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TAS Child Protection > Physical Abuse ✅ > Flashcards

Physical Abuse ✅ Flashcards

1
Q

What is physical abuse defined as?

A

A form of abuse where physical harm is caused

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2
Q

What are some types of physical abuse?

A
  • Hitting
  • Shaking
  • Throwing
  • Poisoning
  • Burning
  • Drowning
  • Suffocating
  • Fabricated or induced illness
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3
Q

What features of the history should raise suspicion of physical abuse?

A
  • 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
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4
Q

What is the most common injury seen in physical abuse?

A

Bruising

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5
Q

What % of 2-9 year old children will have a bruise at any given time?

A

60-90%

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6
Q

What are the features of accidental bruising?

A
  • Tend to be over bony prominences

- Small (1-6mm)

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7
Q

What does the distribution of accidental bruising vary with?

A

The developmental age of the child

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8
Q

Where do crawling babies typically get accidental bruises?

A

Chin, nose, and forehead

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9
Q

Where do older children typically get accidental bruises?

A

Knees and shins

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10
Q

Where can abusive bruising occur?

A

Anywhere, commonly found on soft tissue areas and on head, cheeks, neck, ears, trunk, arms, buttocks, and genitalia

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11
Q

What features of bruising are suspicious?

A

Multiple bruises, or bruises in clusters

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12
Q

What % of babies under 6 months have bruises?

A

1%

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13
Q

When should bruising in a non-ambulant child cause concern?

A

Always

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14
Q

What feature of a bruise is strongly correlated with abuse?

A

Surrounding petechiae (occurs in bruises inflicted with significant force)

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15
Q

Can bruises be reliably aged?

A

No

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16
Q

What should be excluded when considering if bruises are caused by abuse?

A
  • Bleeding disorders
  • Mongolian blue spots
  • Traditional practices such as coining and cupping
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17
Q

What bleeding disorders should be excluded before a diagnosis of NAI is made?

A
  • Von Willebrand disease
  • ITP
  • Inherited disorders of platelet function
  • Coagulation disorders
  • Vitamin K deficiency
  • Drugs
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18
Q

Give 2 examples of inherited disorders of platelet function that should be excluded before diagnosing NAI

A
  • Storage pool disorder

- Glanzmann’s thrombasethenia

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19
Q

Give 2 examples of coagulation disorders that should be excluded before diagnosing NAI

A
  • Factor VIII deficiency

- Factor XIII deficiency

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20
Q

What does a bite mark look like?

A

Oval or circular mark, consisting of 2 symmetrical, opposing, U-shaped arches separated at their base by an open space

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21
Q

What might the arcs of a bite mark include?

A
  • Wounds
  • Indentations
  • Bruisings
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22
Q

What is the problem with determining if a bite mark is due to abuse?

A

Adult bite marks are highly suspicious for abuse, but it is difficult to distinguish child from adult bites

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23
Q

Why is it hard to distinguish child from adult bites?

A

Factors such as amount of skin and fat in the victim, and the force of the bite, will influence measurements

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24
Q

What can help determine if bite marks are abusive?

A

Referral to dentist or forensic odontologist

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25
Q

How can dentists or forensic odontologists help determine if bite marks are due to abuse?

A

They may be able to gather dental imprints or DNA, and can give expert advice on distinguishing child, adult, and animal bites

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26
Q

What should the assessment of if a burn is non-accidental take into account?

A
  • Alleged mechanism of injury

- Developmental stage of the child

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27
Q

In what % of children in a hospital setting with a burn/scald is abuse recorded in?

A

1-14%

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28
Q

What normally causes accidental burns?

A

Flowing water or spills

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29
Q

What are the characteristics of accidental burns?

A
  • Asymmetrical

- More likely to involve head, neck, trunk, and upper extremities

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30
Q

What might cause accidental contact burns?

A

Grabbing hot objects, e.g. iron or hair straightners

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31
Q

Where do accidental contact burns tend to involve?

A

Fingertips or palm of hand

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32
Q

What might accidental contact burns indicate?

A

Lack of supervision and safety precautions

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33
Q

What is the most common type of intentional burn injury?

A

Immersion injury in hot water

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34
Q

What are the features of an immersion injury in hot water?

A
  • Clear margins
  • Symmetrical distribution
  • May have ‘glove and stocking’ distribution
  • May have skin sparing in buttock creases
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35
Q

Where are immersion in hot water injuries most frequently found?

A

Buttocks and lower extremities

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36
Q

What features should increase suspicion of non-accidental burn?

A
  • Co-existent unrelated fractures or injuries
  • History incompatible with examination findings
  • Sibling being blamed for burn
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37
Q

What might inflicted contact burns show?

A

The imprint of whatever is used, e.g. iron burns

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38
Q

How do intentional cigarette burns appear?

A

Symmetrical, round, well-demarcated burn of uniform thickness

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39
Q

What conditions need to be considered when fractures are diagnosed?

A
  • Birth injuries
  • Infection
  • Osteomyelitis
  • Osteogenesis imperfecta
  • Malignancy
  • Caffey disease
  • Metabolic bone disease of prematurity
  • Vitamin A, C, D, or copper deficiency
40
Q

In what bone in particular should birth injury be considered when diagnosing a fracture?

A

Clavicle

41
Q

What is key to making a diagnosis of non-accidental fracture?

A
  • History

- Developmental age of child

42
Q

Can the characteristics of a fracture be used to distinguish between accidental and non-accidental injury?

A

Not alone

43
Q

In what age are fractures caused by abuse most common?

