Genital Manifestations of Physical Abuse in Male Infants and Children.

We present 3 male patients with genital bruising due to physical abuse to improve recognition of genital trauma as a sentinel injury. In the absence of an underlying medical condition or a clear acceptable accidental mechanism for the genital injury, an evaluation for child abuse is recommended.

Dating birth-related clavicular fractures: pediatric radiologists versus artificial intelligence.

BACKGROUND: Fracture dating from skeletal surveys is crucial in the diagnosis and investigation of infant abuse. However, this task is challenging because of the subjective nature of the radiologic interpretation and the lack of ground truth. Researchers have used birth-related clavicle fractures as a surrogate to study the radiographic pattern of healing; however, they did not elucidate the accuracy performance of the radiologists in dating fractures. OBJECTIVE: To determine the accuracy of radiologists in dating birth-related clavicle fractures and compare their performance to that achieved by computer algorithm. MATERIALS AND METHODS: We used a previously assembled birth-related clavicle fracture database consisting of 416 anteroposterior clavicle radiographs as the study cohort. The average and standard deviation of the fracture age within this database were 24 days and 18 days, respectively. Three blinded radiologists independently estimated the ages of the clavicle fractures depicted in the radiographs within the database. We compared these estimation results to those made by a recently published deep-learning (DL) model conducted with the identical infant cohort. We calculated standard error metrics to compare the accuracy performances of the radiologists and the computer model. RESULTS: The intra- and inter-reader agreements of the fracture age estimates by the radiologists were moderate to good. The radiologists estimated the fracture ages with a mean absolute error (MAE) of 6.1-7.1 days, and standard deviation of the absolute error of 6.3-8.3 days. The accuracy performances of the three radiologists were not significantly different from one another. In comparison, the DL model estimated the age of clavicle fractures with an MAE of 4.2 days, significantly lower than all of the radiologists (P < 0.001). CONCLUSION: Three experienced pediatric radiologists dated clavicular fractures with moderate-good intra- and inter-reader agreements. The correlations between the radiologists' estimates and the ground truth were moderate to good. The fracture ages assigned by the DL model showed superior correlation with the ground truth compared to radiologists' dating estimates.

Ehlers-Danlos syndrome: what the radiologist needs to know.

Ehlers-Danlos syndrome is a real diagnosis that is erroneously used to explain multiple fractures in suspected child abuse. This paper reviews the clinical and molecular diagnostic criteria for Ehlers-Danlos syndrome. This knowledge can help prevent misdiagnosis and support clinicians when evaluating infants and young children with multiple fractures.

The radiology report in child abuse.

The radiology report in a case of suspected child abuse is both a medical and a legal document. Such reports should be thorough, specific, well-constructed and without error. Structured templates and standardized reporting contribute to completeness, consistency and communication. Here, the authors discuss common reporting errors. Radiologists should be prepared that the radiology report in a case of suspected child abuse is likely to be used in court.

Curved planar reformatting and convolutional neural network-based segmentation of the small bowel for visualization and quantitative assessment of pediatric Crohn's disease from MRI.

BACKGROUND: Contrast-enhanced MRI of the small bowel is an effective imaging sequence for the detection and characterization of disease burden in pediatric Crohn's disease (CD). However, visualization and quantification of disease burden requires scrolling back and forth through 3D images to follow the anatomy of the bowel, and it can be difficult to fully appreciate the extent of disease. PURPOSE: To develop and evaluate a method that offers better visualization and quantitative assessment of CD from MRI. STUDY TYPE: Retrospective. POPULATION: Twenty-three pediatric patients with CD. FIELD STRENGTH/SEQUENCE: 1.5T MRI system and T1 -weighted postcontrast VIBE sequence. ASSESSMENT: The convolutional neural network (CNN) segmentation of the bowel's lumen, wall, and background was compared with manual boundary delineation. We assessed the reproducibility and the capability of the extracted markers to differentiate between different levels of disease defined after a consensus review by two experienced radiologists. STATISTICAL TESTS: The segmentation algorithm was assessed using the Dice similarity coefficient (DSC) and boundary distances between the CNN and manual boundary delineations. The capability of the extracted markers to differentiate between different disease levels was determined using a t-test. The reproducibility of the extracted markers was assessed using the mean relative difference (MRD), Pearson correlation, and Bland-Altman analysis. RESULTS: Our CNN exhibited DSCs of 75 ± 18%, 81 ± 8%, and 97 ± 2% for the lumen, wall, and background, respectively. The extracted markers of wall thickness at the location of min radius (P = 0.0013) and the median value of relative contrast enhancement (P = 0.0033) could differentiate active and nonactive disease segments. Other extracted markers could differentiate between segments with strictures and segments without strictures (P < 0.05). The observers' agreement in measuring stricture length was >3 times superior when computed on curved planar reformatting images compared with the conventional scheme. DATA CONCLUSION: The results of this study show that the newly developed method is efficient for visualization and assessment of CD. LEVEL OF EVIDENCE: 4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1565-1576.

