A 4-month-old boy presents with irritability for 2 days. He lives with his mother, 21-month-old sister, and 3-year-old brother. On physical examination, the infant has right thigh swelling and tenderness. Radiographs of the right lower extremity reveal a femur fracture.
What is the most likely diagnosis?
What is the next step in the management of this child?
ANSWERS TO CASE 58: Child Abuse
Summary: A 4-month-old boy presents with a 2-day history of irritability. The infant has no history of trauma. A right transverse femur fracture is present.
• Most likely diagnosis: Physical abuse.
• Next step: Obtain a skeletal survey.
ANALYSIS
Objectives
1. Understand the importance of reporting suspected child maltreatment.
2. Recognize that child abuse is suspected if significant inconsistencies exist between the physical injury and the trauma history. It is imperative that the child’s developmental level be assessed in regard to the child’s possible role in an accidental injury.
Considerations
The lack of trauma history is very concerning in this infant who is not mobile. The mother’s delay in seeking medical care for 2 days from symptom onset is concerning. Cases of suspected abuse are reported to Child Protective Services (CPS) or law enforcement. Thus, the next steps are to obtain a complete skeletal survey to detect other bony injuries and to report this child’s possible abuse case to CPS.
APPROACH TO:
Child Abuse
DEFINITIONS
CHILD PROTECTIVE SERVICES (CPS): Local governmental agency responsible for investigating suspected child maltreatment cases.
MUNCHAUSEN SYNDROME BY PROXY: Abuse in which the caretaker falsifies symptoms or inflicts injury upon a child to necessitate medical intervention.
ABUSIVE HEAD TRAUMA (SHAKEN BABY OR SHAKEN IMPACT SYNDROME): Brain injury resulting from violent shaking of the infant or shaking the infant followed by collision of the head against a hard surface. Infants may present with seizures, respiratory arrest, a bulging fontanelle, or irritability. Intracranial injury is found with computed tomography (CT) or magnetic resonance image (MRI), and retinal hemorrhages may be visualized on funduscopy. Skeletal injuries such as rib fractures or classic metaphyseal lesions may also be present.
CLINICAL APPROACH
Child maltreatment is common, with approximately 1 million substantiated cases per year in the United States. Child maltreatment includes neglect and physical, sexual, and emotional abuse; children often suffer from more than one type. Neglect is the most common form of child maltreatment and consists of failure to provide adequate nutrition, shelter, supervision, or medical care. Physical abuse accounts for approximately 20% of cases, occurring when caregivers inflict excessive physical injury. Although the definition of “appropriate” corporal punishment is argued, physical abuse is considered when marks (eg, bruising, lacerations, burns, or fractures) result. Sexual abuse occurs in 10% of substantiated maltreatment cases.
Munchausen syndrome by proxy is a less common form of child abuse. Affected children are hospitalized repeatedly with undiagnosed or vague conditions. Children may also have underlying medical conditions with abnormally frequent or persistent symptoms. The hospitalization is remarkable for a caretaker who takes great interest in the medical staff and interventions and often times has some type of medical background. The caretaker forms relationships with health-care providers and is often noted to be an exemplary parent. Munchausen syndrome by proxy ranges from fabricating symptoms to actual poisoning or suffocations.
Reporting of cases of child maltreatment has been mandated since the 1960s, resulting in increased public and medical awareness. Health-care providers legally are required to report suspected abuse to CPS or law enforcement.
Medical evaluation of suspected child maltreatment cases includes obtaining a medical history and a family assessment, conducting a thorough physical examination, obtaining appropriate diagnostic testing, and interviewing the child and the family. Routine medical history includes information about illnesses, hospitalizations, injuries, and pertinent family history. History should be carefully documented within the medical record as discrepancies to different providers or by different caretakers may provide vital information. A developmental history helps determine if the events described by a family are a plausible explanation for injuries found (eg, a 10-month-old child is unable to climb into a bathtub, turn on the water, and sustain second-degree burns only to the buttocks). Documentation must include who lives in the home and who provides care for the child.
An examination is performed with attention to any skin lesions. Body charts (or photographs) assist in documenting the injuries. A skeletal survey (skull, chest, spine, and limbs) assists in obtaining evidence of prior trauma in children younger than 3 years. Recent fractures may not be detectable on plain radiographs for 1 to 2 weeks after an injury; if necessary, bone scans demonstrate fractures within 24 to 48 hours of injury. Children with bruising often may be evaluated with a platelet count and coagulation studies to eliminate hematologic disorders as a cause.
