1. Kleinman Centennial Article • Commentary
Fractures and Hematoma in
Infants
“Multiple Fractures in the Long
A C E N T U
R Y O F Bones of Infants Suffering from
Chronic Subdural Hematoma”—
MEDICAL IMAGING
A Commentary
Paul K. Kleinman1 mong his many distinctions as a pi- The importance of Caffey’s [1] observa-
Kleinman PK A oneer in the burgeoning field of pe-
diatric radiology, John Caffey [1]
wrote the first systematic clinical
tions notwithstanding, one might wonder
why he failed to make any emphatic state-
ments regarding intentional injury on the
and radiologic study of infants and toddlers part of the caretakers of the children in his
with the now well-recognized features of child 1946 study. According to Silverman [2],
abuse. In this landmark 1946 AJR article, Caf- Caffey was convinced that traumatic events
fey reported six children under 2 years old with resulting in subdural hematomas and in skel-
long-bone fractures and subdural hematomas. etal lesions were causally related and most
Their neurologic symptoms were first reported likely reflected “parental malfeasance” [6].
between the ages of 2 weeks and 10 months Silverman also noted the care with which
(mean age, 5 months), and the age at which Caffey described the circumstances sur-
fractures were first documented ranged from 6 rounding his case reports. He drew attention
weeks to 16 months (mean age, 10 months). In- to Caffey’s comments that “recognized inju-
jury patterns included various shaft fractures, ries may be denied by mothers and nurses
metaphyseal lesions, and periosteal new bone because injury to an infant implies negli-
formation of the upper and lower extremities. gence on the part of its caretaker,” and fur-
There were no skull or rib fractures. There was thermore, “In one of the cases, the infant was
no history of trauma to explain the findings. clearly unwanted by both parents, and this
Frederick Silverman [2], a protégé of Caffey raised the question of intentional ill-treat-
and an important contributor to our current un- ment of the infant” [1]. Silverman thought
derstanding of child abuse, drew attention to that Caffey did not go further because “he
Keywords: child abuse, infants, long-bone fractures,
the work of Ambrose Tardieu, a professor of was concerned about possible legal reper-
neonates, pediatric imaging, pediatric radiology, subdural legal medicine at Faculté de Medicine de Paris cussions” [6]. This reluctance to suggest that
hematomas from 1861 to 1879. In 1860, nearly a half cen- a child has been injured at the hands of a
tury before the advent of diagnostic X-rays, caretaker, despite compelling evidence, re-
DOI:10.2214/AJR.06.0418
Tardieu [3] published an article on the mal- mains a powerful deterrent to mandated re-
Received March 22, 2006; accepted without revision treatment of children that detailed the clinical porting and appropriate adjudication of
March 24, 2006. findings, including the description of fractures. cases of suspected abuse [7].
Although a few case reports of fractures in pa- Great progress has been made in our un-
Each month the American Journal of Roentgenology will tients with subdural hematomas appeared in derstanding of the spectrum of inflicted inju-
republish online one of the 100 most-cited articles from its
first century. A corresponding commentary in the print
the 1930s, 86 years elapsed before Caffey [1] ries in children, and diagnostic imaging has
journal by a contemporary radiologist will provide a current and others [4, 5] documented the radiologic been instrumental in this process. The grow-
perspective. For a full list of these articles, see page 3 of the findings. In a sense, the radiographs provided ing list of entities that may masquerade as
January 2006 issue of the AJR or go to www.ajronline.org. concrete evidence of a phenomenon that could abuse continues to receive much attention
1Department
be traced to antiquity [3]. It appears that the ra- within the medical realm and in various legal
of Radiology, Section of Musculoskeletal
Imaging, Children’s Hospital Boston and Harvard Medical
diographic depiction of inflicted injuries arenas. The intense litigation surrounding
School, 300 Longwood Ave., Boston, MA 02115. brought the notion of abuse to a visual level cases of suspected abuse along with the dif-
Address correspondence to P. K. Kleinman and made it accessible to the medical commu- ficulties encountered by physicians in an ad-
(paul.kleinman@childrens.harvard.edu). nity at large. Currently there is extensive and versarial courtroom setting may present a
AJR 2006; 187:1403–1404
rich literature detailing every facet of child daunting challenge to well-intentioned med-
maltreatment, and diagnostic imaging contin- ical witnesses.
