Updated: 6/12/2021

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
            • 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 and 5-10% chance of death from abuse
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Questions (35)
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(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:
1

CT scan right ankle

12%

(337/2884)

2

Early multidisciplinary evaluation of the patient

79%

(2269/2884)

3

Non-weight bearing and prolonged casting

5%

(137/2884)

4

Tarsal coalition excision and adipose tissue interposition

2%

(48/2884)

5

Referral to a foot and ankle surgeon for another opinion

2%

(71/2884)

L 2 B

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(SBQ13PE.68) All of the following decrease the risk of burn from a cast saw EXCEPT:

QID: 5179
1

Using a vacuum

26%

(651/2544)

2

Using fiberglass cast material

52%

(1328/2544)

3

Casting with a decreased cast thickness

11%

(278/2544)

4

Using an "up and down" saw technique

8%

(194/2544)

5

Checking the blade frequently

3%

(73/2544)

L 4 B

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

QID: 4394
1

Parent recently losing job

3%

(117/3770)

2

A child with cerebral palsy

3%

(114/3770)

3

A step child

3%

(113/3770)

4

A child with no siblings

76%

(2858/3770)

5

A premature child

14%

(544/3770)

L 2 C

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

QID: 4387
1

It is the 2nd most common cause of death in children over 1 year of age

43%

(1585/3665)

2

Fractures in child abuse occur more often children greater than 5 years of age

3%

(118/3665)

3

Burns are the most frequent cause of long-term physical morbidity

6%

(228/3665)

4

Fractures are the most common presenting injury

28%

(1016/3665)

5

Metaphyseal fractures four-times more common than diaphyseal fractures

19%

(696/3665)

L 4 C

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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?

QID: 3556
1

Inform the parents

3%

(100/3182)

2

Inform the school board

0%

(5/3182)

3

Inform the athletic director

1%

(18/3182)

4

Inform the child health and protective services

89%

(2821/3182)

5

Inform the school counselor

7%

(222/3182)

L 2 C

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(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
1

Closed reduction and percutaneous pinning

1%

(23/3359)

2

Casting only

2%

(60/3359)

3

A skeletal survey and contacting the appropriate authorities

96%

(3239/3359)

4

Elbow arthrogram

0%

(16/3359)

5

Open reduction and internal fixation

0%

(14/3359)

L 1 B

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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?

QID: 3089
1

Immediate consultation with child protective services and possible admission to the hospital

98%

(2675/2726)

2

Order serum vitamin D levels

0%

(8/2726)

3

Order serum calcium and phosphorus levels

0%

(13/2726)

4

MRI of the cervical spine

0%

(11/2726)

5

Perform genetic testing for COL1-A1 and COL1-A2

0%

(10/2726)

L 1 C

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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?

QID: 2906
FIGURES:
1

Osteogenesis imperfecta

2%

(52/2837)

2

Larsen’s syndrome

3%

(76/2837)

3

Kwashiorkor

0%

(5/2837)

4

Marfan’s syndrome

3%

(76/2837)

5

Child abuse

92%

(2617/2837)

L 1 B

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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?

QID: 388
1

Child greater than 3 years old

1%

(9/1305)

2

Child is smaller than predicted growth charts

2%

(28/1305)

3

Child has a single parent

2%

(30/1305)

4

Child has multiple siblings

1%

(13/1305)

5

Child had not yet achieved walking age

93%

(1217/1305)

L 2 C

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

QID: 465
1

Skin lesions and head injuries

5%

(120/2216)

2

Skin lesions and fractures

90%

(2002/2216)

3

Visceral injuries and fractures

2%

(50/2216)

4

Visceral injuries and head injuries

0%

(6/2216)

5

Skin lesions and visceral injuries

1%

(33/2216)

L 2 B

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(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
1

a skeletal survey to rule out other fractures.

96%

(411/429)

2

a punch biopsy of the skin for collagen analysis to rule out osteogenesis imperfecta.

1%

(3/429)

3

DNA testing for osteogenesis imperfecta.

1%

(6/429)

4

blood studies for calcium, phosphorus, and alkaline phosphate levels.

1%

(5/429)

5

blood studies for parathyroid hormone levels.

0%

(1/429)

L 1 E

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(OBQ07.73) Which of the following is NOT a common fracture pattern seen in abused children?

QID: 734
1

Metaphyseal corner fractures

5%

(70/1517)

2

Spiral long bone fractures

5%

(80/1517)

3

Multiple fractures in different stages of healing

7%

(103/1517)

4

Anterior translation of the femoral neck relative to the femoral epiphysis

81%

(1228/1517)

5

Posterior rib fractures

2%

(26/1517)

L 5 D

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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?

QID: 876
1

vitamin D & calcium levels

2%

(22/1191)

2

MRI of the knee

1%

(15/1191)

3

aspiration of the hip

1%

(9/1191)

4

admission and activation of child abuse work-up

95%

(1136/1191)

5

hip spica cast

0%

(4/1191)

L 1 C

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

QID: 155
1

fractures

85%

(1088/1275)

2

bruises

10%

(127/1275)

3

retinal detachment

2%

(26/1275)

4

epidural hematoma

2%

(25/1275)

5

pulmonary contusion

0%

(3/1275)

L 1 D

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

QID: 209
1

head injury

1%

(13/1090)

2

retinal hemorrhage

1%

(11/1090)

3

splenic rupture

0%

(3/1090)

4

skin cuts or bruises

73%

(799/1090)

5

fractures

23%

(256/1090)

L 2 D

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(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:
1

whole body SPECT scan

0%

(10/2775)

2

MRI of the brain and spine

1%

(16/2775)

3

CT of the chest, abdomen and pelvis

0%

(11/2775)

4

skeletal survey

97%

(2700/2775)

5

right forearm x-ray

1%

(24/2775)

L 1 D

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

QID: 1046
1

femoral shaft fracture in a nonambulatory infant

2%

(17/870)

2

posterior rib fracture

2%

(21/870)

3

multiple fractures in various stages of healing

1%

(10/870)

4

non-displaced spiral tibial shaft fracture in a toddler

87%

(757/870)

5

metaphyseal corner fractures

7%

(57/870)

L 2 C

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(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:
1

Osteogenesis imperfecta

9%

(168/1972)

2

Rickets

9%

(181/1972)

3

Scurvy

1%

(22/1972)

4

Accidental trauma

2%

(37/1972)

5

Non-accidental trauma

78%

(1540/1972)

L 2 D

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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?

QID: 1335
FIGURES:
1

Long arm cast with the elbow in neutral position

0%

(8/1761)

2

Bone scan and liver enzymes

1%

(12/1761)

3

Notification of hospital child protective services and a skeletal survey

97%

(1708/1761)

4

Genetic testing to evaluate for chromosomal translocation

1%

(23/1761)

5

Sling and discharge home with follow-up in one week

0%

(0/1761)

L 1 C

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