Clinical presentations of Physical child abuse - PowerPoint Presentation

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Clinical presentations of Physical child abuse

Robert Allan Shapiro, MDUniversity of Cincinnati College of Medicine

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ObjectivesAt the end of this session, participants will have an increased knowledge about typical injuries concerning for child physical abuse.

At the end of this session, participants will learn why some injuries indicate likely abuse while others indicate likely accident.At the end of this session, participants will learn about sentinel injuries and how they relate to child abuse.

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Fractures

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Fractures concerning for abuse

Any fracture in a non-ambulatory childUnclear / changing / developmentally wrong / insufficient trauma historySpecific fractures that are often from abuseRib, Scapular, Vertebral

Classic metaphyseal (CML)

Fractures of different ages / occult fractures

Report might include other medical workup:

Calcium, alkaline phosphorus, PTH, Vit D 25-OH

Skeletal Survey – initial and 10 day follow-up

Abdominal labs & CT / Head CT

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Usually from Abuse

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Rib Fractures- Signs & Symptoms

Rib fractures are always concerning for abuseEspecially posterior rib fracturesA history of pain is often absent in infantsCrepitus, respiratory distress, bruising is not typically seenWith normal bones rarely occurs

Physicians will be looking for bone fragility

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Metaphyseal Fracture

Often called CML or Classic Metaphyseal LesionUsually children < 1 y/o and most commonly seen…The knee(distal femur, proximal

tibia)

The ankle

(distal tibia)

The shoulder

(proximal

humerus

)

Usually from Abuse

We don’t see these fractures with accidental injury

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Spiral Fracture

Abuse or Accident

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Buckle Fracture

axial load

Falling onto an outstretched arm

unique to children’s bones

Usually Accidental

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6 week old - Left Femur Fracture

Infant held by father when father tripped on dogFather fell backward but held onto infantFather held infant’s left foot during the fallInjuries includethe femur fracture

mild trauma to upper lip

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2 year old – Femur Fracture

Child with 5 other siblings at time of traumaChildren report one of the older children pulled a blanket out from this infant’s feet while he was standingMother noticed swelling and tendernessNo other injuries

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What is the best next step?

Will a description of these fractures help us to differentiate accident from abuse (i.e. spiral ?)What additional workup is indicated?Head CT ?Skeletal survey ?Coags / LFTs ?Is there a reasonable concern to report

a suspicion of abuse?

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Initially history thought compatible and family discharged home

Called

back after quality review noted no abuse w/u done

Skeletal survey – positive for healing posterior rib fracture & skull fracture

LFT elevated – AST 90 (20-60) / ALT 250 (5-45)

Abdominal CT – liver laceration caudate lobe

Skeletal survey and LFT normal

Children's service consulted - no prior involvement

No report of abuse made

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Bruising

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“Those Who Don’t Cruise Rarely Bruise”

Examined the frequency /location of bruising973 infants & toddlersIncidence of Bruising by Developmental Stage:Pre-cruisers: 11 of 511 (2.1%)Cruisers: 18 of 101 (17.8%)Walkers: 165 of 318 (51.9%)

Sugar et al. Bruises in Infants and Toddlers. Archives of Pediatric and Adolescent Medicine. 1999;153: 399-403

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Ninety-five children were in this study

71/95 were found to have bruising33/42 children in the abuse group38/53 children in the accident group

A bruising decision rule was created to predict abuse

sensitivity of 97%

specificity of 84%

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TEN-4-FACES

TEN - bruising on the Torso,

E

ar, or

N

eck

torso includes chest, abdomen, back, buttocks,

genitourinary region, and hip

4 -

child

≤4

years old

FACES - Frenulum, Angle of the jaw, Cheek, Eyelid, Scleral Hemorrhage (red spot in the eye)Bruising anywhere infant ≤4 months of age

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Buttocks is very well padded area of the body. Very unusual to bruise falling a fall

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Concerning bruises

Patterned bruisesBruises over fleshy / soft body areasMore bruising than expectedWork-up might require coagulation studies includingCBC with plateletsPT, PTT, Factor VIII and IX, VWF, TT and fibrinogen

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2 year old with many bruises

Child’s babysitter left the infant with her boyfriendHe reported child fell twice during this timeStanding on a chair and fell offFell off of a slideInjuries noted on exam includeLaceration to scalp

Bruises to face, pinna, occiput, abdomen, back, buttocks

Work-up suggested?

