Pediatric Abuse

Author: Jason McKean

Topic updated on 05/10/13 5:53pm

Introduction

Epidemiology
- incidence
  - >1 million children are victims of substantiated abuse or neglect in United States each year
  - child abuse is the most common cause of death in children behind accidental injury.
  - in child abuse, head injury is the most frequent cause of long term physical morbidity in the child
- demographics
  - most common in children < 3 years old
- social risk factors
  - recent job loss of parent
  - children with disabilities (cerebral palsy, premature)
  - step children
Prognosis
- If unreported, 30-50% chance of repeat abuse and 5-10% chance of death from abuse
Differential Diagnosis
- true accidental injury
- osteogenesis imperfecta
- metabolic bone disease

Presentation

History
- injury often inconsistent with history
- red flags
  - long bone fxs in infant that is not yet walking
  - multiple bruises
  - multiple fxs in various stages of healing
  - corner fxs
    - primary spongiosa (metaphyseal)
    - high specificity for child abuse
  - posterior rib fractures
  - bucket handle fractures
    - same as corner fractures
    - avulsed bone fragment is seen en face as a bucket handle
  - transphyseal separation of the distal humerus
Symptoms
- pain related to fractures
  - fractures are the second most common lesion in abused children
    - frequency of fractures
      - humerus > tibia > femur
      - diaphyseal fractures 4 times more common than metaphyseal
Physical exam
- skin lesions
  - most common presenting lesion

Imaging

Radiographs
- recommended views
  - AP and lateral of bone or joint of suspicion
  - initial evaluation should include skeletal survey
Bone scan
- used as an alternative or adjunctive study for patients 5 years of age or older as skeletal surveys not as reliable in older children

Treatment

Nonoperative
- report abuse to appropriate agency
  - indications
    - reporting suspected child abuse is mandatory
    - early involvement of social workers and pediatricians is essential
- hospital admission
  - indications
    - admit infants with fractures to the hospital and consult child protective services
    - obtain social service consult
Operative
- definitive treatment as indicated for particular injury

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Qbank (15 Questions)

TAG

(OBQ12.27) Which of the following statements regarding child abuse is correct? Topic

Review Topic

1. It is the 2nd most common cause of death in children over 1 year of age
2. Abuse is most common in children from ages 3-6 years
3. Burns are the most frequent cause of long-term physical morbidity
4. Fractures are the most common presenting injury
5. Metaphyseal fractures four-times more common than diaphyseal fractures

PREFERRED RESPONSE ▶

DISCUSSION: Child abuse is the 2nd most common cause of death in children > 1 year of age, behind accidental injury.

More than 1 million children are victims of substantiated abuse or neglect in United States each year. Red flags in the history include long bone fractures in an infant that is not yet walking, multiple bruises, multiple fractures in various stages of healing.

Kocher et al. review the topic of child abuse and point out that there is no single pathognomonic sign or symptom, necessitating that the treating physician look at the case as a whole. The child's age, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case.

McClain et al. investigated the claim of increased deaths in children due to abuse or neglect from 1979 to 1988 (information that was collected through surveys). They looked at the cause of death in children and found that death from abuse was second to accidental death. They recommend that the death coding system be modified to make identification of fatal child abuse or neglect easier for ongoing surveillance.

Illustration A shows an example of a metaphyseal corner fracture, which is considered a red flag for child abuse.

Incorrect Answers:
Answer 2: Child abuse is most common in children < 3 years old.
Answer 3: Head injury is the most frequent cause of long term physical morbidity.
Answer 4: Skin lesions are the most common presentation.
Answer 5: Diaphyseal fractures are four-times more common than metaphyseal fractures.

Illustrations: A

REFERENCES:

1. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg. 2000 Jan- Feb;8(1):10-20. Review. PubMed PMID: 10666649. PMID:10666649 (Link to Abstract)

2. McClain PW, Sacks JJ, Froehlke RG, Ewigman BG. Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics. 1993 Feb;91(2):338-43. PubMed PMID: 8424007. PMID:8424007 (Link to Abstract)

Question Authors:

Jason McKean MD, Michael Hughes MD, Eric Shirley MD,

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(OBQ12.34) All of the following are social indicators of increased risk of child abuse EXCEPT: Topic

Review Topic

1. Parent recently losing job
2. A child with cerebral palsy
3. A step child
4. A child with no siblings
5. A premature child

PREFERRED RESPONSE ▶

DISCUSSION: Single children have not been shown to be at increased risk of abuse. All the other listed answers are associated with increased stress on the family and have been shown to increase the likelihood of abuse.

