AJR:187, December 2006 1403

AJR 2006; 187:1403–1404

0361–803X/06/1876–1403

© American Roentgen Ray Society

M E D I C A L I M A G I N G

A C E N T U R Y O F

M E D I C A L I M A G I N G

A C E N T U R Y O F

KleinmanFractures and Hematoma in Infants

C e n t e n n i a l A r t i c l e • C o m m e n t a r y

“Multiple Fractures in the Long Bones of Infants Suffering from Chronic Subdural Hematoma”—A Commentary

Paul K. Kleinman1

Kleinman PK

Keywords: child abuse, infants, long-bone fractures, neonates, pediatric imaging, pediatric radiology, subdural hematomas

DOI:10.2214/AJR.06.0418

Received March 22, 2006; accepted without revision March 24, 2006.

Each month the American Journal of Roentgenology will republish online one of the 100 most-cited articles from its first century. A corresponding commentary in the print journal by a contemporary radiologist will provide a current perspective. For a full list of these articles, see page 3 of the January 2006 issue of the AJR or go to www.ajronline.org.

1Department of Radiology, Section of Musculoskeletal Imaging, Children’s Hospital Boston and Harvard Medical School, 300 Longwood Ave., Boston, MA 02115. Address correspondence to P. K. Kleinman (paul.kleinman@childrens.harvard.edu).

mong his many distinctions as a pi-oneer in the burgeoning field of pe-diatric radiology, John Caffey [1]wrote the first systematic clinical

and radiologic study of infants and toddlerswith the now well-recognized features of childabuse. In this landmark 1946 AJR article, Caf-fey reported six children under 2 years old withlong-bone fractures and subdural hematomas.Their neurologic symptoms were first reportedbetween the ages of 2 weeks and 10 months(mean age, 5 months), and the age at whichfractures were first documented ranged from 6weeks to 16 months (mean age, 10 months). In-jury patterns included various shaft fractures,metaphyseal lesions, and periosteal new boneformation of the upper and lower extremities.There were no skull or rib fractures. There wasno history of trauma to explain the findings.

Frederick Silverman [2], a protégé of Caffeyand an important contributor to our current un-derstanding of child abuse, drew attention tothe work of Ambrose Tardieu, a professor oflegal medicine at Faculté de Medicine de Parisfrom 1861 to 1879. In 1860, nearly a half cen-tury before the advent of diagnostic X-rays,Tardieu [3] published an article on the mal-treatment of children that detailed the clinicalfindings, including the description of fractures.Although a few case reports of fractures in pa-tients with subdural hematomas appeared inthe 1930s, 86 years elapsed before Caffey [1]and others [4, 5] documented the radiologicfindings. In a sense, the radiographs providedconcrete evidence of a phenomenon that couldbe traced to antiquity [3]. It appears that the ra-diographic depiction of inflicted injuriesbrought the notion of abuse to a visual leveland made it accessible to the medical commu-nity at large. Currently there is extensive andrich literature detailing every facet of childmaltreatment, and diagnostic imaging contin-ues to influence our understanding and recog-nition of this complex disorder.

The importance of Caffey’s [1] observa-tions notwithstanding, one might wonderwhy he failed to make any emphatic state-ments regarding intentional injury on thepart of the caretakers of the children in his1946 study. According to Silverman [2],Caffey was convinced that traumatic eventsresulting in subdural hematomas and in skel-etal lesions were causally related and mostlikely reflected “parental malfeasance” [6].Silverman also noted the care with whichCaffey described the circumstances sur-rounding his case reports. He drew attentionto Caffey’s comments that “recognized inju-ries may be denied by mothers and nursesbecause injury to an infant implies negli-gence on the part of its caretaker,” and fur-thermore, “In one of the cases, the infant wasclearly unwanted by both parents, and thisraised the question of intentional ill-treat-ment of the infant” [1]. Silverman thoughtthat Caffey did not go further because “hewas concerned about possible legal reper-cussions” [6]. This reluctance to suggest thata child has been injured at the hands of acaretaker, despite compelling evidence, re-mains a powerful deterrent to mandated re-porting and appropriate adjudication ofcases of suspected abuse [7].

Great progress has been made in our un-derstanding of the spectrum of inflicted inju-ries in children, and diagnostic imaging hasbeen instrumental in this process. The grow-ing list of entities that may masquerade asabuse continues to receive much attentionwithin the medical realm and in various legalarenas. The intense litigation surroundingcases of suspected abuse along with the dif-ficulties encountered by physicians in an ad-versarial courtroom setting may present adaunting challenge to well-intentioned med-ical witnesses.