The distal tibial classic metaphyseal lesion: medial versus lateral cortical injury.

BACKGROUND: The distal tibia is a common location for the classic metaphyseal lesion (CML). Prior radiologic-pathologic studies have suggested a tendency for medial, as opposed to lateral, cortical injury with the CML, but there has been no formal study of the geographic distribution of this strong indicator of abuse. OBJECTIVE: This study compares medial versus lateral cortical involvement of distal tibial CMLs in a clinical cohort of infants with suspected abuse. MATERIALS AND METHODS: Reports of 1,020 skeletal surveys performed for suspected abuse (July 2005-June 2016) were reviewed. Twenty-six distal tibial CMLs (14 unilateral, 6 bilateral) with anteroposterior (AP) and lateral projections on the initial skeletal survey and at least an AP view on the follow-up survey were identified in 20 infants. Two blinded pediatric radiologists determined if the medial and/or lateral margins of the distal tibial metaphysis were involved by the CML. RESULTS: Average interreader absolute agreement and kappa scores were 0.69-0.90 and 0.45-0.72, respectively. Average intrareader absolute agreement and kappa scores were 0.65-0.88 and 0.44-0.57, respectively. Analyses showed that the distal tibial CML almost always involved the medial cortical margin (reader 1=89%, reader 2=88%, pooled=89%) and the fracture infrequently involved the lateral cortical margin (reader 1=12%, reader 2=38%, pooled=26%). The percentage point difference between fracture involvement in medial and lateral margins was statistically significant from zero (P<0.001). CONCLUSION: The distal tibial CML is most often encountered medially; lateral involvement is uncommon. This observation should help guide the radiologic diagnosis and could have implications for understanding the biomechanics of this distinctive injury.

Motion-robust parameter estimation in abdominal diffusion-weighted MRI by simultaneous image registration and model estimation.

Quantitative body DW-MRI can detect abdominal abnormalities as well as monitor response-to-therapy for applications including cancer and inflammatory bowel disease with increased accuracy. Parameter estimates are obtained by fitting a forward model of DW-MRI signal decay to the observed data acquired with several b-values. The DW-MRI signal decay models typically used do not account for respiratory, cardiac and peristaltic motion, however, which may deteriorate the accuracy and robustness of parameter estimates. In this work, we introduce a new model of DW-MRI signal decay that explicitly accounts for motion. Specifically, we estimated motion-compensated model parameters by simultaneously solving image registration and model estimation (SIR-ME) problems utilizing the interdependence of acquired volumes along the diffusion-weighting dimension. To accomplish this, we applied the SIR-ME model to the in-vivo DW-MRI data sets of 26 Crohn's disease (CD) patients and achieved improved precision of the estimated parameters by reducing the coefficient of variation by 8%, 24% and 8% for slow diffusion (D), fast diffusion (D*) and fast diffusion fraction (f) parameters respectively, compared to parameters estimated with independent registration in normal-appearing bowel regions. Moreover, the parameters estimated with the SIR-ME model reduced the error rate in classifying normal and abnormal bowel loops to 12% for D and 10% for f parameter with a reduction in error rate by 13% and 11% for D and f parameters, respectively, compared to the error rate in classifying parameter estimates obtained with independent registration. The experiments in DW-MRI of liver in 20 subjects also showed that the SIR-ME model improved the precision of parameter estimation by reducing the coefficient of variation to 7% for D, 23% for D*, and 8% for the f parameter. Using the SIR-ME model, the coefficient of variation was reduced by 4%, 14% and 6% for D, D* and f parameters, respectively, compared to parameters estimated with independent registration. These results demonstrate that the proposed SIR-ME model improves the accuracy and robustness of quantitative body DW-MRI in characterizing tissue microstructure.

