Please rate topic.
Average 4.3 of 59 Ratings
Which of the following statements regarding child abuse is correct?
It is the 2nd most common cause of death in children over 1 year of age
Fractures in child abuse occur more often children greater than 5 years of age
Burns are the most frequent cause of long-term physical morbidity
Fractures are the most common presenting injury
Metaphyseal fractures four-times more common than diaphyseal fractures
Select Answer to see Preferred Response
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.
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.
Worlock et al report that 80% of fractures secondary to abuse are found in children less 18 months of age, whereas 85% of fractures not caused by abuse are greater than 5 years of age. Just adds an additional learning point and reenforces that children under 18 months of age (a standard age cutoff for normal walking age) who present with fracture warrant additional consideration of child abuse
Illustration A shows an example of a metaphyseal corner fracture, which is considered a red flag for child abuse.
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.
McClain PW, Sacks JJ, Froehlke RG, Ewigman BG.
Pediatrics. 1993 Feb;91(2):338-43. PMID: 8424007 (Link to Abstract)
McClain, PEDS 1993
Worlock P, Stower M, Barbor P.
Br Med J (Clin Res Ed). 1986 Jul 12;293(6539):100-2. PMID: 3089406 (Link to Abstract)
Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S.
BMJ. 2008;337:a1518. Epub 2008 Oct 2. PMID: 18832412 (Link to Abstract)
Kemp, BMJ 2008
Please rate question.
Average 2.0 of 21 Ratings
All of the following are social indicators of increased risk of child abuse EXCEPT:
Parent recently losing job
A child with cerebral palsy
A step child
A child with no siblings
A premature child
Children without siblings 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 place children at a higher risk for abuse. Some of them are obvious, such as spousal abuse while others are more subtle, i.e. separation of mother's parents. It is important for the treating physician to screen for the presence of these factors to identify situations of child abuse.
Kempe et al. discusses that certain children are more vulnerable to abuse (hyperactive, precocious, premature, adopted, and step child). Often the act of abuse is a final common pathway of conflict when there is potential for abuse in combination with certain child characteristics as viewed by the involved parent.
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.
Arch Dis Child. 1971 Feb;46(245):28-37. PMID: 5555488 (Link to Abstract)
Average 3.0 of 18 Ratings
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?
Inform the parents
Inform the school board
Inform the athletic director
Inform the child health and protective services
Inform the school counselor
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.
Pediatrics. 2005 Aug;116(2):506-12. PMID: 16061610 (Link to Abstract)
Kellogg, PEDS 2005
Am Fam Physician. 2007 Jan 15;75(2):221-8. PMID: 17263217 (Link to Abstract)
Average 2.0 of 35 Ratings
Which of the following must be done whenever a non-ambulatory infant presents to the ER with a diaphyseal long bone fracture?
Immediate consultation with child protective services and possible admission to the hospital
Order serum vitamin D levels
Order serum calcium and phosphorus levels
MRI of the cervical spine
Perform genetic testing for COL1-A1 and COL1-A2
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.
Banaszkiewicz PA, Scotland TR, Myerscough EJ
J Pediatr Orthop. 2002 Nov-Dec;22(6):740-4. PMID: 12409899 (Link to Abstract)
Banaszkiewicz, JPO 2002
Average 3.0 of 21 Ratings
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?
Closed reduction and percutaneous pinning
A skeletal survey and contacting the appropriate authorities
Open reduction and internal fixation
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 callus 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.
Kocher MS, Kasser JR.
J Am Acad Orthop Surg. 2000 Jan-Feb;8(1):10-20. PMID: 10666649 (Link to Abstract)
Kocher, JAAOS 2000
Akbarnia BA, Silberstein MJ, Rende RJ, Graviss ER, Luisiri A.
J Bone Joint Surg Am. 1986 Apr;68(4):599-602. PMID: 3957985 (Link to Abstract)
Akbarnia, JBJS 1986
Average 3.0 of 14 Ratings
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?
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.
DeLee JC, Wilkins KE, Rogers LF, Rockwood CA.
J Bone Joint Surg Am. 1980 Jan;62(1):46-51. PMID: 7351415 (Link to Abstract)
DeLee, JBJS 1980
Average 4.0 of 22 Ratings
Child abuse should be suspected in an isolated spiral femur fracture of a child in which of the following situations?
Child greater than 3 years old
Child is smaller than predicted growth charts
Child has a single parent
Child has multiple siblings
Child had not yet achieved walking age
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.
Schwend RM, Werth C, Johnston A.
J Pediatr Orthop. 2000 Jul-Aug;20(4):475-81. PMID: 10912603 (Link to Abstract)
Schwend, JPO 2000
Blakemore LC, Loder RT, Hensinger RN.
J Pediatr Orthop. 1996 Sep-Oct;16(5):585-8. PMID: 8865041 (Link to Abstract)
Blakemore, JPO 1996
Average 3.0 of 20 Ratings
What are the two most common lesions seen in abused children?
Skin lesions and head injuries
Skin lesions and fractures
Visceral injuries and fractures
Visceral injuries and head injuries
Skin lesions and visceral injuries
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 surgeons 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.
Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS
J Pediatr Orthop. 2009 Sep;29(6):618-25. PMID: 19700994 (Link to Abstract)
Pandya, JPO 2009
Average 3.0 of 19 Ratings
Which of the following is NOT a common fracture pattern seen in abused children?
Metaphyseal corner fractures
Spiral long bone fractures
Multiple fractures in different stages of healing
Anterior translation of the femoral neck relative to the femoral epiphysis
Posterior rib fractures
Anterior translation of the femoral neck relative to the femoral epiphysis best describes Slipped Capital Femoral Epiphysis (SCFE) and is not typically associated with abuse or non-accidental trauma.
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 healing
4) single transverse long bone fractures
5) posterior rib fractures
6) skull fractures
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".
King J, Diefendorf D, Apthorp J, Negrete VF, Carlson M.
J Pediatr Orthop. 1988 Sep-Oct;8(5):585-9. PMID: 3170740 (Link to Abstract)
King, JPO 1988
Average 1.0 of 72 Ratings
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?
vitamin D & calcium levels
MRI of the knee
aspiration of the hip
admission and activation of child abuse work-up
hip spica cast
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).
Average 3.0 of 42 Ratings
What is the second most common presenting sign of child abuse?
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.
Average 2.0 of 32 Ratings
What is the most common presenting sign of child abuse?
skin cuts or bruises
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.
All of the following injuries are highly suggestive of child abuse EXCEPT:
femoral shaft fracture in a nonambulatory infant
posterior rib fracture
multiple fractures in various stages of healing
non-displaced spiral tibial shaft fracture in a toddler
metaphyseal corner fractures
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.
Kleinman PK, Marks SC Jr, Nimkin K, Rayder SM, Kessler SC.
Radiology. 1996 Sep;200(3):807-10. PMID: 8756936 (Link to Abstract)
Zillmer DA, Bynum DK Jr, Kocher MS, Robb WJ 3rd, Koshy SA.
Instr Course Lect. 2003;52:791-802. PMID: 12690903 (Link to Abstract)
Average 3.0 of 16 Ratings
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?
Long arm cast with the elbow in neutral position
Bone scan and liver enzymes
Notification of hospital child protective services and a skeletal survey
Genetic testing to evaluate for chromosomal translocation
Sling and discharge home with follow-up in one week
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.
Average 4.0 of 19 Ratings