Much can be learned from Caffey’s [1] arti-cle, not only in substance but also in what it

A

Kleinman

1404 AJR:187, December 2006

says about his scholarship. Thorne Griscom[8], an avid student of the history of pediatricradiology, noted that Caffey was “supremelyorganized in his approach to pediatric radiol-ogy. He focused on the diagnostic challengeand gave it his undivided attention.” Radiologywill continue to play a central role in the diag-nosis of child abuse and its simulators. Caffey’sseminal article will remain a primer for all thosewho wish to learn the history and contribute toour future understanding and management ofthis important public heath concern.

References1. Caffey J. Multiple fractures in the long bones of in-

fants suffering from chronic subdural hematoma.

AJR 1946; 56:163–173

2. Silverman FN. Unrecognized trauma in infants, the

battered child syndrome, and the syndrome of Am-

broise Tardieu. Rigler Lecture. Radiology 1972;

104:337–353

3. Tardieu A. Étude médico-légale sur les sévices et

mauvais traitments exercés sur des enfants. Ann

Hyg Publ Med Leg 1860; 13:361–398

4. Sherwood D. Chronic subdural hematoma in in-

fants. Am J Dis Child 1930; 39:980

5. Ingraham F, Heyl H. Subdural hematoma in infancy

and childhood. JAMA 1939; 113:198–204

6. Silverman FN. Re: parental or custodial factors in

what is now recognized as child abuse. (letter). Pe-

diatr Radiol 1994; 24:541

7. Flaherty EG, Sege R. Barriers to physician identi-

fication and reporting of child abuse. Pediatr Ann

2005; 34:349–356

8. Griscom NT. Imaging of nonaccidental head

trauma in children. (commentary) Acad Radiol

1999; 6:81

F O R Y O U R I N F O R M A T I O N

Each month the American Journal of Roentgenology will republish one of the 100 most-citedarticles from its first century accompanied by a commentary by a contemporary radiologist toprovide a current perspective. For a full list of these articles, see page 3 of the January 2006issue of AJR or www.ajronline.org. “Multiple Fractures in the Long Bones of Infants Sufferingfrom Chronic Subdural Hematoma” can be viewed in the archives at www.ajronline.org.

AJR:187, December 2006 1403

AJR 2006; 187:1403–1404

0361–803X/06/1876–1403

© American Roentgen Ray Society

M E D I C A L I M A G I N G

A C E N T U R Y O F

M E D I C A L I M A G I N G

A C E N T U R Y O F

KleinmanFractures and Hematoma in Infants

C e n t e n n i a l A r t i c l e • C o m m e n t a r y

“Multiple Fractures in the Long Bones of Infants Suffering from Chronic Subdural Hematoma”—A Commentary

Paul K. Kleinman1

Kleinman PK

Keywords: child abuse, infants, long-bone fractures, neonates, pediatric imaging, pediatric radiology, subdural hematomas

DOI:10.2214/AJR.06.0418

Received March 22, 2006; accepted without revision March 24, 2006.

Each month the American Journal of Roentgenology will republish online one of the 100 most-cited articles from its first century. A corresponding commentary in the print journal by a contemporary radiologist will provide a current perspective. For a full list of these articles, see page 3 of the January 2006 issue of the AJR or go to www.ajronline.org.

1Department of Radiology, Section of Musculoskeletal Imaging, Children’s Hospital Boston and Harvard Medical School, 300 Longwood Ave., Boston, MA 02115. Address correspondence to P. K. Kleinman (paul.kleinman@childrens.harvard.edu).

mong his many distinctions as a pi-oneer in the burgeoning field of pe-diatric radiology, John Caffey [1]wrote the first systematic clinical

and radiologic study of infants and toddlerswith the now well-recognized features of childabuse. In this landmark 1946 AJR article, Caf-fey reported six children under 2 years old withlong-bone fractures and subdural hematomas.Their neurologic symptoms were first reportedbetween the ages of 2 weeks and 10 months(mean age, 5 months), and the age at whichfractures were first documented ranged from 6weeks to 16 months (mean age, 10 months). In-jury patterns included various shaft fractures,metaphyseal lesions, and periosteal new boneformation of the upper and lower extremities.There were no skull or rib fractures. There wasno history of trauma to explain the findings.

