Diagnostic Evaluation in
Child Abuse
Robert Benowicz, MS4
OHSU
Introduction
• Definitions/Epidemiology
• Clinical Manifestations
– Skeletal Trauma
– Soft Tissue/Visceral Trauma
– Head Trauma
• Diagnostic Evaluation
• Management/Psychosocial Considerations
Definitions
• Child Abuse Prevention and Treatment Act
(CAPTA)
– Any recent act or failure to act that results in death, serious physical or
emotional harm, sexual abuse, or exploitation; or imminent risk of
serious harm
– Involves a child under the age of 18 and his/her parent or caretaker
• Types of Abuse
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Physical Abuse
Sexual Abuse
Emotional Abuse
Child Neglect
Epidemiology
• Annual Incidence 15-42 cases per 1000
children
• Greater than 1 million children are victims of
abuse/neglect per year
• Over 1200 children die annually as a result of
abuse with almost half of these cases occurring
in ages less than 12 months
• Minorities have higher rates of reported abuse
than do whites
– But minorities tend to be evaluated and reported for suspected abuse
more frequently than whites
Epidemiology
• Usual Suspects
– Fathers, mother’s boyfriends, female babysitters, mothers
• Risk Factors
– Young/single parents, unstable families, lower education levels,
drug/EtOH abuse, psych illnesses, parents/caregivers whom were
abused themselves, unrealistic expectations of their children, poor
coping skills, financial stresses
• Victims of Abuse
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Age (majority of cases are less than 12 mos)
Past Hx of Abuse
Disabilities (physical, learning, speech/language)
Psychiatric (hyperactive, conduct disorders)
Medical Conditions (chronic illnesses, prematurity/low birth wt)
Clinical Manifestations
• Skeletal Trauma
– Eg. Fractures
• Skin Trauma
– Eg. Bruises, burns
• Visceral Trauma
– Eg. Splenic lacerations, hepatic contusions, GI
perforation
• Head Trauma
– Eg. Scalp injury, skull fracture, intracranial injury,
facial injury
Skeletal Trauma
• Patterns
– Most common fx involve skull,
long bones, and ribs
– Nonaccidental fx most
common in children under 3
yrs of age (infants especially)
– Classic Metaphyseal Lesions
(CML), skull and rib fx most
common in infancy (<12 mos)
– Long bone shaft fx are more
common in toddlers and are
the most prevalent in all cases
of child abuse
Long Bone Fractures
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A-longitudinal
B-transverse
C-oblique
D-spiral
E-impacted
F-comminuted
G-greenstick
H-bowing
I-torus
Diaphyseal Fractures
• Diaphyseal vs
Metaphyseal
– Four times more common
• Femur, Humerus, Tibia
– most common sites
– Spiral and transverse most
prevalent, but greenstick fx (right)
also occur
• Ambulatory vs Nonambulatory
– Amb toddlers have higher rate of
accidental fx
– Suspect abuse in non-ambulatory
infants
Metaphyseal Fractures
• Classic Metaphyseal
Lesion (CML)
– Aka “corner fracture” or
“bucket-handle fracture”
– Triangular or disk-like
fragment of the metaphysis
– Occur when extremity is pulled
hard or twisted and can occur
during violent shaking
– Typically asymptomatic
Rib Fractures
• Uncommon but frequently
indicative of child abuse
– 5-27% of all skeletal injuries in
one study
– Can also occur after serious
accidental injuries, birth trauma, or
2° to bone fragility
• Anterior-Posterior
compression
– 94% of abused infants had
posteriorly or laterally located
fractures in same study
•
Bulloch et al. Pediatrics April
2000.
