Patterns of Injury that Should Raise Suspicion for Child Abuse
Author: Mark Mannenbach, MD, Division Head, Pediatric Emergency Medicine, Assistant Professor, Department of Pediatric and Adolescent Medicine, Mayo Medical Center, Rochester, Minnesota
Peer Reviewer: Kirsten Bechtel, MD, Assistant Professor of Pediatrics, Yale University School of Medicine, Attending Physician, Pediatric Emergency Department, Yale New Haven Children’s Hospital, New Haven, Connecticut
The emergency department (ED) physician is continually challenged to identify children who may have sustained an injury secondary to abuse. Reaching a balance between protecting a child from possible harm and putting a family through the ordeal of an unwarranted investigation is challenging. The process of a child abuse evaluation is not benign; it may result in the child’s physical separation from the family. If the child’s condition is due to abuse or an underlying medical problem, a delay in diagnosis and treatment may occur, resulting in devastating consequences for the child. This article reviews the common patterns of injury that should raise concern for abuse. — The Editor
Introduction
The young child who presents with multiple bruises, multiple broken bones, or intracranial bleeding certainly would prompt a clinician to make a report of suspected abuse. But often cases are less than clear. For example, there has been doubt raised regarding the presence of retinal hemorrhages as pathognomonic of abusive injury. In a recent article, Lantz and colleagues1 stated that there are situations in which retinal hemorrhages were found in a child who did not clearly suffer from abuse. A prospective study by Bechtel2 demonstrates that it is not just the presence of retinal hemorrhages, but the location (e.g., within the retinal and preretinal layers) and area over which the retinal hemorrhages extend (i.e., to the periphery of the retina and over the macula) that are more likely to be suggestive of abuse.
There are many situations in which child abuse cannot be definitely determined at the time of a clinician’s evaluation; this article is intended to aid the clinician faced with such a dilemma. Patterns of injury that would raise suspicion of child abuse are reviewed to help the clinician develop a comfort level with clinical situations that most likely are due to abuse. The article also highlights the limitations in making the diagnosis of child abuse.
Epidemiology
In 2001, 903,000 children were victims of maltreatment including neglect, medical neglect, physical abuse, sexual abuse, and psychological maltreatment. Neglect was the most common form of maltreatment involving 57% of children; 19% of children were abused physically, 10% were abused sexually, 7% were maltreated psychologically, and 2% experienced medical neglect.3 In 2001, there were an estimated 1,300 child deaths attributed to either child abuse or neglect. Of those deaths, 41% occurred in children younger than 1 year, and 85% occurred in children younger than 6 years.4 The leading cause of death for abused children younger than 2 years was head injury.4
Why Abuse Often Is Missed
Clinicians do not always recognize when abuse has occurred, possibly because the injury indeed could be explained by the mechanism offered by the caregivers. Often a series of injuries must occur before a pattern of abuse becomes evident. Sometimes a clinician may fail to accept that abuse can occur in a particular child or in a particular family. Although child abuse is more common in lower socioeconomic groups, abusive injuries do occur in situations in which a family’s socioeconomic status is above average. In one study of six young children with abusive head trauma, the authors point out that the injuries suffered by these children were more likely to be reported when the children were from minority groups.5
In general, many clinicians believe what they are told. To think otherwise requires a certain level of cynicism and pessimism about people in general, a tendency that may be difficult for some clinicians to overcome. Also, medical personnel tend to concentrate on the task at hand. For example, a patient with respiratory arrest, cardiac arrest, or status epilepticus may have abuse as the underlying the acute problem, but the clinician may not be able to step back and see the etiology behind the problem at hand. Consulting services, such as orthopedics or neurosurgery, may become involved, and again, lead to failure to recognize the underlying cause of the problem. Finally, the clinician simply may be unaware of patterns of injury that should raise concerns for abuse.
The History and Physical Exam
A thorough history and physical examination are essential for a child presenting with any injury to the ED. If possible, the child should be interviewed separately to hear the report of the event; caregivers or other witnesses also should be interviewed separately. The history should be correlated with the developmental capability of the child. Use open-ended questions; many children are reluctant to offer much information and likely will respond with one-word answers if given the opportunity. Time is a difficult concept for young children to understand; therefore, tying circumstances of the injury to known events (e.g., meal times, television programming, or other regular events in a child’s life) is suggested. Previous history regarding other injuries, fractures, or hospitalizations should be included. Underlying medical problems also must be considered in the child with repeated injuries. For example, frequent bone fractures could be an indication of an underlying medical problem, such as osteogenesis imperfecta.
Perform a complete physical examination. Special attention should be paid to the head and oral cavity. Bruising or bleeding about the ears may indicate a pinching injury secondary to abuse (Figure 1). A tear of the upper frenulum or the frenulum beneath the tongue could occur from a simple fall, but without that information being given in the history, the clinician should be concerned; a caretaker may have become frustrated in caring for the baby and possibly forced the bottle into the child’s mouth, causing the injuries. The short neck of a child may interfere with discovery of bruises in this area. Make a point to inspect the skin of the neck. Palpation of the thorax and abdomen are also important in uncovering other injuries. A toddler or infant with abdominal traumatic injury may not be easy to examine initially, and repeat exams may be required. An overall assessment of the child’s mental status and interaction with the family also is important to note.
Figure 1. 18-month-old with Bruising
of Left Pinna Noted as Part of Routine
Physical Exam; Parents Offered
No Mechanism of Injury.
Cutaneous Injuries
Skin injuries are the most commonly recognized manifestation of abuse. More than 90% of child abuse victims present with this type of injury.6
Bites. Bite marks certainly may be an indication of child abuse. In addition to identifying bites caused by abuse, take steps early to avoid contamination of potential evidence collection. Local cleansing of the wound may remove the saliva of the perpetrator of the bite. Infiltration of the area with lidocaine can distort the view of the bite marks making potential identification of the perpetrator much more difficult.
