ABUSE & IMAGING PEDS & GERIATRICS SOME IMAGES MAY BE DISTURBING YOU HAVE A LEGAL RESPONSIBILITY TO REPORT POSSIBLE ABUSE All states require that you report any known or suspected child abuse. Call the police and Child Protection Services

CHILD ABUSE MULTIPLE INJURIES COVERS MORE THAN 1 PLANE DEFENSIVE WOUNDS BE ALERT

Most abused and neglected children never come to the attention of government authorities. This is particularly true for neglected and sexually abused children, who may have no physical signs of harm. In the case of sexual abuse, secrecy and intense feelings of shame may prevent children, and adults aware of the abuse, from seeking help. Therefore, official government statistics do not indicate actual rates of child abuse. Government statistics are based on cases that were (a) reported to social service agencies, (b) investigated by child protection workers (c) had sufficient evidence to determine that a legal definition of "abuse" or "neglect" was met.

Battered child syndrome; Physical abuse - children This syndrome referred to multiple fractures in different states of healing. The fractures occurred at different times in children too young to have received the fractures as a result of an accident. The definition of child abuse has since expanded significantly. Physical child abuse or non-accidental child trauma refers not only to multiple fractures at different ages, but it also includes numerous other signs of injury.

This bone scan confirms the long bone fractures. There is an obvious hot spot right radius. left femur and right tibia also the occiput suggesting a fracture or a subperiosteal contusion. There are no obvious vertebral hot spots suggesting that the flattened vertebral bodies may not represent fractures After being fitted with an orthopedic harness, child protective services placed the infant in a foster home. The young children living in the household were also removed and placed in foster homes.

SHAKEN BABY SYNDROME is a severe form of head injury caused by the baby's brain rebounding inside of the baby's skull when shaken. Rib Fx also can be seen In this injury there is bruising of the brain, swelling, pressure, and bleeding (intracerebral hemorrhage). This can easily lead to permanent, severe brain damage or death. If a child has this injury there are usually no outward physical signs of trauma, but there may be a change in the child's behavior such as irritability, lethargy, pale or bluish skin, vomiting, and convulsions.

1 year old child brought in by ambulance comatose. This child was violently shaken, causing severe brain injury, evidenced by diffuse cerebral edema.

Symptoms of physical abuse Cigarette burns on exposed areas or the genitals Black eyes in an infant or a similar, unexplained injury in a child Human bite marks Lash marks Choke marks around neck Circular marks around wrists or ankles (indicating twisting or tying up) Separated sutures Bulging fontanelle Evidence of unexplained abdominal injury (such as bruised or ruptured intestines due to punching) Unexplained unconsciousness in infant

The following tests can reveal physical injuries Bone x-ray -- a skeletal survey is done whenever physical abuse is suspected. All the child's bones, including the skull, are x-rayed to look for unseen fractures or old, healing fractures. MRI or CT scan of the head or abdomen are done if there is a skull fracture, bleeding in the eye, unexplained vomiting, severe bruising of the face, skull or abdomen, or unexplained neurological symptoms, headaches, or loss of consciousness.

There are several types of suspicious bone fractures including: Oblique - a fracture which goes at an angle to the axis Comminuted - a fracture of many relatively small fragments Spiral - a fracture which runs around the axis of the bone Compound - a fracture (also called open) which breaks the skin

Recognize the warning signs of potential abuse. For example, a caregiver may: Previously abused a child Fail to maintain the child's proper hygiene or care Appear to lack love or concern Have alcohol or drug problems Have emotional problems or mental illness Was abused as a child Has high stress factors, including poverty

Sexual abuse - children Child sexual abuse is the deliberate exposure of minor children to sexual activity. This means a child is forced or talked into sex or sexual activities by another person. Such abuse includes touching (fondling), sexual intercourse, oral sex, pornography, and other sexual activity.

Treatment   All children who have been sexually abused or traumatized in any way should receive mental health counseling. Suspicion of child sexual abuse must be reported to child protective services and the police. Medical professionals, teachers, and child care professionals are required by law to make a report. TELL YOUR SUPERVISOR Once a case is reported, child protection agencies and the police must investigate. If the allegation is considered true, the child must be protected from further abuse. Placement with a non-abusing parent, another relative, or a foster home may result. In physical abuse cases, the goal of child protection agencies is to educate an abusing caretaker and attempt to re-join the family together, if safe

3,500 Number of deaths due to child abuse and neglect in 27 developed nations worldwide. The United States, Mexico, and Portugal have death rates 10 to 15 times higher than many of the other countries. 40-47 Percent of sexual assaults perpetrated against girls age 15 or younger worldwide. 76 Percent of United States child abuse fatalities that were in children aged 4 years or younger. More than 1/3 Number of U.S. child abuse fatalities that were associated with neglect, or in other words, the denial of a child’s basic need for food, warmth, clothing, and medical care.