Spatially-constrained probability distribution model of incoherent motion (SPIM) for abdominal diffusion-weighted MRI.

Quantitative diffusion-weighted MR imaging (DW-MRI) of the body enables characterization of the tissue microenvironment by measuring variations in the mobility of water molecules. The diffusion signal decay model parameters are increasingly used to evaluate various diseases of abdominal organs such as the liver and spleen. However, previous signal decay models (i.e., mono-exponential, bi-exponential intra-voxel incoherent motion (IVIM) and stretched exponential models) only provide insight into the average of the distribution of the signal decay rather than explicitly describe the entire range of diffusion scales. In this work, we propose a probability distribution model of incoherent motion that uses a mixture of Gamma distributions to fully characterize the multi-scale nature of diffusion within a voxel. Further, we improve the robustness of the distribution parameter estimates by integrating spatial homogeneity prior into the probability distribution model of incoherent motion (SPIM) and by using the fusion bootstrap solver (FBM) to estimate the model parameters. We evaluated the improvement in quantitative DW-MRI analysis achieved with the SPIM model in terms of accuracy, precision and reproducibility of parameter estimation in both simulated data and in 68 abdominal in-vivo DW-MRIs. Our results show that the SPIM model not only substantially reduced parameter estimation errors by up to 26%; it also significantly improved the robustness of the parameter estimates (paired Student's t-test, p < 0.0001) by reducing the coefficient of variation (CV) of estimated parameters compared to those produced by previous models. In addition, the SPIM model improves the parameter estimates reproducibility for both intra- (up to 47%) and inter-session (up to 30%) estimates compared to those generated by previous models. Thus, the SPIM model has the potential to improve accuracy, precision and robustness of quantitative abdominal DW-MRI analysis for clinical applications.

Fractures Related to Metabolic Bone Disease in Children with Congenital Heart Disease.

OBJECTIVE: Critically ill children with congenital heart disease (CHD) are at risk for metabolic bone disease (MBD) and bone fractures. Our objective was to characterize a cohort of CHD patients with fractures and describe a Fragile Bone Protocol (FBP) developed to reduce fractures. DESIGN/SETTING: Patients who developed fractures in the Cardiac Intensive Care Unit (CICU) of Boston Children's Hospital from 3/2008 to 6/2014 were identified via quality improvement and radiology databases. The FBP (initiated July 2011) systematically identifies patients at risk for MBD and prescribes special handling precautions. RESULTS: Twenty-three fractures were identified in 15 children. Median age at fracture identification was 6.2 months, with a median duration of hospitalization before fracture diagnosis of 2.7 months. Six patients (40%) had single ventricle CHD. Hyperparathyroidism and low 25-OH vitamin D levels were present in 77% and 40% of those tested, respectively. Compared with patients not diagnosed with fractures, fracture patients had increased exposure to possible risk factors for MBD and had elevated parathyroid and decreased calcitriol levels.Six patients (40%) did not survive to hospital discharge, compared with an overall CICU mortality rate of 2.6% (P < .01). The fracture case rate before implementation of the FBP was 2.6 cases/1000 admissions and was 0.7/1000 after implementation of the FBP (P = .04). CONCLUSIONS: Critically ill CHD patients are at risk for fractures. They represent a complex group who frequently has hyperparathyroidism and decreased calcitriol levels, and each may predispose to fractures. FBPs consisting of identification and careful patient handling should be considered in at-risk patients.

Motion Compensated Abdominal Diffusion Weighted MRI by Simultaneous Image Registration and Model Estimation (SIR-ME).

Non-invasive characterization of water molecule's mobility variations by quantitative analysis of diffusion-weighted MRI (DW-MRI) signal decay in the abdomen has the potential to serve as a biomarker in gastrointestinal and oncological applications. Accurate and reproducible estimation of the signal decay model parameters is challenging due to the presence of respiratory, cardiac, and peristalsis motion. Independent registration of each b-value image to the b-value=0 s/mm(2) image prior to parameter estimation might be sub-optimal because of the low SNR and contrast difference between images of varying b-value. In this work, we introduce a motion-compensated parameter estimation framework that simultaneously solves image registration and model estimation (SIR-ME) problems by utilizing the interdependence of acquired volumes along the diffusion weighting dimension. We evaluated the improvement in model parameters estimation accuracy using 16 in-vivo DW-MRI data sets of Crohn's disease patients by comparing parameter estimates obtained using the SIR-ME model to the parameter estimates obtained by fitting the signal decay model to the acquired DW-MRI images. The proposed SIR-ME model reduced the average root-mean-square error between the observed signal and the fitted model by more than 50%. Moreover, the SIR-ME model estimates discriminate between normal and abnormal bowel loops better than the standard parameter estimates.