Bite marks should be suspected when bruising, abrasions, or lacerations are found in an elliptical or ovoid pattern. Often caregivers report that animals (e.g., cats or dogs) caused bites to abused children. Human bites often can be clinically distinguished from bites caused by animals. Bites produced by animals tend to tear flesh, whereas human bites compress flesh and rarely cause avulsion of tissue. A typical human bite mark is best described as an elliptical or oval injury composed of two U-shaped marks. These two marks represent the upper and lower teeth and are separated at their bases by open space. The bite marks may have a central area of ecchymosis caused by two potential forces. The first force could result from positive pressure with the closing of the teeth resulting in disruption of the small vessels in the area between the teeth themselves. Ecchymosis also could be caused by negative pressure caused by suction and tongue thrusting.7
The normal distance between the maxillary canine teeth in an adult human is 2.5–4.0 cm.8 If the intercanine distance is fewer than 2.5 cm, a child probably caused the bite. If the intercanine distance is 2.5–3.0 cm, a child or possibly a smaller adult produced the bite. Finally, if this distance is more than 3.0 cm, an adult most likely caused the bite.
Photographing the lesions is the best documentation of wounds thought to be secondary to an inflicted bite. The photographs should be taken perpendicular to the bite itself, and an identification tag and scale marker (such as the one developed by The American Board of Forensic Odontology [AFBO]) should be included in the photograph itself.8
The duration of visibility of a bite mark depends upon the duration and magnitude of force of the actual bite and the degree of the resulting injury. For example, teeth marks that do not break the skin may last from several minutes to 24 hours.9 Similar to other bruising, the appearance of a bite will change over time with a decrease in swelling and inflammation. These changes may be especially rapid in children due to a more rapid healing process.10
Another aspect of evidence collection to be considered is collection of saliva found in the bite wound itself. Blood group substances can be secreted in saliva; DNA present in epithelial cells from the mouth may be deposited in these bite wounds. Even after saliva and cells have dried, they can be collected on a sterile cotton swab moistened with distilled water. These swabs, then, should be dried and placed in a cardboard specimen tube or envelope. A control sample also should be obtained from an uninvolved area of the child’s skin, and the samples sent to a certified forensic laboratory for analysis. As with all evidentiary material, a chain of custody must be maintained on all samples submitted for forensic analysis.
Sometimes, a forensic odontologist or a forensic pathologist may be helpful in the decisions regarding the collection of evidentiary material. (Names and contact information for an ABFO certified odontologist may be obtained from its Web site at www.abfo.org.) A transparent overlay of the suspect’s dentition may be compared to that of the bite wounds themselves. Dental casts of the suspect are scanned into a computer, and the biting edges of the suspect’s dental casts are selected out with the production of a hollow volume overlay. These overlay patterns are then compared to an impression of the bite injury that has been fabricated with the use of vinyl polysiloxane impression materials.8 The impressions can be cast in plaster and provide a long-lasting record of the injury itself. A study determined that forensic dentists correctly identified the biter in 86% of cases presented to them.11 Again, if deemed necessary, the creation of these overlays and impressions is best performed by a forensic dentist. If the bite were located in an area clearly inaccessible to the victim, such as on the back, then certainly this evidence would not be required.
Bruises. Certainly the presence of bruises is not pathonomic for the presence of child abuse. Due to their activity level and curiosity, children often will become involved in activities that lead to bruising. However, when evaluating children with bruises, there are factors that should raise suspicion for child abuse. Bruising found with patterns recognizable as coming from specific objects are concern for abuse (Figure 2). These patterns can result from a variety of objects. For example, finger imprints across the face are certainly indicative of abuse. These bruises are seen in a linear fashion tracing the outline of the fingers of the abuser. The areas of sparing between the marks of the bruising represent the point of impact of the fingers themselves. Blood is driven away from the site of impact that causes a sudden increase in capillary pressure. The linear bruises result from the ruptured capillaries and create the outline of the fingers.
Figure 2. 7-year-old Child with Thigh
Bruising Secondary to an Electrical Cord
Location is another distinguishing feature of bruises caused by abuse. Circumferential bruises around the wrists and ankles suggest the use of some type of bonding or holding the patient down. Bruises to the buttocks or to the flank are worrisome; these are areas where children usually are not injured as a part of an accidental injury. Pay close attention to injuries of the face and head, outer ears, neck, chest, abdomen, buttocks, genitalia, and the inner aspect of the thighs. Generally, these areas are not injured as a part of an accidental traumatic injury.
Bruises found in infants who are not developmentally able to move about on their own should raise suspicion for abuse. In a study of children younger than 36 months, the frequency and location of bruises in normal infants and toddlers was determined through the use of a cross-sectional survey of community primary care pediatric offices.12 The researchers report that bruises were found in 203 (20.9%) of 973 children who had no known medical cause for bruising and in whom abuse was not expected. Not surprisingly, the most frequent site of bruises was over the anterior shin and knee. Bruises on the forehead and upper leg were common among walkers, but bruises on the face and trunk were rare. Bruises on the hands and buttocks were not observed at any age, and there were no differences in bruise frequency by gender. The researchers concluded that bruises are rare in normal infants and in those children who are not yet cruising or walking; the discovery of bruises in infants younger than 9 months and not yet beginning to ambulate should lead to consideration of abuse or a medical illness as an explanation for the bruising. In addition, bruises located in atypical areas (e.g., the trunk, hands, or buttocks) in toddlers should prompt the same concerns.
The issue of dating bruises has resulted in much controversy. Several authors have attempted to delineate the age of bruising dependent upon its appearance at the time of evaluation. In one study, children who presented to an ED of a children’s hospital with accidental bruises of known age and origin were evaluated by emergency pediatricians, other physicians, and trainees.13 The authors found that emergency pediatricians’ accuracy of age estimation within 24 hours of actual age was 47.6%, 29.4% for other physicians, and 36.8% for trainees. The observers reported using color primarily to estimate age, followed by tenderness, and then, swelling. None of these factors was correlated significantly with accuracy. The authors of this study concluded that estimation of the age of bruises is highly inaccurate within 24 hours of the actual age of the injury. They reported large individual variability, poor interrater reliability, and suggest that caution must be used when interpreting these estimates.