2.9 million Number of reports of child abuse and neglect received by U.S. Child Protective Services from concerned teachers, policemen, social workers, day care workers, friends and neighbors (2003). That’s 39 referrals for every 1,000 children. 79 % of U.S. child abuse or neglect deaths where one or both parents were involved. Much of the time, the parent is young, without a high school diploma, living in poverty, depressed, and has experienced violence in his or her own life.

Injuries Worrisome for Child Physical Abuse Skin and Soft Tissue Injury bruises on face, lips, mouth, torso, back, buttocks, thighs especially if in various stages of healing degree of bruising is greater than expected for the activity level of the child bilateral black eyes ("raccoon eyes") patterned bruise (of inflicting instrument such as belt buckle, hairbrush, or hand) human bite marks cigarette burns, especially on palms, soles of feet, back, buttocks immersion burns patterned burns (curling iron, clothes iron, stove burner) rope burns

Skeletal Injuries fractures of ribs, ends of long bones (near growth plates), spine multiple fractures fractures of differing ages any fracture inconsistent with the developmental capabilities of the child

Head Injuries bleeding into/onto brain (subdural hemorrhage) brain swelling (cerebral edema) multiple skull fractures ("eggshell" fracture)

This 2 month old baby girl was brought into the local ER with scalp swelling Patterns of skull fracture that suggest child abuse are multiple ('eggshell') fractures (as in this case)

Abdominal Injuries small bowel injury (duodenal or jejunal hematoma, bowel laceration) pancreatitis or pancreatic injury injury to liver, spleen, adrenal glands

Upper GI shows a mass in the wall of the descending duodenum 3 1/2 year old with 4 day history persistent vomiting after eating and abdominal pain. Upper GI shows a mass in the wall of the descending duodenum This is consistent with a duodenal hematoma.

Signs of Neglect lack of appropriate hygiene inappropriate dress bald spots severe diaper rash failure to thrive lack of immunizations lack of dental care lack of supervision abandonment

Parental Behavior Patterns Seen in Abuse lack of concern or detachment about injury lack of response to child in pain overly concerned about trivial injuries has unrealistic expectations of the child (to be behaviorally more mature) parents themselves may exhibit or have a history of: drug or alcohol addiction psychosis lack of trust in health professionals

Radiographic skeletal survey in all children less than 2 yrs suspected of abuse. The abuse skeletal survey consists of individual frontal X-rays of the following body parts: chest skull (also lateral) upper arms (humeri) forearms hands pelvis upper legs (femurs) lower legs (tibia/fibula) ankles (also lateral views) feet   In children 12 months or younger, also perform: lateral thoracolumbar spine film

with mammography or high-detail extremity film (exquisite detail) NOTE: Expert attention to technique and detail is necessary for quality radiographs that show some of the very subtle injuries of abuse. These are the radiographs that will go to court - it is imperative that they be well-performed. It is recommended that these films be obtained: with mammography or high-detail extremity film (exquisite detail)

More CASE STUDIES OF PEDIATRIC ABUSE Ped injury – corner fx

CORNER OR BUCKLE FX 4 month old baby with brain injury suspicious for child abuse. Skeletal survey performed to evaluate for other injuries of abuse. There is a corner fracture of the distal femur

6-week old male was well until two days prior to presenting to the ED when his left thigh suddenly became swollen. There is also a one-year old female sibling a 2-year old female cousin, and great grandparents all living in the same house, who sometimes play with the infant. Both mother and father are 18 years of age.

This radiograph shows an obvious oblique fracture of the proximal shaft of the left femur, with superior and anterior displacement of the distal fracture fragment Because of the strong suspicion of intentional trauma (child abuse), the infant is hospitalized and a skeletal survey is done

The vertebral body of T12 appears much flatter than the other thoracic vertebra. T10 and L2 may also be slightly flattened. Because of the difficulty in diagnosing these as vertebral body compression fractures, a bone scan is done for correlation.

