Clinical presentations of Physical child abuse

1. Clinical presentations of Physical child abuse Robert Allan Shapiro, MD University of Cincinnati College of Medicine

2. Objectives • At 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.

3. Fractures

4. Fractures concerning for abuse • Any fracture in a non-ambulatory child • Unclear / changing / developmentally wrong / insufficient trauma history • Specific fractures that are often from abuse • Rib, 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

5. Usually from Abuse

6. Rib Fractures- Signs & Symptoms • Rib fractures are always concerning for abuse • Especially posterior rib fractures • A history of pain is often absent in infants • Crepitus, respiratory distress, bruising is not typically seen • With normal bones rarely occurs • Physicians will be looking for bone fragility

7. Metaphyseal Fracture Usually from Abuse • Often called CML or Classic Metaphyseal Lesion • Usually children < 1 y/o and most commonly seen… • The knee(distal femur, proximal tibia) • The ankle(distal tibia) • The shoulder(proximal humerus) We don’t see these fractures with accidental injury

8. Spiral Fracture Abuse or Accident

9. Buckle Fracture Usually Accidental • axial load • Falling onto an outstretched arm • unique to children’s bones

10. 6 week old - Left Femur Fracture • Infant held by father when father tripped on dog • Father fell backward but held onto infant • Father held infant’s left foot during the fall • Injuries include • the femur fracture • mild trauma to upper lip

11. 2 year old – Femur Fracture • Child with 5 other siblings at time of trauma • Children report one of the older children pulled a blanket out from this infant’s feet while he was standing • Mother noticed swelling and tenderness • No other injuries

12. Skeletal survey and LFT normal • Children's service consulted - no prior involvement • No report of abuse made • 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

13. Bruising

14. “Those Who Don’t Cruise Rarely Bruise” • Examined the frequency /location of bruising • 973 infants & toddlers • Incidence 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

15. Ninety-five children were in this study • 71/95 were found to have bruising • 33/42 children in the abuse group • 38/53 children in the accident group • A bruising decision rule was created to predict abuse • sensitivity of 97% • specificity of 84%

16. TEN-4-FACES • TEN - bruising on the Torso, Ear, or Neck • 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

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

18. 2 year old with many bruises • Child’s babysitter left the infant with her boyfriend • He reported child fell twice during this time • Standing on a chair and fell off • Fell off of a slide • Injuries noted on exam include • Laceration to scalp • Bruises to face, pinna, occiput, abdomen, back, buttocks Is this likely accidental or from child abuse?

19. Kids bite one another. Sometimes not easy to differentiate a child’s bite from that of an adult

20. Loop marks indicate inflicted injury

21. Ear trauma is often a sign of child abuse

22. Phytophotodermatitis • Phototoxic inflammatory skin reaction • Psoralen-containing products react with the skin after exposure to UVA light • Lemon, lime, fig, parsnip, carrot, dill, celery, clover, and buttercup plants • Erythema and blistering can be the initial presentation followed by hyperpigmentation • Often linear configuration or resembling fingerprints/handprints Not a sign of child abuse

23. 2 year old with Phytophotodermatitis

24. 2 month old with buttock bruise Mother explained that the child fell Mother later admitted that she got mad at the infant and punched her buttocks. There was no fall. • Skeletal survey – • Head CT – • LFT – • Coags/CBC – Is this an accidental bruise?

25. 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.

26. 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.

27. Subdural Hematoma

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

29. 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

30. Why Recognizing Sentinel Injuries is Important • Greater than 1 in 4abused children had a prior sentinel injury noted by a medical provider. • Unrecognized abuse can lead to repeated abuseand 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%)andmouth injuries (11%) are the most commonly dismissed sentinel injuries.

34. Labs / Radiographs / Exam Findings that might be included in a report of suspected abuse • Growth Chart • Looking for neglect, Failure to Thrive • Blood tests • ALT/AST >80 to screen for abdominal injury • PT, PTT, platelets to screen for bleeding problems • Radiographs • Skeletal survey in children < 2-3 years old • Repeat in 10-14 days from time of suspected injury • Brain CT or MRI

35. Abuse Likelihood • The medical will not necessarily make a diagnosis of child abuse • The opinion might be expressed in terms of likelihood • This will always be tied to the available trauma history • Corroborating information should be combined with the medical opinion to make a determination

36. Questions? Thank you