Assessment of the age of bruises is very difficult. A variety of factors including depth, location, and skin complexion will affect the appearance and color of a bruise. The timing of appearance of a particular color may vary in part according to injury depth. Smith and Fiddes report that the presence of yellow coloring of a bruise was believed to generally appear in 7-10 days, but may appear in 3 days if the bruise was superficial.14 Another study noted that yellow develops more quickly in bruises that are superficial, a fact that highlights the difficulty of assessment in the child with bruises of multiple colors.15 If a child is bruised in both deep and superficial fashions at the same time, the bruises actually may be different colors although they occurred at the same time. There are widely disparate opinions regarding how bruise color changes over time. In a 1977 article, Wilson reviewed five forensic pathology texts that address this issue.16 He found estimates of the appearance of yellowish-green color to appear in “at least several days” in one reference and “at the end of about two weeks” in another text. The five forensic texts he tabulated portray significant variations in the timing of and appearance of the color scheme of bruises. There does not appear to be agreement regarding the initial color of the bruise, evolution of the bruise color, or that specific successive colors can be assumed. The table Wilson created did not represent a single opinion of bruise evolution, but rather tabulated various opinions. Although he recognized the lack of clear definitions for bruise age determination, as well as the lack of consensus in the literature, and concluded that the estimation of the contusion age is inexact, his table has been cited by many textbooks on child abuse,17 emergency medicine,17 and trauma.18 Other studies are based upon experiences with postmortem adult subjects and yet are used often to estimate age of bruises in the clinical evaluation of children.19,20
In a 1991 study, researchers attempted to determine the accuracy of the age of a bruise by looking at its color.15 They reviewed 369 photographs taken of bruises of known ages and origins for 89 inpatients, staff, and patients in an ED. The researchers concluded that: 1) a bruise with any yellow must be older than 18 hours; 2) red, blue, and purple or black may occur any time from one hour of bruising to resolution; 3) red has no bearing on the age of the bruise because red is present in bruises no matter what their ages; and 4) bruises of identical age and cause on the same person and that appear as the same color may not change at the same rate. Research such as this suggests that the development of bruise color is indeed variable. The presence of yellow color although believed to be a reliable sign of an older bruise may appear relatively early and certainly earlier than many current forensic charts indicate.
Unfortunately, the current literature on estimation of bruise ages remains an inexact science. Although these estimates may offer the only way to associate an injury with a particular perpetrator, it is difficult to make such strong conclusions as would be suggested by the composite charts found in many texts. Schwartz and Ricci advise that “the estimated age of a bruise should never be the sole criterion for a diagnosis of child abuse, but rather one component of a comprehensive assessment that incorporates a careful history of the injury, past medical history, family history, associated risk factors, a detailed physical examination, and appropriate laboratory testing”.17
Therefore, the clinician faced with the challenge of assessing bruises found in a child also must consider medical explanations. Harley reports two cases of idiopathic thrombocytopenia purpura and one case of hemophilia with unexplained bruising as the presenting problem.21 He recommends that any child with unexplained or implausible bruising receive a screen for coagulation disorders consisting of a complete blood count including platelet count, as well as a prothrombin time, a partial thromboplastin time, and bleeding time measurements. In another study, 50 children who were referred to a child abuse team during a 10-year period with suspected abusive injury were found to have a medical condition that explained their bruises. Of these, nine children had impetigo, five children had hemostatic disorders, and five children had normal “blue spots” or “mongolian spots” that had been misidentified as bruises. The authors recommended follow-up examination of a child as a way to make a clinical assessment of the presence or absence of bruises. Progressive color changes of actual bruises will become evident with repeated examinations over time. These authors also emphasized the importance of obtaining coagulation studies to exclude bleeding disorders. (See Table 1.)
Table 1. Differential Diagnosis of
Excessive
or Atypical Bruising
Burns. Approximately 10% of all pediatric hospital admissions involve abuse, and up to 20% of all hospitalized pediatric burn patients incur their injuries as a result of child abuse.22 As with other injuries, the evaluation of burns requires careful attention to the history, physical examination, and scene investigation to determine if child abuse indeed has occurred. The history provided by caregivers and the developmental capabilities of a particular child again play important roles in assessment of the etiology for a particular burn. An injury that is inconsistent with the history provided by the caregiver is the most common predictive factor of inflicted injury.23,24
Familiarity with burn patterns will allow for appropriate recognition of both accidental and inflicted injuries. Burns to hands, legs, feet, and buttocks have been described throughout the literature as the predominant sites for abuse.25,26 Burns to the buttocks, perineum, and feet in a symmetric pattern are diagnostic of deliberate injury.27
The importance of burn pattern recognition was highlighted in a study of three cases of toddlers with accidental scald burns occurring in sinks.28 Each case involved bilateral scald burns of the lower extremities. In two of the three cases, the sole of at least one foot also was involved; although both lower extremities were involved, the burn pattern demonstrated asymmetry with one of the extremities substantially more affected than the other. Researchers also reported that the burns were not circumferential and did not mimic a stocking distribution. The burn margins also were irregular with occasional scalloped edges rather than the clearly demarcated margins of burns resulting from forced immersion. The burns also were irregular in depth in contrast to inflicted immersion injuries that are of uniform depth because of the inability of the child to move in the water while being restrained. Child abuse was not believed to be a cause after scene investigation. Each child had sat on a bathroom sink after climbing on an adjacent toilet, and had turned on the water that was at least 140ºF. Each had a history of playing in the sink before the injuries occurred. A group of risk factors identified by emergency physicians to identify children with burns suspicious for abuse can be found in Table 2.23
Table 2. Burns Suspicious for Abuse
Researchers studied 507 consecutive admissions to a pediatric burn unit during a three-year period in Australia; 86% of children with burns suffered injuries that were accidental with no evidence of deliberate injury or gross neglect.29 Eight percent of the admissions were referred for abuse and neglect, resulting in a social service agency becoming involved; an additional 6% raised concerns about the reason for the child’s injury, but no formal intervention was undertaken by social service agencies. Children in these latter two groups were more likely to require skin grafting and treatment in the intensive care unit. They also were more likely to come from single parent families and were more likely to have burns involving either hands or both legs. There were few other distinguishing factors, except for prior notification for abuse and neglect.