3 month old child with vertebral abnormality noted on chest X-ray. Compression injury to the body of L1. Notice the angulation of L1 relative to T12 above it and the defect in the anterior superior margin of the body of L1

Review- signs of abuse Sexual Abuse Symptoms of sexually transmitted diseases Injury to genital area Difficulty and/or pain when sitting or walking Sexually suggestive, inappropriate behavior or verbalization Sexual victimization of other children       

Review- signs of abuse Maltreatment Obvious malnourishment, listlessness or fatigue Stealing or begging for food Poor personal hygiene, torn and/or dirty clothes Need for glasses, dental care or other medical attention Frequent absence from or tardiness to school Child inappropriately left unattended or without supervision

4 month old with cough, chest X-ray request says "rule out pneumonia." Posterior rib fracture of the left 7th rib This fracture is less than 14 days old as there is no visible callus. This is a case of child abuse incidentally found on CXR because of the detection of the rib fracture, which was unrelated to the child's presenting complaint

Healing right posterior 5th-7th and 9th rib fractures, as well as multiple healing right lateral rib fractures 3 MO OLD – BROUGHT IN FOR ABD PAIN AND VOMITING

11 month old female with possible right-sided posterior rib fractures at recent skeletal survey. Bone scan shows focal increased uptake along multiple posterior right ribs , the left humeral shaft & both humeral heads Therefore, plain X-rays of the skeleton (in the areas of abnormality identified at bone scan) are almost always still needed to evaluate for the exact nature of the abnormality. Use of bone scans for when there is an equivocal finding or there is high clinical suspicion but the plain X-rays are normal. Bone scans will detect those difficult to see posterior rib fractures, as in this case.

ELDER ABUSE

Healthcare workers are responsible for their patients’ safety.

ELDER ABUSE Abuse can be Domestic (in their home) or Institutional (in a facility). Healthcare abusers can be doctors, nurses, hospitals, caregivers, unlicensed “professionals”, and nonprofessional healthcare providers. Abusers may be family members, visitors or intruders. Never assume why someone may abuse an elder. Report all instances of abuse to your immediate on-site supervisor and your staffing specialist. Be able to report specific information about the incident.

ABUSERS Most abuse occurs in the home, and usually by a family member. Most commonly the perpetrators of elderly abuse are spouses or partners of elders. Next most frequent abusers are the adult children of elders. Abusers can be men or women. Men ages thirty-six to fifty are the most common perpetrators. In nursing homes & other long-term care facilities, abusers may be employees, visitors, or intruders. Anyone associated with an elder may abuse them: friends, relatives, doctors, lawyers, bankers, accountants, clergy,caregivers, or strangers.

Taking care of the elderly, whether at home or in an institution, can be very stressful. The incidence of depression isvery high among caregivers. Caregivers habitually lack exercise and outdoor time, have inadequate nutrition, and need more sleep. Many people with dementia have trouble sleeping so caregivers are kept up caring for them. Caregivers have a high level of anxiety.

SIGNS & SYMPTOMS OF ELDER ABUSE Warning Signs are frequent arguments between elder and caregiver or changes in personality or behavior of elder. If you suspect elderly abuse, but aren't sure, look for clusters of the following physical and behavioral signs

PHYSICAL ABUSE 􀂃 Unexplained bruises, pressure marks, black eyes, welts, lacerations, cuts, or burns Bone fractures 􀂃 Sprains or dislocations 􀂃 Bite marks or restraint marks 􀂃 Broken glasses 􀂃 Underutilization of medication or overdose (via lab findings) 􀂃 Elder is not left alone with visitors 􀂃 Elder reports physical abuse

EMOTIONAL ABUSE 􀂃 Upset or agitated 􀂃 Withdrawn, depression or non-communication 􀂃 Sucking, biting or rocking (usually with dementia) 􀂃 Caregiver belittling or controlling elder 􀂃 Desertion at an institution (hospital, nursing home, etc or public locations) 􀂃 Physical or chemical restraints 􀂃 Elder reports emotional abuse

ELDER NEGLECT Dehydration, malnutrition, or hunger Physical weakness Hazardous or unsafe living conditions Unsanitary & unclean living Clothing unsuitable for weather Poor hygiene, foul body or household odor Lack of medical aids

SEXUAL ABUSE 􀂃 Bruises around breasts or genitals 􀂃 Unexplained VD or infections 􀂃 Unexplained vaginal or anal bleeding 􀂃 Torn, stained or bloody underclothing 􀂃 Elder reports sexual abuse

HEALTHCARE ABUSE Duplicate billings for services Pill counts are under or over the number the patient was prescribed Lack of inadequate medical care even though bills are paid

HOW TO REPORT ELDER ABUSE If an elder is in danger: Notify your on-site supervisor