, SPNBF can be easily overlooked, as it may appear only
as a faint haziness/irregularity of the affected cortex. In other instances it may be seen as a
thin layer of bone separated from the underlying cortex by a narrow radiolucent interval.45
High-quality radiographs, and multiple and coned views may be required for confident fi
diagnosis or exclusion of SPNBF. The radiographic bone changes represent a healing
response to trauma and are only visible about seven days after the injury has occurred.
SPNBF may occur in isolation in physical abuse. However its detection should prompt
close scrutiny of the underlying bone to exclude a subtle hairline fracture. This should
12 RADIOLOGICAL ATLAS OF CHILD ABUSE

include projections at right angles to each other, as a hairline fracture may be invisible on
one view alone. Once again the need for high-quality examinations cannot be overstated.

LESS COMMON FRACTURES WITH HIGH SPECIFICITY FOR PHYSICAL

ABUSE
These include the following:
 axial skeleton: vertebral body, superior pubic ramus
 appendicular skeleton: acromion and body of scapula, metacarpals, metatarsals, epi-
physeal fracture/dislocations of upper and lower limb.

RADIOLOGICAL DATING OF FRACTURES

It has been said that in making a diagnosis of physical abuse, the single most important
factor is the relationship between the alleged timing of the injury and the radiographic
appearance of that injury.84 However, it may be argued that the single most important factor
is in fact the multiplicity of injuries, and that fracture age becomes more important as the
number of fractures detected decreases. This by no means belittles the role played by the
radiographic dating of fractures in the diagnosis of abuse, as evidenced by the fact that in
a recent publication it was recorded that an isolated long bone fracture was seen in 89 of
467 (19%) children with suspected physical abuse.39 The correct dating of injuries is also
of importance to the courts when establishing culpability.
The radiographic changes parallel the histopathological changes; however, it should be
noted that there is a signifi ficant subjective element to fracture dating by either discipline,
and not all radiologists would agree with the time sequence as described.
When a fracture is apparent on radiographs, the presence of significant fi soft tissue
swelling with loss of the normal fat planes informs the radiologist that the injury is recent,
probably within the preceding seven (and certainly within the preceding ten) days.
SPNBF F is seen on radiographs only once calcifi fication has begun (i.e., about seven to
ten days after the fracture has been sustained). Repetitive injury to a non-immobilised
fracture as may be seen in physical abuse, leads to further subperiosteal haemorrhage and
subsequent exuberant callus formation.52 It should be noted that SPNBF might not be seen
in the healing process of CML,84 skull, or vertebral fractures.
Fracture margins An acute fracture has well-defi fined sharp margins. This appearance
is present for about seven to ten days after a fracture has occurred. In the early stages of
fracture repair, macrophages begin to resorb non-viable tissues including the ends of the
affected bone. Radiographically this corresponds to a loss of definitionfi of the fracture
margins, with apparent widening of the fracture gap after about seven days. This is the
only reliable means by which the CML can be dated.84
Soft callus The laying down and calcifi fication of osteoid is visible on radiographs as
a subtle increase in density around the fracture site. At this stage the fracture line is still
discernible. This is a gradual and ongoing process from about one to six weeks.
This is first seen about seven to ten days after a fracture has been sustained and gradu-
ally increases in volume and density.
Hard callus The complete conversion of woven to lamellar bridging bone marks the
stable union of the fracture. Radiographically this is evidenced by definite
fi sclerosis around
the fracture and consolidation of the callus. By this stage the fracture line may or may not
be discernible. The fracture line usually disappears about six to eight weeks after a fracture
has occurred.
Remodelling The variability in duration of this phase means that it is not a reliable
radiological method of dating fractures. By this stage the acute healing phase is over and
 EVIDENCE-BASED RADIOLOGY IN CHILD ABUSE 13

the fracture line is not discernable. In undisplaced fractures of long bones and ribs the
remodelling process is more or less complete by twelve weeks after a fracture.
The radiologist should be aware that the healing of fractures is dependent on many vari-
ables including patient age, affected bone, degree of displacement, presence of re-fracturing,
force of injury, fixation and immobilisation of the affected fragments, etc.

There are some exceptions to the generalisations given above.