In one comparison of children whose burns were believed to be due to neglect and children who were believed to be abused, the abused children again had inconsistent mechanisms of injury reported, the injuries were more often bathroom related, and were likely to have a history of abuse or stigmata of abuse on exam.30
A case series of face-first inflicted immersion burn victims and a comparison group of consecutive hospitalized scald-burn victims younger than five years of age,31 led researchers to conclude that lower extremity immersion burns, as well as buttock injuries were common with abuse. Bilateral lower extremity tap water immersion scalds occurred in 100% (6/6) of abusive and 29% (2/7) of unintentional injuries (P = 0.02). Buttock and perineal injuries occurred in 67% (4/6) inflicted versus 29% (2/7) unintentional tap water immersion scalds. (P = 0.28). Other fluids caused lateral lower extremity immersion burns in 33% (3/9) of unintentional injured patients but no abused children. The authors concluded that lower extremity immersion burns, as well as buttock injuries were common with abuse.
Fractures
The distinction between children with unintentional fractures and those with fractures due to child abuse is not made easily. Again, an emphasis should be placed on a complete history, including the developmental state of the child, and a complete physical examination. Certain types of fractures are considered specific for abuse (e.g., rib fractures in infants or metaphyseal corner fractures in young children).
In a descriptive retrospective chart review of children younger than 3 years presenting with a fracture to a pediatric ED and orthopedic clinic at an urban teaching hospital, researchers concluded that it was not possible to rule out inflicted injury in 42% of the patients based on the retrospective review of the documentation provided.32 Also, 23% of the charts reviewed raised suspicion of inflicted trauma. They concluded that there was a need to ensure that adequate information was obtained and documented in hospital records to rule out inflicted injury; they proposed changes in the use of forms, protocols, and periodic chart review. Physicians must clearly document their concerns or lack thereof regarding child abuse when children present for care.32
In a study of 253 fractures found in 215 children younger than 3 years who were identified from ED logs or the hospital’s child abuse registry, researchers found that fractures likely were due to abuse when: 1) caretakers reported either a change in the child’s behavior but no accidental event or minor fall, but the injury was more severe than expected; 2) fractures of the radius/ulna, tibia/fibula, or femur occurred in children younger than 1 year; or 3) midshaft or metaphyseal fractures of the humerus were found. Linear fractures of the parietal bone were the most common skull fractures whether due to abuse or unintentional injuries.33
A common history given for children with fractures is that of a fall. Simple fractures often occur from falls of a short distance. However, changing stories with repeated questioning should raise suspicion. The nature of a fall should be explored and is best assessed by asking questions of the child and the caregiver separately. As much as possible, the clinician should remain as neutral and objective with provision of medical care as the first priority.
A complete examination must be performed to look for evidence of other injuries in addition to those found concerning for abuse. Multiple exams may be necessary to complete an entire exam. The child’s overall appearance also should be noted. Signs of neglect (e.g., poor hygiene, severe diaper rash, or bald spots to the scalp) are more likely to be seen in children who have been abused and neglected. After the history and physical examination have been obtained, the clinician should continue to address pain relief and comfort of the child. The patient and the family must see the clinician as a physician first rather than a detective. Underlying medical problems should be investigated before raising the possibility of abuse to the caregivers.
The use of a skeletal survey or a bone scan has little value in children older than 5 years. Patients in the 2- to 5-year-old group must be handled individually based upon the specific clinical indicators of abuse. When clinical findings point to a specific site of injury, the usual radiographic techniques for imaging that area should be used. If plain radiographs do not reveal any evidence of fracture, but the clinical suspicion is high, other imaging modalities (e.g., magnetic resonance imaging or scintigraphy) may be indicated, especially when metaphyseal separations are suspected. If a child is placed in a safe environment, a follow-up skeletal survey in 2 to 3 weeks would most likely yield the information necessary.
The American Academy of Pediatrics (AAP) Section of Radiology’s position statement on the diagnostic imaging of child abuse discourages the use of the body gram, a study that encompasses the entire infant or young child on only one or two radiographic exposures.34 According to the statement, abbreviated skeletal surveys have “no role in the imaging of the subtle but highly specific bony abnormalities of the abused child.” The radiographic skeletal survey was considered the method of choice for skeletal imaging in cases of suspected abuse. The American College of Radiology’s standards for skeletal surveys of children can be found in its publication on the topic.35 Modern pediatric imaging systems commonly use special film cassettes and intensifying screens to minimize exposure. Low-dose, all-purpose pediatric imaging systems provide insufficient anatomic detail to image the skeleton of an infant or young child. These systems are adequate for chest and abdominal imaging, but they fail to provide the necessary contrast and spatial resolution to image subtle metaphyseal, rib, and other high specificity injuries that are characteristic of abuse. Also, a film must be coned or restricted to the specific anatomic area of interest. The use of larger anatomic regions when skeletal surveys are performed results in areas of underexposure and overexposure and loss of resolution. The standard skeletal survey imaging protocol developed by the American College Radiology is listed in Table 3.
Table 3. The Standard Skeletal Survey
When performed by staff experienced with pediatric nuclear imaging, skeletal scintigraphy (a bone scan) may offer an alternative or adjunct to the radiographic skeletal survey in selected cases, particularly in children older than 1 year. Scintigraphy seems to provide increased sensitivity for detecting rib fractures, subtle shaft fractures, and areas of early periosteal elevation. The AAP policy statement also states that “data are limited about the sensitivity of scintigraphy for classic metaphyseal lesions of abuse, particularly when the lesions are bilateral as well as subtle spinal injuries, features that carry a high specificity for abuse in infants.”34
One study compared the effectiveness of radiological survey with bone scintigraphy for the detection of bony injuries in children discharged from the hospital with a diagnosis of child abuse.36 The authors found 124 bony injuries identified among the 30 children; 64 of these bony injuries were identified on the bone scan and 77 on the skeletal survey. Rib fractures represented 48% of the bony injuries and were present in 53% of the children, of which 62.5% had multiple rib fractures. Excluding rib fractures, 52% had bony injuries, of which 33% were seen on both imaging modalities, 44% were seen on the skeletal survey only, and 25% were seen on bone scans alone. Metaphyseal lesions, typical of child abuse, were present in 31% of cases on skeletal surveys; only 35% of these were identified on bone scan. Six children (20%) had normal skeletal survey results, but had abnormalities shown on bone scan. There were three children (10%) with normal bone scans who were shown to have injuries radiographically.