0361–803X/06/1876–1403
ues to influence our understanding and recog- Much can be learned from Caffey’s [1] arti-
© American Roentgen Ray Society nition of this complex disorder. cle, not only in substance but also in what it
AJR:187, December 2006 1403

2. Kleinman
says about his scholarship. Thorne Griscom References fants. Am J Dis Child 1930; 39:980
[8], an avid student of the history of pediatric 1. Caffey J. Multiple fractures in the long bones of in- 5. Ingraham F, Heyl H. Subdural hematoma in infancy
radiology, noted that Caffey was “supremely fants suffering from chronic subdural hematoma. and childhood. JAMA 1939; 113:198–204
organized in his approach to pediatric radiol- AJR 1946; 56:163–173 6. Silverman FN. Re: parental or custodial factors in
ogy. He focused on the diagnostic challenge 2. Silverman FN. Unrecognized trauma in infants, the what is now recognized as child abuse. (letter). Pe-
and gave it his undivided attention.” Radiology battered child syndrome, and the syndrome of Am- diatr Radiol 1994; 24:541
will continue to play a central role in the diag- broise Tardieu. Rigler Lecture. Radiology 1972; 7. Flaherty EG, Sege R. Barriers to physician identi-
nosis of child abuse and its simulators. Caffey’s 104:337–353 fication and reporting of child abuse. Pediatr Ann
seminal article will remain a primer for all those 3. Tardieu A. Étude médico-légale sur les sévices et 2005; 34:349–356
who wish to learn the history and contribute to mauvais traitments exercés sur des enfants. Ann 8. Griscom NT. Imaging of nonaccidental head
our future understanding and management of Hyg Publ Med Leg 1860; 13:361–398 trauma in children. (commentary) Acad Radiol
this important public heath concern. 4. Sherwood D. Chronic subdural hematoma in in- 1999; 6:81
F O R YO U R I N F O R M AT I O N
Each month the American Journal of Roentgenology will republish one of the 100 most-cited
articles from its first century accompanied by a commentary by a contemporary radiologist to
provide a current perspective. For a full list of these articles, see page 3 of the January 2006
issue of AJR or www.ajronline.org. “Multiple Fractures in the Long Bones of Infants Suffering
from Chronic Subdural Hematoma” can be viewed in the archives at www.ajronline.org.
1404 AJR:187, December 2006

3. Kleinman Centennial Article • Commentary
Fractures and Hematoma in
Infants
“Multiple Fractures in the Long
A C E N T U
R Y O F Bones of Infants Suffering from
Chronic Subdural Hematoma”—
MEDICAL IMAGING
A Commentary
Paul K. Kleinman1 mong his many distinctions as a pi- The importance of Caffey’s [1] observa-
Kleinman PK A oneer in the burgeoning field of pe-
diatric radiology, John Caffey [1]
wrote the first systematic clinical
tions notwithstanding, one might wonder
why he failed to make any emphatic state-
ments regarding intentional injury on the
and radiologic study of infants and toddlers part of the caretakers of the children in his
with the now well-recognized features of child 1946 study. According to Silverman [2],
abuse. In this landmark 1946 AJR article, Caf- Caffey was convinced that traumatic events
fey reported six children under 2 years old with resulting in subdural hematomas and in skel-
long-bone fractures and subdural hematomas. etal lesions were causally related and most
Their neurologic symptoms were first reported likely reflected “parental malfeasance” [6].
between the ages of 2 weeks and 10 months Silverman also noted the care with which
(mean age, 5 months), and the age at which Caffey described the circumstances sur-
fractures were first documented ranged from 6 rounding his case reports. He drew attention
weeks to 16 months (mean age, 10 months). In- to Caffey’s comments that “recognized inju-
jury patterns included various shaft fractures, ries may be denied by mothers and nurses
metaphyseal lesions, and periosteal new bone because injury to an infant implies negli-
formation of the upper and lower extremities. gence on the part of its caretaker,” and fur-
There were no skull or rib fractures. There was thermore, “In one of the cases, the infant was
no history of trauma to explain the findings. clearly unwanted by both parents, and this
Frederick Silverman [2], a protégé of Caffey raised the question of intentional ill-treat-
and an important contributor to our current un- ment of the infant” [1]. Silverman thought
derstanding of child abuse, drew attention to that Caffey did not go further because “he
Keywords: child abuse, infants, long-bone fractures,
the work of Ambrose Tardieu, a professor of was concerned about possible legal reper-
neonates, pediatric imaging, pediatric radiology, subdural legal medicine at Faculté de Medicine de Paris cussions” [6]. This reluctance to suggest that
hematomas from 1861 to 1879. In 1860, nearly a half cen- a child has been injured at the hands of a
tury before the advent of diagnostic X-rays, caretaker, despite compelling evidence, re-
DOI:10.2214/AJR.06.0418
Tardieu [3] published an article on the mal- mains a powerful deterrent to mandated re-
Received March 22, 2006; accepted without revision treatment of children that detailed the clinical porting and appropriate adjudication of
March 24, 2006. findings, including the description of fractures. cases of suspected abuse [7].