Firstly, unless the adjacent periosteum is damaged, SPNBF does not occur with the heal-
ing of CMLs. In such cases the most reliable means by which these fractures can be dated
is by assessment of the fracture line.84 It is unusual to see soft tissue changes associated
with CMLs. Undisplaced CMLs have usually healed radiographically by consolidation to
the adjacent bone by four weeks after they were sustained. Kleinman, et al.85 correlated
radiological with histopathological changes of CMLs in a retrospective analysis of 13 distal
tibial CMLs. Nine of these fractures were shown histologically to be in a healing phase, and
all nine were associated with a focal radiolucent extension from the growth plate into the
metaphysis. The authors imply that with knowledge of the relative growth rates of various
bones, the minimum age of a metaphyseal fracture can be calculated based on the depth of
the radiolucency into the metaphysis.
Secondly, skull fractures do not demonstrate the radiological features listed. The associ-
ated scalp swelling may help to date acute fractures, but literature on this topic is limited.
Swelling is best evaluated on bone window settings of the CT head scan.
Thirdly, rib fractures are diffificult to detect radiographically, particularly in the acute
phase. SPNBF may not be differentiated from overlying pulmonary vascular markings.
Indeed SPNBF may not develop, particularly with anterior costochondral rib fractures.83,86
This is similar to the healing pattern of CMLs, with which they are analogous. The sub-
sequent formation of callus helps to identify and date previously unidentified fi fractures
or suspicious areas. In one study, repeat radiographs approximately two weeks after the
initial ones increased the pick-up of fractures by 27%, and yielded important informa-
tion regarding age of fracture in 19% of 70 previously detected fractures. The majority
of these fractures were rib fractures and CMLs.20 Follow-up surveys might therefore be
recommended in suspicious cases to provide a more accurate assessment of bony injury.
In some institutions follow-up surveys form part of the routine skeletal survey. The BSPR
standard8 does not address this issue.

A recent systematic review of studies related to fracture dating performed between 1966
and 2004 found only three suitable for inclusion.87 The conclusion was that there is an
urgent need for research to validate the criteria used in the radiological dating of fractures
in children less than five years.
Although the radiological dating of fractures is occasionally described as more of an art
than a science, it does in fact require considerable experience of the various appearances
of fracture healing in infants.
It is advised that radiologists date fractures with caution, and always cite a range rather
than a specifi fic age for each injury identifi
fied.

DIFFERENTIAL DIAGNOSIS
There are a number of pathological conditions and normal variants that may be misdiag-
nosed as abuse. Particularly in the case of pathology, there may be other radiological and/
or clinical findings that help in reaching the diagnosis.
A defi finite diagnosis may not always be reached, and on occasion it is benefi ficial to
14 RADIOLOGICAL ATLAS OF CHILD ABUSE

perform follow up radiographs in 14 days, particularly in the case of suspected normal

variants. A fracture evolves with healing, whereas a normal variant remains unchanged
(over the 14-day time period).
The importance of a detailed history (including mechanism of injury) cannot be over-
emphasised, as often this is the only way of distinguishing accidental from non-accidental
trauma.

SUMMARY
This chapter has consisted of a review of the current literature.
There are many areas in which further prospective research is required; nevertheless,
some important conclusions can be reached.
 All infants and children less than two years of age who are suspected of being physically
abused should have a skeletal survey performed.
 The skeletal survey should be performed according to the BSPR guidelines.8
 The skeletal survey should routinely include a CT of the brain.
 All imaging should be reviewed by paediatric radiologists with experience of cases of
suspected abuse.
 Until more research has been carried out, fractures should be dated with caution. A
range of dates should be cited.
 The current belief is that CMLs may be caused by either direct tractional/torsional
forces or by the acceleration-deceleration forces associated with violent shaking.
 Anterior fractures of the lower ribs are commonly associated with intra-abdominal
injury.
 Fractures will evolve with time (over the course of two weeks); normal variants will
not – and are usually bilateral and symmetrical.
 Physiological periosteal reaction is symmetrical and does not extend to the metaphyseal
regions of the bones.
 A signifificant number of acute rib fractures may be missed on the initial chest radio-
graphs, and delayed radiographs (10–14 days) are advocated.
 SECTION B

Skeletal injuries in
child abuse
 I Axial skeleton
CHAPTER 2

Skull
Skull fractures result from a direct impact of the head against a hard object or surface.
Accidental falls under the force of gravity will result in the infant’s head, because of its
disproportionately large size and weight, impacting the fl floor first. In infants there needs
to be a history of an accident of suffi ficient magnitude to account for a fracture. The vast
majority of domestic falls of up to five feet, solely under the force of gravity do not result
in a skull fracture. Rare cases are reported of fractures occurring from low falls. Any force
added to the force of gravity increases the likelihood of a fracture occurring. For example
this may occur when a carer falls while carrying the infant. In this situation there is the
height of the fall (gravity) together with the forward momentum and propulsive force
exerted by the adult.

