5 B s of Child Physical Abuse: Bruises, Burns, Bones, Bellies, and Brains
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1 5 B s of Child Physical Abuse: Bruises, Burns, Bones, Bellies, and Brains Kristen Reeder, MD Child Abuse Pediatrician, REACH Program Children s Health SM Children s Medical Center Dallas Assistant Professor of Pediatrics University of Texas Southwestern Medical Center
2 Handout Notification Not all slides are contained in the handouts. I do not provide slides of cases (photos, x-rays, etc) used as examples in handouts.
3 Indicators of Child Abuse and Neglect Histories inconsistent with injuries History incompatible with child s development History that changes with time Contradictory histories Delay in seeking treatment Pathognomonic injuries
4 Diagnostic Utility of History 163 children with acute traumatic intracranial injury 49 (30%) definitely abused Examined clinical history of trauma No history of trauma specific for abuse History of no or low impact fall with persistent neurologic sequelae diagnostic of abuse Home resuscitation excuse suggests abuse Hettler and Greenes. Pediatrics 2003:602-7.
5 Can the initial history predict whether a child with a head injury has been abused? Hettler and Greenes. Pediatrics 2003:602-7.
6 Can the initial history predict whether a child with a head injury has been abused? Hettler and Greenes. Pediatrics 2003:602-7.
7 5 B s of Physical Abuse Bruises Burns Bones (fractures) Bellies (abdominal trauma) Brains
8 Bruises Bruises are caused when soft tissue is compressed between 2 hard surfaces and blood vessels leak blood into the tissue Swelling is secondary to inflammation Swelling resolves over the first 2-3 days Three characteristics separate abusive from accidental bruises: AGE OF PATIENT / DEVELOPMENTAL LEVEL LOCATION PATTERN
9 When Inflicted Injuries Constitute Child Abuse AAP policy statement A definition of significant trauma is any injury beyond temporary redness of the skin Practical criterion often used any inflicted injury that lasts more than 24 hours constitutes significant injury and child abuse Pediatrics, September 2002:
10 Percentage of Children with Bruises by Age (n=930) Sugar, et al. "Bruises in infants and toddlers" Arch of Peds and Adol Med. 1999; 153:
11 Location of Skin Lesions INFLICTED Upper arms Trunk Upper anterior legs Sides of face Ears and neck Genitalia, buttocks ACCIDENTAL Shins Bony prominences Lower arms Forehead Under chin
12 TEN-4 Rule Bruising in 33/42 abuse patients, 38/53 non-abuse patients in ICU Characteristics predictive of abuse: bruising on the torso, ear, or neck for a child 4 years of age bruising in any region for an infant <4 months of age MC Pierce, Pediatrics. 125, 1. Jan,
13 Aging of Bruises Color changes occur as bruises age Colors vary widely with age of bruises Variability in color dependent upon: Depth of bruise Location Vascularity of underlying tissue Age and complexion of child Cannot be done with any certainty!
14 Burn Injuries - Inflicted 10-25% of burns are inflicted 30% mortality rate Scald burns most common Random splash Spill Immersion Forced immersion Simultaneous deep scald burns of the buttocks, perineum, and both feet were pathognomonic of deliberate injury (immersion) Purdue GF, et al. "Child abuse by burning" Journal of Trauma 1988:
15 Burn Injuries - Accidental 2% mortality rate Neglectful supervision is usually an issue! Thermal burns Steam irons, curling/flat irons, hot surfaces, flame Scald burns Water, oil, hot foods Spills, pullovers, random splash, microwaved foods/liquids Chemical burns HISTORY is very important Home / scene environment must be investigated
16 Superficial Burns (1 st deg) Redness Dry skin Skin is painful to touch Pain lasts 48 to 72 hours Peeling skin in later stages
17 Partial Thickness Burns (2 nd deg) Blisters Deep redness of skin Skin is very painful to touch Burn may be white, discolored
18 Full Thickness Burns (3 rd deg) Dry, leather-like skin White, yellow, black skin Swelling, Lack of pain New skin will not grow