Frederick Silverman [2], a protégé of Caffeyand an important contributor to our current un-derstanding of child abuse, drew attention tothe work of Ambrose Tardieu, a professor oflegal medicine at Faculté de Medicine de Parisfrom 1861 to 1879. In 1860, nearly a half cen-tury before the advent of diagnostic X-rays,Tardieu [3] published an article on the mal-treatment of children that detailed the clinicalfindings, including the description of fractures.Although a few case reports of fractures in pa-tients with subdural hematomas appeared inthe 1930s, 86 years elapsed before Caffey [1]and others [4, 5] documented the radiologicfindings. In a sense, the radiographs providedconcrete evidence of a phenomenon that couldbe traced to antiquity [3]. It appears that the ra-diographic depiction of inflicted injuriesbrought the notion of abuse to a visual leveland made it accessible to the medical commu-nity at large. Currently there is extensive andrich literature detailing every facet of childmaltreatment, and diagnostic imaging contin-ues to influence our understanding and recog-nition of this complex disorder.

The importance of Caffey’s [1] observa-tions notwithstanding, one might wonderwhy he failed to make any emphatic state-ments regarding intentional injury on thepart of the caretakers of the children in his1946 study. According to Silverman [2],Caffey was convinced that traumatic eventsresulting in subdural hematomas and in skel-etal lesions were causally related and mostlikely reflected “parental malfeasance” [6].Silverman also noted the care with whichCaffey described the circumstances sur-rounding his case reports. He drew attentionto Caffey’s comments that “recognized inju-ries may be denied by mothers and nursesbecause injury to an infant implies negli-gence on the part of its caretaker,” and fur-thermore, “In one of the cases, the infant wasclearly unwanted by both parents, and thisraised the question of intentional ill-treat-ment of the infant” [1]. Silverman thoughtthat Caffey did not go further because “hewas concerned about possible legal reper-cussions” [6]. This reluctance to suggest thata child has been injured at the hands of acaretaker, despite compelling evidence, re-mains a powerful deterrent to mandated re-porting and appropriate adjudication ofcases of suspected abuse [7].

Great progress has been made in our un-derstanding of the spectrum of inflicted inju-ries in children, and diagnostic imaging hasbeen instrumental in this process. The grow-ing list of entities that may masquerade asabuse continues to receive much attentionwithin the medical realm and in various legalarenas. The intense litigation surroundingcases of suspected abuse along with the dif-ficulties encountered by physicians in an ad-versarial courtroom setting may present adaunting challenge to well-intentioned med-ical witnesses.

Much can be learned from Caffey’s [1] arti-cle, not only in substance but also in what it

A

Kleinman

1404 AJR:187, December 2006

says about his scholarship. Thorne Griscom[8], an avid student of the history of pediatricradiology, noted that Caffey was “supremelyorganized in his approach to pediatric radiol-ogy. He focused on the diagnostic challengeand gave it his undivided attention.” Radiologywill continue to play a central role in the diag-nosis of child abuse and its simulators. Caffey’sseminal article will remain a primer for all thosewho wish to learn the history and contribute toour future understanding and management ofthis important public heath concern.

References1. Caffey J. Multiple fractures in the long bones of in-

fants suffering from chronic subdural hematoma.

AJR 1946; 56:163–173

2. Silverman FN. Unrecognized trauma in infants, the

battered child syndrome, and the syndrome of Am-

broise Tardieu. Rigler Lecture. Radiology 1972;

104:337–353

3. Tardieu A. Étude médico-légale sur les sévices et

mauvais traitments exercés sur des enfants. Ann

Hyg Publ Med Leg 1860; 13:361–398

4. Sherwood D. Chronic subdural hematoma in in-

fants. Am J Dis Child 1930; 39:980

5. Ingraham F, Heyl H. Subdural hematoma in infancy

and childhood. JAMA 1939; 113:198–204

6. Silverman FN. Re: parental or custodial factors in

what is now recognized as child abuse. (letter). Pe-

diatr Radiol 1994; 24:541

7. Flaherty EG, Sege R. Barriers to physician identi-

fication and reporting of child abuse. Pediatr Ann

2005; 34:349–356

8. Griscom NT. Imaging of nonaccidental head

trauma in children. (commentary) Acad Radiol

1999; 6:81

F O R Y O U R I N F O R M A T I O N

Each month the American Journal of Roentgenology will republish one of the 100 most-citedarticles from its first century accompanied by a commentary by a contemporary radiologist toprovide a current perspective. For a full list of these articles, see page 3 of the January 2006issue of AJR or www.ajronline.org. “Multiple Fractures in the Long Bones of Infants Sufferingfrom Chronic Subdural Hematoma” can be viewed in the archives at www.ajronline.org.