PATTERNS OF SKULL FRACTURES

 A linear, hairline, unilateral parietal fracture is the commonest type of skull fracture
seen either as a result of accidental or abusive trauma.
 Other fracture types indicate that forces have occurred that are greater than those gener-
ated following a simple fall. They may be more suggestive of abusive physical trauma
but need to be put into the context of the history.
• A fracture crossing a suture line (more than one skull bone fractured). Fractures
may travel along the sutures for a short distance and therefore a single impact may
result in discontinuous fractures across a suture affecting two bones. Sometimes sym-
metrical fractures may be present affecting both parietal bones, but not crossing or
involving the sagittal suture. These may be the result of two separate impacts, with a
higher specifificity for abuse, or the result of a single crushing force applied simultane-
ously to both sides of the head (for example standing on the head of the infant).
• Wide fractures are those equal to or greater than 4 mm in width measured on the
skull radiographs, NOT from CT images of the head.
• Fissured, branching or stellate fractures. These are more likely to occur following
an impact against an object with a relatively small surface area, rather than a fl flat
surface.
• Depressed fractures. An uncommon type of depressed fracture is the ‘ping-pong’
fracture in which there is a saucer-shaped depression of the convexity, often with a
short fracture line in the centre of the concavity. These should not be confused with
the extrinsic concave depression(s) seen as a result of intrauterine moulding and
associated with oligohydramnios.
• Growing fractures are those, which over time, carry on increasing in width. They
result from separation of the fracture by the leptomeninges.
• Fractures not involving the parietal bones, especially occipital fractures.

17
18 RADIOLOGICAL ATLAS OF CHILD ABUSE

Soft tissue swelling usually becomes apparent overlying the position of a skull fracture as
a combination of the direct effect of the impact and bleeding from the site of the fracture.
The swelling may be immediately obvious, or may gradually develop over the course of
several hours or days. The swelling becomes maximal and then gradually decreases, the
whole process taking 7–10 days. Swelling may initially be identifified from the feeling of a
soft or boggy sensation on handling the infant’s head during bathing or dressing. The time
at which the swelling is noted by carers is extremely variable and will depend upon:
 the speed with which the swelling develops
 the carers’ observational abilities
 the thickness of the infant’s hair
 outer clothing.
SKULL FRACTURE HEALING AND DATING
Skull fractures heal by gradual apposition and fibrous union of the fracture margins over
a variable period of time. In the first week or two, the edges of the fracture appear clearly
defifined and gradually there is then loss of defi finition of the fracture margins. These appear-
ances may remain the same for weeks or even months after the fracture has occurred and
therefore are not helpful in dating a skull fracture. Soft tissue swelling (as identifiedfi on
soft tissue windows of CT rather than on radiographs), reliably indicates that the fracture
is recent. This means that the fracture has occurred within the previous 7–10 day period.
CT soft tissue swelling will be apparent even when this is not clinically appreciated. Any
associated intracranial injuries may also be helpful in dating a traumatic head injury, assum-
ing that they have occurred on the same occasion as the impact injury causing the fracture.
Any skull fracture may be associated with subarachnoid or subdural bleeding directly under
the site of the fracture. The impact injury may also result in other more serious intracranial
injuries. This is the province of a specialist paediatric neuroradiologist.

EFFECT OF A SKULL FRACTURE

The effects are extremely variable and the severity depends on any associated intracranial
injuries resulting either from the impact itself or an associated shaking episode.
 The majority of accidental skull fractures are not associated with intracranial trauma
and result in pain at the time the fracture occurs and minor tenderness on direct palpa-
tion over the site of the fracture for hours or days afterwards.
 Soft tissue swelling may be apparent for about ten days after the fracture is sustained.
 More serious effects resulting from intracranial injury may range from mild concussion
with drowsiness and vomiting to unconsciousness, respiratory arrest and death.

