Physical Abuse ✅ Flashcards
What is physical abuse defined as?
A form of abuse where physical harm is caused
What are some types of physical abuse?
- Hitting
- Shaking
- Throwing
- Poisoning
- Burning
- Drowning
- Suffocating
- Fabricated or induced illness
What features of the history should raise suspicion of physical abuse?
- Significant injury with no explanation
- Explanation that does not fit pattern of injury seen, or motor-developmental stage of child
- Injuries in infants who are not independently mobile
- Explanation that varies when described by same or different parents/carers
- Unusual/inappropriate interaction between child and carer
- Aggression towards staff, child, or other relative/carer
- Inappropriate time delay in seeking appropriate medical assessment or treatment
- History of inappropriate child response, e.g. did not cry, felt no pain
- Presence of multiple injuries
- Child or family known to children’s social care, or subject to a Child Protection Plan
- Previous history of unusual injury/illness
- Repeated attendance with injuries that may be due to neglect or abuse
What is the most common injury seen in physical abuse?
Bruising
What % of 2-9 year old children will have a bruise at any given time?
60-90%
What are the features of accidental bruising?
- Tend to be over bony prominences
- Small (1-6mm)
What does the distribution of accidental bruising vary with?
The developmental age of the child
Where do crawling babies typically get accidental bruises?
Chin, nose, and forehead
Where do older children typically get accidental bruises?
Knees and shins
Where can abusive bruising occur?
Anywhere, commonly found on soft tissue areas and on head, cheeks, neck, ears, trunk, arms, buttocks, and genitalia
What features of bruising are suspicious?
Multiple bruises, or bruises in clusters
What % of babies under 6 months have bruises?
1%
When should bruising in a non-ambulant child cause concern?
Always
What feature of a bruise is strongly correlated with abuse?
Surrounding petechiae (occurs in bruises inflicted with significant force)
Can bruises be reliably aged?
No
What should be excluded when considering if bruises are caused by abuse?
- Bleeding disorders
- Mongolian blue spots
- Traditional practices such as coining and cupping
What bleeding disorders should be excluded before a diagnosis of NAI is made?
- Von Willebrand disease
- ITP
- Inherited disorders of platelet function
- Coagulation disorders
- Vitamin K deficiency
- Drugs
Give 2 examples of inherited disorders of platelet function that should be excluded before diagnosing NAI
- Storage pool disorder
- Glanzmann’s thrombasethenia
Give 2 examples of coagulation disorders that should be excluded before diagnosing NAI
- Factor VIII deficiency
- Factor XIII deficiency
What does a bite mark look like?
Oval or circular mark, consisting of 2 symmetrical, opposing, U-shaped arches separated at their base by an open space
What might the arcs of a bite mark include?
- Wounds
- Indentations
- Bruisings
What is the problem with determining if a bite mark is due to abuse?
Adult bite marks are highly suspicious for abuse, but it is difficult to distinguish child from adult bites
Why is it hard to distinguish child from adult bites?
Factors such as amount of skin and fat in the victim, and the force of the bite, will influence measurements
What can help determine if bite marks are abusive?
Referral to dentist or forensic odontologist
How can dentists or forensic odontologists help determine if bite marks are due to abuse?
They may be able to gather dental imprints or DNA, and can give expert advice on distinguishing child, adult, and animal bites
What should the assessment of if a burn is non-accidental take into account?
- Alleged mechanism of injury
- Developmental stage of the child
In what % of children in a hospital setting with a burn/scald is abuse recorded in?
1-14%
What normally causes accidental burns?
Flowing water or spills
What are the characteristics of accidental burns?
- Asymmetrical
- More likely to involve head, neck, trunk, and upper extremities
What might cause accidental contact burns?
Grabbing hot objects, e.g. iron or hair straightners
Where do accidental contact burns tend to involve?
Fingertips or palm of hand
What might accidental contact burns indicate?
Lack of supervision and safety precautions
What is the most common type of intentional burn injury?
Immersion injury in hot water
What are the features of an immersion injury in hot water?
- Clear margins
- Symmetrical distribution
- May have ‘glove and stocking’ distribution
- May have skin sparing in buttock creases
Where are immersion in hot water injuries most frequently found?
Buttocks and lower extremities
What features should increase suspicion of non-accidental burn?
- Co-existent unrelated fractures or injuries
- History incompatible with examination findings
- Sibling being blamed for burn
What might inflicted contact burns show?
The imprint of whatever is used, e.g. iron burns
How do intentional cigarette burns appear?
Symmetrical, round, well-demarcated burn of uniform thickness
What conditions need to be considered when fractures are diagnosed?
- Birth injuries
- Infection
- Osteomyelitis
- Osteogenesis imperfecta
- Malignancy
- Caffey disease
- Metabolic bone disease of prematurity
- Vitamin A, C, D, or copper deficiency
In what bone in particular should birth injury be considered when diagnosing a fracture?
Clavicle
What is key to making a diagnosis of non-accidental fracture?
- History
- Developmental age of child
Can the characteristics of a fracture be used to distinguish between accidental and non-accidental injury?
Not alone
In what age are fractures caused by abuse most common?
Infants (<1 year) and toddlers (1-3 years)
What % of accidental fractures occur in children over 5?
