Physical Abuse

The spectrum of injuries in children who have been intentionally traumatized is wide. Familiarity with this spectrum enables physicians in the emergency department to arrive at the correct diagnosis in a timely manner. Two-thirds of the victims of physical abuse are under the age of 3 years, and one-third are under 6 months. The physical vulnerability of such small children is easy to understand.

Historical data may raise suspicions of inflicted trauma. A history that is inconsistent with the nature or the extent of the injuries (e.g., a fractured femur in an infant from a fall off a bed), a history that keeps changing as to the circumstances surrounding the injury, a discrepancy between the story the child gives and the story the caretaker gives, a history of previous trauma in the patient or siblings, or a delay in seeking medical attention should raise one's index of suspicion of physical abuse.28 Knowledge of normal motor development assists physicians in determining the likelihood that an injury happened in the stated manner. Children under the age of 6 months are incapable of inducing accidents or accidentally ingesting any drugs or poisons. The evaluating physician should record the developmental milestones the child has achieved, e.g., the age of sitting unsupported, walking, etc. A recent study showed that developmental milestones were recorded in none of the emergency department visits in which physical abuse was suspected.29 Parental behavior in the emergency department should be observed, and it should be noted if the parents appear intoxicated or under the influence of drugs. The level of parental concern about the injury should also be noted.

Toddlers and older children should be questioned about the circumstances of the injury, and the comments should be recorded verbatim on the record. These statements are frequently admissible in court under exceptions to the hearsay rule and may help establish the diagnosis of child abuse.

The physical examination should note the child's overall hygiene and well-being. Normal children, especially toddlers who are just learning how to walk, may have multiple ecchymoses over the anterior shins, the forehead, and other bony prominences. Most falls result in bruises on only one body surface. Bruises over multiple areas, especially the low back, buttocks, thighs, cheeks, ear pinnae, neck, ankles, wrists, corners of the mouth, and lips suggest physical abuse. Handprints may be observed, or there may be uniform but bizarre bruises caused by belts, buckles, cords, or blunt instruments. 30 Bites produce bruising in a characteristic oval pattern, with teeth indentations along the periphery. Lacerations of the frenulum or oral mucosa may be present, especially in infants who have been force fed. Lacerations and abrasions in the genital area are seen in toddlers who are "punished" because of toilet-training accidents.

The duration of a bruise can be estimated by the color of the lesion. No discoloration is noted initially, although the bruised area may be swollen and tender. Within a day or two, the lesion becomes reddish-blue, and this lasts for about 5 days. This changes to green (days 5 to 7), then to yellow (days 7 to 10), and finally to brown (days 10 to 14) before resolving.31 For instance, reddish-blue lesions are inconsistent with a 2-week-old injury. However, variability does exist and depends on the size and depth of the hematoma.32

Children with multiple bruises should be evaluated with a complete blood cell count, a differential blood count, and coagulation studies including a platelet count, a prothrombin time, and a partial thromboplastin time. Occasionally, a child with leukemia, aplastic anemia, or thrombocytopenia is brought for evaluation because of multiple bruises.

Burns constitute another form of inflicted injuries.33 These may be scald burns caused by immersion in hot water. Such burns do not conform to a splash configuration; rather, an entire hand or foot ("glove-and-stocking" pattern) may be involved. There is sharp demarcation of the burn margin. The buttocks may be burned during toilet-training "punishment" by immersion in a bathtub filled with hot water. Knees, anterior thighs, feet, and portions of the abdomen are spared, and the buttocks and genitalia are scalded. Cigarette burns leave small (approximately 5 mm) circumferential scab-covered injuries. These lesions may resemble impetigo, as do scald injuries, which may resemble bullous impetigo. A culture of material from these lesions differentiates the burn from the infection. Other inflicted burns can result from forced contact with metal objects, such as an iron, curling iron, or heater grid.

