NAI Imaging Guidelines: Essential Protocols for Radiographers

Introduction

Non-accidental injury (NAI), also referred to as suspected physical abuse, presents one of the most sensitive and clinically significant imaging scenarios radiographers will encounter. The newly released Guideline for Imaging of Suspected Non-Accidental Injury provides essential protocols to assist radiologists and imaging professionals in these challenging cases.

This article summarises the key recommendations from the guideline and outlines the practical implications for radiographers working in clinical settings.

Understanding the Role of Medical Imaging in NAI

Medical imaging plays a crucial role in detecting, documenting, and characterising injuries that may indicate non-accidental trauma. Radiographers are often the first imaging professionals to interact with these vulnerable patients, making their role essential in the diagnostic pathway.

The primary objectives of imaging in suspected NAI include:

• Detection of occult injuries not visible on clinical examination
• Documentation of injury patterns that may indicate abusive trauma
• Determining injury age through radiological signs of healing
• Supporting multi-disciplinary team assessments with objective evidence

Skeletal Survey Protocols

The skeletal survey remains the cornerstone of NAI imaging assessment, particularly in children under 2 years of age. The guideline emphasises the importance of obtaining a complete, high-quality skeletal survey following standardised protocols.

Mandatory Views

A complete skeletal survey should include:

Body Region	Required Views
Skull	AP and lateral
Spine	Lateral cervical, AP thoracolumbar, lateral thoracolumbar
Chest	AP (to include clavicles and ribs)
Pelvis	AP
Upper limbs	AP humeri, AP forearms, PA hands
Lower limbs	AP femora, AP tibiae/fibulae, AP feet

Technical Considerations

Radiographers should ensure:

• Appropriate exposure factors for paediatric imaging with dose optimisation
• Correct positioning to demonstrate all anatomical structures clearly
• Individual exposures for each anatomical region (no "babygrams")
• Immobilisation techniques that do not obscure areas of clinical interest
• Repeat imaging if initial images are suboptimal

Head Imaging Recommendations

Head injuries represent a significant proportion of NAI cases and carry substantial morbidity and mortality. The guideline provides clear recommendations for neuroimaging.

CT Head

CT remains the first-line investigation for acute head injury due to its:

• Rapid acquisition time
• High sensitivity for acute haemorrhage
• Availability in emergency settings
• Ability to detect skull fractures

MRI Brain

MRI is recommended as a follow-up investigation and offers superior:

• Soft tissue characterisation
• Detection of parenchymal injuries
• Assessment of injury timing
• Identification of subtle subdural collections

The guideline recommends MRI within 3-5 days of presentation where NAI is suspected, even if initial CT appears normal.

The Follow-Up Skeletal Survey

A critical recommendation in the guideline is the follow-up skeletal survey performed 11-14 days after the initial examination. This second survey is essential because:

1. Healing fractures become visible - Some fractures, particularly metaphyseal corner fractures and rib fractures, may not be apparent on initial imaging but become visible as callus forms
2. Injury dating - The stage of healing helps determine injury age
3. Previously missed injuries - A second examination provides another opportunity to detect occult fractures

Radiographers should ensure follow-up appointments are scheduled and that patients are not lost to follow-up.

Documentation and Image Quality

The guideline emphasises meticulous documentation and image quality standards. Every image may potentially be used as evidence in legal proceedings, making quality paramount.

Image Annotation

All images should include:

• Patient demographics clearly visible
• Date and time of examination
• Anatomical markers (left/right)
• Institution identification

Reporting Turnaround

The guideline recommends urgent reporting within 24 hours for suspected NAI cases, with provisional findings communicated immediately when significant injuries are identified.

Multi-Disciplinary Coordination

NAI cases require coordinated multi-disciplinary input. Radiographers should be aware of local protocols for:

• Referral pathways to specialist paediatric services
• Communication procedures with safeguarding teams
• Chain of custody for imaging and documentation
• Information sharing between agencies

The Radiographer's Responsibilities

While diagnosis is not the radiographer's role, they have important responsibilities:

1. Performing high-quality examinations according to protocol
2. Documenting any additional clinical observations such as visible injuries or patient demeanour
3. Escalating concerns through appropriate channels
4. Maintaining confidentiality while supporting information sharing
5. Completing safeguarding training as required by their institution

Special Considerations

Differential Diagnoses

The guideline acknowledges that some medical conditions can mimic NAI on imaging. Radiographers should be aware that the reporting radiologist will consider:

• Osteogenesis imperfecta
• Metabolic bone disease of prematurity
• Vitamin D deficiency rickets
• Menkes disease
• Other rare bone fragility conditions

These considerations underscore why high-quality imaging is essential for accurate diagnosis.

Cultural Sensitivity and Communication

Imaging in suspected NAI requires particular sensitivity. Radiographers should:

• Maintain a non-judgmental approach
• Communicate clearly with accompanying adults
• Provide age-appropriate explanations to the child
• Document interactions objectively
• Seek support from senior colleagues when needed

Implementation in Practice

To implement the guideline effectively, imaging departments should:

Protocol Development

• Review current skeletal survey protocols against guideline recommendations
• Ensure exposure charts are optimised for paediatric imaging
• Establish clear workflows for urgent NAI cases

Staff Training

• Provide training on NAI imaging protocols to all relevant staff
• Include NAI awareness in safeguarding training programmes
• Conduct regular audit of skeletal survey quality

Equipment and Resources

• Ensure appropriate immobilisation equipment is available
• Maintain adequate staffing for timely examination completion
• Facilitate rapid access to imaging equipment for urgent cases

Quality Assurance

The guideline recommends regular audit against quality standards, including:

• Completeness of skeletal surveys
• Image quality assessment
• Reporting turnaround times
• Follow-up survey completion rates
• Compliance with local safeguarding procedures

Conclusion

The Guideline for Imaging of Suspected Non-Accidental Injury provides essential direction for radiographers and imaging departments managing these sensitive cases. Key takeaways include:

• Complete skeletal surveys following standardised protocols
• Follow-up imaging at 11-14 days
• Head imaging with CT acutely and MRI for follow-up
• Meticulous documentation and image quality
• Multi-disciplinary coordination and safeguarding awareness

By adhering to these guidelines, radiographers contribute significantly to child protection while maintaining the highest professional standards.

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This article is intended for educational purposes and summarises key recommendations. Always refer to your institution's local protocols and the full guideline document for clinical practice.