Physical abuse accounts for approximately 16% of all cases of child abuse and is perhaps the most easily identified type of maltreatment.1 Child physical abuse is defined as injury inflicted on a child by a caregiver. Injuries can occur to all parts of the body, but the more commonly injured areas are the skin (bruising, burns), skeleton (fractures), head, and abdomen. Evaluate the child medically and treat injuries. Medical evaluation and treatment of the child always take precedence over the legal investigation. Although the forensic or legal evaluation is best performed by trained investigators or child abuse specialists, data gathered in the ED often guides and informs further investigation.
Obtain a detailed history from all involved including the child, parents, caregivers, and any witnesses. Document details of the onset and progression of symptoms leading to the ED visit. Especially in young infants, pinpoint the last time the child was completely well. In a critically ill child, provide immediate resuscitation. In most cases of accidental injury, there is a clear and consistent history of an accident with the child presenting for care soon afterward. Historical features concerning for abuse include no history of trauma, changing important details of the history, explanations inconsistent with the injury or with the developmental stage of the child, discrepancies in the history provided by different caregivers, or a significant delay in seeking care.8,9,10
Obtain past medical history including the birth history, chronic or congenital conditions, previous injuries, and previous hospitalizations and surgeries. Document any family history of bleeding or bone disorders and any relevant metabolic or genetic conditions. Review the diet and medication history including vitamin K at birth and any subsequent vitamin or nutritional supplementation. Note current developmental status and progress. Important social history should identify the primary caregiver and other caregivers, household composition, any history of past abuse to the child or siblings, and previous child protective services involvement.
Begin with a general assessment of the child's alertness and demeanor. A brief evaluation of the work of breathing, cardiovascular perfusion, and level of alertness will identify a critically ill child in need of resuscitation. Note whether there is spontaneous and symmetric movement of the extremities. Lack of use of an extremity or pain with examination or movement may indicate a fracture. Document the head circumference and examine the scalp, noting any hematomas or step-offs, which may indicate a skull fracture. Funduscopic exam may reveal retinal hemorrhages, although it is often very difficult to perform an undilated exam in a child. Injuries to the mouth, such as a torn frenulum, may be indicative of forced feeding. Fully expose the skin and document the precise location, size, and shape of any bruises, burns, bite marks, or scars. Palpate the chest, abdomen, spine, and extremities for any tenderness. Perform and document a neurologic examination if there is concern for head trauma.
Bruising is the most common manifestation of physical abuse and is often overlooked. Up to a third of children with fatal or near-fatal abusive injuries have previous medical assessments in which bruising was noted.11,12 Because bruising is also very common in nonabused children, distinguishing between nonaccidental and accidental bruising requires careful consideration of the child's age and developmental level, the history, and any other associated injuries. Accidental bruises occur on the front of the body over bony prominences, on the extremities, and on the forehead.13 Nonaccidental bruises, on the other hand, are more commonly found on the torso, neck, and ears (Figure 148-1) and the soft parts of the body such as the cheeks and the buttocks. Nonaccidental bruises are also more likely than accidental bruises to be found in clusters, to be on the back of the body, and to be symmetrical. In addition, nonaccidental bruises tend to be larger and more numerous than accidental bruises. Patterned bruises may be evident if a child has been struck with a hand or an implement (Figure 148-2). Although the presence of bruises of different colors was previously thought to indicate bruises of different ages, the dating of bruises is highly inaccurate, so document bruise description and do not attempt to date the bruises.14
Bruising and petechiae on the ear from physical abuse.
Multiple bruises to the back and buttock from physical abuse. Note the patterned loop bruising from impact with a cord.
