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
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.

9. Buckle Fracture axial load unique to children’s bones
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 ;153:

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 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

17. 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

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 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 % 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.

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 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)

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