Purpose or Case Report: Many normal variants in the skeletal survey can be misconceived as signs of child abuse. Accurate differentiation between the two is crucial in subjecting only the perpetrators to trial. The present exhibit educates on the radiographic signs and techniques that can help differentiate between normal variants and child abuse on the skeletal survey.
Methods & Materials: All publications on the topic to date were compiled to create a list of normal variants that simulate child abuse on the skeletal survey. For the purpose of this exhibit, normal variants are categorized into the three categories: skull, appendicular skeleton, and axial skeleton. Common normal variants in each of the three categories are described. Key characteristic radiographic features that can differentiate these normal variants from child abuse are also examined.
Results: Skull suture variants particularly in the parietal and occipital bones are oftentimes erroneously interpreted as fractures. Radiographic findings of normal skull sutures include zigzag pattern with sclerotic borders, absence of diastasis, bilateral and symmetric appearance, absence of soft tissue swelling. Calvarial fractures on the other hand are lucent with nonsclerotic edges, typically unilateral, widen when approaching the suture, and sometimes cross the suture.

Normal metaphyseal variants including step-off, beak, spur, and fragmentation mimic child abuse. Differentiation of metaphyseal findings can be difficult but the awareness of normal variants, acquisition of AP and lateral coned views, and follow up radiographs are all important.

The notable anatomical variants of the spine include normal synchondrosis, ossification centers, intersegmental clefts, anterior wedging of up to 3mm particularly at C3, and pseudoxubluxation at the C2-C3 level. Anatomical variants of the cervical spine can be differentiated by the knowledge of normal variants, technique or position dependent changes, preservation of the posterior cervical line, and absence of prevertebral soft tissue thickening.
Conclusions: Differentiation between normal variants and child abuse on the skeletal survey requires knowledge of the normal variants and key radiographic features that favor one from another. Since the final report generated by radiologists directly impacts the management of suspected cases of child abuse, proper education on this topic is of utmost clinical importance.