Spatially constrained incoherent motion method improves diffusion-weighted MRI signal decay analysis in the liver and spleen.

PURPOSE: To evaluate the effect of the spatially constrained incoherent motion (SCIM) method on improving the precision and robustness of fast and slow diffusion parameter estimates from diffusion-weighted MRI in liver and spleen in comparison to the independent voxel-wise intravoxel incoherent motion (IVIM) model. METHODS: We collected diffusion-weighted MRI (DW-MRI) data of 29 subjects (5 healthy subjects and 24 patients with Crohn's disease in the ileum). We evaluated parameters estimates' robustness against different combinations of b-values (i.e., 4 b-values and 7 b-values) by comparing the variance of the estimates obtained with the SCIM and the independent voxel-wise IVIM model. We also evaluated the improvement in the precision of parameter estimates by comparing the coefficient of variation (CV) of the SCIM parameter estimates to that of the IVIM. RESULTS: The SCIM method was more robust compared to IVIM (up to 70% in liver and spleen) for different combinations of b-values. Also, the CV values of the parameter estimations using the SCIM method were significantly lower compared to repeated acquisition and signal averaging estimated using IVIM, especially for the fast diffusion parameter in liver (CVIV IM = 46.61 ± 11.22, CVSCIM = 16.85 ± 2.160, p < 0.001) and spleen (CVIV IM = 95.15 ± 19.82, CVSCIM = 52.55 ± 1.91, p < 0.001). CONCLUSIONS: The SCIM method characterizes fast and slow diffusion more precisely compared to the independent voxel-wise IVIM model fitting in the liver and spleen.

Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions.

PURPOSE: To determine if rickets is present in cases of infant homicide with classic metaphyseal lesions (CMLs) and other skeletal injuries. MATERIALS AND METHODS: This study was exempt from the institutional human subjects board review because all infants were deceased. An archival review (1984-2012) was performed of the radiologic and histopathologic findings of 46 consecutive infant fatalities referred from the state medical examiner's office for the evaluation of possible child abuse. Thirty infants with distal femoral histologic material were identified. Additional inclusion criteria were as follows: (a) The medical examiner determined that the infant had sustained a head injury and that the manner of death was a homicide, (b) at least one CML was evident at skeletal survey, (c) CMLs were confirmed at autopsy, and (d) non-CML fractures were also present. Nine infants (mean age, 3.9 months; age range, 1-9 months) were identified. Two pediatric radiologists independently reviewed the skeletal surveys for rachitic changes at the wrists and knees. A bone and soft tissue pathologist reviewed the distal femoral histologic slices for rickets. RESULTS: There were no radiographic or pathologic features of rickets in the cohort. CONCLUSION: The findings provide no support for the view that the CML is due to rickets. Rather, they strengthen a robust literature that states that the CML is a traumatic injury commonly encountered in physically abused infants.

The yield of high-detail radiographic skeletal surveys in suspected infant abuse.

BACKGROUND: Skeletal surveys are routinely performed in cases of suspected child abuse, but there are limited data regarding the yield of high-detail skeletal surveys in infants. OBJECTIVE: To determine the diagnostic yield of high-detail radiographic skeletal surveys in suspected infant abuse. MATERIAL AND METHODS: We reviewed the high-detail American College of Radiology standardized skeletal surveys performed for suspected abuse in 567 infants (median: 4.4 months, SD 3.47; range: 4 days-12 months) at a large urban children's hospital between 2005 and 2013. Skeletal survey images, radiology reports and medical records were reviewed. A skeletal survey was considered positive when it showed at least one unsuspected fracture. RESULTS: In 313 of 567 infants (55%), 1,029 definite fractures were found. Twenty-one percent (119/567) of the patients had a positive skeletal survey with a total of 789 (77%) unsuspected fractures. Long-bone fractures were the most common injuries, present in 145 children (26%). The skull was the site of fracture in 138 infants (24%); rib cage in 77 (14%), clavicle in 24 (4.2%) and uncommon fractures (including spine, scapula, hands and feet and pelvis) were noted in 26 infants (4.6%). Of the 425 infants with neuroimaging, 154 (36%) had intracranial injury. No significant correlation between positive skeletal survey and associated intracranial injury was found. Scapular fractures and complex skull fractures showed a statistically significant correlation with intracranial injury (P = 0.029, P = 0.007, respectively). CONCLUSION: Previously unsuspected fractures are noted on skeletal surveys in 20% of cases of suspected infant abuse. These data may be helpful in the design and optimization of global skeletal imaging in this vulnerable population.

