Child Abuse Case File
Eugene C. Toy, MD, Andrew J. Rosenbaum, MD, Timothy T. Roberts, MD, Joshua S. Dines, MD
CASE 16
An 8-month-old boy is brought to the emergency department by his parents with a 48-hour history of left thigh swelling and irritability. They also state that the child has been barely moving his left lower extremity over this time. The parents do not recall any injury or recent trauma. After further discussion, the mother does recall that approximately 2 days ago, the child fell from the changing table (~3 feet off the ground) onto the carpeted floor of their apartment. On examination, the child is developmentally appropriate but irritable. His left thigh is swollen and exquisitely tender. He will not move his leg. You also note several other bruises on the child’s right arm. Radiographs are taken ( Figure 16–1 ).
Figure 16–1. Spiral femur and proximal tibia fracture. Note displaced spiral femur fracture with faint
callus formation and more solid (older) periosteal reaction of the proximal tibia. Child abuse is likely
because there are 2 injuries that occurred at different times and no treatment was obtained. (Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AB, et al. Atlas of Emergency Medicine. 3rd ed. New York, NY: McGraw-Hill; 2009:Fig. 15-26. Photo contributor: Alan E. Oestreich, MD.)
► What is the most likely diagnosis?
► What is your next diagnostic step?
ANSWER TO CASE 16:
Child Abuse
Summary: An 8-month-old boy presents with a 48-hour history of irritability and left thigh swelling. The parents at first deny any recent trauma but then recall the child falling from his changing table 2 days prior. On examination, the thigh is swollen and the child is irritable. You also note bruising of the right upper extremity. Radiographs of the left femur reveal a spiral fracture and an older proximal tibia fracture.
- Most likely diagnosis: Physical abuse.
- Next step: Skeletal survey.
ANALYSIS
Objectives
- Recognize orthopaedic injuries associated with child abuse.
- Know the proper workup for suspected child maltreatment.
- Understand the importance of reporting suspected child abuse.
Considerations
The proposed mechanism of injury, a fall from a changing table only 3 feet off the ground, is unlikely to cause a femur fracture. Furthermore, the spiral nature of the fracture is inconsistent with the mother’s story, as these fractures typically result from twisting injuries and not simple falls. Additional concerns include the bruising observed on the child’s right upper extremity, the older proximal tibia fracture, and the mother’s delay in seeking medical attention for 2 days from the initial accident. Many pediatricians who frequently encounter child abuse advocate for clinicians to assume that any long bone fracture in a child under 3 years of age is child abuse until proven otherwise. Therefore, it is imperative that after a complete skeletal survey of this child to assess for other bony injuries, this case be reported to children’s protective services for suspected abuse.
APPROACH TO:
Child Abuse
DEFINITIONS
SKELETAL SURVEY: Dedicated radiographs of every anatomic region of the body used to look for signs of previous and/or acute injuries when abuse is suspected. Anteroposterior (AP) and lateral images of the axial skeleton and frontal projections of each extremity are included.
CHILDREN’S PROTECTIVE SERVICES: Local governmental agency responsible for conducting civil investigations of children alleged to have been abused or neglected.
THE CHILD ABUSE PREVENTION AND TREATMENT ACT: Defines child abuse as “at a minimum, any act or failure to act resulting in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker who is responsible for the child’s welfare.”
CLINICAL APPROACH
Each year more than 1 million children are the victims of abuse or neglect, and more than 1200 of them die as a result of the abuse. Although health care providers are mandated to report all cases of suspected abuse as dictated by civil statutes, the diagnosis is rarely straightforward. It often requires consideration of sociobehavioral factors and clinical findings. Fractures are the second most common presentation of physical abuse after skin lesions. It is therefore pivotal that the orthopaedist understand the signs of nonaccidental trauma to increase the likelihood of recognition and proper management.
General Considerations
A thorough history and complete general and orthopaedic examination is necessary in cases of suspected child abuse. An abused child may be either overly passive or overly aggressive. Irritability, hyperactivity, and destructive behavior may all be observed on exam. Age-appropriate questions must be asked. Leading questions should be avoided. The parents’ behavior may also provide clues regarding whether this is a case of abuse. Red flags include a vague history that lacks detail, providing an injury mechanism inconsistent with the physical findings, or parents who are hostile or too casual during questioning ( Table 16–1 ).
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Table 16–1 • CONCERNING FEATURES THAT MAY BE
ASSOCIATED WITH CHILD ABUSE
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Evolving or absent history about injury Delay in seeking care for concerning condition Unusual interactions between child and parent Overly compliant child with painful medical procedures Overly affectionate behavior from child to medical staff Protective of abusing parent Parental substance abuse or intoxication Poor self-esteem in parent History of abuse in parent’s childhood History of domestic violence Loss of control of parent triggered by child’s behavior |
Figure 16–2. Classic metaphyseal lesions of the distal left femur and proximal left tibia in a 27-monthold child. (Reproduced, with permission, from Tintinalli J, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2010:Fig. 290-4.)
Musculoskeletal Features
Approximately one third of children who are victims of nonaccidental trauma require orthopaedic care, with fractures most common in younger children due to the vulnerability of their developing skeletons and defenselessness. Although multiple fractures in various stages of healing are very common in abused children, many will present with only 1 fracture.
Long bone (femur or humerus) fractures are the most commonly fractured bones in child abuse. Certain types, such as the midshaft spiral femur fracture, were once thought of as indicative of nonaccidental trauma. However, studies have found that no specific fracture pattern in the femur is pathognomonic of abuse and that all patterns can be observed. Fractures of the hands, feet, and clavicle are uncommon in abuse, as are physeal fractures. The lone exception is transphyseal fractures of the distal humerus in children less than 1 year old. Metaphyseal fractures are less common than diaphyseal injuries, but are very concerning for physical abuse ( Figure 16–2 ).
