Nonaccidental trauma

Background

  • Newer term that encompasses child abuse
  • Infant and children with disabilities are at higher risk
  • In >80% of cases, the parent or primary guardian is the abuser
  • Report suspicion
    • Transparent, frank discussion with caregivers
    • Social work or child protection agency involvement
      • Protect the child first, admit if suspicious
      • Social work may follow-up as outpatient for very low risk cases

Risk Factors

Red flags

  • History given is inconsistent with the mechanism of injury
  • Changes in caregivers report
  • Significant delays in care
  • Any injury to a young, pre-ambulatory infant
  • Injuries to multiple organ systems
  • Injuries in different stages of healing;
  • Patterned injuries
  • Injuries to non-bony or other unusual locations, (torso, ears, face, neck, or upper arms)
  • Significant injuries that are unexplained
  • Other evidence of child neglect.

Clinical Features

Bruises

  • Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, buttocks, ears, torso, neck if the child is not cruising yet
  • Bruises in clusters or patterned marks
  • Bruising of any child less than or equal to 6 months of age (or non-ambulatory) warrants a full child abuse work-up

Oral injuries

  • Torn frenulum in premobile children is highly associated with physical abuse
  • Other reported oral injuries include laceration/bruising to the lips, mucosal lacerations, dental trauma, tongue injuries, and gingival lesions

Burns

  • Most commonly immersion injuries of the extremities, buttocks, or perineum
  • More likely symmetrical with clear upper margins
  • Many will also have occult fractures; children <24mo should undergo a skeletal survey

Fractures

Bucket Handle Fracture (Courtesy of Michael Mojica[1])
Metaphyseal Chip Fracture (Courtesy of Michael Mojica)
  • Fractures highly suspicious of abuse:
    • Rib fracture, especially posterior
    • Metaphyseal or Corner Fracture (Bucket Handle)
    • Scapula fracture
    • Spinous process fractures
    • Sternum fracture
    • Fracture not consistent with developmental stage (any fracture in non-ambulatory child)
  • Fractures moderately suspicious of abuse:
    • Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
    • Multiple bilateral fractures
    • Different stages of healing with multiple fractures
    • Epiphyseal separations
    • Vertebral body separation
    • Complex skull fractures (i.e. depressed or cross suture lines)
    • Pelvic fractures

Head Trauma

  • Leading cause of death in abused children <2 years old
  • Shaken baby syndrome - Retinal hemorrhages
    • Present in up to 75% of cases and are virtually pathognomonic
    • Described as “dot and blot” hemorrhages or flame or splinter hemorrhages

Abdominal Trauma

  • Most from a direct blow or from being thrown
  • Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
  • Consider abuse in preschool aged children with any hollow viscus or pancreatic injury

Sexual Trauma

  • Even among children who report vaginal or anal penetration, the rate of abnormal physical examination findings is only 5 to 15%
  • Consult your local sexual assault response team or transfer to an appropriate facility as indicated.
  • Females
    • Preferred positioning for adequate examination: child lying supine with her hips externally rotated and knees flexed (frog-leg) or the prone knee-chest position.
    • Examine hymen for lacerations, transections, and bruising.
    • Prepubertal females do not require a speculum exam unless there is active bleeding.
    • Vaginal discharge in a prepubertal female should prompt testing for sexually transmitted infections.
    • The diameter of the hymenal orifice is not a marker for whether or not vaginal penetration occurred.
  • Males
    • Examine for lacerations, burns, bite marks, and bruises to the genital region. Penile and anal injuries are more common than scrotal injuries.
    • Swab any anal or penile discharge for sexually transmitted infections.

Differential Diagnosis

Crying Infant

Psychosocial and Related

Evaluation

Multiple rib fractures in an infant secondary to child abuse.
  • Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
    • Skull AP and lateral view (left and right)
    • Chest AP and lateral view
    • Right and left oblique of the chest
    • AP of the abdomen to include pelvis and hips
    • AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
    • AP bilateral humerus
    • AP bilateral forearms
    • AP bilateral femurs
    • AP bilateral tibia and fibula
    • Posterior view of the hands
    • Dorsoplantar view of the feet
  • Head CT without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
  • Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
    • Consider CPK and platelet function studies if extensive bruising is present
    • If trauma labs are abnormal (AST or ALT > 80, lipase > 100), obtain a CT of abdomen/pelvis with IV contrast
  • Consider a dilated fundoscopic exam if under 2 years
  • Photograph injuries
  • Obtain a social work consult

Inpatient Workup[2]

  • Ophtho consult for retinal hemorrhages
  • CBC
  • CMP, Mg, phos
  • PT/INR/aPTT, fibrinogen
  • PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
  • vW panel (vW AT, ristocetin cofactors, factor VIII)

Management

  • Treat injuries as indicated
  • Keep alleged perpetrator separate from the patient if possible and/or keep patient supervised at all times
  • Report abuse to the appropriate state child protection authority

Disposition

  • Admit for medical treatment or if any question of child's safety

See Also

External Links

References

  1. ↑ Mojica, Michael. 2015. PEM Guides. NYU Langone Health.
  2. ↑ Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.
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