Nonaccidental trauma

Background

• Newer term that encompasses child abuse
• 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
• Children with disabilities or children who require significant medical care
• Unrealistic expectations for the child

Red flags

• History given is inconsistent with the mechanism of injury
• Changes in caregivers report
• Significant delays in care
• Any injury to a young, pre-ambulatory infant
• Injuries to multiple organ systems
• Injuries in different stages of healing;
• Patterned injuries
• Injuries to non-bony or other unusual locations, (torso, ears, face, neck, or upper arms)
• Significant injuries that are unexplained
• Other evidence of child neglect.

Clinical Features

Bruises

• Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, buttocks, ears, torso, neck if the child is not cruising yet
• Bruises in clusters or patterned marks
• Bruising of any child less than or equal to 6 months of age (or non-ambulatory) warrants a full child abuse work-up

Oral injuries

• Torn frenulum in premobile children is highly associated with physical abuse
• Other reported oral injuries include laceration/bruising to the lips, mucosal lacerations, dental trauma, tongue injuries, and gingival lesions

Burns

• Most commonly immersion injuries of the extremities, buttocks, or perineum
• More likely symmetrical with clear upper margins
• Many will also have occult fractures; children <24mo should undergo a skeletal survey

Fractures

Bucket Handle Fracture (Courtesy of Michael Mojica)

Metaphyseal Chip Fracture (Courtesy of Michael Mojica)

• Fractures highly suspicious of abuse:
  • Rib fracture, especially posterior
  • Metaphyseal or Corner Fracture (Bucket Handle)
  • Scapula fracture
  • Spinous process fractures
  • Sternum fracture
  • Fracture not consistent with developmental stage (any fracture in non-ambulatory child)

• 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 (i.e. depressed or cross suture lines)
  • Pelvic fractures

Head Trauma

• Leading cause of death in abused children <2 years old
• 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

Abdominal Trauma

• Most from a direct blow or from being thrown
• Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
• Consider abuse in preschool aged children with any hollow viscus or pancreatic injury

Sexual Trauma

• Even among children who report vaginal or anal penetration, the rate of abnormal physical examination findings is only 5 to 15%
• Consult your local sexual assault response team or transfer to an appropriate facility as indicated.
• Females
  • Preferred positioning for adequate examination: child lying supine with her hips externally rotated and knees flexed (frog-leg) or the prone knee-chest position.
  • Examine hymen for lacerations, transections, and bruising.
  • Prepubertal females do not require a speculum exam unless there is active bleeding.
  • Vaginal discharge in a prepubertal female should prompt testing for sexually transmitted infections.
  • The diameter of the hymenal orifice is not a marker for whether or not vaginal penetration occurred.
• Males
  • Examine for lacerations, burns, bite marks, and bruises to the genital region. Penile and anal injuries are more common than scrotal injuries.
  • Swab any anal or penile discharge for sexually transmitted infections.

Differential Diagnosis

• Bruising
  • Mongolian spots (congenital dermal melanosis)
  • Bleeding disorders
  • Hemangiomas
  • Phytophotodermatitis
  • Malignancy
  • Connective tissue disease
  • Cultural healing practices (eg, coining and cupping)
  • Osteogenesis imperfecta
  • Vasculitis (Henoch-Schönlein purpura)
  • Ink stains (e.g. caused by new clothing)
• Burns
  • Hypersensitivity reaction
  • Friction blisters
  • Impetigo (may be confused with cigarette burns)
  • Phytophotodermatitis
  • Dermatitis herpetiformis
  • Accidental laxative ingestion
  • Healing practices (eg, coining, cupping, and moxibustion)
• Fractures
  • Rickets
  • Congenital syphilis (can cause periosteal elevation)
  • Birth trauma
  • CPR (rarely causes rib fractures and very rarely causes posterior rib fractures)
  • Osteogenesis imperfecta
  • Caffey disease
  • Osteomyelitis
• Subdural hematoma
  • Bleeding disorders
  • Vascular malformations
  • Glutaric aciduria type 153
  • Benign extra-axial fluid
  • Menkes disease
• Retinal hemorrhage
  • Vasculitis
  • Vascular obstruction
  • Vaginal delivery (generally disappear by 4 weeks of age)
  • CPR (retinal hemorrhages are rare after chest compressions and, if present, are usually in the presence of other risk factors for hemorrhage)

Crying Infant

• Occult infection
  • Sepsis
  • Meningitis
  • UTI
  • Otitis media
  • Pneumonia
• GI
  • Intussusception
  • GERD
  • Incarcerated hernia
  • Milk protein intolerance
  • Anal fissure
• Ophtho
  • Corneal abrasion
• 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

Multiple rib fractures in an infant secondary to child abuse.

• 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
  • Skull AP and lateral view (left and right)
  • 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 without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
• Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
  • Consider CPK and platelet function studies if extensive bruising is present
  • If trauma labs are abnormal (AST or ALT > 80, lipase > 100), obtain a CT of abdomen/pelvis with IV contrast
• Consider a dilated fundoscopic exam if under 2 years
• Photograph injuries
• Obtain a social work consult

Inpatient Workup

• Ophtho consult for retinal hemorrhages
• CBC
• CMP, Mg, phos
• PT/INR/aPTT, fibrinogen
• PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
• vW panel (vW AT, ristocetin cofactors, factor VIII)

Management

• Treat injuries as indicated
• Keep alleged perpetrator separate from the patient if possible and/or keep patient supervised at all times
• Report abuse to the appropriate state child protection authority

Disposition

• Admit for medical treatment or if any question of child's safety

See Also

• Trauma (peds)
• Abusive head trauma

External Links

• Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare
• https://www.childhelp.org/wp-content/uploads/2019/02/CPS-Phone-Numbers-2.1.19.pdf
• Pediatric EM Morsels: Abuse