Child abuse: Difference between revisions
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**Skull AP and lateral view | **Skull AP and lateral view |
Revision as of 18:44, 21 July 2016
Background
- Infant and children with disabilities are at higher risk
- In >80% of cases, the parent or primary guardian is the abuser
- Report suspicion
- Transparent, frank discussion with caregivers
- Social work or child protection agency involvement
- Protect the child first, admit if suspicious
- Social work may follow-up as outpatient for very low risk cases
Risk Factors
- Domestic violence
- Maternal depression
- Drug and alcohol abuse
- Premature birth
- Unrealistic expectations for the child
Clinical Features
- History given is inconsistent with the mechanism of injury
- Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, back, neck of if the child is not cruising yet
- Bruises in clusters or patterned marks
Fractures
- Fractures highly suspicious of abuse:
- Rib fractures, especially posterior
- Metaphyseal or Corner Fracture (Bucket Handle)
- Scapular fractures
- Spinous process fractures
- Sternal fractures
- Fractures moderately suspicious of abuse:
- Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
- Multiple bilateral fractures
- Different stages of healing with multiple fractures
- Epiphyseal separations
- Vertebral body separation
- Complex skull fractures
- Pelvis fractures
Head Trauma
- Shaken Baby Syndrome - Retinal Hemorrhages
- Present in up to 75% of cases and are virtually pathognomonic
- Described as “dot and blot” hemorrhages or flame or splinter hemorrhages
Differential Diagnosis
Crying Infant
- Occult infection
- GI
- Intussusception
- GERD
- Incarcerated hernia
- Milk protein intolerance
- Anal fissure
- Ophtho
- Occult trauma
- Hair tourniquet (on extremities, penis)
- Non-accidental trauma
- Diaper pin
- Insect bites
- Burns in mouth
- Misc
- Colic
- Scorpion envenomation
- SVT
- Testicular torsion
- Drug exposure/overdose (commonly methamphetamine or cocaine)
- Neonatal abstinence syndrome, drug withdrawal
Evaluation
- Skeletal survey for all children < 2 years of age
- Skull AP and lateral view
- Chest AP and lateral view
- Right and left oblique of the chest
- AP of the abdomen to include pelvis and hips
- AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
- AP bilateral humerus
- AP bilateral forearms
- AP bilateral femurs
- AP bilateral tibia and fibula
- Posterior view of the hands
- Dorsoplantar view of the feet
- Head CT for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
- Consider osteogenesis imperfecta with incidence of 1:20,000 and can present at any age due to a wide spectrum of severity
Management
- Treat injuries as indicated
- Report abuse to the appropriate state child protection authority
Disposition
- Admit for medical treatment or if any question of child's safety upon discharge
See Also
External Links
Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare