Child Abuse

By admin On Jun 16, 2024

Ovid: Pediatrics

Editors: Tornetta, Paul; Einhorn, Thomas A.; Cramer, Kathryn E.; Scherl, Susan A.

Title: Pediatrics, 1st Edition

> Table of Contents > Section II: – Emergency Department > 16 – Child Abuse

Child Abuse

Joshua T. Snyder

Jeffrey R. Sawyer

Child abuse has plagued humankind for centuries, but has
been recognized in literature by the medical community only in the past
50 years. Dr. John Caffey, a pediatric radiologist, published the first
contemporary medical report in 1946, and about 20 years later the term battered child syndrome
was coined by Kempe and colleagues in 1962. Currently, the deliberate
harm of children by the people who care for them is known as child
abuse. Reports of child abuse are increasing as the medical profession
gains experience recognizing the signs and symptoms of abuse. This
increase demands significant attention from medical professionals to
prevent and investigate abuse as well as to care for those children who
are abused. Prevention of further episodes of abuse to the child is
essential as the rate of reabuse if the initial event is missed is 35%
with a mortality rate of 5%. It is important for orthopaedic surgeons
and all other professionals in contact with children to have a clear
understanding of what child abuse is, how it presents, and what steps
can be taken to identify and treat it once it is identified.

PATHOGENESIS

Etiology

The U.S. Department of Health and Human Services defines four main types of child maltreatment:

Neglect: 52% of reported cases
Physical abuse: 24%
Sexual abuse: 12%
Emotional abuse: 6%

Many children fit into more than one category.
Orthopaedic surgeons are more often consulted for cases of physical
abuse and neglect rather than cases of sexual and emotional abuse.

Physical abuse involves inflicting a physical harm to a
child, through beating, burning, choking, biting, shaking, pushing,
restraining, kicking, or any other mechanism that may have been meant
to hurt or punish the child. Signs of neglect are not as objective and
often do not carry the same visual impact as signs of physical abuse.
Neglect, however, defined as not meeting a child’s basic needs of life,
may aid in diagnosing cases of physical abuse. For example, caregivers
delaying or not seeking medical attention for routine care in times of
illness can alert suspicion and warrant further investigation. Physical
abuse and chronic neglect of young children tend to be recurrent, and
often result in permanent sequelae, such as skeletal deformities, brain
injury, and even death.

Epidemiology

Children

It has been reported, in 1997, that within 45 states
nearly 3 million children were alleged victims of maltreatment. This is
a rate of 42 children per 1,000. Over 4,000 children die each year in
the United States from abuse and neglect. Most abused children are
white (53%), followed by African-American children (27%), Hispanic
(11%), Native-American (2%), and Asian children (1%). There is a
slightly higher rate of physical abuse in girls than boys (52% vs.
48%), and girls are three times more likely to be sexually abused. Boys
suffer emotional abuse more frequently and also have a 24% higher risk
for serious physical injury.

Perpetrators

Some 77% of perpetrators are parents, with relatives
accounting for 11%. Most abusers are between the ages of 20 and 40,
with women slightly more likely than men to be abusers.

Family

The family of an abused child is more likely to be a
single-parent family and the incidence of abuse is higher if the
children are living with the father than the mother. Children from
larger families (more than four children) are more likely to be abused
than children from families with less than three children. Other family
risk factors are low socioeconomic status, low education, psychiatric
disorders, drug or alcohol abuse, and poor social support systems.

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TABLE 16-1 SEVEN-POINT SCALE FOR RATING THE CLINICAL LIKELIHOOD OF CHILD ABUSE

Classification	Description
Definite	Positive skeletal survey, eyewitness, multiple internal injuries, suggestive bruises, sibling also abused, suggestive injury with definite later abuse
Likely original	Doctors called injury abuse and history inconsistent or insufficient for injury
	Inappropriate delay in seeking care
Questionable	History inconsistent, not sufficient for injury or story of accident changes
Unknown cause	Insufficient information available in charts
Questionable accident	Isolated incident, social worker/physician had no suspicion of abuse, story somewhat inconsistent with the extent of injury, but consistent with type of injury
Likely accident	Consistent story, social worker/physician had no suspicion of abuse, isolated injury or aggressive or irresponsible behavior involved: however, injury not directly inflicted
Definite accident	Motor vehicle accident, multiple witnesses, pedestrian hit by automobile
Adapted from Levinthal JM, Thomas SA, Rosenfield NS, et al. Fractures in young children: distinguishing child abuse from unintentional injuries. Am J Dis Child 1993;147:87.

Classification

Given the complex nature of child abuse, it is difficult
to objectively and accurately classify it. A seven-point scale has been
developed to rate the clinical likelihood of abuse, which is helpful in
both the clinical and research settings (Table 16-1).

DIAGNOSIS

History

Many details in the history must be documented;
therefore, a uniform and stepwise approach is beneficial. The American
Medical Association provided a set of recommendations that were
modified by Jain to serve as guidelines for an adequate history. It is
important to obtain an individual history from all sources separately
including the child, caretakers, and any other witnesses at the scene
of the injury. During the interview, a nonaccusatory, objective
demeanor must be used at all times. After taking each history, the
details should be compared to identify any discrepancies. Events
related to the injury should also be documented such as activities
immediately preceding the injury, was the injury observed or not, and
were there any circumstances that could have precipitated an abusive
event. It is also important to understand who the child’s primary
caregiver is and who else participates in that child’s care. Box 16-1
provides a list of what to look for during an interview to suggest
child abuse. Also in the history, certain risk factors can be
identified to aid in the diagnosis (Boxes 16-2 and 16-3).

Physical Examination

Orthopaedic surgeons who are involved in the care of
children should be able to recognize the common presentations of child
abuse and to differentiate these from normal development and common
injuries of childhood. It is important to examine the entire child when
abuse is considered,

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not
just the location of pain. Often the child presents to the medical
practitioner with nonspecific symptoms such as failure to thrive,
feeding difficulties, irritability, or lethargy that may be related to
recurrent brain injury. A pattern of physical findings, including
bruises and fractures in areas unlikely to be accidentally injured,
patterned bruises from objects, and circumferential burns or bruises in
children not yet mobile should be viewed as suspicious for child abuse.
Toddlers frequently have accidental bruising to the chin, brow, elbows,
knees and shins, but bruises to other areas including the back of the
head, genitals, abdomen, posterior calf, and thigh are suspicious for
abuse.

Clinical Features

Young children are prone to accidental injuries during
normal activities and recreation. These patterns of injury however can
be distinguished from those injuries of nonaccidental causes. Even
though child abuse injuries can affect any organ system and can mimic
accidental trauma, certain patterns of soft tissue injury strongly
suggest nonaccidental causes (Box 16-4).

Head injury
- □ Child abuse is the most common cause of
  serious head injury in infants and the most common cause of mortality
  in victims of child abuse.
- □ Signs of head injury are usually
  nonspecific: irritability, lethargy, poor feeding, seizures, varying
  states of consciousness, bradycardia, apnea, and cardiorespiratory
  arrest.
- □ Skull fractures from abuse are more
  likely to be bilateral, comminuted, depressed, wider than 1 mm, and
  involving nonparietal bone or crossing suture lines.
- □ Subdural hematomas strongly suggest nonaccidental trauma.
Abdominal trauma
- □ Second most common cause of death
- □ Tears, lacerations, and perforations of organs, including the spleen, small and large bowel, kidney, and pancreas
- □ High mortality rate secondary to delay in seeking treatment
Fractures
- □ Long bone fractures in children less than 1 year of age
- □ Rib fractures.
- □ Metaphyseal “corner fractures”
- □ Fractures of different ages

Radiologic Features

In addition to history and physical exam, a focused
radiographic examination is helpful in making the diagnosis of child
abuse. As with any musculoskeletal injury, the radiographic workup
begins with plain radiographs of the affected area(s). If an injury is
detected or the index of suspicion for abuse remains high, a skeletal
survey should be obtained. Total body radiographs or “babygrams” should
be avoided. It is important to estimate the age of the fracture(s) as
well. In most children, periosteal reaction and new bone formation
occurs within 7 to 14 days following fracture. Loss of resolution of
fracture lines (3 weeks), dense callus formation (3 to 6 weeks), and
remodeling (more than 6 weeks) are typically later findings. There is
some variability between patients in the rate of bone healing, but
these general guidelines can help with attempting to date fractures. If
the first skeletal survey is negative and the index of suspicion for
abuse is high, it may be necessary to repeat the skeletal survey in
several weeks to attempt to find these later radiographic changes.