There are certain social, parental and child indicators that statistically put children at a higher risk for abuse. Some of them are as obvious as a parent abusing a spouse while some are more subtle like separation of mother's parents. It is important for the treating physician to screen for these factors to identify situations of child abuse.

Kempe et al. provide and article which is an adaption from a lecture given in 1970 and gives a broad overview of child abuse. There are a few teaching points that are relavent to this question. Kempe discusses the idea that certain children are more vulnerable to abuse (hyperactive, precocious, premature, adopted, and step child). He also points out the act of abuse is a final common pathway of conflict when there is a problem with the parent or baby and for this to occur there must be; potential for abuse, certain characteristics of a certain child as seen by the particular parent, and conflict.

Rockwood and Wilkins' chapter on child abuse includes a list of parental, social, and child risk factors. A few from each group include: Parental- age <20 years, lower education, history of psychiatric disease; Social- job loss, family death, job loss, unplanned births, high levels of stress; Child- age <3 years, premature, stepchildren, handicapped.

Illustration A is a table showing some of the clinical findings in child abuse.

Illustrations: A

REFERENCES:

1. Kempe CH. Paediatric implications of the battered baby syndrome. Arch Dis Child. 1971 Feb;46(245):28-37. PubMed PMID:; PubMed Central PMCID: PMC1647584. PMID:5555488 (Link to Abstract)

2. Schwend RM, Blakemore LC, Lowe L. The orthopaedic recognition of child maltreatment. In: Beaty JH, Kasser JR, Skaggs D, Flynn JM, eds. Rockwood and Wilkins’ Fractures in Children. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:192-224.

Question Authors:

Jason McKean MD, Jan Szatkowski MD, Michael Hughes MD,

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(OBQ11.133) A 12-year-old basketball player is seen for a routine physical. During the physical, he is reluctant to partake in the full physical exam. Upon further questioning, he states that a member of the coaching staff has touched him inappropriately on repeated occasions. Which of the following best outlines your legal responsibility as a physician? Topic

Review Topic

1. Inform the parents
2. Inform the school board
3. Inform the athletic director
4. Inform the child health and protective services
5. Inform the police

PREFERRED RESPONSE ▶

DISCUSSION: The scenario described strongly suggests child abuse. Any suspicion of child (<18 yrs) abuse should be reported to Child Protective Services (CPS) as this is typically required by law. Laws regarding reporting and age of consent between minors varies from state to state and physicians must be aware of their state requirements.

Kellog’s clinical report in 1999 updated the “Guidelines for the Evaluation of Sexual Abuse of Children” from 1991. He defined sexual abuse as a “child engaging in sexual activities that he or she cannot comprehend, is developmentally unprepared for and cannot give consent." Over 19% of adolescents who use the internet are solicited for sex by strangers.

McDonald reported 4.3% of children under 18 years are victims of child abuse. When any of the four types of abuse (neglect and emotional, physical or sexual abuse) are suspected, they must be reported to the CPS.

REFERENCES:

1. Kellogg N. American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005 Aug;116(2):506-12. PMID:16061610 (Link to Abstract)

2. McDonald KC. Child abuse: approach and management. Am Fam Physician. 2007 Jan 15;75(2):221-8. PMID:17263217 (Link to Abstract)

Question Authors:

Terrill Julien MD, Eric Shirley MD, Ben Taylor MD,

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(OBQ10.1) Which of the following must be done whenever a non-ambulatory infant presents to the ER with a diaphyseal long bone fracture? Topic

Review Topic

1. Immediate consultation with child protective services and possible admission to the hospital
2. Order serum vitamin D levels
3. Order serum calcium and phosphorus levels
4. MRI of the cervical spine
5. Perform genetic testing for COL1-A1 and COL1-A2

PREFERRED RESPONSE ▶

DISCUSSION: Each of the answers could be performed in this scenario as part of a diagnostic evaluation. However, missing a case of child abuse could result in further abuse of the child or even death, making this the most important issue to address.