A

Infants (<1 year) and toddlers (1-3 years)

44
Q

What % of accidental fractures occur in children over 5?

A

85%

45
Q

What % of abusive fractures occur under 18 months of age?

A

80%

46
Q

At what age is the highest incidence of abusive fractures?

A

Under 4 months

47
Q

Which type of fractures have the highest probability of abuse?

A

Rib fractures

48
Q

What % of rib fractures are due to abuse?

A

70%

49
Q

What does the evidence show regarding chest compressions and rib fractures?

A

Chest compressions very rarely cause rib fractures, and when present are anterior or anterolateral

50
Q

What is the probability of abuse for a humeral fracture?

A

50%

51
Q

What kind of humeral fracture is more common in abuse than non-abuse?

A

Mid-shaft

52
Q

What kind of humeral fracture is more common in non-abuse that abuse?

A

Supracondylar fracture

53
Q

What are the most common types of abusive humeral fractures in children aged under 5?

A

Spiral or oblique

54
Q

When do humeral fractures have a stronger association with abuse?

A

In those under 18 months

55
Q

In who are femoral fractures from abuse more likely to be seen in?

A

Children who are not yet walking

56
Q

What is the most common type of femoral fracture in abuse?

A

Mid-shaft

57
Q

What is the most common type of femoral fracture in non-abuse?

A

Mid shaft

58
Q

Are metaphyseal fractures more common in abuse or non-abuse?

A

Abuse

59
Q

What is required to find metaphyseal fractures?

A

Rigorous radiological techniques

60
Q

When are metaphyseal fractures frequently described?

A

Fatal abuse

61
Q

What is recommended in children under 2 with unexplained or suspicious fractures?

A

Skeletal survey with follow up scan

62
Q

Why is skeletal survey recommended in children under 2 with unexplained or suspicious fractures?

A

Abusive fractures are often occult

63
Q

Why is the follow up scan required in children under 2 with suspicious/unexplained fractures?

A

A skeletal survey will miss fractures

64
Q

What fractures in particular might a skeletal survey miss?

A

Acute rib and metaphyseal fractures

65
Q

What can be used for the follow up scan in children under 2 years with unexplained/suspicious fractures?

A
  • Second skeletal survey

- Nuclear medicine bone scan

66
Q

How long after the initial scan should the follow up scan in under 2’s with suspicious/unexplained fractures?

A

11-14 days

67
Q

What does skeletal imaging allow?

A
  • 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
68
Q

What disorders of bone may be found on skeletal survey?

A
  • Osteopenia

- Osteogenesis imperfecta

69
Q

Who else should skeletal survey be considered in?

A
  • 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
70
Q

What is the purpose of estimating fracture age?

A
  • 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
71
Q

How precisely are radiologists able to estimate the age of a fracture?

A
  • Acute (<1 week)
  • Recent (1-5 weeks old)
  • Old (More than 5 weeks old)
72
Q

What is the chance that an infant with a skull fracture is being abuse?

A

1/3

73
Q

What are the most common types of skull fracture in abuse?

A

Parietal and linear

74
Q

What are the most common types of skull fractures in non-abuse?

A

Parietal and linear

75
Q

What do fractures resulting from accidental domestic falls rarely result in?

A

Intracranial injury

76
Q

Can skull fractures be dated from radiological appearances?

A

No

77
Q

Why can’t skull fractures be dated from radiological appearances?

A

They do not heal by developing a callus

78
Q

What does soft tissue swelling present overlying the skull fracture indicate?

A

Likely to have occurred in previous 7 days

79
Q

What is the leading cause of death in abused children?

A

Shaken baby syndrome

80
Q

Who is shaken baby syndrome predominantly seen in?

A

Children under 2, most common under 6 months

81
Q

What can shaken baby syndrome cause?

A

Injury to the brain or bleeding within the structures around the brain

82
Q

What is the most common site of bleeding in shaken baby syndrome?

A
  • Subdural haemorrhage

- Intraocular bleeding

83
Q

What is the prognosis for survivors of shaken baby syndrome?

A

May be left with long-term brain damage - half the survivors have residual disability of variable severity

84
Q

What is the mortality of shaken baby syndrome?

A

30%

85
Q

What causes the intracranial injury in shaken baby syndrome?

A

May be caused by impact, shaking, or combination of both

86
Q

How might shaken baby syndrome be identified?

A
  • Overlying soft, boggy swelling

- Obvious bruising

87
Q

When should head trauma be part of the differential diagnosis?

A
  • Low GCS
  • New onset seizures
  • Unexplained drowsiness or irritability
88
Q

When might the signs of shaken baby syndrome be less obvious?

A

Infants with open fontanelle

89
Q

How might an infant with shaken baby syndrome and an open fontanelle present?

A
  • Poor feeding

- Excessive crying

90
Q

What is highly correlated with inflicted injury in children with brain injuries?

A
  • Presence of apnoeas

- Inflicted brain injury

91
Q

What investigations should be done on the day of presentation in abusive head trauma?

A

Head CT

92
Q

What investigations should be done on day 1-2 in suspected abusive head trauma?

A

Skeletal survey, including skull films (if child well enough, if not ASAP)

93
Q

What investigations should be done on day 3-4 of admission in suspected abusive head injury?

A

If initial CT head abnormal, perform head MRI. If not, repeat CT brain

94
Q

What should a head MRI include when done for suspected abusive head injury?

A

Spine (to exclude co-existing injury to spinal cord)

95
Q

What may be required in abusive head injury if the initial CT or MRI was abnormal?

A

Repeat at around 10 days, and possibly 2-3 months after initial injury

TAS Child Protection (4 decks)

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