DIFFERENTIAL DIAGNOSIS
 Accidental trauma. This requires the careful evaluation of the history given in relation
to the severity and type of injury sustained. The history should be consistent over time
and between any witnesses of the injury. Evidence of further injury would detract from
the diagnosis of accidental trauma.
 Normal variant findings include fissures and accessory sutures and these may be mis-
interpreted as fractures. Persistent membranous fissures
fi are a common feature of the
young infant’s skull. They gradually ossify with continued growth of the skull over
weeks or months. Radiographically they appear as short (1–2 cm), tapering, radiolucent
lines arising from and at right angles to, the sagittal or lambdoid sutures. Accessory
sutures are most commonly present in the lambdoid bone. They are almost always
bilaterally symmetrical and lack the clear-cut appearance and parallelism of fracture
 SKULL 19

lines. Larger intrasutural or wormian bones may be present in the lambdoid suture
and result in confusion with fractures. Wormian bones are present at birth and remain
visible throughout childhood. Up to ten wormian bones are considered a normal vari-
ant finding.
 Cephalhaematomas may occur during delivery, especially following ventouse extraction.
A rim of calcifi
fication may develop in the haematoma, or they may exert a compression
effect and give rise to a cystic appearance in the vault, which may be mistaken for a
depressed fracture.
 A ‘ping-pong’ fracture may mistakenly be interpreted as the result of compression from
faulty intra-uterine packing due to oligohydramnios, or vice versa the compression may
be interpreted as a fracture.
20 RADIOLOGICAL ATLAS OF CHILD ABUSE

2.1 SIMPLE LINEAR (HAIRLINE) PARIETAL FRACTURE

Age of fracture: Less than 10 days (soft tissue swelling on CT

– arrowhead)
Degree of force: Moderate (simple fracture, <4 mm wide)
Mechanism: Simple/domestic fall
Height of fall: 3.5 to 5 feet
General prevalence: Common
Prevalence in abuse: Common (7%–30%)
Specificity for abuse: Low (commonest fracture in both accidental injury
and physical abuse)

➥ Whenever possible, obtain lateral radiograph with side of soft tissue

swelling/clinical abnormality closest to imaging plate.
➥ CT may demonstrate soft tissue swelling that is not clinically detectable.
➥ The width of skull fractures is determined from radiographs and NOT from
CT scans (original studies64 measured fracture width from radiographs).

A: Lateral skull
 SKULL 21

B: AP skull

C: CT head (bony windows)

22 RADIOLOGICAL ATLAS OF CHILD ABUSE

2.2 SIMPLE LINEAR (HAIRLINE) PARIETAL FRACTURE

Age of fracture: Less than 10 days (soft tissue swelling on CT

– arrowhead)
Degree of force: Moderate (simple fracture, <4 mm wide)
Mechanism: Simple/domestic fall
Height of fall: 3.5 to 5 feet
Prevalence in abuse: Common (7%–30%)
Specificity for abuse: Low (commonest fracture in both accidental injury
and physical abuse)

➥ Depending on the angle of the tomographic cut relative to the fracture,

CT may miss skull fractures. In this example, only the anterior part of the
fracture adjacent to the right coronal suture was demonstrable by CT
(arrow).
➥ Seee Plate 2.9.

A: Lateral skull
 SKULL 23

B: AP skull

C: CT head (bony windows)

24 RADIOLOGICAL ATLAS OF CHILD ABUSE

2.3 SIMPLE LINEAR (HAIRLINE) OCCIPITAL FRACTURE

Age of fracture: Uncertain (in the absence of soft tissue swelling,

skull fractures cannot be reliably dated)
Degree of force: Moderately severe (simple fracture, <4 mm wide,
involves the occiput)
Mechanism: Fall plus gravity
Height of fall: 3.5 to 5 feet
Prevalence in abuse: Common (7%–30%)
Specificity for abuse: Moderate (non-parietal location)

➥ Obtain a Towne’s projection if an occipital fracture is suspected.

