Evaluation for Nonaccidental Trauma

Karen L. Lakin

• Introduction

Orthopedic injuries are common in childhood. Fractures accounted for 788,925 visits to the emergency department in the United States in 2010.¹ Although most fractures are accidental, the clinician must be alert to injuries that are the result of child abuse. The orthopaedist must also be alert to other nonorthopedic injuries that may be red flags for abuse. Failure to recognize these injuries could result in a child at risk for continued abuse, or worse, death. Over diagnosing abuse may result in separation of a child from caregivers resulting in further emotional and psychological trauma to the child. Failing to diagnose a medical condition that can lead to bone fragility can also delay possible treatment.

• Epidemiology

In the United States, approximately 4.1 million referrals were made to Child Protective Services for allegations of child maltreatment in 2017, of which 9.6% were made by medical personnel. Reports were substantiated for 674,000 child victims of abuse or neglect, with 1720 child fatalities reported in 2017 directly attributed to abuse or neglect, or as a contributing factor for the death.

There are four major categories of child maltreatment. Neglect refers to failure to provide for a child’s basic needs resulting in physical, emotional, psychological, or education harm. This is the largest category of abuse, approximately 74.9% of all cases reported. Physical abuse, which comprises 18.3% of reported cases, is the second most common type of child maltreatment. Physical abuse is defined as infliction of injury as the result of punching, beating, kicking, biting, burning, shaking, or otherwise harming a child. Sexual abuse makes up 8.6 % of reported cases. Psychological or emotional abuse is reported in 5.7% of cases. The remaining cases involve types of maltreatment that do not fit into the major categories such as drug exposed infants and medical child abuse.²

Multiple studies have identified factors associated with an increased risk for abuse. These include child-specific factors including age of the victim, history of prematurity, chronic illness, and developmental delay.³,⁴ Children under the age of one have the highest incidence of abuse, 25.2 per 1000 children. Females are at a slightly increased risk for abuse than males; however, males are more likely to die from abuse with a rate of 2.68/100,000 compared to females at 2.02/100,000.²

Perpetrator risk factors include alcohol and drug abuse by the caregiver, young parenthood, low educational status, mental health issues, and lower socioeconomic status. Lack of understanding by the caregiver of normal childhood behavior and development often leads to frustration of the caregiver with the victim. Parents are implicated as perpetrators in 77.6% of the reported cases. Environmental factors in the home include a history of domestic violence/abuse, a nonbiological caregiver present in the home, and social isolation. Community factors include neighborhood violence and poverty.⁵

Fractures are the second most common injury identified in inflicted injury, behind soft tissue injuries. Children under the age of three have the highest incidence of nonaccidental fractures, with 69% under the age of one.⁶ Understanding the mechanisms required to result in specific types of fractures in conjunction with the developmental stage of the child is critical in considering whether an injury is the result of abuse.

• The Medical Evaluation

History of Present Illness

As with all medical conditions, evaluating the pediatric patient with an orthopedic injury begins with a comprehensive history of the present illness. The caregiver needs to provide a detailed history with information about the circumstances of the injury: mechanism of injury, positioning of the child, specifics regarding the distances, objects, etc, who was present, when the patient showed symptoms, intervening treatment, and when medical care was obtained. Although we accept the history as reported by the caregivers initially, the plausibility of the history should be compared with the objective diagnosis of the patient. Considerations that may increase the level of suspicion that the history is unreliable include mechanism of injury reported inconsistent with the fracture pattern, severity of injury inconsistent with the mechanism, and an injury inconsistent with the developmental stage of the child. An unwitnessed injury is particularly concerning in young children due to concerns for lack of supervision.

Changing histories are also concerning, but consider small variations in history may be reported by a distressed caregiver. For example, in a crisis, the caregiver may report the patient seized for 10 minutes when it was less than 3 minutes. Discrepancies in location of individuals present at the time of the incident are significant and a red flag for a changing history that may indicate possible abuse.

The developmental stage of the child as well as the plausibility of the reported mechanism in relation to the degree of injury must be assessed. Careful attention should be made to the reported history by the caregiver, however, because semantics matter. For example, one would not expect a three-week-old infant to be able to “roll over”; however, a caregiver may report that the patient “fell” off a couch. Even an inanimate object may fall if placed in an unstable position. It is important to clarify descriptions of the circumstances when taking a history from the caregiver.

Past Medical History

Past medical history provides additional information that is important in your assessment. This includes history of birth, nutrition, medications, and development. Birth history is important as birth trauma may result in fractures at the time of delivery, particularly for a large infant or difficult presentation. Common fractures reported include clavicle, humerus, and femur fractures. Although the birth records may not specifically note “trauma,” information may be obtained from the caregivers and other family members regarding bruising noted at birth, observed lack of movement of a limb, prolonged labor, and a history of use of instrumentation at delivery.

Nutritional information is important since breast-fed infants may require vitamin D supplementation, especially in darker pigmented infants and infants born in the winter months. As the child gets older, toddler diets lacking in vitamin D or nutritional problems may contribute to osteopenia. Medications such as diuretics, antiepileptic medications, and steroids may also affect bone loss. Nonweight bearing children, such as children with cerebral palsy, may have diffuse osteopenia, as well as children with medical conditions affecting absorption of calcium and vitamin D such as cystic fibrosis.

Because the developmental stage of the child is essential in assessing the plausibility of the reported cause of the injury, a careful history of the developmental milestones of the patient should be taken and documented. In addition, information regarding possibility of developmental delay could identify a known risk factor for abuse.⁷

Family History

Family history may provide clues to genetic conditions that may predispose a patient to orthopedic injuries. These include a history of Ehlers-Danlos syndrome, osteogenesis imperfecta, X-linked hypophosphatemia, and neuromuscular diseases. Family may often not know the actual diagnosis, so questions related to frequent fractures, early hearing loss, and dental issues may provide clues to guide your evaluation.