Banaszkiewicz et al performed a retrospective review over a five year period on children < 1 year of age who presented to the ER with a fracture. They found that 28% of the time, abuse was underestimated at the time of evaluation. They recommend admitting all patients in this age group with any fracture and consulting child protection services.

REFERENCES:

1. Novacheck TF. The role of the orthopaedic surgeon in diagnosing child abuse. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter's Pediatric Orthopaedics. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:1527-1545.

2. Banaszkiewicz PA, Scotland TR, Myerscough EJ. Fractures in children younger than age 1 year: importance of collaboration with child protection services. J Pediatr Orthop. 2002 Nov-Dec;22(6):740-4. PMID:12409899 (Link to Abstract)

Question Authors:

Master Admin MD, Eric Shirley MD, Michael Hughes MD,

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(OBQ10.141) An 10-month-old child is brought to the emergency room with left elbow swelling and an intact neurovascular exam. The parents report no history of trauma. A radiograph demonstrates a minimally displaced distal humerus physeal separation with abundant callous formation. The next step in managament should include? Topic

Review Topic

1. Closed reduction and percutaneous pinning
2. Casting only
3. A skeletal survey and contacting the appropriate authorities
4. Elbow arthrogram
5. Open reduction and internal fixation

PREFERRED RESPONSE ▶

DISCUSSION: Distal humeral physeal separations in the infant or young child are most often the result of violent traction or rotation and are commonly associated with child abuse. They may initially be difficult to recognize in newborns and young infants when the secondary ossification center is not apparent. In these cases, arthrography, ultrasound, or magnetic resonance imaging may be required to make the diagnosis. For young children presenting more than 3 weeks out abundant callous formation may be noted. In children where there is ossification of the epiphyseal ossific nucleus the diagnosis is typically made on plain radiographs. Once the diagnosis is confirmed the next step should be further workup to assess for other injuries and to contact the appropriate authorities. The American Academy of Pediatrics Section on Radiology has recommended a mandatory skeletal survey in all cases of suspected abuse in children younger than 2 years of age. This may be followed by closed reduction and casting, pinning, or rarely open reduction but this is not the first step prior to assessing for other injuries and abuse in a neurovascularly intact child. The paper by Akbarnia et al details arthrography perfomed in six infants with an elbow injury confirming 4 Salter-Harris type I injuries and 2 Salter-Harris type II fractures. Abuse was confirmed in 2 patients and suspected in 2. The paper by Kocher is a comprehensive review of the orthopaedic aspects of child abuse.

REFERENCES:

1. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg. 2000 Jan-Feb;8(1):10-20. PMID:10666649 (Link to Abstract)

2. Akbarnia BA, Silberstein MJ, Rende RJ, Graviss ER, Luisiri A. Arthrography in the diagnosis of fractures of the distal end of the humerus in infants. J Bone Joint Surg Am. 1986 Apr;68(4):599-602. PMID: 3957985 (Link to Abstract)

Question Authors:

Robert Boykin MD, Eric Shirley MD,

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(OBQ09.93) A 2-year-old male is brought to the emergency room complaining of pain in the left elbow. Radiographs are shown in Figures A and B. This injury pattern should raise concern for which of the following? Topic

Review Topic

FIGURES: A

1. Osteogenesis imperfecta
2. Larsen’s syndrome
3. Kwashiorkor
4. Marfan’s syndrome
5. Child abuse

PREFERRED RESPONSE ▶

DISCUSSION: The radiographs show a transphyseal separation of the distal humerus. This injury pattern is a result of a rotatory shear mechanism and has a high association with child abuse.

Arthrograms may be of assistance to confirm the diagnosis of a transphyseal separation and to rule out other conditions including a very distal supracondylar fracture, lateral condyle fracture, and elbow dislocation. In the child with a visible ossification center at the capitellum, a true elbow dislocation will have disruption of the radiocapitellar line and transphyseal separation of the distal humerus will not.