A: AP skull
 SKULL 25

B: Fronto-occipital projection
26 RADIOLOGICAL ATLAS OF CHILD ABUSE

2.4 SIMPLE LINEAR (HAIRLINE) OCCIPITAL FRACTURE

Age of fracture: <8 days (the patient is an 8-day-old neonate)

Degree of force: Severe (branching fracture, involves the occiput)
Mechanism: Fall plus gravity
Height of fall: >6 feet
Prevalence in abuse: Common (7%–30%)
Specificity for abuse: High (non-parietal location, age of patient,
absent history)

➥ Normal vaginal delivery in the absence of instrumentation will not lead to

a skull fracture.
➥ Ventouse delivery is unlikely to lead to a skull fracture.
➥ Forceps delivery may lead to fractures, usually of the parietal bone(s).

A: Towne’s projection
 SKULL 27

B: CT head (bony windows)

28 RADIOLOGICAL ATLAS OF CHILD ABUSE

2.5 COMPLEX BILATERAL SKULL FRACTURES

Age of fractures: Uncertain (soft tissue swelling not apparent)

Degree of force: Severe (complex fractures, >4 mm wide, cross
sutures to involve all bones, depressed fragments)
Mechanism: Several impacts to both sides of the head or
crushing forces
Height of fall: >6 feet or equivalent forces
Prevalence in abuse: Common (7%–30%)
Specificity for abuse: High (in the absence of an acceptable history)

➥ A single impact may result in a discontinuous fracture crossing a suture;

however, the complex fractures illustrated here will have resulted from
more than one impact or crushing force.

A: Patient 1: AP skull
 SKULL 29

B: Patient 1: Lateral skull

Exploring the Variety of Random
Documents with Different Content
 7. Or, do you fancy a soldier has nothing to do with judgment?
Will you say then (as poor Captain Uratz did, when he was ask’d a
few minutes before his death, if he had made his peace with God) “I
hope God will deal with me like a gentleman?” But God said unto
him, “Thou fool! I will deal with thee, as with all mankind. There is
no respect of persons with me. I reward every man according to his
works.” Thou also shalt receive of the righteous judge, according to
the things which thou hast done in the body. Death levels all; it
mingles in one dust the gentleman, soldier, clown and beggar; it
makes all these distinctions void. When life ends so do they. Holy or
unholy is the one question then. Lo! the books are opened, that all
the dead may be judged according to the things that are written
therein! O may thy name be found written in the book of life!
 8. For, have soldiers nothing to do with hell? Why then is it so
often in thy mouth? Dost thou think God does not hear the prayer?
And how often hast thou prayed him, To damn thy soul? Is his ear
waxed heavy that it cannot hear? I fear thou wilt find it otherwise.
Was not he a soldier too, (and a terrible one) to whom God said of
old, “Hell from beneath is moved for thee, to meet thee at thy
coming?” And what marvel? For sin is the high road to hell. And
have soldiers nothing to do with sin? Alas! How many of you wallow
therein, yea and glory in your shame? How do you labour to work
out your own damnation! O poor work, for poor wages! The wages
of sin is death; the wages of cursing, of swearing, of taking the
name of God in vain, of sabbath-breaking, drunkenness, revenge, of
fornication, adultery, and all uncleanness. Now, art thou clear of
these? Does not thy own heart smite thee? Art thou not condemned
already? What voice is that which sounds in thine ears? Is it not the
voice of God? Shall I not visit for these things, saith the Lord? Shall
not my soul be avenged on such a sinner as this? It is a fearful thing
to fall into the hands of the living God! Be very sure that thou art
stronger than he, before thou fliest in his face! Do not defy God,
unless thou canst overcome him. But canst thou indeed? O no. Do
not try. Do not dare him to do his worst. Why should he destroy
both thy body and soul in hell? Why shouldst thou be punished with
everlasting destruction, from the presence of the Lord and from the
glory of his power?