Rib fractures. The flexibility of the thoracic area of young children permits the anterior ribs to be compressed to meet the posterior ribs. Most often rib fractures are diagnosed by a screening chest film or as part of a skeletal survey performed during the initial evaluation (Figure 3). Broken ribs certainly are an indicator of significant injury transfer. Whenever rib fractures are found in children younger than three years, child abuse should be a major concern. Children with suspected bone fragility from osteogenesis imperfecta, rickets, or prematurity could be at high risk for rib fractures from non-abusive situations. Children with such conditions often can be identified by characteristics on physical examination (e.g. blue sclera) or on radiographic evaluation (e.g., wormian bones, osteopenia).
Figure 3. 4-month-old with Healing
Fractures of Left 5th, 6th, 7th, and 8th Ribs
Rib fractures have been reported to occur in 5-27% of abused children. In a retrospective chart review, researchers showed that rib fractures were attributed to child abuse in 84% (15/18) of infants identified.37 The initial presentation in these abused infants was most often the result of intracranial pathology and limb fractures. In four cases, however, the rib fractures were incidental findings when abuse had not been suspected. In three cases, the rib fractures were an isolated finding.
In a retrospective review of infants younger than 12 months with rib fractures, researchers found that all fractures were determined to be attributable to child abuse, birth injury, bone fragility, or accidental trauma and that most rib fractures in infants are caused by child abuse.38 The researchers suggest that a thorough clinical evaluation including complete imaging studies is mandatory for children with rib fractures. Finally, in another study, a rib fracture had a positive predictive value of 95% for the diagnosis of abusive trauma.39 After children with a defined history of accident or disease were excluded, the positive predictive value for abusive trauma in children with rib fractures increased to 100%.40 Rib fractures were the only skeletal manifestations of abusive trauma in 29% of the children included in this study.
Again, these findings highlight several important points about the presence of rib fractures in infants and young children. Once rib fractures are identified, a complete evaluation for child abuse should be done as well as investigation to uncover possible underlying medical conditions. A thorough physical examination of all infants and young children who present for care should be performed, which should include visual inspection of the child’s thoracic area as well as palpation of the child’s rib cage. One researcher reported on the discovery of “clicking ribs” in children who had presented for care with a parental complaint of feeling a clicking sensation or grating feeling in the rib cage area.39 Often this sign has been ignored, and the children have then been sent home only to return with further injury.
In infants, rib fractures have been reported to represent the most frequent type of fracture of abuse.31,42 These fractures occur when an infant is grabbed around the thoracic cage and either violently squeezed and/or shaken. The compressive force results in multiple rib fractures, most often posteriorly. When more force is implied, lateral and anterior rib fractures also can occur. It is important to highlight that the absence of overlying abrasions or contusions should not provide the clinician with a false sense of security; abused children with rib fractures usually do not present with visible injury.
Rib fractures may be difficult to detect radiographically. In a postmortem study of 31 abused infants, only 30 of 84 (36%) rib fractures were seen on the skeletal survey although most were healed fractures.42 Radiographs should be performed specifically to look for the evidence of rib fracture and possibly should include oblique views when there is high suspicion. The fracture lines of these injuries are thin and usually are nondisplaced without significant angular deformity. The presence of other osseous and soft-tissue structures over the region of the fracture further limit detection of these rib fractures.43
Case study. A case report by Swischuk highlights the value of the discovery of rib fracture as part of the skeletal survey.44 A young infant presented to the ED with inability to bear weight on his left leg. The parents reported that several days earlier, the infant was in a baby swing on the first floor of their home while being cared for by the maternal grandmother. The parents stated that they were home at the time but were upstairs. They reported that the swing broke, and the infant fell to the floor. They said that the infant was fussy, and that during the next several days the mother had noticed that the infant would not push on his left leg when in his bouncing chair. The mother also noted that touching the infant’s leg resulted in the child crying.
A radiograph was obtained and initially interpreted as normal. Further review of the radiograph by the radiologist identified the presence of a distal femur fracture. The child was referred to a pediatric orthopedic clinic for further evaluation and treatment. Anterior-posterior and lateral radiographs of the left lower extremity were obtained, and a subtle supracondylar buckle-type fracture of the distal femur was identified. The injury did appear to be consistent with the reported history of an infant falling out of a bouncing seat. However, a skeletal survey also was obtained, revealing the presence of a healing rib fracture. The skeletal survey was obtained because the child was younger than 2 years, raising the concern for possible abuse. No explanation for the presence of a rib fracture was given based upon the history provided by the parents and the grandmother. Further evaluation of the child included an ophthalmologic exam, which revealed retinal hemorrhages. This case highlights the importance of the presence of rib fractures in making the diagnosis of child abuse.
Clinicians may question the possibility of rib fractures being caused by cardiopulmonary resuscitation done prior to a child’s arrival in the ED. Several studies have been conducted with little evidence to support the fact that rib fractures in infants can be caused by chest compressions during resuscitation.45
Humerus fractures. The humerus has been described as the most commonly fractured bone in abused children.46 The mechanism of injury is a rotational or twisting force being applied to the upper arm while the child is being held. Most often the resulting fractures are spiral or oblique and are located in the mid-shift or in the metaphyseal area (Figure 4). The classic metaphyseal injury seen in abuse often involves the humerus. These fractures are identified as corner fractures, metaphyseal radiolucencies and irregularities, a discrete fracture line, or flame-shaped metaphyseal extensions.30
Figure 4. 4-month-old with Healing
Fracture
of the Left Humerus
Found on Skeletal Survey
Case study. Acute injuries may result in no radiographic changes being seen initially. Repeat or highly detailed radiographs should be performed if abuse is suspected. Moucha and Mason report on an uncommon injury of distal humeral epiphyseal separation.47 A 4-month-old female was brought to the ED after allegedly falling out of her crib. The physical examination showed human bite marks on the anterior aspect of her right thigh and abrasions on her left cheek and forehead. The left elbow was markedly swollen, deformed, and tender. Both active and passive ranges of motion of that elbow were limited by pain. The patient was able to move her left wrist and fingers and had a normal radial pulse as well as the appearance of having intact sensory function of the median, ulnar, and radial nerves with light touch testing at the hand. Plain radiographs of the left elbow were remarkable for a fracture separation of the distal humeral epiphysis. A skeletal survey showed corner fractures of the distal left femur, proximal right tibia, and proximal and distal fibula. Healing fractures of the left 5th, 6th, and 7th ribs, left proximal humeral metaphysis, left radioulnar shafts, right distal radius and ulna, the midshaft of the right femur, and the left proximal tibia also were found. Magnetic resonance imaging confirmed an isolated fracture separation of the distal humeral epiphysis without metaphyseal extension of the fracture line. The elbow was reduced with flexion and pronation and placed in a long-arm cast. The patient was discharged to a local child protection agency.