Although a few case reports of fractures in pa- Great progress has been made in our un-
Each month the American Journal of Roentgenology will tients with subdural hematomas appeared in derstanding of the spectrum of inflicted inju-
republish online one of the 100 most-cited articles from its
first century. A corresponding commentary in the print
the 1930s, 86 years elapsed before Caffey [1] ries in children, and diagnostic imaging has
journal by a contemporary radiologist will provide a current and others [4, 5] documented the radiologic been instrumental in this process. The grow-
perspective. For a full list of these articles, see page 3 of the findings. In a sense, the radiographs provided ing list of entities that may masquerade as
January 2006 issue of the AJR or go to www.ajronline.org. concrete evidence of a phenomenon that could abuse continues to receive much attention
1Department
be traced to antiquity [3]. It appears that the ra- within the medical realm and in various legal
of Radiology, Section of Musculoskeletal
Imaging, Children’s Hospital Boston and Harvard Medical
diographic depiction of inflicted injuries arenas. The intense litigation surrounding
School, 300 Longwood Ave., Boston, MA 02115. brought the notion of abuse to a visual level cases of suspected abuse along with the dif-
Address correspondence to P. K. Kleinman and made it accessible to the medical commu- ficulties encountered by physicians in an ad-
(paul.kleinman@childrens.harvard.edu). nity at large. Currently there is extensive and versarial courtroom setting may present a
AJR 2006; 187:1403–1404
rich literature detailing every facet of child daunting challenge to well-intentioned med-
maltreatment, and diagnostic imaging contin- ical witnesses.
0361–803X/06/1876–1403
ues to influence our understanding and recog- Much can be learned from Caffey’s [1] arti-
© American Roentgen Ray Society nition of this complex disorder. cle, not only in substance but also in what it
AJR:187, December 2006 1403

4. Kleinman
says about his scholarship. Thorne Griscom References fants. Am J Dis Child 1930; 39:980
[8], an avid student of the history of pediatric 1. Caffey J. Multiple fractures in the long bones of in- 5. Ingraham F, Heyl H. Subdural hematoma in infancy
radiology, noted that Caffey was “supremely fants suffering from chronic subdural hematoma. and childhood. JAMA 1939; 113:198–204
organized in his approach to pediatric radiol- AJR 1946; 56:163–173 6. Silverman FN. Re: parental or custodial factors in
ogy. He focused on the diagnostic challenge 2. Silverman FN. Unrecognized trauma in infants, the what is now recognized as child abuse. (letter). Pe-
and gave it his undivided attention.” Radiology battered child syndrome, and the syndrome of Am- diatr Radiol 1994; 24:541
will continue to play a central role in the diag- broise Tardieu. Rigler Lecture. Radiology 1972; 7. Flaherty EG, Sege R. Barriers to physician identi-
nosis of child abuse and its simulators. Caffey’s 104:337–353 fication and reporting of child abuse. Pediatr Ann
seminal article will remain a primer for all those 3. Tardieu A. Étude médico-légale sur les sévices et 2005; 34:349–356
who wish to learn the history and contribute to mauvais traitments exercés sur des enfants. Ann 8. Griscom NT. Imaging of nonaccidental head
our future understanding and management of Hyg Publ Med Leg 1860; 13:361–398 trauma in children. (commentary) Acad Radiol
this important public heath concern. 4. Sherwood D. Chronic subdural hematoma in in- 1999; 6:81
F O R YO U R I N F O R M AT I O N
Each month the American Journal of Roentgenology will republish one of the 100 most-cited
articles from its first century accompanied by a commentary by a contemporary radiologist to
provide a current perspective. For a full list of these articles, see page 3 of the January 2006
issue of AJR or www.ajronline.org. “Multiple Fractures in the Long Bones of Infants Suffering
from Chronic Subdural Hematoma” can be viewed in the archives at www.ajronline.org.
1404 AJR:187, December 2006