Although bruises and lacerations are common abuse indicators, they also are common in nonabused children. Accidental bruises are usually found over bony areas (knees, shins, elbows, forehead) and are appropriate for the child’s developmental milestones. Abdomen, buttocks, thighs, and inner arm bruises occur less frequently in cases of accidental trauma. Characteristic child abuse injury patterns include looped cord marks, belt buckle–shaped lesions, multiple bruises in various stages of healing, hand prints, bite marks, and circumferential cord marks around the neck from strangulation. Burn injuries may resemble the insulting object, such as a steam or curling iron. Intentional hot water immersion usually leaves a sharply demarcated border; the “stocking glove” distribution is a classic pattern.Cigarette burns are circular and may appear similar to impetigo or insect bites.
The differential diagnosis of multiple ecchymoses includes hemophilia, immune (idiopathic) thrombocytopenic purpura (ITP), Henoch-Schönlein purpura (or other vasculitis), and disseminated intravascular coagulation (DIC). Patterned injury can result from folk medicine practices, such as cupping (a heated cup applied to the skin leaves a circular injury) or coin rubbing (leaves linear red marks on the back). A history, physical examination, and a few screening tests can help eliminate these diagnostic considerations.
Skeletal injuries suspicious for abuse include long bone metaphyses injuries, rib or complex skull fractures, and multiple fractures (especially those in various stages of healing). Spiral or oblique long bone fractures can result from unintentional rotating force injuries; they are no longer considered diagnostic of abuse. Nursemaid’s elbow (radial head subluxation) occurs accidentally when a toddler falls while walking and holding an adult’s hand (elbow dislocation occurs as the limb is pulled and twisted). Osteogenesis imperfecta, scurvy, cortical hyperostosis, and Menkes kinky hair disease are rare pediatric conditions with increased risk of bony injury.
COMPREHENSION QUESTIONS
58.1 A 2-year-old boy presents 4 hours after a left arm injury. He tried to run into the street, and his mother held his left hand tightly and he fell. Since then he has not moved his arm. Now he holds the arm close to his body with the elbow flexed and the forearm pronated. The elbow is not erythematous or edematous. He cries when the elbow is touched. Which of the following is the best next step in management?
A. Obtain a radiograph of the left elbow.
B. Order a skeletal survey.
C. Place the left arm in a sling.
D. Supinate the child’s forearm while applying pressure over the radial head.
E. Apply traction to the forearm while increasing the degree of pronation.
58.2 A 15-year-old adolescent female has 2 days of nasal congestion and cough. Upon auscultation of her back, you find the lesions noted (Figure 58-1). Which of the following is the most likely etiology for her condition?
Figure 58-1. Picture of a child’s back.
A. Cupping
B. Physical abuse
C. Disseminated intravascular coagulation
D. Henoch-Schönlein purpura
E. Coining
58.3 Which of the following describes the most common form of child maltreatment?
A. Sexual abuse
B. Physical abuse
C. Neglect
D. Emotional abuse
E. Munchausen syndrome by proxy
58.4 A 4-month-old girl is fussy, appears to have pain on palpation of the right leg, and has bluish sclerae. Radiographs reveal a right femur fracture. Her parents deny any severe trauma but report she had multiple fractures as a child. Family history is also likely to include which of the following?
A. Blindness
B. Hearing loss
C. Tall stature
D. Renal disease
E. Aortic aneurysm
ANSWERS
58.1 D. This child’s history is consistent with a traction injury involving an outstretched arm. The elbow is not swollen and the arm is held in a flexed and pronated position. The child likely has “nursemaid’s elbow.” To reduce the subluxation, apply radial head pressure while supinating the arm. If treatment is not delayed, the child will usually begin using the arm promptly.
58.2 A. This adolescent has multiple perfectly circular lesions on her back consistent with cupping; when asked, she gives the history of cupping. Physical abuse injuries likely would not be identical in appearance. Patients with DIC will have significant systemic manifestation, and the pattern of ecchymoses would not be symmetrical. Coining causes ecchymosis in a linear pattern.
58.3 C. The most common form of child maltreatment is neglect (failure to provide adequate nutrition, shelter, supervision, or health care).
58.4 B. This infant has features of osteogenesis imperfecta, an autosomal dominant genetic disorder most often caused by point mutations of COL1A1 or COL1A2. Features include long bone fractures and vertebral injury with minimal trauma, short stature, deafness, and blue sclerae. Four main types exist: type 1 is mild; type 2 is lethal (in uteroor shortly thereafter); type 3 is the most severe; and type 4 is moderately severe. The recently described types 5-7 do not have mutations of type 1 collagen.
CLINICAL PEARLS
All cases of suspected child maltreatment must be reported to Child Protective Services or law enforcement.
If the history of trauma does not fit a patient’s injury pattern, child abuse is suspected.
If a child’s development is inconsistent with the injury history, child abuse is suspected.
REFERENCES
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Dubowitz H, Lane WG. Abused and neglected children. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:135-142.
Leventhal JM, Asnes AG. Child maltreatment: neglect to abuse. In: Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA eds. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011: 137-143.
Marini JC. Osteogenesis imperfecta. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:2437-2440.
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