Abdominal CT shows free fluid but no organ damage

Head CT and skeletal survey were also ordered - negative

Injuries were not thought to be accidental

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2 year old with many bruises

Child’s babysitter left the infant with her boyfriendHe reported child fell twice during this timeStanding on a chair and fell offFell off of a slideInjuries noted on exam includeLaceration to scalp

Bruises to face, pinna, occiput, abdomen, back, buttocks

Is this likely accidental or from child abuse?

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Kids bite one another.

Sometimes not easy to differentiate a child’s bite from that of an adult

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Loop marks indicate inflicted injury

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Ear trauma is often a sign of child abuse

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Phytophotodermatitis

Phototoxic inflammatory skin reactionPsoralen-containing products react with the skin after exposure to UVA lightLemon, lime, fig, parsnip, carrot, dill, celery, clover, and buttercup plantsErythema and blistering can be the initial presentation followed by hyperpigmentationOften linear configuration or resembling fingerprints/handprints

Not a sign of child abuse

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2 year old with Phytophotodermatitis

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2 year old with patterned bruises

What is the cause of these markings?

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2 month old with buttock bruise

Mother explained that the child fell

Is this an accidental bruise?

Skeletal survey –

Head CT –

LFT –

Coags

/CBC –

Mother later admitted that she got mad at the infant and punched her buttocks.

There was no fall.

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ALTE - Acute Life Threatening Event

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3 mo old with ALTE

Mother calls 911 – infant stopped breathingRequired minimal resuscitationCPAP for bilateral pneumoniaResolved in 48 hours

HPI – mother found blood on the crib sheets

Past history of ALTE x 2 in the past

Exam normal – no trauma, no bruising

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Apnea vs SuffocationHistory of

oronasal blood is not uncommonNormal autopsyNo other trauma foundDeath scene investigation should be negative

Frank oronasal bleeding may be present

Autopsy may be normal

Fractures, other signs of abuse might be found

Death scene investigation may reveal cause

Apnea / SIDS (< 1 y/o)

Suffocation

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What is the best next step?

Additional workup?Reasonable concern to report suspicion of abuse?

Mother confessed to holding her hands over the infants mouth and nose to make the baby stop crying

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Take home messages

Even simple appearing cases / findings may surprise youLook for abuse / look for mimicsAn investigation may increase what is known and can help increase certaintyDiagnostic certainty is often impossible when making or excluding a diagnosis of abuseIn some cases you may make an incorrect determination

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Head injury

SCALP INJURY

These scalp injuries are caused by trauma and are often the result of an accidental trauma.

Skull fracture can result from an accidental or abusive trauma. The type and severity of the fracture can help to differentiate the likelihood of abuse.

The detailed history of trauma is always important.

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Head injury

INTRACRANIAL INJURY

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Head injury

INTRACRANIAL INJURY

These injuries are under the skull and most often indicate significant trauma has occurred.

Epidural is most commonly an accidental injury

Subdural is most commonly an abusive injury.

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Subdural Hematoma

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Inflicted Head TraumaLethargy

IrritabilitySeizuresAltered muscle toneImpaired consciousnessPoor feedingRespiratory distressApneaVomiting

Physical exam often reveals no other injury

RH – specific patterns

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Severe Retinal Hemorrhages are often seen following inflicted head injury and are unusual following accidental head trauma.

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“No Retinal Hemorrhages”

“Few Retinal Hemorrhages Around Pole”

“Diffuse Retinal Hemorrhages (TNTC) To Periphery”

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Causes of retinal hemorrhages

TraumaBirthflame hemorrhages resolve in 1 week; dot/blot 6 weeksCPRCoagulopathies, liver diseaseRuptured AVM, CNS infection & tumorEndocarditis, vasculitis

Hypertension

Carbon monoxide poisoning

43

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Mechanism of retinal hemorrhages in abusive head injury

Raised intraocular venous pressurefrom sudden rise in ICPraised CVPRapid deceleration (whiplash)Cycles of rapid accelerations & decelerations

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What helps identify RH due to abusive head injury?

