His X-ray vision reveals child abuse

It was late afternoon one recent day. Outside the sun was shining. But in Dr. Paul K. Kleinman's office at Children's Hospital Boston, it was dark, the shades were drawn, and he was staring at images of an infant's skeleton, looking for the telltale signs of child abuse.

"These X-rays," he said, "are from 13 minutes ago."

There were shots of the skull, the rib cage, the legs and arms, each from multiple angles. It's known as a skeletal survey, and doctors at Children's and most other hospitals request it whenever they're dealing with a child who may be suffering from abuse.

Kleinman sees these surveys all the time. As a pediatric radiologist, he has dedicated his career to creating standards to determine which injuries have been caused by child abuse and which have not. He has pushed for the use of skeletal surveys like this one. But more important , he has taught a generation of pediatricians and pediatric radiologists how to read the X-rays and know when they have more than just a medical problem on their hands.

Lawyers from all over the world contact him about child abuse cases. A decade ago he supervised a postmortem skeletal survey at UMass Memorial Medical Center for one of the most infamous child abuse cases Massachusetts has ever seen -- the case of the English au pair Louise Woodward and 8-month-old Matthew Eappen, who died in her care (Kleinman says he was not involved enough in the case to make a professional judgment about whether the boy was abused, but he understands how physicians involved in the case came to that conclusion). And he has published so much medical research that Dr. Betty Spivack , a pediatrician specializing in child abuse in Louisville, Ky., said, "It's hard to talk about Dr. Kleinman without gushing."

But please, begs a modest Kleinman, don't pay him any mind.

"The key is the kids," he said. "I really try to focus on them."

Kleinman, 61, was born and raised in tiny Ellenville, N.Y., where as a boy he dreamed of having a large impact on society. He earned his medical degree in 1971 and completed residencies in both pediatrics and radiology before joining the faculty at UMass Medical School in Worcester in 1978.

At that time, pediatricians might have had a hunch that a certain injury wasn't accidental. But Dr. Bob Reece , a pediatrician at Tufts-New England Medical Center, said it wasn't until Kleinman began doing research that doctors could eliminate guesswork and base their judgments on cold, hard science.

"It was terribly significant," said Reece. "It was such breakthrough information. He was the one able to determine certain kinds of fractures that were highly suggestive of abuse."

To make these determinations, Kleinman, along with Brian Blackbourne, then the state's chief medical examiner, removed the bones from dead children, examined them microscopically, and then worked backward to determine what might have caused such a break.

Mysteries unraveled and fractures indicative of abuse emerged. Take, for example, a rib fracture near the spine or a broken radius fractured near the wrist. A generation ago, parents might have been able to explain this away by saying their child fell down the stairs. Now, with the help of Kleinman's work, this rib fracture is known to be caused by forceful squeezing, and a break in a long bone near a joint is known to be most likely caused by twisting and pulling, not a fall.

"It's not just that he's taught us what studies to do and how to interpret them," said Dr. Kent Hymel , a pediatrician specializing in child abuse at Inova Fairfax Hospital for Children in Falls Church, Va. "But he's taught us which injuries have the greatest specificity for abuse. He's taught us a very systematic approach. He's changed systems, not just individual practice. He's changed standards. He's written standards."

In fact, Kleinman has written the book. It's called "Diagnostic Imaging of Child Abuse." Pediatric radiologists and pediatricians specializing in child abuse call it the bible for their field.

But even as he prepares to write the third edition of it, Kleinman prefers to talk about what hasn't been achieved yet: consistency in identifying the signs of child abuse from hospital to hospital. One day, he said, that's what he'd like to see in his dark office with the shades drawn.

"We're trying to make the difference," he said, "between a child being sent home into a violent environment or identifying a fracture that would allow us to set into motion the process of determining whether this child and others in the home are at risk."

Fact Sheet

Hometown: Born and raised in Ellenville, N.Y., now living in Cambridge.

Family: Married to Patricia Kleinman, an epidemiologist who often collaborates with Kleinman on his research. Has a grown daughter from a previous marriage.

Education: Earned a bachelor's degree in biology from Boston University in 1967 and later graduated from medical school at State University of New York Downstate Medical Center in 1971.

Kleinman on his book: "I'm not sure people go home and curl up with it in a comfortable chair and read it. But I'd like to think it's a helpful resource."

Others on his book: Betty Spivack, a pediatrician specializing in child abuse in Louisville, Ky., called it "the single most important reference for either pediatricians or radiologists on what child abuse imaging looks like."