Other Fractures
• Spinal
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most commonly L1-2
Cervical injury w/ violent shaking of
head/neck
Very few cases reported
• Hands/Feet
–
Torus/buckle fx
• Sternum, Scapula, Pelvis
–
fractures not highly specific for abuse
but outside of high energy traumatic
injury suspicion should be high
• Multiple Fractures (right)
– High suspicion of abuse,
especially if the fx are in various
stages of healing
•
•
Levin et al. Ped Radiol (2003)
Hecther et al. Ped Radiol (2002)
Great Imitators of Skeletal Trauma
• Skeletal Fractures
– Accidental trauma
• Eg. Toddlers Fx (top right)
– Normal variants
– Birth trauma
– Pathologic fractures
• Metabolic bone disease
– Rickets
• Neoplasm
– Skeletal Dysplasia
• Osteogenesis Imperfecta (bottom
right)
• Periosteal Reaction
– Infection
• Osteomyelitis, Congenital syphilis
– Drug toxicity
• Vit A, MTX, Prostaglandin
Skin Trauma
• Bruises
– Most common type of injury
related to abuse
– Orofacial injuries
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Racoon eyes
Traumatic alopecia
Ruptured TM’s
OP gonorrhea or syphilis
– Noninflicted bruises on bony
prominences whereas inflicted
bruises are more central
– Multiple bruises in clusters raises
suspicion of abuse
– Immobile infants with specific
bruising patterns should raise
suspicion
Skin Trauma
Skin Trauma
• Burns
– Occur in 6-20% of physically
abused children
– Specific patterns can be highly
suggestive of abuse
– Types
• Brands/contact burns
• Cigarette burns
• Immersion burns (most
common)
• Caustic material burns
– Delay in seeking medical
attention for abusive burns
Great Imitators of Skin Trauma
• Bruises
– Bleeding disorders
• ITP, hemophilia (VIII/IX),
vonWIllebrand disease
– Vasculitis
• HSP
– Mongolian spots
• Burns
– Phytophotodermatitis (top right)
– Impetigo
• Cultural Practices
– Cupping (bottom right)
– Coining
– Salting
Visceral Trauma
• Typically occur in setting of high-energy
trauma
– Suspect inflicted injury if there is no such history
• Thoracic trauma
– Esophageal perforation, pulmonary lacerations/contusions, chylothorax
• Cardiac trauma
– Dysrhythymias, contusions, traumatic VSD
• Abdominal trauma
– Liver (most common), splenic, pancreatic, GI tract (perf vs hematoma)
• Urinary tract trauma
– Renal, ureteral, bladder
Splenic Laceration
Liver Laceration
Duodenal Hematoma
Head Trauma
• Initial assessment
– Bradycardia,
apnea/brachypnea,
hypothermia, poor motor tone,
nystagmus, seizures, bulging
fontanel may all be present
– Numerous retinal
hemorrhages at multiple
layers of the retina is highly
suggestive of shaken baby
syndrome
• Optho consult if available
– Cutaneous lesions are not as
specific as retinal hemorrhage
but can hint at further abuse
Head Trauma
• Levels of damage
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Scalp hematomas
Skull fractures (top right)
Epidural hemorrhages
Focal subdural hemorrhages
(bottom right)
– Brain contusion/laceration
– Distant sites
• Basilar skull fractures
– Retinal hemorrhages often
present
• Brainstem compression
– Coma and/or death
Epidural Hemorrhage
Subdural Hemorrhage
Diffuse Axonal Injury
Intraventricular Hemorrhage
Subarachnoid Hemorrhage
Great Imitators of Head Trauma
• Non-accidental Head Injury Mimics
– Benign Infantile enlargement of the subarachnoid space
• Symmetric, absence of assoc. lesions, and absence of blood products
– Diastatic sutural injury vs. sutural splitting/widening from increased ICP
– Hemorrhage due to DIC, infection, anticoagulant therapy
– Accidental trauma
• Falls from less than 3 feet rarely produce severe head injury
– Edema due to smoke inhalation, drowning, or circulatory collapse
• Demaerel et al. Eur Radiol (2002)
Initial Evaluation
• Medical Evaluation
– History
– Physical Examination
– Observation of Parent’s Behavior
• Laboratory Evaluation
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Bleeding studies
Urinalysis
Chemistries
Toxicology screen
• Radiographic Evaluation
Diagnostic Evaluation
• Skeletal Trauma
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Skeletal survey vs. scintigraphy
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Methods of global imaging in suspected
child abuse
Orthogonal radiographs
•
Bone tenderness, swelling, deformity,
limited ROM
• Recommendations
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0-12 mos. (reqd)
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12 mos to 2 yrs (reqd)
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Skeletal survey or scintigraphy in cases
where abuse is strongly suspected
5 yrs and older
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Skeletal survey or scintigraphy
2 to 5 yrs
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Skeletal survey
F/U survey at 2 weeks
Radiographs of individual sites of injury
suspected on clinical grounds
Kleinman, PK. Diagnostic Imaging of
Child Abuse, 2nd ed.