Transphyseal separations of the distal humerus are treated with closed reduction and percutaneous pin fixation similarly as to a supracondylar humerus fracture.

DeLee et all looked at sixteen patients with fracture-separations of the distal humeral epiphysis. All sixteen patients revealed posteromedial displacement of the distal humeral epiphysis on the initial roentgenogram. Child-abuse was documented or suspected as a cause in six of the sixteen fractures (38%).

Akbarnia et al performed a Level 4 review of 6 infants that underwent an arthrograph because their elbow injuries were not clearly identified from the plain radiographs. They found that in over 75% of cases the management changed as a result of the arthrograph information. Salter-Harris I fractures were the most common injury pattern diagnosis. Child abuse was confirmed or suspected in 4 of 6 cases (66%).

Illustrations A and B show radiographs of the contralateral limb which can be a helpful tool when assessing for the presence of a transphyseal fracture.

Illustrations: A

REFERENCES:

1. DeLee JC, Wilkins KE, Rogers LF, Rockwood CA. Fracture-separation of the distal humeral epiphysis. J Bone Joint Surg Am. 1980 Jan;62(1):46-51. PMID:7351415 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Eric Shirley MD,

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(OBQ08.2) Child abuse should be suspected in an isolated spiral femur fracture of a child in which of the following situations? Topic

Review Topic

1. Child greater than 3 years old
2. Child is smaller than predicted growth charts
3. Child has a single parent
4. Child has multiple siblings
5. Child had not yet achieved walking age

PREFERRED RESPONSE ▶

DISCUSSION: According to Schwend et al, "whether a child had not yet achieved walking age (toddler) is the strongest predictor of likely abuse" in children with isolated femur fractures. Blakemore et al found the "likelihood of intentional injury to the femoral shaft appears to be low; unfortunately, there were no discriminating clinical parameters to help to determine which injuries were intentional." Both studies argue that clinicians should continue to have a high index of suspicion and have the circumstances investigated if suspicion exists.

REFERENCES:

1. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop. 2000 Jul-Aug;20(4):475-81. PMID:10912603 (Link to Abstract)

2. Blakemore LC, Loder RT, Hensinger RN. Role of intentional abuse in children 1 to 5 years old with isolated femoral shaft fractures. J Pediatr Orthop. 1996 Sep-Oct;16(5):585-8. PMID:8865041 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Eric Shirley MD,

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(OBQ08.79) What are the two most common lesions seen in abused children? Topic

Review Topic

1. Skin lesions and head injuries
2. Skin lesions and fractures
3. Visceral injuries and fractures
4. Visceral injuries and head injuries
5. Skin lesions and visceral injuries

PREFERRED RESPONSE ▶

DISCUSSION: The annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children increasing. Skin lesions are the most common presentation, followed by fractures. Approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that orthopaedic surgerons have an understanding of physical abuse in the hopes of increasing the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Several factors including the age of the child, the ambulation status, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. The differential diagnosis of abuse includes true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary with the key being recognition. Abused children have a substantial risk of repeated abuse and death.

The Pandya et al article found that age is a key factor to consider in the evaluation. They stated that kids <18 months old with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Conversely, kids >18 months old with long bone fractures (ie, femur and humerus) are more likely to be related to accidental trauma than child abuse.

REFERENCES:

1. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg. 2000 Jan-Feb;8(1):10-20. PMID:10666649 (Link to Abstract)

2. Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS. Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. J Pediatr Orthop. 2009 Sep;29(6):618-25. PMID:19700994 (Link to Abstract)

Question Authors:

Doug Nowak MD, Derek Moore, Guillem Lomas MD,

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(OBQ07.73) Which of the following is the most common presenting fracture pattern seen in abused children? Topic

Review Topic

1. Metaphyseal corner fractures
2. Spiral long bone fractures
3. Multiple fractures in different stages of healing
4. Single transverse long bone fractures
5. Posterior rib fractures

PREFERRED RESPONSE ▶

DISCUSSION: Fracture patterns associated with child abuse which should raise one's suspicion include:

1) metaphyseal corner fractures
2) spiral fractures
3) multiple fractures at different stages of heeling
4) single transverse long bone fractures
5) posterior rib fractures
6) skull fractures

Of the fracture patterns listed in the question, single transverse long bone fractures are the most common presenting fracture pattern in abused children.