85%
What % of abusive fractures occur under 18 months of age?
80%
At what age is the highest incidence of abusive fractures?
Under 4 months
Which type of fractures have the highest probability of abuse?
Rib fractures
What % of rib fractures are due to abuse?
70%
What does the evidence show regarding chest compressions and rib fractures?
Chest compressions very rarely cause rib fractures, and when present are anterior or anterolateral
What is the probability of abuse for a humeral fracture?
50%
What kind of humeral fracture is more common in abuse than non-abuse?
Mid-shaft
What kind of humeral fracture is more common in non-abuse that abuse?
Supracondylar fracture
What are the most common types of abusive humeral fractures in children aged under 5?
Spiral or oblique
When do humeral fractures have a stronger association with abuse?
In those under 18 months
In who are femoral fractures from abuse more likely to be seen in?
Children who are not yet walking
What is the most common type of femoral fracture in abuse?
Mid-shaft
What is the most common type of femoral fracture in non-abuse?
Mid shaft
Are metaphyseal fractures more common in abuse or non-abuse?
Abuse
What is required to find metaphyseal fractures?
Rigorous radiological techniques
When are metaphyseal fractures frequently described?
Fatal abuse
What is recommended in children under 2 with unexplained or suspicious fractures?
Skeletal survey with follow up scan
Why is skeletal survey recommended in children under 2 with unexplained or suspicious fractures?
Abusive fractures are often occult
Why is the follow up scan required in children under 2 with suspicious/unexplained fractures?
A skeletal survey will miss fractures
What fractures in particular might a skeletal survey miss?
Acute rib and metaphyseal fractures
What can be used for the follow up scan in children under 2 years with unexplained/suspicious fractures?
- Second skeletal survey
- Nuclear medicine bone scan
How long after the initial scan should the follow up scan in under 2’s with suspicious/unexplained fractures?
11-14 days
What does skeletal imaging allow?
- Detection and description of any fractures
- Broadly estimate the age of fractures
- Check bones are normal, and identify any underling skeletal disorder
- Detect any other bony injury
What disorders of bone may be found on skeletal survey?
- Osteopenia
- Osteogenesis imperfecta
Who else should skeletal survey be considered in?
- Severe inflicted injury in child older than 2
- Child with localised pain, limp, or reluctance to use limb when abuse is suspected
- Child with previous history of skeletal trauma and suspected abuse
- Child with explained neurological presentation or suspected acute head trauma
- Child dying in suspicious or unusual circumstances
- Twin, or sibling less than 2 years old, of an infant with signs of physical abuse
- Older children with a disability and suspected physical abuse
What is the purpose of estimating fracture age?
- Inform inconsistencies between appearance of fracture and timing of injury describes
- Determine if multiple fractures are of the same or different ages, thereby indicating one or more episodes of trauma
How precisely are radiologists able to estimate the age of a fracture?
- Acute (<1 week)
- Recent (1-5 weeks old)
- Old (More than 5 weeks old)
What is the chance that an infant with a skull fracture is being abuse?
1/3
What are the most common types of skull fracture in abuse?
Parietal and linear
What are the most common types of skull fractures in non-abuse?
Parietal and linear
What do fractures resulting from accidental domestic falls rarely result in?
Intracranial injury
Can skull fractures be dated from radiological appearances?
No
Why can’t skull fractures be dated from radiological appearances?
They do not heal by developing a callus
What does soft tissue swelling present overlying the skull fracture indicate?
Likely to have occurred in previous 7 days
What is the leading cause of death in abused children?
Shaken baby syndrome
Who is shaken baby syndrome predominantly seen in?
Children under 2, most common under 6 months
What can shaken baby syndrome cause?
Injury to the brain or bleeding within the structures around the brain
What is the most common site of bleeding in shaken baby syndrome?
- Subdural haemorrhage
- Intraocular bleeding
What is the prognosis for survivors of shaken baby syndrome?
May be left with long-term brain damage - half the survivors have residual disability of variable severity
What is the mortality of shaken baby syndrome?
30%
What causes the intracranial injury in shaken baby syndrome?
May be caused by impact, shaking, or combination of both
How might shaken baby syndrome be identified?
- Overlying soft, boggy swelling
- Obvious bruising
When should head trauma be part of the differential diagnosis?
- Low GCS
- New onset seizures
- Unexplained drowsiness or irritability
When might the signs of shaken baby syndrome be less obvious?
Infants with open fontanelle
How might an infant with shaken baby syndrome and an open fontanelle present?
- Poor feeding
- Excessive crying
What is highly correlated with inflicted injury in children with brain injuries?
- Presence of apnoeas
- Inflicted brain injury
What investigations should be done on the day of presentation in abusive head trauma?
Head CT
What investigations should be done on day 1-2 in suspected abusive head trauma?
Skeletal survey, including skull films (if child well enough, if not ASAP)
What investigations should be done on day 3-4 of admission in suspected abusive head injury?
If initial CT head abnormal, perform head MRI. If not, repeat CT brain
What should a head MRI include when done for suspected abusive head injury?
Spine (to exclude co-existing injury to spinal cord)
What may be required in abusive head injury if the initial CT or MRI was abnormal?
Repeat at around 10 days, and possibly 2-3 months after initial injury