Skeletal injuries may be detected when a child presents with unexplained swelling of an extremity or refusal to walk or to use an extremity. These fractures may take any form, but spiral fractures caused by torsion (twisting) of a long bone, and metaphyseal chip fractures, suggest inflicted injury, especially when present in infants under 6 months of age. Skeletal surveys referred to as a trauma series (or trauma x) should be obtained. These include films of all long bones, the ribs, the clavicles, the fingers, the toes, the pelvis, and the skull. They may reveal periosteal elevation secondary to new bone formation at sites of previous microfractures or periosteal injury; multiple fractures at different stages of healing; fractures at unusual sites such as the ribs, the lateral clavicle, the sternum, or the scapula; or repeated fractures to the same site. Such x-ray findings support the diagnosis of child abuse. Sometimes, bone scans will reveal fractures not readily apparent on x-rays. 34

Head injuries are a serious and potentially lethal form of child abuse. 35 Infants with significant intracranial hemorrhage may have no apparent external injuries. Intracranial hemorrhages may result from vigorous shaking of the infant or from thrusting the infant down onto a surface, such as a mattress. This is referred to as shaken baby or shaken impact syndrome.36 Older children may have been beaten about the head or face. Changes in mental status should therefore be evaluated by head computed tomography if there is any suspicion of abuse. Bruises around the ears, eyes, and cheeks, as well as swelling of the scalp secondary to subgaleal hematomas or underlying skull fractures, may be noted. Funduscopic examination may reveal retinal hemorrhages, which are usually associated with subdural hematomas. Such hemorrhages may result from direct trauma to the skull or severe shaking of the child.37 These children should be evaluated with computed tomography, and coagulation studies should be performed to rule out underlying coagulopathies. Magnetic resonance imaging studies are also being used to help differentiate recent from older intracranial bleeding episodes. Additional eye injuries caused by trauma may include hyphema, lens dislocation, and retinal detachment.

Injuries to the abdomen are equally serious and are a common cause of death from child abuse.38 Symptoms include recurrent vomiting, abdominal pain and tenderness, diminished bowel sounds, and/or abdominal distention. A history of injury as well as bruising of the overlying skin may be absent. Abdominal x-ray films may reveal a distended stomach with a "double-bubble sign" secondary to a duodenal hematoma. Diffuse distention may also be noted. Laboratory studies may reveal anemia, an elevated amylase level from traumatic pancreatitis, or hematuria from kidney trauma. Other abdominal injuries caused by trauma may include hepatic or splenic rupture, intestinal perforation, or rupture of intraabdominal blood vessels.

Any serious injury in a child under the age of 5 years should be viewed with suspicion. Other injuries that may be viewed as suggestive of child abuse include those which the child states were inflicted by another, were self-inflicted, or were inflicted by an unknown assailant.

The behavioral interaction between the child, the parent, and the physician may provide supportive evidence of the diagnosis of abuse. These children are often very compliant and submissive. They do not resist the medical examiner and readily submit to painful procedures such as blood drawing. They are overly affectionate to the medical staff, frequently preferring the nurse or the physician over the parent. Sometimes they are protective of the abusing parent, try to foster to his or her needs, and lie to cover up the true nature of the injury.

Parental behavior is less uniform, but certain distinct characteristics may be noted. The parents may not interact with the child in a comforting or supportive manner during the examination. They may become angry at the physician early in the course of the evaluation and may refuse diagnostic studies. They may appear to be intoxicated or under the influence of drugs. They may have brought the child in for seemingly minor complaints and ignored the major injuries or lesions. They may insist on hospital admission of the child for these minor problems and may readily confess they can no longer cope with the child. They may express fears of losing control.

The social service assessment may reveal an unstable home situation with frequent moves, poor parental support systems, low parental self-esteem (often caused by battering during their own childhood), parental substance abuse, and/or domestic violence. This adds further supportive evidence of a high-risk situation.

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