title: Three-Dimensional Computed Tomography Skull Reconstructions as an Aid to Child Abuse Evaluations.
abstract: OBJECTIVE
  Skull fractures can be difficult to recognize on radiographs and axial computed tomography (CT) bone windows. Missed findings may delay abuse diagnosis. The role of three-dimensional (3-D) reconstructions in child abuse evaluations was retrospectively evaluated.
  
  
  METHODS
  Twelve exemplary cases between August 2006 and July 2009 are described. All, except 2 medical-legal cases, were clinical abuse consultations. With the use of a 1-to-3 scale, ease and accuracy of interpretation of findings between plain films, bone windows, and 3-D CT images were independently assessed by 2 radiologists.
  
  
  RESULTS
  In 7 cases, skull fractures were missed on initial review of skull films and/or bone windows. Three children sustained additional abusive injury before 3-D CT reconstructions demonstrated subtle skull fractures, though imaged, were missed on initial readings. Three children with initially unrecognized fractures had timely 3-D reconstructions confirming fractures, allowing protective intervention before additional injury. An unrecognized ping-pong fracture was discovered on 3-D reconstructions with an inflicted subdural hemorrhage, defining the injury as an impact. Two 3-Ds demonstrated communication of biparietal fractures along the sagittal suture. This changed interpretation to single, rather than 2 separate, concerning impacts. Three potential skull fractures were found to represent large sutural bones. In all cases, ease and accuracy of interpretation scores were highest for 3-D CT.
  
  
  CONCLUSIONS
  Without increasing patient radiation exposure, 3-D CT reconstructions may reveal previously unrecognized skull fractures, potentially allowing abuse diagnosis before additional injury. They may clarify normal skull variants and affirm accidental injury causes. We now routinely include 3-D reconstructions on cranial CTs for children younger than 3 years.
authors.affiliation: From the Departments of *Radiology, and †Pediatrics, ‡Seattle Children's; §University of Washington School of Medicine; and ∥Harborview Hospital, University of Washington School of Medicine, Seattle, WA.
authors.forename: Marguerite T
authors.initials: MT
authors.lastname: Parisi
authors.forename: Rebecca T
authors.initials: RT
authors.lastname: Wiester
authors.forename: Stephen L
authors.initials: SL
authors.lastname: Done
authors.forename: Naomi F
authors.initials: NF
authors.lastname: Sugar
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Feldman
mesh_terms: D000293:Adolescent; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D007223:Infant; D012189:Retrospective Studies; D012887:Skull Fractures / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed