Nonaccidental Trauma

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.

—

Only gold members can continue reading. Log In or Register to continue