An electronic tool for systematic reporting of fractures on skeletal surveys in suspected child abuse: prototype development and physician feedback.

OBJECTIVE: To describe a skeletal survey data entry and compilation tool and assess physician attitudes toward this reporting approach. BACKGROUND: Narrative skeletal survey reports are highly variable and prone to inconsistencies with potential adverse impact on patients. MATERIALS AND METHODS: The prototype skeletal survey data entry and compilation tool was developed and introduced into clinical practice at a large urban children's hospital. Pediatric radiologists and child protection team (CPT) pediatricians completed a survey of reporting preferences. Skeletal survey reports between March 1, 2013, and March 1, 2014, were reviewed to assess use of the tool. RESULTS: The survey response rate was 70% (14/20) for radiologists and 100% (4/4) for CPT pediatricians. Among responding radiologists, 54.5% (6/11) indicated that a skeletal survey data entry and compilation tool was helpful for skeletal surveys with >3 fractures; 80% (8/10) of responding radiologists indicated that tabulated data from prior skeletal survey was helpful when interpreting a follow-up skeletal survey with >3 fractures; 90.9% (10/11) of radiologists thought the tool improved report organization; 72.7% (8/11) thought it improved accuracy. Most radiologists (11/12, 91.7%) and 100% (4/4) of CPT clinicians preferred reports with both free text and a tabulated fracture list for testifying in court when >3 fractures were present. The tool was used in the reporting of 14/23 (61%) skeletal surveys with >3 fractures during a 1-year period. A case example using the application is presented. CONCLUSION: Most radiologists and CPT physicians at our center prefer skeletal survey reports with tabulated data and narrative description; 91.7% (11/12) of radiologists and all CPT clinicians prefer this approach for testifying in court when >3 fractures are present.

Evaluating children with fractures for child physical abuse.

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

Prevalence and relevance of pediatric spinal fractures in suspected child abuse.

BACKGROUND: Spinal fractures are uncommon manifestations of child abuse and elimination of the lateral views of the spine from the initial skeletal survey protocol has been recommended. OBJECTIVE: To establish the prevalence of spinal fractures detected on skeletal surveys performed for suspected child abuse and their association with intracranial injury (ICI). MATERIALS AND METHODS: The ACR standardized skeletal surveys and neuroimaging studies of 751 children (ages 0-4 years) were reviewed. A positive skeletal survey was defined as having one or more clinically unsuspected fractures. RESULTS: Fourteen children had a total of 22 definite spinal fractures. This constituted 1.9% (14/751) of the total cohort, and 9.7% (14/145) of children with a positive skeletal survey. Advanced imaging confirmed the fractures in 13 of the 14 children and demonstrated 12 additional spinal fractures. In five cases, spinal fractures were the only positive skeletal findings. In 71% (10/14) of the children, the spinal fractures were accompanied by ICI. Children with spinal fractures were at significantly greater risk for ICI than those without spinal injury (P < 0.05). CONCLUSION: Spinal fractures are not rare in children with positive skeletal surveys performed for suspected abuse and they may be the only indication of skeletal trauma. There is an association between spinal fractures and ICI.

Reliable estimation of incoherent motion parametric maps from diffusion-weighted MRI using fusion bootstrap moves.