19 Pathognomonic Immersion Burn Kempe and Helfer. The Battered Child.
20 Importance of Time in Causation of Cutaneous Burns Henriques and Moritz. Am J Path 1947;2:
21 Fractures in Child Abuse Fractures seen in 5-18% of abused children History is key! Timing Mechanism Age of patient Developmental stage Activity level
22 The Skeletal Survey Plain x-ray studies Mandatory in all cases of suspected abuse in kids <2 years Patients age 2-5 years based on clinical indicators AAP. Diagnostic imaging of child abuse Pediatrics; 2000;105:
23 Pierce MC, et al. Child Abuse and Neglect. 2004;28:
24 Spiral Fracture Torsional loading (twisting) caused to twist about its longitudinal axis NOT diagnostic of abuse Example: Toddler injuries Pierce MC, et al. Child Abuse and Neglect. 2004;28:
25 Buckle Fracture Typically results from axial loading (compression) Usually occurs at the junction of the metaphysis and the diaphysis Example: Fall onto outstretched arm Pierce MC, et al. Child Abuse and Neglect. 2004;28:
26 Transverse Fracture Fracture line that is perpendicular to the long axis of the bone Failure under tensile loading and from bending loads Example: direct blow to the leg Pierce MC, et al. Child Abuse and Neglect. 2004;28:
27 Oblique Fracture Result of combination loading (compression, rotation, transverse) Example: fall from bed with twisting at impact or forced bending of extremity Pierce MC, et al. Child Abuse and Neglect. 2004;28:
28 Metaphyseal Fracture Planar fracture through the immature metaphyseal bone Shear and tensile stresses Examples: pulling and yanking on an extremity Pierce MC, et al. Child Abuse and Neglect. 2004;28:
29 Comminuted Fracture Multiple fracture fragments Increasing forces results in increased number of fracture fragments
30 Subperiosteal New Bone Formation (SPNBF) Presence may indicate healing of a bone injury Also may represent subperiosteal hemorrhage Non-specific finding Pierce MC, et al. Child Abuse and Neglect. 2004;28:
31 Fractures in Young Children Fractures are highly suspicious if: No history of accident provided but instead reports change in child History of minor fall Fracture of radius, ulna, tibia, fibula, femur, humerus in child < 1 year Fractures felt to be accidental if: Distal extremity in child > 1 year Femur fracture in child >1 year running and falling Clavicle Leventhal, et al. AJDC January 1993:
32 Rib Fractures Due to compressive forces, not direct blows Seldom see overlying bruises After fractures, infant is usually asymptomatic Not associated with birth trauma Not associated with CPR
33
34 Metaphyseal fractures
35 Classic Metaphyseal Lesion (CML) AKA: Corner fracture Bucket handle fracture Chip fracture Metaphyseal fracture Kleinman, Diagnostic Imaging of Child Abuse 1998
36 CML Corner or Bucket Handle appearance - angle of radiographic projection Rotational forces + rapid accel/decel shearing forces to metaphysis generated w/ shaking Pulling and twisting of the extremity High specificity for abuse
37 Healing Process Stage Time Characteristics Induction 3-7 days Inflammation, pain, swelling Soft callus Infants 7-10 days Children Periosteal new bone formation Hard callus days Union at fx site Remodelling 3 months-1 year Woven to lamellar bone
38 Abusive Abdominal Injury Mechanism of abdominal injury Crushing Sudden compression Shearing Second most fatal form of child abuse 40-50% fatality rate
39 Abusive Visceral Injuries (Sites of Injury) Stomach Liver Duodenum Spleen Pancreas Kidney From: Kleinman Diagnostic Imaging of Child Abuse, 1987
40 Abusive Visceral Injuries Various rates of incidence of abuse 4-15% of all abdominal trauma Usually the result of blunt forces to the abdomen Unusual to find obvious external clues Delay in seeking medical care is common
41 Abusive Visceral Injuries (Obstacles) Victims are young and cannot verbalize Children rarely protect themselves from traumatic force History can be obscured Delayed symptoms Cardiovascular collapse may be sudden No single test/study to diagnose
42 Liver Injuries Common Usually due to blunt trauma Lacerations and subcapsular hematomas Severity of injury varies greatly Can have occult injury Evaluated with LFTs, CT scan Treatment dependent on severity
43 Renal Injuries Renal Trauma Due to severe blows to the flank Seen with other abdominal injuries Medical therapy, surgery not often required Renal Damage (myoglobinuria) Renal injury caused by toxins produced from excessive muscle breakdown
44 Epidemiology of Abusive Head Injury < 3 years old Majority of infants with serious brain injury Perpetrators: Fathers, boyfriends, babysitters, mothers Highest mortality and morbidity of inflicted injuries
45
46 Imaging Modalities CT Scan Rapidly performed Acute Hemorrhage: SDH, SAH Epidural Intraparenchymal Acute edema Skull/Facial fracture with bone windows May miss small bleeds Not as sensitive for older bleeds MRI Longer test Expensive Highest sensitivity and specificity for chronic injury Fully assessing intracranial injury May miss acute SDH/SAH Should be delayed 5-7 days (at least 3 days) AAP, Pediatrics 2000, 105 (6)
47 Intracranial Injuries Epidural hematoma (EDH) Blood between the skull and the dura mater Subdural hematoma (SDH) Blood between the dura mater and the brain Subarachnoid hematoma (SAH) Blood between the arachnoid membrane and the brain Parenchymal contusion Bruise to the brain tissue Infarction Area of tissue death due to lack of blood flow Ischemia Brain damage due to a decrease in oxygen to the brain
48 Pathophysiology of Inflicted Head Injury Tearing of bridging veins SDH Contact injury +/- scalp hematoma, STS, skull fracture Shear injury to brain gliding contusions Hypoxic changes to brain cerebral edema
49 Signs and Symptoms Variable, depending on duration and number of shakes, presence of impact, severity of injury Continuum from: Decreased responsiveness, irritability, lethargy, limpness, vomiting Seizures, tachypnea, bradycardia, hypothermia Coma, death
50 Associated Injuries Retinal hemorrhages Fractures Rib Metaphyseal Skull Other Cervical edema/spinal injury
51
52 RH in Inflicted Neurotrauma Incidence between % Dilated retinal examination Performed by Ophthalmologist Detailed description or photographic documentation IMPORTANT Location topographically, layer, number or severity
53 Missed Abusive Head Injury 173 head injured patients 54/173 with missed diagnosis 15 children were re-injured after missed diagnosis 22 experienced medical complications related to the missed diagnosis 4 deaths might have been prevented if abuse recognized Jenny, et al. JAMA 1999:621-6.
54 Missed Cases 31% Cases were Missed Younger (6 months vs. 9 months) White Both Parents Living with Child Milder Symptoms
55 Predictors of Correct Diagnosis of AHT Abnormal Respiratory Status Seizures Facial/Scalp Injury Parents Not Living Together If none of these factors present, likelihood of physician recognizing AHT is < 1 in 5.
56 Child Protector App Children s Mercy Hospital
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