Bruises in young infants deserve special consideration because infants very rarely sustain accidental bruises. The adage those who don't cruise rarely bruise is supported by the observation of bruising in only 0.6% of infants less than 6 months of age and in only 2.2% of infants not yet able to walk, while bruising is present in over half of toddlers.15 Bruising in infants is associated with more serious abusive injuries. Additional injuries are diagnosed in up to one half of infants with isolated bruising.16 The TEN-4 bruising clinical decision rule identifies bruises to the thorax, ears, and neck, as well as any bruising in infants less than 4 months, as particularly concerning for abuse (Figure 148-3).17
TEN-4 bruising clinical decisions rule for bruises concerning for abuse. LR+ = positive likelihood ratio.
The differential diagnosis of bruises includes skin conditions such as congenital dermal melanocytosis (Mongolian spots) and cultural practices such as cupping and coining. A number of medical conditions are associated with bruising, the most common of which is idiopathic thrombocytopenic purpura. Inherited factor deficiencies such as hemophilia and von Willebrand's disease predispose children to bruising from inconsequential trauma. Other medical conditions include infections (e.g., meningococcemia), leukemia, nutritional deficiencies, and Henoch-Schönlein purpura.
Burns account for 6% to 20% of abusive injuries. Most burns, both accidental and abusive, are scalds and affect children age 1 to 4 years old.18 Accidental scalds typically occur when young children pull hot beverages off tables or stovetops, spilling the hot liquid onto themselves. The resulting burns are generally asymmetric, have irregular borders, are of varying depth, and are distributed over the face, neck, and upper torso.18 In contrast, most inflicted burns are caused by immersion in hot tap water.18 Abusive burns are often in a glove and stocking distribution with a sharp line of demarcation between the burned and uninjured skin. The child may have been held seated in a tub of hot water, resulting in burns to the perineum and feet with doughnut shaped sparing of the buttocks where the skin was in contact with the cooler porcelain of the tub.
When assessing nonscald burns, consider the distribution and extent of the burn. Children usually burn themselves when they reach out and touch a hot object. Most accidental burns, therefore, occur on the palms and the fingers and have an indistinct contour. In contrast, inflicted burns tend to be on the dorsal surface of the hands and on the back of the body. The margins of inflicted burns are often more distinct and may take the shape of the heated object used to inflict the burn.18
Burns due to neglect are nine times more common than inflicted burns.19 Even when a burn itself does not appear inflicted, it is important to consider whether lack of adult supervision or exposure to an unsafe environment or substances played a role in the injury. The differential diagnosis of burns includes bullous impetigo, Stevens-Johnson syndrome, and severe diaper dermatitis.
Fractures are the second most common manifestation of physical abuse. Over 80% of abusive fractures occur in children less than 18 months of age, and 12% to 20% of fractures in infants and toddlers are caused by physical abuse.20,21 Because fractures are also very common accidental injuries, accounting for between 8% and 12% of all pediatric injuries, distinguishing between accidental and abusive fractures can be challenging, particularly when the caregiver may not provide an accurate history.8,22 In children <3 years old, up to 20% of abusive fractures were initially attributed to accidents or other causes.23 Children with abusive fractures may present with nonspecific complaints such as irritability, swelling, not using a limb, or refusal to weight bear. Fractures may also be discovered incidentally during evaluation for other conditions or injuries.
There are a number of historical and clinical factors associated with an increased likelihood of physical abuse; however, the single most important risk factor for abusive fractures is young age (Table 148-3).22 It is very unusual for nonmobile infants to sustain fractures.21,22 Abuse accounts for one in two femur fractures in children less than 1 year of age, whereas the likelihood of abuse as a cause of femur fractures in 2- to 3-year-olds drops to less than one in five.22,23,24,25,26
TABLE 148-3Risk Factors for Physical Abuse in a Young Child with Fracture ||Download (.pdf) TABLE 148-3 Risk Factors for Physical Abuse in a Young Child with Fracture
Age <1 year old with fracture
No history/inconsistent history of trauma
Multiple fractures or fractures of different ages
Presence of other injuries
Any fracture can be caused by either accidental or nonaccidental means; however, certain fracture types are more specific for abuse and should prompt further investigation. Rib fractures are rare in infants and young children and are generally only seen in cases of severe trauma such as motor vehicle collisions (Figure 148-4). In the absence of severe trauma, a child with rib fractures has a 7 in 10 chance of having been abused.22 Posterior rib fractures are most highly correlated with physical abuse.27
Acute left clavicle and healing rib fractures in an infant.
