The Viewing Study Guide for Physical Abuse Slides
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1 The Viewing Study Guide for Physical Abuse Slides Adapted From The Visual Diagnosis of Non-Accidental Trauma and Failure to Thrive A Study Guide By Barton D. Schmitt, M.D. in Cooperation with The American Academy of Pediatrics 1979 Reproduced With Permission By The Institute for Human Services Columbus, Ohio 2003 Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
2 Introduction and Acknowledgments This program was adapted from the book written by Barton D. Schmitt, M.D. and produced by the University of Colorado Medical Center, Denver, CO., in cooperation with the American Academy of Pediatrics. Partial funding was provided by a grant from the National Center on Child Abuse and Neglect, Children's Bureau, Administration for Children, Youth and Families, Office of Human Development, U.S. Department of Health and Human Services, Reproduced and distributed with the permission of the American Academy of Pediatrics for use with Child Protective Services, Module I of the competency-based Core Curriculum for Child Welfare Caseworkers, developed by the Institute for Human Services, Columbus, OH, and published by the Child Welfare League of America, Washington, D.C. The viewing guide was updated and adapted to accompany the new slides available from The American Academy of Pediatrics. A few of the previous slides, which are included in the new slide script, and the script are available from The Institute for Human Services, Columbus, OH. These are available for the cost of reproduction. Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
3 The Study and Note-Taking Guide INFLICTED BRUISES 1. Typical Sites Buttocks and lower back (paddling) Genitals and inner thighs Cheek (slap marks) Ear lobe (pinch marks) Upper lip and frenulum (forced feeding) Neck (choke marks) 2. Human Hand Marks (Pressure Bruises) Oval grab marks (finger tips) Trunk encirclement bruises Knuckle marks Linear marks (fingers) Hand print Pinch marks 3. Human Bite Marks 4. Patterned Marks Points of a wire brush Linear bruises (belts or whips) Loop mark bruises (doubled over cord) Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
4 5. Bizarre Marks Blunt instrument bruises - specific shapes Tattoos, fork tine punctures Circumferential tie marks (ankle, wrist) Gag marks Sucking lesions 6. Multiple Bruises at Different Stages of Healing NORMAL BRUISES Facial scratches in babies from long fingernails Knee and shin bruises Forehead bruises Bruises over bony prominences Dating of Bruises The rate of healing of bruises depends on: The depth of the bruise The amount of bleeding in the tissue The amount of circulation available to the bruised area Generally, bruises progress through a series of color changes as the acute inflammation subsides, the red blood cells break down, and the hemoglobin breaks down. Colors change from red to blue, green, yellow, and brown before clearing. Since there is so much variability in the speed of this progression, it is probably safest to describe bruises as either new (red, purple, or blue) or old (green, yellow, or brown). Conditions often confused with bruises: Idiopathic Thrombocytophenic Purpura (ITP) Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
5 Clotting disorders, such as hemophilia and Von Willebrand s disease Ehler-Danlos Syndrome Mongolian Spots Cultural/medical practices often confused with bruises: Moxibustion CAO GAO (coining) Cupping Bleeding not in slide presentation Facial Marking not in slide presentation INFLICTED BONE INJURIES 1. Usual fractures 2. Chip fractures (of metaphysis) 3. Spiral fractures 4. Bucket handle fractures (of metaphysis) 5. Subperiosteal bleeding and calcification 6. Fractures at different stages of healing 7. Repeated fractures to same site 8. Unusual fractures (ribs, scapula, sternum) Conditions or cultural/medical practices often confused with bone injuries: Rare bone diseases, such as brittle bone disease Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
6 INFLICTED BURNS 1. Scalding 2. Extremities held over gas flame 3. Cigarette Burns 4. Match Tip or Incense Burns 5. Dry Contact Burns (From forced contact with heating devices) Heating grate Electric hot plate Radiators 6. Branding Burns (from touching with heated metals) - specific shapes 7. Scalds From Forced Immersion Buttocks and Perineum (Dunking Burns) Glove or Stocking Burns Reference: Feldman, K.W. et.al. "Tap water scald burns in children." Pediatrics, 62: 1, Conditions or cultural/medical practices often confused with burns: Bullous impetigo Scalded skin syndrome INFLICTED SUBDURAL HEMATOMAS The head can be injured at several levels: a. Scalp lacerations, bruising, and hair pulling. b. Subgaleal hematomas (bleeding under the scalp) Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
7 c. Cephalohematoma (bleeding under the external surface of the skull) d. Skull fractures e. Epidural hematomas f. Subdural hematomas g. Subarachnoid hemorrhage h. Brain contusions, shearing tears, herniation i. Interventrical hemorrhages 1. From Direct Blows Skull fractures Scalp swelling and bruises Retinal hemorrhages 2. From Violent Shaking No skull fractures No scalp swelling or bruises Retinal hemorrhages Long bone fractures (25%) 3. Subdural Hematomas Are Never Spontaneous 4. Subdural Hematomas in Babies Are Inflicted Until Proven Otherwise INFLICTED HEAD INJURIES 1. Subdural Hematomas 2. Subarachnoid Hemorrhages Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
8 3. Scalp Bruises from Direct Trauma 4. Subgaleal Hematoma and/or Traumatic Alopecia (hair loss, bald spots) 5. Black Eye INFLICTED ABDOMINAL INJURIES 1. Ruptured liver or spleen 2. Intestinal perforation 3. Intramural hematoma of duodenum or proximal jejunum 4. Ruptured blood vessel 5. Injury to pancreas 6. Injury to kidneys DIAGNOSTIC CRITERIA FOR FAILURE TO THRIVE DUE TO UNDERFEEDING 1. Underweight condition 2. Failure to gain weight at home 3. Rapid weight gain out of the home 2 oz/day sustained for one week or a striking gain compared to a similar interval at home 4. Ravenous appetite 5. Deprivational behaviors HISTORIES OFFERED FOR INFLICTED INJURIES 1. Eyewitness History Child accuses an adult One parent accuses the other Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
9 One parent confesses 2. Unexplained injury 3. Implausible history 4. Alleged self-inflicted injury (to child not old enough to crawl) 5. Alleged sibling inflicted injury 6. Delay in seeking medical care Written by IHS for the Ohio Child Welfare Training Program FINAL July of 9
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