Child Abuse: Skeletal and Cutaneous Findings,
by Doctor Victoria Robson and Doctor Celeste Wilson.
By the end of this video, the objectives
are for you to be able to identify common risk
factors associated with child abuse,
recognize red flags that should alert you
to the possibility of child abuse,
describe classic skeletal and cutaneous findings,
and differentiate mimics of child abuse
utilizing an appropriate diagnostic workup.
Epidemiology.
Each year, 4 million child maltreatment referrals
are received in the United States
with the highest rate of child abuse reported in children
less than one year of age.
Almost five children die every day from child abuse.
There are different types of child abuse.
75% of victims are neglected, 17% are physically abused,
and 8% are sexually abused.
This video will focus on skeletal and cutaneous abuse,
two forms of physical abuse.
Abusive head injury, sexual abuse,
psychological maltreatment, and neglect
are beyond the scope of this introductory video.
Risk factors.
Risk factors for child abuse can be categorized
into factors affecting the child, the caregiver,
and the environment.
Child-related factors include preterm birth, chronic illness,
physical or developmental disability,
and emotional and behavioral difficulties.
Caregiver level factors include young parental age, substance
or alcohol abuse, mental illness,
and unrealistic expectations for child behavior and development.
Environmental factors include poverty, unemployment,
low educational achievement, social isolation, single parent
status, non-biologically related male living in the home,
and history of intimate partner violence.
It is critical for pediatric health care providers
to recognize that child abuse crosses
all socioeconomic and educational levels, as well
as religious, ethnic, racial, and cultural groups.
As such, no child is immune to child abuse.
Clinical presentation.
There are several red flags from the history and exam
that should alert you to the possibility of child abuse.
The most important clue is discordance between the history
and injury.
In addition to evaluating whether the story provided
makes sense and remains consistent over time,
you must consider whether the mechanism is developmentally
possible, especially in the case of injury
in a non-ambulating child.
Other red flags include delay in seeking medical attention,
multiple injuries in various stages of healing, escalation
of events over time, inappropriate caregiver affect,
and recent triggering event or stressor.
In infants and toddlers, physical abuse
is the cause of up to 20% of fractures.
While a child who has suffered a fracture due to physical abuse
may present with crying, visible swelling, or refusal
to use the affected area, the child
may have minimal symptoms, which can contribute to a delay
in seeking care.
The most common, but least specific type
of fracture found in child abuse cases is a long bone fracture.
The configuration of the fracture
can provide information about the mechanism needed
to cause the break, thereby assisting
the medical professional when determining
the plausibility of the history given to explain the injury.
For example, transverse fractures
are due to a direct blow or bending force perpendicular
to the bone.
Buckle fractures occur from compression
along the axis of the bone.
And spiral fractures result from a twisting force.
There are some fractures that have a high specificity
for child abuse, particularly when
identified in children less than one year of age.
For example, the classic metaphyseal lesion, or CML,
also called a bucket handle fracture or chip fracture,
is caused by a twisting and pulling
force leading to a planar fracture
through the metaphysis.
Posterior medial rib fractures, are also highly specific
and can be caused by squeezing an infant such
that there is anterior to posterior compression
of the chest.
90% of physical abuse victims present
with cutaneous findings.
In fact, a single cutaneous injury
may be the only clinical indicator of child abuse.
It is important to note that although the location
of any cutaneous injury could potentially raise concern
for abuse, certain locations are more indicative of abuse.
Accidental bruising typically occurs on bony prominences,
including the knees and shins.
In contrast, bruises located in protected areas
on the torso, ears, neck, genitals, or buttocks
are uncommon during the course of normal childhood activity,
and should prompt the provider to consider child abuse.
Any bruising in a non-ambulatory infant merits
further evaluation, as those who don't cruise rarely bruise.
Other concerning features include
bruising in a defined pattern to suggest a mechanism of injury,
such as a hand-shaped bruise, an elliptical pattern of abrasion
with central ecchymosis as a result of a bite,
or a loop-configured bruise resulting
from a flexible object folded onto itself,
such as a cord, rope, or belt.
Of note, you cannot date a bruise.
There is no scientific basis for a timeline of color change,
nor is there a standard method to account
for the various factors contributing to the bruise's
color, such as skin pigmentation or tissue injury depth.
With regard to burns, accidental burns such as those
caused by pulling over a pot of boiling water,
tend to be asymmetric and characterized
by irregular edges.
Burns caused by non-accidental scalding immersion,
however, tend to be symmetric, with consistent burn depth,
and well-defined borders.
Immersion burns can affect the lower limbs and perineum,
especially if occurring in association with toilet
training, or may be in a glove and stocking distribution
affecting the hands and feet.
Thermal burns may take on the appearance of the object used,
such as a cigarette or iron.
Diagnosis.
