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