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Updated: Sep 3 2023

Pediatric Abuse

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  • summary
    • Pediatric Abuse is the second most common cause of death in children and 50% of fractures in children younger than 1 year of age are attributable to abuse.
    • Diagnosis can be suspected with a pediatric injury that is inconsistent with the mechanism of injury, a delay in seeking care, long bone fractures in nonambulatory child, or presence of highly specific fractures.
    • Treatment involves reporting abuse to the appropriate agency and hospital admission for multidisciplinary evaluation. Rarely, operative management of fractures may be required. 
  • Epidemiology
    • Incidence
      • >1 million children are victims of substantiated abuse or neglect in United States each year
      • child abuse is the second most common cause of death in children behind accidental injury
      • head injury is the most frequent cause of long term physical morbidity in the child
    • Demographics
      • 90% of fractures due to abuse occur in children younger than 5 years of age
      • 50% of fractures in children younger than 1 year of age are attributable to abuse
      • 30% of fractures in children younger than 3 years of age are attributable to abuse
      • the most common cause of femur fractures in the nonambulatory infant is nonaccidental trauma
    • Social risk factors
      • child
        • first-born
        • unplanned pregnancy
        • premature
        • disabilities (cerebral palsy)
        • step-children
      • parent
        • single-parent home
        • recent social stressor (move, job loss)
        • unemployment
        • drug use
        • personal history of abuse as a child
        • lower socioeconomic status
        • lack of support system
    • Types (can have more than one type present):
      • neglect 78%
      • physical abuse 18%
      • sexual 9%
      • psychological 8%
  • Presentation
    • History
      • injury often inconsistent with history
      • red flags
        • delay in seeking care
        • no history of injury or inconsistent story
        • high specificity fractures
          • long bone fractures in nonambulatory child
          • classic metaphyseal lesion
            • fracture at junction of metaphysis and physis (primary spongiosa)
            • torsional / traction-shearing strain when infant's extremity is pulled or twisted violently
            • high specificity for child abuse
            • bucket handle fractures
              • horizontal avulsion fracture with appearance of central and peripheral components gives the appearance of a bucket handle
              • avulsed bone fragment may be seen en face
          • transphyseal separation of the distal humerus
          • rib fractures, especially posteromedial
          • scapula fractures
          • sternal fractures
          • spinous process fractures
        • moderate specificity fractures
          • multiple fractures in various stages of healing
          • vertebral body fractures and subluxations
          • digital fractures
          • complex skull fractures
        • other injuries concerning for abuse - multiple bruises, burns
    • 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
      • alternative or adjunct to the radiographic skeletal survey in selected cases, particularly for children older than 1 year of age
      • provides increased sensitivity for detecting rib fractures, subtle shaft fractures, and areas of early periosteal elevation
      • not useful in metaphyseal or cranial fractures
  • Differential
    • True accidental injury
    • Osteogenesis imperfecta
    • Osteopenia of prematurity
    • Scurvy
    • Copper deficiency
    • Menkes disease
    • Disuse osteopenia (nonambulatory or minimally ambulatory children)
    • Chronic disease (kidney and liver)
  • Treatment
    • Nonoperative
      • report abuse to appropriate agency
        • indications
          • physicians are mandated reporters and are legally obligated to report suspected child abuse and neglect
          • physicians are granted immunity from civil and criminal liability if they report in good faith, but may be charged with a crime for failure to report
          • early involvement of social workers and pediatricians is essential 
      • hospital admission
        • indications
          • early multidisciplinary evaluation
          • admit infants with fractures to the hospital and consult child protective services
          • obtain social service consult
      • cast application
        • indications
          • most fractures are splinted or casted until adequate callus is formed
    • Operative
      • rarely neccessary
      • definitive treatment as indicated for particular injury
  • Prognosis
    • If unreported
      • 30-50% chance of repeat abuse
      • 5-10% chance of death from abuse
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