The authors point out that the diagnosis of fracture separation at the distal humeral epiphysis usually is made when the posterior medial displacement of the distal fragment is seen on plain radiography. However, given the young age of this child, the capitellum had not yet ossified, and a high index of suspicion was essential in making the correct diagnosis.
Abuse should be considered in all children younger than 15 months with humeral fractures, including those with supracondylar fractures.48 However, the majority of humeral fractures in children are indeed accidental, especially beyond the age of 15 months. Again, obtaining an accurate history is important in evaluating children found to have humerus fractures.
Radius and ulnar fractures. Most fractures of the radius and ulnar are not due to abuse. Toddlers may fall on an outstretched arm and easily can sustain buckle-type fractures of the distal radius and ulna. The nonambulatory child found to have radial and ulna fractures should have further investigation for the possibility of abuse. The radius and ulna should be included in the skeletal survey of all children with suspected abuse. The classic metaphyseal injuries of child abuse are the result of pulling or traction forces applied to the upper extremities of these children.
Femur fractures. In one study, a significant number of femur fractures were due to child abuse: 8.5% of the fractures were due to violent trauma, 12.5% were pathologic fractures, 30% were related to child abuse, and 49% resulted from normal trauma to normal children.49 Researchers also found that child abuse, as a cause of a femur fracture, was more common in children younger than 1 year and among those children with bilateral fractures. The fracture configuration was not usually pathognomonic of abuse, but fractures at the subtrochanteric level and chip fractures of the distal metaphysis were more common in abused children (Figure 5). Researchers concluded that if a reasonable history for the cause of fracture is given, appropriate medical care is sought in a reasonable time frame, and a lack of other evidence of abuse is found, then the likelihood of child abuse is very low. However, they did emphasize that if any of the criteria mentioned above were lacking, a skeletal survey and further evaluation are indicated.
Figure 5. Acute Femur Fracture
in a 2-year-old Child
In another study, the authors found that the strongest predictor of likely abuse was whether a child had achieved the capability of walking.50 They also found that unless other evidence of abuse (e.g, an inconsistent history, bruises, or other fractures) is present, abuse was very unlikely to be involved in the child who was capable of walking. The mechanism in 50% of their series of patients was from a simple fall from a height or from a fall while running. In these cases, only an isolated femoral shaft fracture was found. The authors’ study is limited by the fact that their focus was on the presence of a femur shaft fracture. Fractures involving either the proximal or distal end of the femur with the findings of metaphyseal lucencies, corner fractures, or bucket-handle fractures would be more concerning for abuse. These results should not be interpreted to conclude that a child with femoral shaft fractures has not been abused. A skeletal survey was performed in only 29 cases in this study; it was positive in six patients and negative in 23. As the presence of other fractures would increase the suspicion for abuse, the lack of skeletal survey results for all patients may have resulted in missing some children with abuse.
Jones and colleagues report on two infants who were diagnosed as having proximal femur fractures; each was diagnosed in a delayed fashion because they were brought to care several months after their initial injury.51 Plain radiographs were obtained when the children were noted to have pain with hip motion, asymmetric thigh-skin folds, and limitation of hip abduction. The initial impression was that the children had developmental dysplasia of the hip, but radiographs revealed cranial displacement of the femoral neck. In addition, healing bucket-handle fractures of both proximal humeri and a healing distal bucket-handle fracture of the right distal humerus were found in one patient; healing fractures of the left 4th and 5th, and the right 4th, 5th, and 6th ribs were found in the other child. No history of injury was offered for the first child. The other child’s injury was attributed to a frustrated diapering attempt in which the mother’s boyfriend abducted the child’s thigh and then pushed the femoral shaft toward her acetabulum.
The authors point out that proximal epiphyseal fractures in infants are usually the result of high-energy trauma, (e.g., birth trauma), and the incidence has decreased during the past 30 years due to a decrease in the incidence of traumatic birth injury. The injuries themselves are uncommon with 50 reported cases in literature between 1946 and 1982.51 A transepiphyseal separation should be considered in any infant presenting with an apparently shortened limb that is held flexed, abducted, and externally rotated. Plain radiographs may fail to be diagnostic of a nondisplaced epiphyseal injury due to the lack of femoral head ossification in infants younger than 4 months. It is possible that the femoral shaft may be dislocated from the femoral head and could be seen to be malaligned with the acetabulum on plain x-rays. Such an x-ray might be interpreted as developmental dysplasia of the hip. Compared with most children with developmental dysplasia of the hip, the acetabulum in children with a Type I fracture usually is formed normally; periosteal new bone formation usually takes 7-14 days after injury to become evident on a plain radiograph. Ultrasound may be useful in locating the nonossified femoral head in the diagnosis of developmental dysplasia of the hip and most likely is useful in identifying physeal separation. Distal femoral metaphyseal injuries were believed to be more common than proximal femoral physeal injuries caused by child abuse. Proximal femoral physeal injuries should raise concerns about abuse and warrant further investigation.
In a retrospective study of 207 patients younger than 6 years who had sustained nonpathologic diaphyseal femur fractures, Scher and colleagues concluded that spiral fractures were less common than transverse fractures overall.52 Furthermore, spiral fractures were no more common in the cohort of patients in whom the results of the child abuse investigations were positive. However, those with spiral fractures were over-represented in the cohort that underwent investigation. Spiral fractures were viewed as particularly suspicious for abuse. The authors cautioned that the heightened sensitivity to report spiral fractures of the femur may lead to missed cases of nonaccidental injury in children with transverse fractures.