Diagnostic Evaluation
• Visceral Trauma
– Thoracic Injury
• Orthogonal CXR and C-spine are initial tests of choice
• Followed by CT if patient is stable and further injury is suspected
• Esophageal injury may necessitate contrast esophagography or CT w/ oral
contrast
– Abdominal Injury
• Plain flat/upright radiographs are obtained as part of the initial evaluation
– Further testing warranted based on vital signs, physical exam findings, and lab
results
– Upright or decubitus views if bowel perforation suspected
• Indications for CT
– History/PE suggestive of significant abd injury, hematuria, decreased HCT,
elevated AST/ALT, unaccountable fluid loss/requirements
• Ultrasound is specific but not sensitive and is avoided in favor of CT
• Barium upper GI series w/ small bowel follow-through
Diagnostic Evaluation
• Head Trauma
– There is a major debate over the preferred methods of radiographic evaluation of
non-accidental head injury (NAHI) in the literature
– Skull fractures
• Skull x-rays are a part of the standard skeletal survey
• Do not add much information over more advanced neuroimaging especially if head
trauma is suspected upon initial evaluation
• Suspected fractures of the cranial vault, however, are better seen by x-ray than CT
– Intracranial injury
• Nonenhanced CT is the imaging tool of choice
– Some camps (Demaerel et al. and Stoodley et al.) believe that further investigation w/ MRI is
also warranted
– Other camps (McHugh et al.) believe that even discretion with head CT is necessary (see next
slide)
• MRI indicated when NAHI suspected but CT is normal
– Can detect very small hematomas or subtle extra-axial fluid collections that might be otherwise
missed
– Also good for dating intracranial injury
Diagnostic Evaluation
• Indications
– Known skull fx
– Altered mental status (see coma
scale)
– Focal neuro deficits
– Signs of basilar skull fx
• Retinal hemorrhage
– Seizure
– Palpable skull depression
– Age
• <2 yrs of age,<12 mos, and <6
mos have been proposed as
cutoffs
• Infants and toddlers may have
fewer clinical findings and thus the
CT threshold should be lower
Management
• Suspected Abuse
– Multidisciplinary team
• Social worker, case management, nursing staff, other physicians
– Hospitalization
• All medical issues are addressed first
• Child’s safety is addressed once patient is medically stable
– Protective environment needed until Child Protective Services (CPS) can do an
official evaluation
– Children re-released to a caregiver have a 50% chance of being subjected to
abuse again and a 10% mortality rate
– Talking with parents
– Mandatory reporting
– Documentation
Psychosocial/Medicolegal
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Talking with Parents
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Inform parents why investigation is taking place
Safety and well-being of child
Required by law
Explanation of the CPS process
Mandatory Reporting
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According to Oregon Revised Statute
419B.010, "Any public or private official
having reasonable cause to believe that any
child with whom the official comes in contact
has suffered abuse, or that any person with
whom the official comes in contact has
abused a child shall immediately report or
cause a report to be made . . ." Those "public
or private officials" include:
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Among others
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Physician, including any intern or resident
Licensed practical or registered nurse
http://www.oregon.gov/DHS/children/a
buse/cps/report.shtml
References
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Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. (1998).
Bulloch et al. “Cause and Clinical Characteristics of Rib Fractures in Infants.” Pediatrics Vol 105
No. 4 April 2000.
Hechter et al. “Sternal Fractures as a Manifestation of Abusive Injury in Children.” Pediatric
Radiology 32: 902-906, (2002).
Levin et al. “Thoracolumbar Fracture with Listhesis—An Uncommon manifestation of Child
Abuse.” Pediatric Radiology 33: 305-310, (2003).
Demaerel et al. “Cranial Imaging in Child Abuse.” European Radiology 12: 849-857, (2002).
Carty et al. “Non-accidental Injury: A Retrospective Analysis of a Large Cohort.” European
Radiology 12: 2919-2925, (2002).
Stoodley et al. “Neuroradiological Aspects of Subdural Hemorrhages.” Arch Dis Child 90: 947-951,
(2005).
Stoodley et al. “Apnea and Brain Swelling in Non-accidental Head Injury.” Arch Dis Child 88: 472476, (2003).
McHugh, K. “Neuroimaging in non-accidental Head Injury: If, when, why, and how” Clinical
Radiology 60(1):22-30 Jan 2005.
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