Bone scan may be helpful in evaluating the child for
occult fractures. Bone scan is typically not helpful in evaluating
injuries near the growth plate such as metaphyseal “corner fractures”
due to the high rate of metabolic activity at the open growth plate
which will cause a false-positive reading. Computed tomography (CT),
magnetic resonance imaging (MRI), and ultrasound are useful in certain
situations if the diagnosis remains unclear. CT and MRI may also be
used to rule out brain or spinal cord injury but typically require
sedation in this age group. Boxes 16-5, 16-6 and 16-7
list radiologic features of the skeletal survey that are pathognomonic,
that are highly suggestive, or that have low likelihood of child abuse.

Diagnostic Workup

Obtaining a complete history is the first objective in
any medical visit. Unfortunately, with child abuse cases the
frustration, anger, and apprehension of the parents or caretakers make
a clear and focused history difficult to produce. Suspicion should be
raised if the mechanism of injury is inconsistent with the history
given or the child’s developmental stage.

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A complete physical examination of the entire child
completely undressed must be performed, noting any skin or soft tissue
injury. Signs of sexual abuse should also be noted. This should be
followed by a thorough radiologic examination as previously mentioned.

If an unexplained injury is identified the possibility
of underlying bone disease should be considered. Other conditions
confused with nonaccidental injuries include:

Normal variants
- □ Spurring and cupping of the metaphysis
- □ Periosteal reaction of the newborn
Birth trauma
- □ Clavicle, humerus, and long bone fractures may occur during traumatic birth.
- □ Absence of callus formation at any fracture site found after 2 weeks after delivery strongly suggests abuse.
Osteogenesis imperfecta
- □ Fractures of the long bones
- □ Osteopenia, thin cortices, and bowing or angulation of healed fractures
- □ Blue sclerae, dentinogenesis imperfecta, deafness due to otosclerosis
Rickets
- □ Fraying of metaphysis
- □ Widening of physis
- □ Looser zones (transverse stress fractures in shafts of long bones)
Congenital syphilis
- □ Metaphyseal lucencies parallel to the physis of long bones
- □ Periosteal reaction along the entire length of long bones
- □ Osteolytic metaphyseal long bones
- □ Lesions usually symmetric
Congenital insensitivity to pain
- □ Rare autosomal recessive trait with indifference to painful stimuli
- □ Present with repeated unrecognized injuries to the growth plate
Caffey disease
- □ Infantile cortical hyperostosis in infants younger than 6 months
- □ Painful periosteal reaction resulting in cortical thickening
- □ Mandible, clavicle, and ulna
Vitamin A intoxication
- □ Thick periosteal reaction of the tubular bones: ulna and metatarsals
- □ Widening of the cranial sutures
- □ Metaphyseal and epiphyseal areas are normal radiographically
Leukemia
- □ Periosteal reaction with diffuse demineralization commonly occurs in association with multiple osteolytic lesions
- □ Narrow radiolucent metaphyseal bands (“leukemic lines”).
Hemophilia
- □ Multiple bruises with minimal/no trauma
- □ Bruises at different stages of healing
- □ Family history (X-linked recessive)
Toddler fracture
- □ Commonly occurs between ages of 1 and 3 years
- □ Spiral fracture of distal tibia
- □ Common without history of trauma
Drug-induced bone changes
- □ Periosteal reaction of the ribs and long bones with prostaglandin E1, used to maintain a patent ductus arteriosis.
- □ Methotrexate and antiseizure medications can cause osteopenia and fractures.

The information from the history, physical examination,
and radiographic studies is then combined and the diagnosis of child
abuse can be made. Once the diagnosis is made, physicians and other
health care professionals are mandated reporters and are required to
report suspected abuse to the appropriate child protection agencies.
Health care professionals who report suspected cases of abuse and
neglect in good faith are protected from both civil and criminal
prosecution.

TREATMENT

Because of the enhanced healing capacity of a child’s
skeleton, most of the orthopaedic injuries associated with child abuse
heal very rapidly. A child’s ability of bone to remodel is high,
therefore the potential of late residual

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skeletal
deformity is low. The primary treatment of orthopaedic injuries from
abuse is the same as for any musculoskeletal injury: immobilization of
the injured areas with precise anatomic reduction of rotational
deformities, angulation, or displaced intraarticular fractures. These
injuries rarely require operative management with the exception of
physeal injuries, particularly those to the proximal femur and distal
humerus. Again, equally important to treating the musculoskeletal
injury is preventing the child from sustaining further harm from the
abuser.