*9. But if there were no other hell, thou hast hell enough within
thee. An awakened conscience is hell. Pride, envy, wrath, hatred,
malice, revenge; what are these but hell upon earth? And how often
art thou tormented in these flames? Flames of lust, envy, or proud
wrath? Are not these to thy soul, when blown up to the height, as it
were a lake of fire, burning with brimstone? Flee away before the
great gulph is fixt: escape, escape for thy life! If thou hast not
strength, cry to God, and thou shalt receive power from on high:
and he whose name is rightly called Jesus, shall save thee from thy
sins.
 10. And why should he not? Has a soldier nothing to do with
heaven? God forbid that you should think so! Heaven was designed
for you also. God so loved your soul, that he gave his only begotten
Son, that you, believing in him, might not perish, but have
everlasting life. Receive then the kingdom, prepared for you from
the foundation of the world! This, this is the time to make it sure;
this short, uncertain day of life. Have you then an hour to spare? No;
not a moment. Arise, and call upon thy God. Call upon the Lamb
who taketh away the sins of the world, to take away thy sins. Surely
he hath borne thy griefs, and carried thy sorrows! He was wounded
for thy transgressions, and bruised for thy iniquities. He hath paid
the ransom for thy soul. Believe in him, and thou shalt be saved. Art
thou a sinner? He came, not to call the righteous, but sinners to
repentance. Art thou a lost, undone sinner? He came to seek and to
save that which was lost. May he that gave himself for thee, give
thee ears to hear, and a heart to understand his love! So shalt thou
also say, “The life I now live, I live by faith in the Son of God.” So
shall the love of God be shed abroad in thy heart, and thou shalt
rejoice with joy unspeakable. Thou shalt have the mind that was in
Christ, and shalt so walk as he also walked; till having fought the
good fight, and finished thy course, thou receive the crown that
fadeth not away!

The End of the Ninth Volume.

*** END OF THE PROJECT GUTENBERG EBOOK THE WORKS OF
THE REV. JOHN WESLEY, VOL. 09 (OF 32) ***

Updated editions will replace the previous one—the old editions

will be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States
copyright in these works, so the Foundation (and you!) can copy
and distribute it in the United States without permission and
without paying copyright royalties. Special rules, set forth in the
General Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree
to abide by all the terms of this agreement, you must cease
using and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project Gutenberg™
works in compliance with the terms of this agreement for
keeping the Project Gutenberg™ name associated with the
work. You can easily comply with the terms of this agreement
by keeping this work in the same format with its attached full
Project Gutenberg™ License when you share it without charge
with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project

Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United

States and most other parts of the world at no cost and
with almost no restrictions whatsoever. You may copy it,
give it away or re-use it under the terms of the Project
Gutenberg License included with this eBook or online at
www.gutenberg.org. If you are not located in the United
States, you will have to check the laws of the country
where you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of
the copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
 containing a part of this work or any other work associated with
Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute

this electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1
with active links or immediate access to the full terms of the
Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if
you provide access to or distribute copies of a Project
Gutenberg™ work in a format other than “Plain Vanilla ASCII” or
other format used in the official version posted on the official
Project Gutenberg™ website (www.gutenberg.org), you must,
at no additional cost, fee or expense to the user, provide a copy,
a means of exporting a copy, or a means of obtaining a copy
upon request, of the work in its original “Plain Vanilla ASCII” or
other form. Any alternate format must include the full Project
Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™
works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or

providing access to or distributing Project Gutenberg™
electronic works provided that:

• You pay a royalty fee of 20% of the gross profits you derive
from the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
 payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt
that s/he does not agree to the terms of the full Project
Gutenberg™ License. You must require such a user to return or
destroy all copies of the works possessed in a physical medium
and discontinue all use of and all access to other copies of
Project Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project

Gutenberg™ electronic work or group of works on different
terms than are set forth in this agreement, you must obtain
permission in writing from the Project Gutenberg Literary
Archive Foundation, the manager of the Project Gutenberg™
trademark. Contact the Foundation as set forth in Section 3
below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on,
transcribe and proofread works not protected by U.S. copyright
law in creating the Project Gutenberg™ collection. Despite these
efforts, Project Gutenberg™ electronic works, and the medium
on which they may be stored, may contain “Defects,” such as,
but not limited to, incomplete, inaccurate or corrupt data,
transcription errors, a copyright or other intellectual property
infringement, a defective or damaged disk or other medium, a
computer virus, or computer codes that damage or cannot be
read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except

for the “Right of Replacement or Refund” described in
paragraph 1.F.3, the Project Gutenberg Literary Archive
Foundation, the owner of the Project Gutenberg™ trademark,
and any other party distributing a Project Gutenberg™ electronic
work under this agreement, disclaim all liability to you for
damages, costs and expenses, including legal fees. YOU AGREE
THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT
EXCEPT THOSE PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE
THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY
DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE
TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL,
PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE
NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you