Diffusion-weighted MRI has the potential to provide important new insights into physiological and microstructural properties of the body. The Intra-Voxel Incoherent Motion (IVIM) model relates the observed DW-MRI signal decay to parameters that reflect blood flow in the capillaries (D*), capillaries volume fraction (f), and diffusivity (D). However, the commonly used, independent voxel-wise fitting of the IVIM model leads to imprecise parameter estimates, which has hampered their practical usage. In this work, we improve the precision of estimates by introducing a spatially-constrained Incoherent Motion (IM) model of DW-MRI signal decay. We also introduce an efficient iterative "fusion bootstrap moves" (FBM) solver that enables precise parameter estimates with this new IM model. This solver updates parameter estimates by applying a binary graph-cut solver to fuse the current estimate of parameter values with a new proposal of the parameter values into a new estimate of parameter values that better fits the observed DW-MRI data. The proposals of parameter values are sampled from the independent voxel-wise distributions of the parameter values with a model-based bootstrap resampling of the residuals. We assessed both the improvement in the precision of the incoherent motion parameter estimates and the characterization of heterogeneous tumor environments by analyzing simulated and in vivo abdominal DW-MRI data of 30 patients, and in vivo DW-MRI data of three patients with musculoskeletal lesions. We found our IM-FBM reduces the relative root mean square error of the D* parameter estimates by 80%, and of the f and D parameter estimates by 50% compared to the IVIM model with the simulated data. Similarly, we observed that our IM-FBM method significantly reduces the coefficient of variation of parameter estimates of the D* parameter by 43%, the f parameter by 37%, and the D parameter by 17% compared to the IVIM model (paired Student's t-test, p<0.0001). In addition, we found our IM-FBM method improved the characterization of heterogeneous musculoskeletal lesions by means of increased contrast-to-noise ratio of 19.3%. The IM model and FBM solver combined, provide more precise estimate of the physiological model parameter values that describing the DW-MRI signal decay and a better mechanism for characterizing heterogeneous lesions than does the independent voxel-wise IVIM model.

Characterization of fast and slow diffusion from diffusion-weighted MRI of pediatric Crohn's disease.

PURPOSE: To characterize fast and slow diffusion components in diffusion-weighted magnetic resonance imaging (DW-MRI) of pediatric Crohn's disease (CD). Overall diffusivity reduction as measured by the apparent diffusion coefficient (ADC) in patients with CD has been previously demonstrated. However, the ADC reduction may be due to changes in either fast or slow diffusion components. In this study we distinguished between the fast and slow diffusion components in the DW-MRI signal decay of pediatric CD. MATERIALS AND METHODS: We acquired MRI from 24 patients, including MR enterography (MRE) and DW-MRI with 8 b-values (0-800 s/mm(2)). We characterized fast and slow diffusivity by intravoxel incoherent motion (IVIM) model parameters (f, D*, D), and overall diffusivity by ADC values. We determined which model best described the DW-MRI signal decay. We assessed the influence of the IVIM model parameters on the ADC. We evaluated differences in model parameter values between the enhancing and nonenhancing groups. RESULTS: The IVIM model described the observed data significantly better than the ADC model (P = 0.0088). The ADC was correlated with f (r = 0.67, P = 0.0003), but not with D (r = 0.39, P = 0.062) and D* (r = -0.39, P = 0.057). f values were significantly lower (P < 0.003) and D* values were significantly higher (P = 0.03) in the enhancing segments, while D values were not significantly different between the groups (P = 0.14). CONCLUSION: For this study population the IVIM model provides a better description of the DW-MRI signal decay than the ADC model. The reduced ADC is related to changes in the fast diffusion rather than to changes in the slow diffusion.

Three-dimensional skull models as a problem-solving tool in suspected child abuse.

BACKGROUND: The value of 3-D skull models in evaluation of young children with suspected child abuse is not known. OBJECTIVE: The purpose of this study was to assess the value of 3-D skull models as a problem-solving tool in children younger than 2 years. MATERIALS AND METHODS: We performed a retrospective study on 73 children (ages 0-24 months) seen by a child protection team (CPT) who were undergoing head CT between August 2007 and July 2009. RESULTS: Of the 73 children, volume-rendered 3-D models were obtained in 26 (35.6%). Three-dimensional models changed initial CT interpretation in nine instances (34.6%). Findings thought to be fractures were confirmed as normal variants in four children. Depressed fractures were correctly shown to be ping-pong fractures in two cases. In one case, an uncertain finding was confirmed as a fracture, and an additional contralateral fracture was identified in one child. A fracture seen on skull radiographs but not seen on axial CT images was identified on the 3-D model in one case. Changes in interpretation led to modification in management in five children. CONCLUSION: Use of 3-D skull models can be a problem-solving tool when there is discordance among the CT reading, subsequent radiographic investigations and clinical evaluation.