Child Abuse / Non Accidental Injury

Definition

 

Any act or failure to act that

- results in or potentially results in harm / death / physical / emotional / sexual abuse

- by a parent or caretaker who is responsible for the child

 

4 types

 

Neglect 

Physical (punch / kick / bite / burn / shake)

Sexual 

Emotional

 

Risk factors

 

Low socioeconomic x25 risk

Unemployed

Single parent

Substance abuse

First child

Premature

Unplanned

Stepchildren

Handicapped

Parents were abused

 

Birth parents more likely to abuse

 

50-80% substance abuse

 

Epidemiology

 

Abuse second most common cause of death in infants 1-6/12

- SIDS number 1

 

85% death from child abuse < 5 years

 

10% trauma < 3 years from child abuse

 

1962 landmark paper from USA / Kempe

- battered child syndrome

- poor hygiene

- poor nutrition / failure to thrive

- ST / bone injuries

- subdural haematomas

 

History

 

Delay in presenting

 

History vague, lacking in detail, contradictory

- mechanism of injury insufficient to explain injuries

- history of a fall

 

Characteristics of child

- less than 3 years old

- poor household environment / drug / physical abuse

- overly aggressive or passive

- behavioral problems

- handicapped child

- stepchild

- premature child

- subnormal growth

 

Non orthopaedic findings

 

Skin

- bruises (buttocks, perineum and genitalia, trunk, back of head and legs)

- multiple bruises in various stages of healing

- burns (pattern may reflect mechanism of burn)

 

Head and CNS

- skull fracture (multiple, skull base, crossing suture lines, depressed fractures)

- subdural hematoma, subarachnoid hemorrhage

- retinal hemorrhage, hyphema, retinal detachment

- cognitive disabilities

 

Chest, abdomen, and pelvis

- rib fractures (posterior, multiple), sternal fractures

- pneumothorax, hemothorax

- rupture of organ (liver, spleen, or pancreas / bowel or bladder rupture)

- intramural bowel hematoma

- kidney contusion, retroperitoneal hemorrhage

- sexual abuse

 

Orthopaedic

 

Musculoskeletal system

- multiple fractures

- fractures in various stages of healing

- metaphyseal corner fracture (pathognomonic)

- femoral fracture in child < 1 (more likely than not)

- humeral shaft fracture child < 3 (almost always)

- vertebral compression fractures, spinous process avulsion

- scapular fracture

- epiphyseal separation

 

Imaging

 

Any obvious injuries

 

Skeletal survey (< 5 years age)

- AP bilateral arms

- AP bilateral forearms

- AP bilateral hands

- AP bilateral thighs

- AP bilateral lower legs

- AP bilateral feet

- AP and lateral axial skeleton and trunk

- AP and lateral Skull

 

Bone Scan

 

Costly / difficult to evaluate / lacks specificity / radiation exposure

 

DDx

 

Accidental injury

OI

Rickets

Leukaemia

Congenital syphilis

 

Caffey's disease

- infantile cortical hyperostosis

- < 5 months, fever, pain

- typically mandible

- xrays show hyperostosis

- get periostitis

 

Management

 

Failure to Diagnose

 

30-50% recurrence of abuse

5-10% mortality risk

 

Reporting is mandatory

 

Team approach

 

Paediatrician / social worker / psychologist

General surgeon / Neurosurgeon / Orthopodedic Surgeon / Ophthalmologist / Dermatologist

 

Notify / discuss with

- primary care provider for background history

- police

- legal counsel

- social services

- child protective services

 

Hospital admission to treat acute injuries and remove child from dangerous environment

 

Carefully document all records

Statement regarding level of certainty of abuse

 

Legal consent still required to treat child or release information from chart

Court custody may be needed if family members not co-operative