CHAPTER 49
Nonaccidental Trauma
Introduction/Etiology/Epidemiology
• The spectrum of child maltreatment includes neglect, psychological abuse, sexual abuse, and physical abuse (sometimes called nonaccidental trauma).
• In 2018, more than 678,000 cases of child maltreatment reported to child protective services in the United States were confirmed; at least 1,770 deaths were caused by child maltreatment.
• Fractures are the second most common type of injury caused by child abuse.
• Up to 20% of fractures in infants and toddlers are due to abuse.
• About 80% of all fractures caused by abuse occur in children younger than 18 months.
• In more than 80% of cases, a parent is the abuser.
• Children who have been abused may have identifiable risk factors associated with abuse. However, the absence of risk factors does not rule out abuse.
• Risk factors associated with child abuse are listed in Box 49-1.
Signs and Symptoms of Child Physical Abuse
• Caregiver provides an explanation for an injury that does not match the mechanism causing the injury.
• Caregiver provides no explanation for an injury that could only occur with caregiver knowledge of the event; for example, no trauma history for a humeral fracture in an infant 3 months of age.
• Child is too young or developmentally incapable of causing the injury described; for example, 4 months of age with a “toddler” fracture.
• There is a delay in seeking care for a symptomatic injury.
• Soft tissue injuries are the most common physical findings in the abused child. Consider abuse if
— Bruises, ecchymoses, and other soft tissue injuries are on the cheeks, ears, neck, back, buttocks, chest, abdomen, or genitourinary area, or over other non-bony areas (eg, frenulum)
— Child is not yet cruising
— Bruise has a pattern of an object or instrument (eg, loop marks)
— Child has multiple bruises (> 4) and bruises in clusters
• Fractures can be caused by child abuse or result from non-inflicted trauma, and determining the cause can be difficult.
— Consider child abuse if
■History provided is inconsistent with the mechanism of the type of fracture
Box 49-1. Factors and Characteristics That Place a Child at Risk for Maltreatment
| Child • Emotional/behavioral difficulties • Chronic illness • Physical disabilities • Developmental disabilities • Preterm birth • Unwanted child • Unplanned pregnancy |
| Parent • Low self-esteem • Poor impulse control • Substance abuse/alcohol abuse • Young maternal or paternal age • Parent abused as a child • Depression or other mental illness • Poor knowledge of child development or unrealistic expectations for child • Negative perception of normal child behavior |
| Environment (community and society) • Social isolation • Poverty • Unemployment • Low educational achievement • Single parent • Nonbiologically related male living in the home • Family or intimate partner violence |
From Flaherty EG, Stirling J; American Academy of Pediatrics Committee on Child Abuse and Neglect. The pediatrician’s role in child maltreatment prevention. Pediatrics. 2010;126(4):833–841.
■Child has multiple fractures or fractures in different stages of healing
■Child has other evidence of abuse or neglect (eg, bruises or injuries to other parts of the body)
— Fractures with a high specificity for child abuse
■Rib fracture
■Classic metaphyseal lesion (corner fracture)
■Scapular fractures
■Spinous process fractures
■Sternal fractures
— Long bone fractures can be caused by child abuse (any long bone fracture in a child who is not yet ambulatory is a cause for concern).
■Spiral fractures can be non-inflicted or caused by child abuse.
■Transverse fractures are more commonly associated with child abuse than are spiral fractures.
■A single, isolated fracture is more common than multiple fractures.
■Long bone fracture mechanisms
❖ Transverse fractures are caused by compressive and tensile loads applied perpendicular to the bone (ie, bending). A high-impact load applied to a single location can cause a transverse fracture.
❖ Spiral fractures are caused by torsional loading of the bone (ie, twisting).
❖ Buckle or torus fractures are caused by compressive or axial loading of the bone.
❖ Oblique fractures are caused by a combination of torsional and bending loads applied to the bone.
Differential Diagnosis of Fractures
• Non-inflicted (unintentional) trauma
• Osteogenesis imperfecta (OI)
— OI is much less common than child abuse. Children with OI may also be abused.
— No formal screening guidelines for OI currently exist. Genetic testing may be recommended.
• Suspect OI if there is a family history of OI, multiple fractures, or early-onset hearing loss, or if the patient has blue sclera or osteopenic bones on skeletal survey.
• Rickets
— Bones have characteristic radiologic appearance
• Osteopenia of prematurity
— Neonates born at less than 28 weeks of gestation or who weigh less than 1,500 g at birth are more vulnerable, particularly if they have received prolonged total parenteral nutrition, have bronchopulmonary dysplasia, or have received a prolonged course of diuretics or steroids.
— Preterm neonates may have osteopenic bones, but they are also more vulnerable to being abused.
• Other genetic/metabolic disorders may predispose to fractures, but typically have other key findings suggesting an underlying abnormality.
Diagnostic Considerations
• A high index of suspicion for inflicted trauma must be maintained when evaluating any child with a fracture or other musculoskeletal injury.
• A detailed history about the event causing the fracture should be sought.
— Specific details about the patient’s activity and position just prior to and immediately following the injury event may provide information about the mechanism.
— If a history of trauma is described, determine if it is a plausible cause for the injuries sustained, with careful consideration of the child’s developmental capabilities.
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