Child Abuse
Jeff Erdner D.O.
Case 1
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17 month old boy brought by mom for
evaluation.
Mom states boy has 2 bruises to head
from running into the table and the wall.
“just want to make sure he’s ok”
Case 1
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PMH: none
Exam: healthy smiling baby
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Vital signs: normal
2cm x 1cm purple bruise (linear) above left
eye
2cm x 2cm yellow bruise on right forehead
1cm x .5cm abrasion to right groin
Otherwise exam normal
Case 1
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Child abuse?
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Does the injury fit the story?
Does the injury fit the age?
Child Abuse
Definition:
 Mental or emotional injury affecting growth,
development, or psychological function
 Causing or permitting the child to be in a situation in
which the child sustains injury or increases the risk
for injury
 Failure to make a reasonable effort to prevent harm
 Harmful sexual conduct
 Failure to prevent harmful sexual conduct
 Encouraging the child to engage in such conduct
Child abuse
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Definition:
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Placing a child or failing to remove a child
from a harmful environment
Failure to seek appropriate care
Failure to provide appropriate care
Failure to arrange appropriate care when
returning home
Child Abuse
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1998 National
Institute of Child
Abuse
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3 million referrals
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1/3 substantiated
53% neglect
23% physical
12% sexual
1100 deaths
(1.6/100,000)
Child Abuse
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Victimization rates are highest in the 0-3
yrs age group
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African American -> American Indian ->
Hispanic -> Caucasians -> Pacific Islanders
Overall perpetrators are female
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Sexual and physical tend to be male
Child Abuse
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Risk Factors
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Prematurity
Chronic illness
Mental retardation
Difficult temperament
Child Abuse
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Characteristics of abusers:
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Young parents
Abuse of the caretaker as a child
Previous removal of a child by CPS
Substance abuse
Mental illness
Lack of family support
Low socioeconomic status
Child Abuse
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Stranger Danger
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The vast majority of abuse (all types) occur
by family, relatives, or family
friends/neighbors.
Child Abuse
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Clues to history
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Inconsistency with history and injury or
developmental milestones
Delay in seeking treatment
Projection of blame to a third party
Child Abuse
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Key is high index of suspicion
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Jenny et al. reported that young age of the
child, white race, less severe symptoms, and
an “intact” family were key features that led
to missed diagnoses of abusive head trauma
History and Physical keys
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Overall health of child
History keys
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Bed wetting
Soiling pants
Difficulty urinating
History and Physical keys
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Complete physical – may need to sedate
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Particular attention to mouth (frenulum),
nose, genitalia, rectum
Irritation, pain, redness, bruises, burns, tears
Hymen – age 0-2 under estrogen influences
Start thick, pliable, elastic until age two, then
becomes thin and delicate
 Intrusion without tear
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History and Physical keys
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Exam must correlate with the parents
story
Story must correlate with the child’s age
Child must fit the developmental
milestones
Case 2
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18 month girl brought in by EMS for burns
to bilateral feet.
Early motor milestones
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4 mos raises head
5-6 mos rolls over
8-9 mos sits alone
15 mos walks alone
18 mos climbs stairs
22 mos throws ball overhand
2-3 years pedals tricycle
3 years alternates feet up stairs5
years catches ball bounced
History and Physical keys
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Normal exam does not exclude child abuse
Head Trauma
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Leading cause of non-accidental death in
child abuse is head trauma.
Head Trauma
Shaken Baby Syndrome
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Shaken Baby Syndrome
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Classically describe as occurring in infants less
than 6 months. Classic triad: edema,
subdural hematoma, retinal hemorrhages
AKA Shaken Impact syndrome
Duhaime et al 1987 J Neurosurgery concluded that
severe head injury require impact, not just shaking
 However, significant other literature states shaking
in all that is required.
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Head Trauma
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Accidental vs inflicted
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Short vertical falls less than 4 feet (regardless
of the landing surface) usually result in
minimal or no injury.
May cause small linear skull fractures (thus a few
case reports of epidural hematomas)
 Much more significant force is required for
depressed, stellate, complex, bilateral, or basilar
skull fractures
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S- Sagittal
L- Lambdoidal
P - Parietomastoid (squamosal)
O - Occipitomastoid
C- Coronal
Head Injury
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Most common head
trauma in abuse is
subdural bleeds and
parenchymal injury
(including DIA)
Increased risk of cervical
cord injury because of
the large head to body
ratio
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Spinal cord contusions,
subdural hematomas at the
cervicomedullary junction
Retinal hemorrhages:
Evidence of abuse or abuse of evidence?