Classic metaphyseal fractures are shear injuries to the immature ends of growing bones in infants caused by the rapid acceleration and deceleration associated with yanking or shaking (Figure 148-5). They are highly specific for child abuse.28
Classic metaphyseal fracture of the humerus with bucket handle appearance.
Additional injuries, such as linear skull fractures and long bone fractures, are common in both accidental and nonaccidental injuries. Knowledge of possible injury mechanisms resulting in each fracture type guides the clinician in assessing whether the reported history accounts for the injury.
Consider the differential diagnosis of fractures. Although the lack of any reported history of trauma should raise concern about abusive injuries, toddler's fractures are an exception to this rule. Toddler's fractures are nondisplaced spiral fractures occurring in the distal third of the tibia in ambulatory children between 9 months and 4 years of age. These are accidental fractures that occur when the child twists and falls on a planted foot. Certain medical conditions such as inherited bone diseases (osteogenesis imperfecta), chronic medical conditions (renal osteodystrophy), or nutritional deficiencies result in weaker bones that may fracture with relatively minor trauma. These conditions are far less common than child abuse and are often easily identified by the medical history, the physical exam, and the radiographic appearance of the bones.
Abusive head trauma is the most common cause of traumatic death and disability in infancy and early childhood.29,30,31 Although a number of terms have appeared in the medical literature over the years to describe the spectrum of cranial and ocular injuries that occur due to inflicted head injury in children, the American Academy of Pediatrics currently recommends the term abusive head trauma as the appropriate medical diagnostic terminology.32
Abusive head trauma demonstrates a distinct pattern of injuries characterized by intracranial injury (hemorrhage, edema, or infarction) and ocular injury (retinal hemorrhage or retinoschisis).32,33,34,35,36 Skull, rib, or long bone fractures may be present; however, remarkably, there may also be no external evidence of trauma at all. Retinal hemorrhages occur in up to 80% of patients with abusive head trauma and typically are extensive, occurring in multiple layers of the retina and extending out to the ora serrata.35,36
Infants and children with abusive head trauma are brought to the ED with a broad spectrum of clinical concerns and findings. Children may present in extremis, with obvious signs of physical trauma, or alternately, they may present with only very subtle suggestions of irritability or feeding problems and no history of trauma at all. Apnea and seizures both have a significantly higher association with abusive head trauma than with accidental trauma.37 Unfortunately, a substantial number of cases of abusive head trauma go unrecognized due to the mild, nonspecific nature of the presenting symptoms and signs.11
The differential diagnosis of abusive head trauma includes a number of conditions, but perhaps the two most common are birth-related and accidental trauma. Subdural and retinal hemorrhages secondary to birth are typically asymptomatic, resolving well within the first month of life.36,38 Accidental falls may cause head injury and, very rarely, sparse retinal hemorrhage usually isolated to the posterior pole. Accidental falls are extremely unlikely to result in severe intracranial injury and typically result in focal damage with clear evidence of blunt impact to the head. Other underlying medical conditions such as coagulopathies or metabolic or congenital abnormalities will very rarely present with features similar to abusive head trauma.