DIFFERENTIAL DIAGNOSIS AND WORKUP OF SUSPECTED ABUSE
Any condition that can lead to bruising, fracture, or periosteal changes must be considered in the differential diagnosis of child abuse. Biomechanical testing for metabolic markers for bone disease (ie, calcium, phosphate, alkaline phosphate, copper, parathyroid hormone, and 25-hydroxyvitamin D) should be performed. Osteogenesis imperfecta may present like nonaccidental trauma and should also be investigated with genetic testing and biochemical analysis. When bruising is present, a complete blood count, differential blood count, and coagulation studies must be performed. Occasionally, children with leukemia, hemophilia, or other hematologic disorders are brought in for suspected abuse due to multiple bruises. Other rare pediatric conditions that can present like abuse include Caffey disease, rickets, and congenital syphilis. It is important to note that the practitioner must also always consider accidental trauma and normal radiographic variants as potential causes of the clinical presentation of a patient for whom abuse is suspected.
A skeletal survey should be used in addition to imaging of obvious deformities to detect other acute or healed fractures in potentially abused children. The American Academy of Pediatrics Section on Radiology recommends a mandatory survey in all cases of suspected abuse in children less than 2 years of age. In those between 2 and 5 years of age, a skeletal survey should be done based on clinical indications. In children older than 5 years, the skeletal survey has minimal value. Radionuclide bone scanning for detection of physical abuse is controversial and should be reserved for use when skeletal surveys are negative despite high suspicion for abuse. Additionally, a repeat skeletal survey 2 weeks after initial presentation may reveal injuries not evident in the initial survey in cases with high suspicion for abuse.
MANAGEMENT
In most states, physicians are required to report suspected cases of child abuse based on reasonable suspicion of nonaccidental trauma or maltreatment. Reporters are immune from civil and criminal liability, even if it is ultimately determined that no abuse has occurred.
The treatment of abuse fractures is identical to those incurred accidentally and are typically amenable to closed, nonoperative treatment. However, the orthopaedic management of the abused child is only one component of treatment, and a teamoriented approach is essential. This includes pediatricians, other subspecialists, and social workers.
When the orthopaedist is the first physician to see a potentially abused child, communication with the nearby emergency department or local child abuse agency must be swiftly initiated. Hospital admission is often required to care for the acute injuries and to provide a safe environment where a full workup can be conducted.
COMPREHENSION QUESTIONS
16.1 A 3-year-old girl presents shortly after a right arm injury. The patient’s father reports that he was playing with his daughter by swinging the girl in circles while holding on to her arms when she suddenly complained of pain in the left arm. The patient immediately held the injured arm close to her body with the help of her noninjured arm. Which of the following is most accurate regarding this injury?
A. Represents child abuseB. Requires a skeletal surveyC. Is a common accidental injuryD. Is inconsistent with the described mechanism of injury
16.2 Osteogenesis imperfecta (OI) may present similarly to child maltreatment. However, there are features of OI that may help differentiate the 2, including blue sclera and osteopenia. Which of the following is another distinguishing feature?
A. PolydactylyB. Patent foramen ovaleC. Multiple fractures in the setting of minimal traumaD. Dental involvement
16.3 The pediatrician of a 2-year-old girl orders a skeletal survey because of suspected abuse. The imaging identifies multiple fractures, including the right humerus, left tibia, and right femur. Because it is important to distinguish between those that are acute versus those that are older and already healing, the pediatrician calls her colleagues in the Orthopaedics Department, who reviews with her the age-based features of fracture healing. At what point does new periosteal bone formation become apparent on plain radiographs?
A. 4 to 14 daysB. 1 to 2 monthsC. 1 yearD. Within hours
ANSWERS
16.1 C. This case represents a nursemaid’s elbow, which is caused by a traction force on an outstretched arm. This is a common accidental injury in which the patient presents with a slightly flexed and pronated arm. The injury is reduced by flexion and supination of the patient’s forearm with concurrent pressure over the radial head. A successful reduction should return the patient to full use of the arm immediately.
16.2 D. Multiple medical conditions can present similarly to nonaccidental trauma, including OI. This autosomal dominant genetic disease often presents with multiple fractures in the setting of minimal trauma. However, distinguishing features include osteopenia, blue sclera, family history, and dental involvement. Polydactyly and a patent foramen ovale are not typical features of OI.
16.3 A. To estimate the age of a fracture, it is important to know the age-dependent radiographic features of healing fractures. Listed below is a timeline for the appearance of various radiographic features:
Days 2 to 10: Soft tissue swelling subsides
Days 4 to 14: New periosteal bone formation becomes apparent
Days 10 to 21: Loss of definition of fracture line, presence of soft callus
Days 14 to 42: Presence of hard callus
Months 3 to 12: Fracture remodeling
CLINICAL PEARLS
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► Although multiple fractures in various stages of healing are very common in abused children, many will present with only 1 fracture. ► Any condition that can lead to bruising, fracture, or periosteal changes must be considered in the differential diagnosis of child abuse. ► The American Academy of Pediatrics Section on Radiology recommends a mandatory survey in all cases of suspected abuse in children less than 2 years of age. ► A team-oriented approach to the abused child is crucial and involves pediatricians, subspecialists, and social workers. |
REFERENCES
Jayakumar P, Ramachandran M. Orthopaedic aspects of paediatric non-accidental injury. J Bone Joint Surg Br. 2010;92:189-195.
Kocher MS, Kasser JA. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg . 2000;8:10-20.
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