One study found that the twisting motion generated by an infant stationary activity center might be consistent with the generation of forces necessary to cause femoral fractures.53 In this study, two nonambulatory children sustained oblique, distal femoral metaphyseal fractures extending through the growth plate. Investigation regarding the cause of the injury found that both children had been playing in an infant stationary activity center called an Exersaucer. These children had complete skeletal surveys, which revealed no other fractures. The authors do not suggest that a report of suspected abuse not be made, but rather point out the value of a child abuse investigation.
Tibia and fibula fractures. The tibia commonly is broken as a result of accidental trauma. Unintentional oblique or spiral fractures of the tibia can occur in young children when they begin to walk, often called “toddler’s fractures” and are the result of a twisting motion occurring most often when a younger child falls to the ground (Figure 6). Initial x-rays may not reveal evidence of a fracture, but clinical suspicion should be high when the application of a slight torsional force to the lower leg of a child in this age group reproduces pain. Oblique x-rays of the lower leg may show the fracture at the initial evaluation for the child who refuses to bear weight.
Figure 6. 3-year-old with a Toddler’s
Fracture; Refused to Bear Weight
after a Witnessed Fall
Nonaccidental injury should be considered in those children with lower leg fractures who are otherwise healthy but nonambulatory. Violent grabbing with twisting of the lower leg can produce transverse, spiral, or oblique fractures. Periosteal reaction as these fractures heal may be found as an incidental finding or as part of a skeletal survey. The medial margin of the tibia may be more susceptible to the various mechanical forces involved in abuse.54
Estimation of Time of Skeletal Trauma
There are limitations in establishing a time frame for when abusive skeletal injuries have occurred. Delays in seeking medical care and the reluctance of those involved in reporting the exact details and timing of abusive injuries make it difficult to establish a time frame for when these injuries actually occur. Some degree of swelling due to hemorrhage and inflammation in the tissues surrounding the areas of the fracture will be evident at some point. The swelling and inflammation may resolve in several days, but still could be present on plain radiographs for as long as 10-14 days after the fracture occurred.55 Subperiosteal new bone formation may be seen on plain radiographs as soon as 4-7 days after injury. The loss of a definitive fracture line may occur within 10-21 days after the injury. Some evidence of callus formation is present radiographically within 10-21 days after the injury. Hard callus often is seen within 14-42 days after injury. Complete remodeling has been reported to occur as soon as six months after the injury.55
Head Trauma
One study found that nearly a third of infants with an inflicted head injury were not diagnosed on initial presentation for medical care; 25% were re-injured before they were appropriately diagnosed, and nearly 10% of these missed cases suffered fatal injury after initial presentation.5 In this study, children who did not present with seizures or apnea or who came from intact families with health insurance were most likely to have the diagnosis of abusive head trauma missed on first presentation.
Laskey and colleagues concluded from their record review that neither retinal hemorrhage nor historic factors were sensitive markers for abnormalities found with neuroimaging.56 They recommend that clinicians have a low threshold for neuroimaging when physical abuse is suspected in a young child.
Most children who present with head trauma due to abuse again have inconsistent histories provided by caregivers. The information provided might be vague or ill defined. The clinician must pay attention to less clearcut symptoms, such as the infant who presents only with poor feeding or occasional vomiting. In one study, the most common diagnosis of patients with missed abusive head trauma was gastroenteritis.5
The physical examination of children with abusive head trauma may be relatively unremarkable. Close attention to the patient’s respiratory effort and maintenance of airway patency should be the primary concern. The presence of swelling of the fontanelle, as well as pupillary reactivity, must be assessed carefully. The imaging test of choice is computed tomography (CT) without intravenous contrast. It has high sensitivity and specificity for diagnosing acute intraparenchymal, subarachnoid, subdural, and epidural hemorrhage. This type of study allows for prompt recognition of abnormalities that would require emergent surgical intervention. The CT scan also is performed easily in younger children and rarely requires the use of sedation. Skull fractures also may be diagnosed with CT imaging, but a complete skeletal survey including views of the skull also is indicated as part of the evaluation (Figure 7).
Figure 7. 5-month-old with Multiple
Skull Fractures with Report of
Fall off Couch
The most common finding in the abused child with head injury is a subdural hematoma (Figure 8). Features of the subdural hematoma that are suspicious for a nonaccidental trauma include: 1) the presence of subdurals without a skull fracture; 2) bilateral subdural hematomas; 3) subdural hematomas of different ages; 4) subdural hematomas in the presence of retinal hemorrhages; and 5) acute interhemispheric subdural or falx hemorrhage.57
Figure 8. 5-month-old with Subdural
Hematoma with Report of a Fall off Couch
Recently, there has been some controversy in the literature regarding diagnostic criteria for abusive head trauma. In one evidence-based case report, systematic review of the medical literature on perimacular retinal folds associated with abusive head trauma in infants and young children found that statements that perimacular retinal folds are diagnostic of shaken baby syndrome are not supported by objective scientific evidence.1 Noncomparative observational reports and unsystematic narrative review articles contain insufficient evidence to provide unbiased support for or against diagnostic specificity. The authors did not believe that there is significant objective medical evidence to draw conclusions about associations, causal or otherwise, between the presence of perimacular retinal folds and abusive head trauma. They did, however, report that clinical and autopsy evidence of ocular lesions must be considered alongside other physical findings and a thorough investigation before concluding whether a head injury is caused by abuse. A review of the literature showed a weak scientific evidence base to draw definite conclusions about this issue. The incidence of perimacular retinal folds in shaken baby syndrome varies from 6% in a consecutive clinical case series to 50% in a sequential autopsy case series; authors concluded that clinical and autopsy studies with appropriately matched controls are needed to determine the causal mechanism of perimacular retinal folds and their specificity for abusive head injury.48,58
Low-level falls can cause both subdural and retinal bleeding.59 At times, caregivers who have attempted to provide resuscitation efforts to a child with an apparent life-threatening event may inflict some injuries that overlap with those found in abusive head trauma. However, the clinicians are reminded that their role in the evaluation of children with head injuries is to report suspicion of abuse, not a definitive diagnosis. The clinician may not be able to prove or disprove whether abuse has occurred based on a short-term evaluation in the ED. Any child who has subdural hemorrhages accompanied by retinal hemorrhages warrants an investigation into possible abuse. When these injuries are found, the clinician has an obligation to investigate further with the completion of a skeletal survey and possibly screening for intra-abdominal injuries in an effort to completely evaluate the child for nonaccidental trauma.