Although abdominal injuries due to child abuse are less common than other types of abusive injuries, abdominal trauma is the second leading cause of death in abused children, after abusive head injury.9 Injuries to virtually every organ have been reported; however, liver and small bowel injuries are the most commonly seen. While no single feature allows identification of children with intra-abdominal trauma, features associated with a higher likelihood of abusive trauma than of accidental abdominal injuries include young age and small bowel injury.9 Abdominal injuries due to abuse are much more common in toddlers (median age, 2.6 years), whereas accidental injuries are more common in older children (median age, 7.8 years). Accidental injury to the small intestine is exceedingly rare in children less than 5 years of age. In older children, accidental small bowel injuries most commonly are the result of motor vehicle collisions or handlebar injuries. Duodenal injuries in particular are very concerning for abuse in young children.9 The mechanism of injury is typically a direct blow to the abdomen compressing the fixed duodenum against the spine.
Because many cases of abdominal trauma are asymptomatic or have other confounding injuries and there is often no history of trauma provided, be alert for any potential sign of injury and have a low threshold for investigation. Although bruising to the abdomen is a clear sign to consider intra-abdominal injury, it is only present in 20% of cases.39 Signs and symptoms of intra-abdominal injury range from nonspecific irritability, lethargy, vomiting, poor feeding, and abdominal discomfort or distention to shock with frank peritonitis.
The gold standard for diagnosis of intra-abdominal trauma is a CT scan of the abdomen; however, given the difficulty in identifying abdominal injuries due to abuse, some advocate screening for intra-abdominal injuries using hepatic transaminases in all young children where there are concerns about physical abuse.10,39,40 However, hepatic transaminases may not be elevated in cases of small bowel injury, so obtain abdominal CT scan if clinical suspicion warrants.
LABORATORY TESTING AND IMAGING FOR SUSPECTED ABUSE AND NEGLECT
Investigations for any form of injury are guided by the nature and severity of the injury, the age of the child, and the physical examination findings. In general, the more severe the injury and the younger the child, the more extensive the investigations required and the more likely they are to reveal additional injuries. Consultation with a pediatrician or child abuse specialist is recommended.
Laboratory investigations include a CBC with differential and coagulation studies, including a platelet count, a prothrombin time, and a partial thromboplastin time. Results may reveal anemia secondary to an intracranial hemorrhage or an abnormal coagulation profile due to the brain injury itself. Further coagulation studies may be indicated in cases of extensive bruising or intracranial hemorrhage. In the child with unexplained fractures, obtain a serum calcium, phosphate, and alkaline phosphatase. Children with severe injuries, including those suspected of abusive head trauma or occult abdominal trauma, should undergo a complete trauma panel including hepatic transaminases.
A skeletal survey is a specific series of radiographs of all the long bones, chest, spine, hands, feet, pelvis, and skull that is indicated in all infants and young children in whom there is a concern for inflicted trauma.8,10,16 A properly performed skeletal survey frequently reveals previously unsuspected injuries including multiple fractures or fractures at various stages of healing.
Noncontrast head CT is indicated for any child suspected of sustaining acute intracranial trauma. Radiologic features with significant association for abusive head trauma include subdural hemorrhage, particularly if diffuse, interhemispheric, or infratentorial; hypoxic ischemic injury; and cerebral edema.41 MRI may further delineate the extent of brain injury and may offer some guidance for the timing of injuries. Inclusion of the neck and spine in MRI studies may identify ligament injury or spinal hemorrhage.42
Abdominal CT should be included when there is concern for intra-abdominal injury.10 Although it may be tempting to screen for intra-abdominal injury by US, US is not sensitive enough to identify all clinically significant intra-abdominal injuries in both abusive and accidental injuries.40,43
TREATMENT AND DISPOSITION
Rapidly identify and resuscitate life-threatening injuries. Once the child has been stabilized, attention shifts to further medical and legal evaluation. Because the comprehensive investigation of child abuse requires a multidisciplinary approach, most potential victims of serious physical abuse should be admitted to the hospital while the appropriate medical, surgical, and child protection teams complete their respective investigations. Children with head and abdominal injuries due to abuse have both longer hospitalizations and higher mortality compared with children with accidental injury.31,44
Older children with minor or superficial injuries may be discharged provided they have been assessed by child protective services and a safe environment can be assured.