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 corner fractures discrete avulsion of the metaphysis 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
QUESTIONS 1 of 34 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Previous Next (OBQ18.78) Which of the following pediatric femur fractures is most suggestive of nonaccidental trauma? QID: 212974 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 74% (1646/2221) 2 Figure B 6% (137/2221) 3 Figure C 2% (35/2221) 4 Figure D 16% (366/2221) 5 Figure E 1% (24/2221) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ14.95) A well-educated nurse is seeking a third opinion regarding her 4-year-old daughter with right ankle pain. She states her daughter has sprained her ankle 15 to 20 times over the past year. She insists her daughter has a diagnosis of tarsal coalition that requires immediate surgery. She is also due to see a neurologist for a second opinion regarding unwitnessed seizure activity, despite reassurance from the last subspecialist that the child is healthy. The examination of the right ankle was normal. Radiographs of the foot and ankle are seen in Figures A and B. What would be the next best step in treatment? QID: 5505 FIGURES: A B Type & Select Correct Answer 1 CT scan right ankle 11% (356/3097) 2 Early multidisciplinary evaluation of the patient 79% (2450/3097) 3 Non-weight bearing and prolonged casting 5% (143/3097) 4 Tarsal coalition excision and adipose tissue interposition 2% (52/3097) 5 Referral to a foot and ankle surgeon for another opinion 2% (73/3097) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ13PE.68) All of the following decrease the risk of burn from a cast saw EXCEPT: QID: 5179 Type & Select Correct Answer 1 Using a vacuum 25% (674/2734) 2 Using fiberglass cast material 53% (1445/2734) 3 Casting with a decreased cast thickness 11% (309/2734) 4 Using an "up and down" saw technique 8% (208/2734) 5 Checking the blade frequently 3% (75/2734) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.34) All of the following are social indicators of increased risk of child abuse EXCEPT: QID: 4394 Type & Select Correct Answer 1 Parent recently losing job 3% (120/3905) 2 A child with cerebral palsy 3% (119/3905) 3 A step child 3% (120/3905) 4 A child with no siblings 76% (2954/3905) 5 A premature child 14% (566/3905) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ12.27) Which of the following statements regarding child abuse is correct? QID: 4387 Type & Select Correct Answer 1 It is the 2nd most common cause of death in children over 1 year of age 43% (1673/3846) 2 Fractures in child abuse occur more often children greater than 5 years of age 3% (121/3846) 3 Burns are the most frequent cause of long-term physical morbidity 6% (238/3846) 4 Fractures are the most common presenting injury 27% (1053/3846) 5 Metaphyseal fractures four-times more common than diaphyseal fractures 19% (737/3846) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 3556 Type & Select Correct Answer 1 Inform the parents 3% (105/3346) 2 Inform the school board 0% (6/3346) 3 Inform the athletic director 1% (21/3346) 4 Inform the child health and protective services 89% (2976/3346) 5 Inform the school counselor 7% (222/3346) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.141) A 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 callus formation. The next step in managament should include? QID: 3229 Type & Select Correct Answer 1 Closed reduction and percutaneous pinning 1% (26/3647) 2 Casting only 2% (64/3647) 3 A skeletal survey and contacting the appropriate authorities 96% (3515/3647) 4 Elbow arthrogram 0% (18/3647) 5 Open reduction and internal fixation 0% (16/3647) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ10.1) Which of the following must be done whenever a non-ambulatory infant presents to the ER with a diaphyseal long bone fracture? QID: 3089 Type & Select Correct Answer 1 Immediate consultation with child protective services and possible admission to the hospital 98% (2881/2938) 2 Order serum vitamin D levels 0% (11/2938) 3 Order serum calcium and phosphorus levels 0% (13/2938) 4 MRI of the cervical spine 0% (14/2938) 5 Perform genetic testing for COL1-A1 and COL1-A2 0% (10/2938) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 2906 FIGURES: A B Type & Select Correct Answer 1 Osteogenesis imperfecta 2% (57/3042) 2 Larsen’s syndrome 3% (82/3042) 3 Kwashiorkor 0% (7/3042) 4 Marfan’s syndrome 3% (85/3042) 5 Child abuse 92% (2798/3042) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.2) Child abuse should be suspected in an isolated spiral femur fracture of a child in which of the following situations? QID: 388 Type & Select Correct Answer 1 Child greater than 3 years old 1% (13/1504) 2 Child is smaller than predicted growth charts 2% (29/1504) 3 Child has a single parent 2% (32/1504) 4 Child has multiple siblings 1% (15/1504) 5 Child had not yet achieved walking age 94% (1407/1504) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ08.79) What are the two most common lesions seen in abused children? QID: 465 Type & Select Correct Answer 1 Skin lesions and head injuries 5% (127/2385) 2 Skin lesions and fractures 90% (2150/2385) 3 Visceral injuries and fractures 2% (54/2385) 4 Visceral injuries and head injuries 0% (9/2385) 5 Skin lesions and visceral injuries 2% (39/2385) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07PE.55) A 6-month-old child is seen in the emergency department with a spiral fracture of the tibia. The parents are vague about the etiology of the injury. There is no family history of a bone disease. In addition to casting of the fracture, initial management should include QID: 6115 Type & Select Correct Answer 1 a skeletal survey to rule out other fractures. 