When creating a differential diagnosis,
it is first important to consider whether the injury is
accidental or non-accidental.
As such, providers will need to determine
if the history provided is sufficient to explain
the injury.
Given the consequences of a diagnosis of child abuse,
it is also critical to determine whether there
is an underlying medical condition causing
similar findings.
A couple of selected examples are described in this section,
but by no means is this an exhaustive list.
In the case of fractures, the differential
may include rickets and osteogenesis imperfecta.
With rickets, patients may also present
with multiple fractures, but classic findings
include frayed metaphyses, osteopenia, bowing of the legs,
and a rachitic rosary upon palpation
of the costochondral joints.
For osteogenesis imperfecta, you should
evaluate for features such as blue sclera, Wormian bones,
or irregular bones within the cranial suture,
and a positive family history.
For children presenting with bruising,
the differential also includes a bleeding disorder.
You should therefore ask whether the child has
any previous history of bleeding from the umbilical cord stump
or circumcision procedure, easy bruising,
or bleeding with previous surgeries,
as well as conduct a detailed family history
to assess for bleeding problems.
In the workup of skeletal and cutaneous abuse,
it is important to consider potential mimickers
such as those previously described.
A comprehensive history and physical exam,
as well as lab evaluation is critical.
In a child with fractures concerning for abuse,
relevant labs include evaluation of bone health,
calcium, phosphorus, alkaline phosphatase,
25-hydroxy-vitamin D, and parathyroid hormone,
as well as consideration of genetic testing
for osteogenesis imperfecta.
Consultation with genetics and/or endocrine
may also be indicated.
For a child presenting with bruising,
relevant labs include complete blood count, platelets,
coagulation studies, Von Willebrand disease testing,
and factor VIII and IX levels.
Consultation with hematology can help further guide
the laboratory evaluation.
Radiographic imaging is also an essential component
of the workup of suspected physical abuse.
A skeletal survey should be obtained
in all cases of suspected child abuse in children
less than two years of age.
A skeletal survey consists of approximately 21
different radiographs, including images
of the long bones, hands, feet, skull, spine, pelvis, and ribs.
The advantages of a skeletal survey
are high sensitivity for acute and healing fractures, as well
as relatively low radiation exposure.
Management.
The first priority in the care of physically abused children
is medical assessment and stabilization,
which may require hospitalization of the child.
If available, the hospital's child protection team
should be notified, as the final determination of child abuse
will require a coordinated interdisciplinary evaluation.
If there is any concern for potential abuse,
the case must be reported to child protective services as
mandated in the state, with notification of law enforcement
as required in some jurisdictions.
It is important to note that medical students are also
considered mandated reporters.
The child's pediatrician should be contacted.
An extensive social evaluation should be performed,
ideally by a child protective services social worker.
Full evaluation of siblings for abuse may be indicated.
Ultimately, long term treatment may
include referral to mental health providers
due to the psychological effects of abuse
on the child, siblings, and non-offending caregiver,
family members may also require additional assistance
to address drug abuse or intimate partner violence,
given that these are risk factors for child abuse.
The pediatrician plays a key role
in the prevention of child abuse.
A child's pediatrician may be the first to recognize
sentinel signs of child abuse meriting further evaluation,
such as a bruise in a non-ambulatory infant.
Importantly, awareness of developmental triggers
for physical abuse such as toilet training and generalized
frustration with the emerging developmental skills
of the child can prompt anticipatory guidance
that enhances parents' coping skills.
Pediatricians can also develop a longitudinal supportive
relationship with families, in which they regularly
assess for abuse risk factors, and provide
resources to help address the family's
social and economic needs.
Finally, the pediatrician can serve
as an advocate for funding and implementation
of evidence-based child abuse prevention programs,
whether at the national or community level.
The sequelae of physical abuse in childhood
extend far beyond the medical consequences
of skeletal or cutaneous injuries.
Victims of physical abuse ultimately
have higher rates of depression, conduct disorder,
and drug abuse.
In one study about 80% of 21-year-olds
who were abused as children met criteria
for at least one psychological disorder.
Nearly one third of abused and neglected children
will later abuse their own children, further perpetuating
the family cycle of abuse.
Summary.
Key takeaway points from this video are as follows.
When evaluating a child for possible physical abuse,
it is essential to recognize whether the story fits
the injury, and the developmental skills
of the child.
Although any clinical constellation of injury
can result from abuse, certain skeletal and cutaneous injuries
are unlikely to be accidental, particularly
in a non-ambulatory child.
It is important to differentiate mimics
of child abuse such as rickets, osteogenesis imperfecta,
and bleeding disorders in the workup of suspected child
abuse.
The pediatrician ultimately serves as a critical pillar
of education and support in the prevention of child abuse
in the community.
Thank you for watching this video on child abuse.