Researchers in one retrospective study of children younger than two years admitted with injuries suspicious for child abuse, recommend universal CNS screening in abused children with no neurologic symptoms when any of the following high-risk criteria are found: rib fractures, multiple fractures, facial injury, or age younger than 6 months.60 They emphasize this approach especially in children younger than 1 year, but did not believe that ophthalmologic examination was a good screening method for occult head injury.
Another possible presentation of the child who has suffered an abusive head injury is an apparent life-threatening event (ALTE). ALTEs consist of the sudden occurrence of changes in breathing pattern, muscle tone, mental status, or color in an infant. There is a wide spectrum of diseases and disorders that can precipitate an ALTE (e.g., metabolic disorders, seizure disorders, or gastroesophageal reflux). Pay close attention to the history of the event and physical examination of the patient. Consider an ophthalmologic evaluation and cranial imaging for these patients unless another cause becomes clearly evident.61
Inflicted Abdominal Trauma
One of the less commonly recognized injuries in abused children is that of abdominal trauma. Some studies demonstrate fatality rates as high as 50%, which is higher than that caused by accidental blunt trauma.62 Researchers examined the use of markers for abdominal trauma in the evaluation of cases of child physical abuse.63 The study included children younger than 12 years who presented to the ED of a children’s hospital for evaluation of suspected physical abuse and were entered prospectively into the study. They compared the use of liver transaminase and LDH levels as a marker for occult liver injury to the use of a skeletal survey in looking for evidence of hidden fractures. The authors recommended incorporation of these studies as part of a routine protocol for evaluating children suspected of being victims of physical abuse. The findings of the study highlighted that abused children with less severe abdominal injuries are under recognized and, therefore, most likely underreported. The child’s symptoms may be nonspecific, or the child may not have the verbal skills to explain his symptoms. External indications of abdominal trauma often are lacking at the time of presentation.
Wide ranges of abdominal injuries are possible in children suffering from abusive injuries. Solid organ injuries are common, both with accidental and inflicted injuries, although hollow visceral injuries more commonly are associated with abuse.64 Liver and spleen injuries are the most common injuries due to abuse followed by duodenojejunal rupture, duodenal rupture, and pancreatic, vena cava, and renal trauma.65 Any child presenting with signs and symptoms of acute bleeding, peritonitis, or hemorrhagic shock should have abuse as part of the differential diagnosis for the etiology of his condition. Delays in seeking care may add to the severity of an abused child’s condition at initial presentation.
A study evaluated injury causes and patient’s outcomes in young children with abdominal injuries extracted from the National Pediatric Trauma Registry.® 66 The three most common mechanisms of abdominal injury were motor vehicle accidents (61.27%), child abuse (15.75%), and falls (13.59%). Patient outcomes were more severe in abused children or those with concomitant central nervous system injury. These two factors were the only variables independently associated with increased mortality in this patient population. Child abuse compared with falls was independently associated with a six-fold increase in in-hospital mortality.
At times, plain radiographs may reveal information suggesting intestinal perforation. Generally, these children will have signs or symptoms of ileus or obstruction. A CT scan is the most rapid and reliable modality to give further detail of abdominal injury secondary to abuse. Although ultrasonography may be helpful for detecting small intestinal hematomas or lacerations of solid organs, it is less helpful for determining the extent of the injuries. The use of contrast during a CT scan of the abdomen may detect intramural hematomas. A more definitive test (e.g., an upper gastrointestinal series or upper endoscopic examination) may be necessary to clearly identify the presence of a duodenal hematoma.
An eight-year retrospective review of a pediatric Level I trauma center database of patients with duodenal injury was considered. Records for 2179 patients younger than 3 years were reviewed.67 Thirty children (0.3%) were found to have injury to the duodenum with 20 hematomas and 10 perforations. The mechanism of injury included nine collisions involving motor vehicles, four collisions involving bicycles, and two collisions involving all-terrain vehicles. All children younger than 4 years were victims of nonaccidental trauma and represented 2.8% of all child abuse admissions. Only one of the abused children was found to have a duodenal injury as an isolated finding. Rib fractures, multiple bruises and contusions, and spiral fractures of long bones were identified in the remainder. One child had bilateral subdural hematomas and a parietal skull fracture. Contusions to the upper abdomen were noted on only one child. Three of the eight children presented with duodenal perforations. The traumatic nature of the injury initially was not appreciated in two of these children who were taken to the operating room with a preoperative diagnosis of probable perforated appendicitis. It was only after the duodenal injury was discovered at the time of surgery that a full evaluation for child abuse was then initiated. Another abused child presented 24 hours after a reported fall down 13 stairs. She also was noted to have bilateral subdural hematomas and a skull fracture. Six of the eight abused children underwent CT imaging of the abdomen with findings suggesting the diagnosis of duodenal injury. The other two had evidence of peritonitis and were taken to the operating room where they were found to have perforations of the duodenum.
There certainly is a challenge for those caring for victims of child abuse to appropriately diagnose the underlying maltreatment syndrome. Some of these children presented to the ED without a clearly defined illness and no reported history of trauma. In other cases, the history was not consistent with the injuries noted. As with all injuries due to abuse, a high index of suspicion must be maintained, and a complete evaluation must be completed to uncover the underlying cause.
Conclusion
The clinician faced with caring for acutely ill and injured pediatric patients will encounter children who have been abused. The identification of these abused children may be a difficult task, and the clinician must maintain a high index of suspicion to identify an abused child. A thorough history and complete physical examination must occur. The constellation of injuries uncovered through this process and the incongruent nature of the history compared to the injuries found are the strongest indicators that abuse has occurred. After assembling all of the information available, including diagnostic studies to rule out underlying medical problems, the clinician must be prepared to make a report of suspected abuse. Thorough documentation of the findings, including detailed descriptions or photographs of injuries found, should be made. All clinicians should be familiar with their requirement to report suspected abuse and become familiar with the agencies responsible for these investigations. Because the ED physician is often the frontline evaluator of injured children, he must assume a primary role in prompt identification of the child who has been abused.
Special thanks to Judy Roberson for her help in preparing this manuscript and to Lorraine Gray and Dr. Kristen Thomas for their help in obtaining the photographs and radiographs.
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