King et al found that skull fractures were the most prevalent fractures seen in battered children. Second to skull fractures were single, transverse long bone fracture in prevalence.

Kemp et al found that fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (<1 year) and toddlers (between 1 and 3 years old). They noted that "when infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause".

REFERENCES:

1. King J, Diefendorf D, Apthorp J, Negrete VF, Carlson M. Analysis of 429 fractures in 189 battered children. J Pediatr Orthop. 1988 Sep-Oct;8(5):585-9. PMID:3170740 (Link to Abstract)

2. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008 Oct 2;337:a1518. doi: 10.1136/bmj.a1518. Review. PubMed PMID: 18832412; PubMed Central PMCID: PMC2563260. PMID:18832412 (Link to Abstract)

Question Authors:

Chris Souder MD, Eric Shirley MD, John Badylak MD,

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(OBQ07.215) A 6-month-old boy is brought to the emergency department by his mother because he has been irritable for the last week. Initially the mother reports no history of trauma, but later she says that he may have fallen from a changing table. Radiographs of the knee demonstrate metaphyseal corner lesions of the distal femur and proximal tibia. White blood cell count and erythrocyte sedimentation rate values are normal. What is the most appropriate next step in treatment? Topic

Review Topic

1. vitamin D & calcium levels
2. MRI of the knee
3. aspiration of the hip
4. admission and activation of child abuse work-up
5. hip spica cast

PREFERRED RESPONSE ▶

DISCUSSION: As described in the review by Kocher, fractures are the second most common presentation of physical abuse after skin lesions and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Radiographic findings that have high specificity for child abuse include metaphyseal corner lesions, posterior rib fractures, scapular fractures, spinous process fractures, and sternal fractures. The remaining options would be appropriate for suspected rickets (1), oncologic lesion (2), septic hip (3), and displaced femoral shaft fracture (5).

REFERENCES:

1. Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10-20 PMID:10666649 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Eric Shirley MD,

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(OBQ06.44) What is the second most common presenting sign of child abuse? Topic

Review Topic

1. fractures
2. bruises
3. retinal detachment
4. epidural hematoma
5. pulmonary contusion

PREFERRED RESPONSE ▶

DISCUSSION: Skin lesions are the most common presentation of physical abuse followed by fractures. Approximately one third of abused children will eventually be seen by an orthopaedic surgeon.

The annual incidence of child abuse is approximately 15 to 42 cases per 1,000 children and appears to be increasing. Greater than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse.

REFERENCES:

1. Akbarnia BA, Campbell RM: The role of the orthopaedic surgeon in child abuse, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilking, 2001, pp 1423-1445.

2. Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. JAAOS 2000;8:10-20. PMID:10666649 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Derek Moore,

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(OBQ06.98) What is the most common presenting sign of child abuse? Topic

Review Topic

1. head injury
2. retinal hemorrhage
3. splenic rupture
4. skin cuts or bruises
5. fractures

PREFERRED RESPONSE ▶

DISCUSSION: The annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. Head injury causes the most morbidity in the long term care of the abused child. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. The review article by Kocher et al reviews the responsibility of orthopaedic surgeons in the diagnosis and treatment of child abuse.

REFERENCES:

1. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg. 2000 Jan-Feb;8(1):10-20. PMID:10666649 (Link to Abstract)

2. Akbarnia BA, Campbell RM: The role of the orthopaedic surgeon in child abuse, in Morrissy RT, Weinstein SL (eds): Lovell & Winter's Pediatric Orthopaedics, ed 5, Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 1423-1445.