95% (563/591) 2 a punch biopsy of the skin for collagen analysis to rule out osteogenesis imperfecta. 1% (6/591) 3 DNA testing for osteogenesis imperfecta. 2% (10/591) 4 blood studies for calcium, phosphorus, and alkaline phosphate levels. 1% (7/591) 5 blood studies for parathyroid hormone levels. 0% (1/591) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ07.73) Which of the following is NOT a common fracture pattern seen in abused children? QID: 734 Type & Select Correct Answer 1 Metaphyseal corner fractures 4% (73/1718) 2 Spiral long bone fractures 5% (93/1718) 3 Multiple fractures in different stages of healing 6% (103/1718) 4 Anterior translation of the femoral neck relative to the femoral epiphysis 82% (1409/1718) 5 Posterior rib fractures 2% (27/1718) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 876 Type & Select Correct Answer 1 vitamin D & calcium levels 2% (27/1367) 2 MRI of the knee 1% (17/1367) 3 aspiration of the hip 1% (9/1367) 4 admission and activation of child abuse work-up 95% (1302/1367) 5 hip spica cast 0% (6/1367) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.44) What is the second most common presenting sign of child abuse? QID: 155 Type & Select Correct Answer 1 fractures 85% (1239/1459) 2 bruises 11% (155/1459) 3 retinal detachment 2% (27/1459) 4 epidural hematoma 2% (28/1459) 5 pulmonary contusion 0% (4/1459) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ06.98) What is the most common presenting sign of child abuse? QID: 209 Type & Select Correct Answer 1 head injury 1% (18/1336) 2 retinal hemorrhage 1% (13/1336) 3 splenic rupture 0% (3/1336) 4 skin cuts or bruises 75% (1001/1336) 5 fractures 22% (293/1336) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ05.37) A 10-month-old male is diagnosed with a femoral shaft fracture as seen in Figure A. The parents can not clearly explain the cause of the injury and the child has several other bruises on the right arm. In addition to femur x-rays, what radiologic study is most appropriate? QID: 74 FIGURES: A Type & Select Correct Answer 1 whole body SPECT scan 0% (10/2886) 2 MRI of the brain and spine 1% (18/2886) 3 CT of the chest, abdomen and pelvis 1% (15/2886) 4 skeletal survey 97% (2802/2886) 5 right forearm x-ray 1% (27/2886) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ05.160) All of the following injuries are highly suggestive of child abuse EXCEPT: QID: 1046 Type & Select Correct Answer 1 femoral shaft fracture in a nonambulatory infant 2% (17/1057) 2 posterior rib fracture 2% (25/1057) 3 multiple fractures in various stages of healing 1% (11/1057) 4 non-displaced spiral tibial shaft fracture in a toddler 88% (931/1057) 5 metaphyseal corner fractures 6% (65/1057) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ04PE.65) You are asked by your hospital to review several cases in the emergency department as part of a quality improvement project. Which of the following radiographs would make you most concerned for non-accidental trauma? QID: 2250 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 2% (31/1701) 2 Figure B 1% (15/1701) 3 Figure C 2% (41/1701) 4 Figure D 94% (1596/1701) 5 Figure E 1% (11/1701) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ04PE.37) A single mother is in the emergency room with her 6-month-old infant stating he fell and sustained the injury seen in Figure A. The mother reports her oldest son has a confirmed diagnosis of a bone disorder. Laboratory studies are normal. Further imaging is obtained as seen in Figures B-D. Based on this information what is the most likely diagnosis? QID: 2222 FIGURES: A B C D Type & Select Correct Answer 1 Osteogenesis imperfecta 8% (175/2131) 2 Rickets 9% (189/2131) 3 Scurvy 1% (26/2131) 4 Accidental trauma 2% (39/2131) 5 Non-accidental trauma 79% (1678/2131) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 1335 FIGURES: A B Type & Select Correct Answer 1 Long arm cast with the elbow in neutral position 0% (9/1930) 2 Bone scan and liver enzymes 1% (12/1930) 3 Notification of hospital child protective services and a skeletal survey 97% (1873/1930) 4 Genetic testing to evaluate for chromosomal translocation 1% (25/1930) 5 Sling and discharge home with follow-up in one week 0% (0/1930) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
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