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

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.

Fractures

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

Usually from Abuse

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

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

Spiral Fracture Abuse or Accident Toddler’s fractures – common in children aged 9 months to 3 years, nondisplaced, often the result of a trivial injury that is not observed, localized tenderness is often the only finding. Usually seen because of failure to bear weight or apparent pain in the affected limb.

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

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

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

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

Bruising

“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

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%

TEN-4-FACES Bruising anywhere infant ≤4 months of age 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

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

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?

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

Loop marks indicate inflicted injury

Ear trauma is often a sign of child abuse

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

2 year old with Phytophotodermatitis

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?

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.

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.

Subdural Hematoma

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

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

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.

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 14% fractures in children < 2 y/o with burns.(5/36 Hicks. DeGraw 18% 18/97)

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

Questions? Thank you