# and locationLayers involvedPredisposing conditionsExamination findings and Radiographs

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8 mo old with Cataracts

Unknown etiology of bilateral cataracts24 hours after surgery retinal exam is doneTMTC multilayered RH extending to the peripheryMost consistent with SBS – possible post-op findingReferred to the ED for further evaluation

No known history of abuse or shaking

Social history is chaotic

Examination is otherwise normal

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2 mo old w/Retinopathy of Prematurity

Routine ophtho f/u exam for ROPMany single layer RH extending into the periphery in one eye onlyNot birth related– worrisome but not diagnostic of SBSSent to ED for evaluationNo history of abuse or shaking

Family describes familial bleeding history and immune deficiencies

Examination otherwise atraumatic

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12 mo old Retinopathy of Prematurity

Former 24 week premie seen for ROP f/u examFew pre-RH found by ophthalmologist in one eyeEtiology not known, not specific for SBSSent to ED for evaluationNo history of abuse or shakingSocial history includes many households and caretakers

Physical examination normal

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What is the best next step?

What additional workup is indicated?Head CT ?Skeletal survey ?Coags / LFTs ?In what cases is there a reasonable concern to report suspicion of abuse?Other steps that should be taken?

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Retuned 6 months later after a fall down the stairs.

Her father found her seizing and 911 was called.

Head CT - subdural hemorrhage

Eye exam - multilayered RH out to the periphery, vitreous hemorrhage and retinoschisis

Head CT - subdural hemorrhage

Mother admitted to shaking the infant, coag workup is normal

Head CT, Skeletal survey, LFT and coags normal

Report made - Children's Services finds concerning signs of neglect in home

Placed with relative but no finding of abuse

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Retinal Hemorrhages and AHT

The ophthalmology examination should be part of the evaluation of the child with suspected AHTRetinal hemorrhages are a cardinal manifestation of AHT but Are not always presentNot needed to make the diagnosisRetinal hemorrhages associated with AHT may be

Unilateral or bilateral

May vary in size and distribution between the two eyes

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Sentinel Injuries

Any injury in an infant <6 months old, including

Bruise

Mouth injury (including frenulum tear, lip laceration)

Eye injury (subconjunctival hemorrhage is suspicious)

Genital injury

Burn or laceration

Fracture

Abdominal injury

Intracranial injury

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Why Recognizing Sentinel Injuries is Important

Greater than 1 in 4

abused children had a prior sentinel injury noted by a medical provider

.

Unrecognized abuse can

lead to repeated abuse

and more severe injury.

Recurrent child abuse is associated with

increased morbidity and mortality

in Ohio (mortality - 24.5% vs. 9.9%)

Sentinel injuries are

easy to dismiss

when

minor and quickly resolving.

Bruises (80%)

and

mouth injuries (11%)

are the most commonly dismissed sentinel injuries.

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Immersion Burns

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Lighter burn

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Labs / Radiographs / Exam Findings that might be included in a report of suspected abuse

Growth ChartLooking for neglect, Failure to ThriveBlood testsALT/AST >80 to screen for abdominal injuryPT, PTT, platelets to screen for bleeding problemsRadiographs

Skeletal survey in children < 2-3 years old

Repeat in 10-14 days from time of suspected injury

Brain CT or MRI

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Abuse Likelihood

The medical will not necessarily make a diagnosis of child abuseThe opinion might be expressed in terms of likelihoodThis will always be tied to the available trauma history

Corroborating information should be combined with the medical opinion to make a determination

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Questions?

Thank you

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Assessing abuse likelihoodPast Medical History

Reevaluate prior injuriesPatterns of neglectCollateral sources of informationRisk assessment

Substance abuse

Mental illness

Social isolation

Lack of parenting knowledge

Single parent

Low income

IPV