Social History

It is important to know the context of the child’s social environment and how it affects the patient’s risk for abuse. The primary caregivers and their relationship to the child should be documented as well as other caregivers that may have access to the child, including babysitters and extended family members. Information regarding other children in the home should be obtained to have children formally interviewed as potential witnesses and more importantly, also examined for signs of abuse. The home environment is also helpful to note including what type of bed the child sleeps in, the type of flooring, stairs present, etc. Prior history with child protective services and/or law enforcement should be noted as well as any history of domestic violence or illicit drug use.

Physical Examination

The general appearance of the child should be documented including height, weight, head circumference in infants, overall nutritional status, and hygiene of the patient. The neurological status of the patient should be evaluated as well as documentation of development.

The physical examination should be thorough and begin with examination of the skin. Cutaneous injuries are the most common injuries in abused children. Bruises, abrasions, ecchymosis, and burns should be documented. Photographs can be helpful, and should be taken for medical purposes, ie, to follow progression of a lesion. If abuse is suspected, it is important that caregivers or legal authorities photograph injuries for evidence purposes.

The lack of bruising does not mean the child has not been exposed to nonaccidental orthopedic injuries.⁸,⁹ However, 90% of physical abuse victims present with cutaneous injuries, including bruising, abrasions, alopecia, scars, burns, and bite marks.¹⁰ The location and pattern of a cutaneous injury gives clues as to whether the injury is accidental or nonaccidental. Bruising in nonambulating children is almost always concerning for abuse. Young children who are mobile tend to fall forward, resulting in bruising to foreheads, elbows, knees, and shins. Injuries around the ear, abdomen, genitals, back, and buttocks are less likely to be injured from falls. Common patterns of bruising include implement-shaped lesions such as belts, cords, and paddles (Figures 8.1 and 8.2).

Oval-shaped bruising in clusters may be indicative of knuckles or fingerprints (Figure 8.3). Multiple fine lines, evenly spaced, may signify a handprint (Figure 8.4). Although hematomas often have certain patterns of coloration, bruising cannot be dated.¹¹

FIGURE 8.1 Three-year-old with cord marks from beating with an extension cord. The patient also suffered partial thickness burns to the buttocks, genital area, and bilateral feet.

FIGURE 8.2 Rectangular patterned bruising in a toddler struck with a belt.

FIGURE 8.3 Two-year-old critically ill toddler with internal injuries and head trauma. Multiple oval-shaped bruises are noted from knuckles.

FIGURE 8.4 Seven-month-old with patterned facial bruising. Linear marks are a result of the leakage of blood into the tissue from the capillaries forming a negative imprint of the offending hand.

FIGURE 8.5 Bite mark on a three-year-old who was sexually and physically abused.

Other external injuries that may be present on physical examination that are suspicious for nonaccidental trauma (NAT) in young children include bite marks, torn frenulum from forced feeds, and auricle hematomas (Figures 8.5 and 8.6). Petechiae may be present because of blunt trauma, friction, choking, or vomiting (Figure 8.7A and B).

Bruising in nonambulatory infants is especially concerning and may be a red flag for more serious injury, particularly if there is bruising to the face.¹² Suspicion for abusive head trauma warrants a comprehensive evaluation for intracranial trauma, possible presence of retinal hemorrhages, and skeletal trauma (Figure 8.8).

Always pay attention to the sclera and teeth as blue sclera or altered dental development may indicate osteogenesis imperfecta (Figure 8.9).

FIGURE 8.6 Auricle hematoma and alopecia in a five-year-old with malnutrition, healing fractures, and old subdural hemorrhage. No history of trauma was given.

FIGURE 8.7 A, Developmentally delayed five-year-old with periumbilical bruising and petechiae. B, Patient sustained circumferential partial thickness burns to right foot and splash burn to left foot while in the care of mother’s boyfriend.

FIGURE 8.8 Eight-month-old found unresponsive and seizing in her crib while in the care of her father’s girlfriend. On physical examination, the patient had right scalp soft tissue swelling and bruising to the right ear. The patient was diagnosed with bilateral retinal hemorrhages, vitreous hemorrhage, acute bilateral subdural hemorrhages, and a posterior rib fracture of the left ninth rib.

FIGURE 8.9 Blue sclera seen in patients with osteogenesis imperfecta.

Abusive head trauma is the most lethal form of child abuse and is a leading cause of death in children less than 2 years of age.¹³ The term abusive head trauma is used to describe all forms of intracranial injury from nonaccidental or inflicted trauma. The most common intracranial injury seen in NAT is a subdural hemorrhage; however, subarachnoid hemorrhages, parenchymal contusions, and epidural hemorrhages may occur in NAT. The traumatic intracranial injury is often found in association with retinal hemorrhages, usually complex, and fractures, especially rib fractures inconsistent with the history of trauma. Injury to the spine including vertebral fractures, spinal cord contusions, and ligamentous injuries may also be found in cases of abusive head trauma. The mechanism may involve blunt force trauma to the head as well as violent shaking alone or with direct impact.¹⁴ Clinically, infants may present with a wide spectrum of nonspecific symptoms including irritability, vomiting, altered mental status, seizures, coma, and death. Infants that have an evolving subdural hemorrhage over time may present with an enlarging head circumference, irritability, and a history of vomiting that may have previously been diagnosed as gastroesophageal reflux.¹⁵

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