Question Authors:

Greg Galano MD, Derek Moore, Eric Shirley MD,

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(OBQ05.160) All of the following injuries are highly suggestive of child abuse EXCEPT: Topic

Review Topic

1. femoral shaft fracture in a nonambulatory infant
2. posterior rib fracture
3. multiple fractures in various stages of healing
4. non-displaced spiral tibial shaft fracture in a toddler
5. metaphyseal corner fractures

PREFERRED RESPONSE ▶

DISCUSSION: Fractures related to abuse can occur in almost any bone of the body. However, the long bones, ribs, and skull are common locations. Musculoskeletal injury patterns suggestive of non-accidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys, follow-up radiography, and evaluation from child protective services may be of benefit in cases of suspected abuse of younger children. Toddler's fractures are non-displaced spiral fractures of the tibial shaft that are common in children of walking age. The reference from Kleinman et al found that in 31 infants who died with inflicted skeletal injuries associated with abuse, 51% of the fractures found were rib fractures. The reference by Zillmer et al is a review article that discusses the role of the orthopaedic surgeon in the diagnosis and treatment of orthopaedic injuries related to abuse.

REFERENCES:

1. Kleinman, Marks, Nimkin, et al: Rib fractures in 31 abused infants: Postmortem radiologic-histopathologic study. Radiology 1996; 200:807-810 PMID:8756936 (Link to Abstract)

2. Zillmer, Bynum, Kocher, et al. Family Violence: Tools for the orthopaedic surgeon. Inst Course Lect 2003; 52:791-802 PMID:12690903 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Eric Shirley MD,

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(OBQ04.230) A 12-month-old girl is brought to the emergency room by her father. He states that she has not been moving her arm and has been more irritable than usual. A radiograph of the elbow is depicted in Figure A. On examination of her lower extermities, she has mild tenderness and prominence over her left thigh but does not have any bony instability. A radiograph of her left thigh is shown in Figure B. In addition to a complete history and physical, management should include which of the following? Topic

Review Topic

FIGURES: A

1. Long arm cast with the elbow in neutral position
2. Bone scan and liver enzymes
3. Notification of hospital child protective services and a skeletal survey
4. Genetic testing to evaluate for chromosomal translocation
5. Sling and discharge home with follow-up in one week

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a distal humeral physeal separation. Figure B depicts a healing left femur fracture. In the pediatric population, these findings are highly suggestive of child abuse. As such, management should include notification of hospital Child Protective Services (CPS) and a skeletal survey. Kocher et al identified patterns suggestive of child abuse. They noted metaphyseal lesions, posterior rib fractures, long bone fractures in non-ambulatory children, and multiple fractures in various stages of healing as being highly suggestive of non-accidental trauma. Workup includes a skeletal survey to rule out other fractures, ophthalmologic examination to rule out intracranial hemorrhage, evaluation for osteogenesis imperfecta when suspected, and further imaging such as bone scan if the skeletal survey is negative but examination remains suspicious.

REFERENCES:

1. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg. 2000 Jan-Feb;8(1):10-20. PMID:10666649 (Link to Abstract)

Question Authors:

Terrill Julien MD, John Badylak MD, Eric Shirley MD,

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Groups

ABOS II: Pediatric Abuse

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Akbarnia BA, Silberstein MJ, Rende RJ, Graviss ER, Luisiri A. Arthrography in the diagnosis of fractures of the distal end of the humerus in infants. J Bone Joint Surg Am. 1986 Apr;68(4):599-602. PMID:3957985 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Banaszkiewicz PA, Scotland TR, Myerscough EJ. Fractures in children younger than age 1 year: importance of collaboration with child protection services. J Pediatr Orthop. 2002 Nov-Dec;22(6):740-4. PMID:12409899 (Link to Abstract)
Kellogg N. American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005 Aug;116(2):506-12. PMID:16061610 (Link to Abstract)
Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008 Oct 2;337:a1518. doi: 10.1136/bmj.a1518. Review. PubMed PMID: 18832412; PubMed Central PMCID: PMC2563260. PMID:18832412 (Link to Abstract)
Kempe CH. Paediatric implications of the battered baby syndrome. Arch Dis Child. 1971 Feb;46(245):28-37. PubMed PMID:; PubMed Central PMCID: PMC1647584. PMID:5555488 (Link to Abstract)
McDonald KC. Child abuse: approach and management. Am Fam Physician. 2007 Jan 15;75(2):221-8. PMID:17263217 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
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