discover a defect in this electronic work within 90 days of
receiving it, you can receive a refund of the money (if any) you
paid for it by sending a written explanation to the person you
received the work from. If you received the work on a physical
medium, you must return the medium with your written
explanation. The person or entity that provided you with the
defective work may elect to provide a replacement copy in lieu
of a refund. If you received the work electronically, the person
or entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund.
If the second copy is also defective, you may demand a refund
in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set

forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’,
WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS OR
IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF
MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this
agreement violates the law of the state applicable to this
agreement, the agreement shall be interpreted to make the
maximum disclaimer or limitation permitted by the applicable
state law. The invalidity or unenforceability of any provision of
this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the

Foundation, the trademark owner, any agent or employee of the
Foundation, anyone providing copies of Project Gutenberg™
electronic works in accordance with this agreement, and any
volunteers associated with the production, promotion and
distribution of Project Gutenberg™ electronic works, harmless
from all liability, costs and expenses, including legal fees, that
arise directly or indirectly from any of the following which you
do or cause to occur: (a) distribution of this or any Project
Gutenberg™ work, (b) alteration, modification, or additions or
deletions to any Project Gutenberg™ work, and (c) any Defect
you cause.

Section 2. Information about the Mission

of Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new
computers. It exists because of the efforts of hundreds of
volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project
Gutenberg™’s goals and ensuring that the Project Gutenberg™
collection will remain freely available for generations to come. In
2001, the Project Gutenberg Literary Archive Foundation was
created to provide a secure and permanent future for Project
Gutenberg™ and future generations. To learn more about the
Project Gutenberg Literary Archive Foundation and how your
efforts and donations can help, see Sections 3 and 4 and the
Foundation information page at www.gutenberg.org.

Section 3. Information about the Project

Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a non-
profit 501(c)(3) educational corporation organized under the
laws of the state of Mississippi and granted tax exempt status
by the Internal Revenue Service. The Foundation’s EIN or
federal tax identification number is 64-6221541. Contributions
to the Project Gutenberg Literary Archive Foundation are tax
deductible to the full extent permitted by U.S. federal laws and
your state’s laws.

The Foundation’s business office is located at 809 North 1500

West, Salt Lake City, UT 84116, (801) 596-1887. Email contact
links and up to date contact information can be found at the
Foundation’s website and official page at
www.gutenberg.org/contact
 Section 4. Information about Donations to
the Project Gutenberg Literary Archive
Foundation
Project Gutenberg™ depends upon and cannot survive without
widespread public support and donations to carry out its mission
of increasing the number of public domain and licensed works
that can be freely distributed in machine-readable form
accessible by the widest array of equipment including outdated
equipment. Many small donations ($1 to $5,000) are particularly
important to maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws

regulating charities and charitable donations in all 50 states of
the United States. Compliance requirements are not uniform
and it takes a considerable effort, much paperwork and many
fees to meet and keep up with these requirements. We do not
solicit donations in locations where we have not received written
confirmation of compliance. To SEND DONATIONS or determine
the status of compliance for any particular state visit
www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states

where we have not met the solicitation requirements, we know
of no prohibition against accepting unsolicited donations from
donors in such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot

make any statements concerning tax treatment of donations
received from outside the United States. U.S. laws alone swamp
our small staff.

Please check the Project Gutenberg web pages for current

donation methods and addresses. Donations are accepted in a
number of other ways including checks, online payments and
credit card donations. To donate, please visit:
www.gutenberg.org/donate.

Section 5. General Information About

Project Gutenberg™ electronic works
Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could
be freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose
network of volunteer support.

Project Gutenberg™ eBooks are often created from several

printed editions, all of which are confirmed as not protected by
copyright in the U.S. unless a copyright notice is included. Thus,
we do not necessarily keep eBooks in compliance with any
particular paper edition.

Most people start at our website which has the main PG search
facility: www.gutenberg.org.

This website includes information about Project Gutenberg™,

including how to make donations to the Project Gutenberg
Literary Archive Foundation, how to help produce our new
eBooks, and how to subscribe to our email newsletter to hear
about new eBooks.
Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebookfinal.com