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| ==Background==
| | #REDIRECT[[Nonaccidental trauma]] |
| *Infant and children with disabilities are at higher risk
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| *In >80% of cases, the parent or primary guardian is the abuser
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| *Report suspicion
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| **Transparent, frank discussion with caregivers
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| **Social work or child protection agency involvement
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| ***Protect the child first, admit if suspicious
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| ***Social work may follow-up as outpatient for very low risk cases
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| ===Risk Factors===
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| *Domestic violence
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| *Maternal depression
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| *Drug and alcohol abuse
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| *Premature birth
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| *Children with disabilities or children who require significant medical care
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| *Unrealistic expectations for the child
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| ==Clinical Features==
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| *History given is inconsistent with the mechanism of injury
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| *Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, back, neck of if the child is not cruising yet
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| *Bruises in clusters or patterned marks
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| *Bruising of any child under 4 months of age warrants a full child abuse work-up
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| ===Fractures===
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| *[[Fractures]] highly suspicious of abuse:
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| **[[Rib fracture]], especially posterior
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| **Metaphyseal or [[Corner Fracture (Bucket Handle)]]
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| **[[Scapula fracture]]
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| **Spinous process fractures
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| **[[Sternum fracture]]
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| *Fractures moderately suspicious of abuse:
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| **Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
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| **Multiple bilateral fractures
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| **Different stages of healing with multiple fractures
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| **Epiphyseal separations
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| **Vertebral body separation
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| **Complex skull fractures
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| **[[Pelvic fractures]]
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| ===Head Trauma===
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| *Shaken Baby Syndrome - Retinal Hemorrhages
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| **Present in up to 75% of cases and are virtually pathognomonic
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| **Described as “dot and blot” hemorrhages or flame or splinter hemorrhages
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| ===Abdominal Trauma===
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| *Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
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| ==Differential Diagnosis==
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| {{Template:Child abuse DDX}}
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| {{Crying infant DDX}}
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| ==Evaluation==
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| *Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
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| **Skull AP and lateral view (left and right)
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| **Chest AP and lateral view
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| **Right and left oblique of the chest
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| **AP of the abdomen to include pelvis and hips
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| **AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
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| **AP bilateral humerus
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| **AP bilateral forearms
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| **AP bilateral femurs
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| **AP bilateral tibia and fibula
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| **Posterior view of the hands
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| **Dorsoplantar view of the feet
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| *Head CT without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
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| *Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
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| **Consider CPK and platelet function studies if extensive bruising is present
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| **If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast
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| *Consider a dilated fundoscopic exam if under 2 years
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| *Photograph injuries
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| *Obtain a social work consult
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| ==Management==
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| *Treat injuries as indicated
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| *Report abuse to the appropriate state child protection authority
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| ==Disposition==
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| *Admit for medical treatment or if any question of child's safety upon discharge
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| ==See Also==
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| *[[Trauma (peds)]]
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| ==External Links==
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| [http://pemplaybook.org/podcast/vomiting-in-the-young-child-nothing-or-nightmare/ Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare]
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| ==References==
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| [[Category:Pediatrics]]
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