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Extraordinary force
Unilateral or bilateral hemorrhages
are present in 75-95% of abusive
head trauma
Common with birth trauma but
resolve within 4 weeks
Other causes of retinal
hemorrhages include: hematologic
abnormalities, central nervous
system vascular malformations,
infections, high-altitude mountain
climbing, during normal deliveries
of newborns, and as a
complication of general anesthesia
Head Injury
Retinal Hemorrhages
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Odom A et al. Prevalence of retinal hemorrhages in pediatric patients after
in-hospital cardiopulmonary resuscitation: a prospective study.
1997- Divisions of Critical Care, Le Bonheur Children's Medical Center,
University of Tennessee, Memphis
Prospective study with 43 pediatric patients undergoing CPR for greater
than 1 minute. Not included if child abuse is suspected, trauma, near
drowning or seizures. All patients survived recessitation. Afterward, 2 pedi
opthomologist examined the retina and found only one case of retinal
hemorrhage. Conclusion- retinal hemorrhage is very uncommon in CPR
Abdominal and Thoracic Injury
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2nd most common cause of death from
child abuse
Duodenal Injury common
Spleen, liver
Accidental vs Non-accidental
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Suspect in non-walking children
Skeletal Manifestations
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80% of abusive fractures are under age 18
months
Clavicle most common fracture of childhood –
most common is the middle third
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Lateral third more suspect
Buckethandle fractures of the metaphysis
Skeletal Manifestations
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Rib fractures highly suggestive
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Multiple posterior fractures result from
shaking
Femur fracture highly suggestive
Tibial fracture
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Toddler’s fracture – non displaced oblique
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Normal
Spiral fractures highly suggestive
Skeletal Manifestations
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Vertebral fractures- occur from severe
hyperflexation
Facial, sternal, scapular, pelvic
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High force
Highly suggestive
Skin Marking
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Normal Trauma
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Extensor surfaces to arms and legs
Protruding bony surfaces of face
Protected area’s
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Inner arms
Throat
Abdomen
Lower back
Inner thighs
Skin Marking
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Dating Bruises?
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Depth, skin color, location, amount of
bleeding in the tissue
Fresh: red/purple -> blue -> brown ->
yellow/green
Cannot effectively date bruises.
Document location, size, shape, color
Skin Marking
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Pattern injuries
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Central clearing
Hand
 Iron
 Belt
 Baseball bat
 Fingers
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Oral lesions
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Upper frenulum and upper lip from
external forces
Frenulum under tongue internal force
Burns
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Accidental- irregular, indistinct margins, satellite
splash lesions, “v-shape”
Suspected burns:
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Stocking/glovelike
Bilateral
Uniform degree of the burn
Multiple burns
Coexistent with trauma
Cigar burns ~ 8mm
Bite Wounds
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Animal vs human
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Child vs adult
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Animal sharp canine teeth
Human uniform
Canine to canine measurment – 3cm adult
Oval vs arch
Suck would
Swab wounds- 80% have ABO blood group
identifiers
Neglect
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Major needs of the child are not met
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Major needs: food, shelter, protection,
clothing, health care, education, emotional
support
Most common cause of abuse
Underdiagnosed and underreported
Neglect
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Clues:
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Poor hygiene, inappropriate clothing, fatigue,
medical/physical problems unattended to,
failure to thrive
Risk for potential harm
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Unattended
Munchausen by Proxy
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DSM IV – facticious disorder
Uncommon
Usually mother
Medically educated
Two types
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Simulated
Produced
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Poisoned
Scratch (look like rash)
Treatment
Conditions that Mimic Child Abuse
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Bruising
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Mongolian spots
Congenital coagulopathy
Birth trauma
Accidental trauma
Fractures
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Osteogenisis Imperfecta
Rickets
Scurvy
Syphilis
Copper Deficiency- Menke’s kinky hair syndrome
Cultural healing
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Cupping- Mexican/ Eastern European
Coining- Southeast Asia, Vietnam
Spooning- China
Moxibustion
Maquas- Arabs, Jews, Russian
Salting
“sunken fontanel” Mexican American
Communities
Management
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Diagnosing child abuse is a team approach
Released to a safe place
Duty to report
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A person having cause to believe that a child’s
physical or mental health or welfare has been
adversely affected by abuse or neglect by any person
must immediately make a report.
Any state or local law agency
Texas department of protective and regulatory
services
Documentation
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Extremely important to document correctly
Use diagrams
Measure with a ruler
Document what you see, not what it
implies
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“Vaginal tears consistent with abuse”
Conclusion
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It’s the EP’s job to become educated
about abuse and how to evaluate the
possible abused so that we do not, 1) miss
and abused child and 2) accuse innocent
people of abuse
Correlate the age, story, milestones
The End