Pediatric Abuse

Topic updated on 01/25/16 3:05pm
  • Epidemiology
    • incidence
      • >1 million children are victims of substantiated abuse or neglect in United States each year
      • child abuse is the second most common cause of death in children behind accidental injury. 
      • in child abuse, head injury is the most frequent cause of long term physical morbidity in the child
    • demographics q
      • astounding 79% of all cases of nonaccidental trauma occur in children younger than 4 years of age
      • 50% of fractures in children younger than 1 year of age are attributable to abuse
      •  the most common cause of femur fractures in the nonambulatory infant is nonaccidental trauma
    • social risk factors q
      • recent job loss of parent
      • children with disabilities (cerebral palsy, premature)
      • step children
    • 4 Types (can have more than one type present):
      • Neglect 78%
      • Physical Abuse 18%
      • Sexual 9%
      • Psychological 8%
  • Prognosis
    • If unreported, 30-50% chance of repeat abuse and 5-10% chance of death from abuse
  • Differential Diagnosis
    • true accidental injury
    • osteogenesis imperfecta
    • metabolic bone disease
  • History
    • injury often inconsistent with history
    • red flags q q 
      • long bone fxs in infant that is not yet walking q 
      • multiple bruises
      • multiple fxs in various stages of healing
      • corner fxs  q  
        • primary spongiosa (metaphyseal)
        • high specificity for child abuse
      • posterior rib fractures   
      • bucket handle fractures  
        • same as corner fractures
        • avulsed bone fragment is seen en face as a bucket handle
      • transphyseal separation of the distal humerus   
  • Symptoms
    • pain related to fractures
      • fractures are the second most common lesion in abused children  q q
        • frequency of fractures
          • humerus > tibia > femur q
          • diaphyseal fractures 4 times more common than metaphyseal
  • Physical exam
    • skin lesions 
      • most common presenting lesion q 
  • Radiographs
    • recommended views
      • AP and lateral of bone or joint of suspicion 
      • initial evaluation should include skeletal survey q 
  • Bone scan
    • used as an alternative or adjunctive study for patients 5 years of age or older as skeletal surveys not as reliable in older children
  • Nonoperative
    • report abuse to appropriate agency
      • indications
        • Physicians are mandated reporters, and are legally obligated to report suspected child abuse and neglect.
        • Physicians are granted immunity from civil and criminal liability if they report in good faith, but may be charged with a crime for failure to report
        • early involvement of social workers and pediatricians is essential
    • hospital admission
      • indications
        • early multidisciplinary evaluation  
        • admit infants with fractures to the hospital and consult child protective services 
        • obtain social service consult
  • Operative
    • definitive treatment as indicated for particular injury


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Qbank (22 Questions)

(OBQ12.27) Which of the following statements regarding child abuse is correct? Topic Review Topic

1. It is the 2nd most common cause of death in children over 1 year of age
2. Fractures in child abuse occur more often children greater than 5 years of age
3. Burns are the most frequent cause of long-term physical morbidity
4. Fractures are the most common presenting injury
5. Metaphyseal fractures four-times more common than diaphyseal fractures

(OBQ12.34) All of the following are social indicators of increased risk of child abuse EXCEPT: Topic Review Topic

1. Parent recently losing job
2. A child with cerebral palsy
3. A step child
4. A child with no siblings
5. A premature child

(OBQ11.133) A 12-year-old basketball player is seen for a routine physical. During the physical, he is reluctant to partake in the full physical exam. Upon further questioning, he states that a member of the coaching staff has touched him inappropriately on repeated occasions. Which of the following best outlines your legal responsibility as a physician? Topic Review Topic

1. Inform the parents
2. Inform the school board
3. Inform the athletic director
4. Inform the child health and protective services
5. Inform the police

(OBQ10.1) Which of the following must be done whenever a non-ambulatory infant presents to the ER with a diaphyseal long bone fracture? Topic Review Topic

1. Immediate consultation with child protective services and possible admission to the hospital
2. Order serum vitamin D levels
3. Order serum calcium and phosphorus levels
4. MRI of the cervical spine
5. Perform genetic testing for COL1-A1 and COL1-A2

(OBQ10.141) A 10-month-old child is brought to the emergency room with left elbow swelling and an intact neurovascular exam. The parents report no history of trauma. A radiograph demonstrates a minimally displaced distal humerus physeal separation with abundant callus formation. The next step in managament should include? Topic Review Topic

1. Closed reduction and percutaneous pinning
2. Casting only
3. A skeletal survey and contacting the appropriate authorities
4. Elbow arthrogram
5. Open reduction and internal fixation

(OBQ09.93) A 2-year-old male is brought to the emergency room complaining of pain in the left elbow. Radiographs are shown in Figures A and B. This injury pattern should raise concern for which of the following? Topic Review Topic
FIGURES: A   B        

1. Osteogenesis imperfecta
2. Larsen’s syndrome
3. Kwashiorkor
4. Marfan’s syndrome
5. Child abuse

(OBQ08.2) Child abuse should be suspected in an isolated spiral femur fracture of a child in which of the following situations?

Topic Review Topic

1. Child greater than 3 years old
2. Child is smaller than predicted growth charts
3. Child has a single parent
4. Child has multiple siblings
5. Child had not yet achieved walking age

(OBQ08.79) What are the two most common lesions seen in abused children? Topic Review Topic

1. Skin lesions and head injuries
2. Skin lesions and fractures
3. Visceral injuries and fractures
4. Visceral injuries and head injuries
5. Skin lesions and visceral injuries

(OBQ07.73) Which of the following is NOT a common presenting fracture pattern seen in abused children? Topic Review Topic

1. Metaphyseal corner fractures
2. Spiral long bone fractures
3. Multiple fractures in different stages of healing
4. Anterior translation of the femoral neck relative to the femoral epiphysis
5. Posterior rib fractures

(OBQ07.215) A 6-month-old boy is brought to the emergency department by his mother because he has been irritable for the last week. Initially the mother reports no history of trauma, but later she says that he may have fallen from a changing table. Radiographs of the knee demonstrate metaphyseal corner lesions of the distal femur and proximal tibia. White blood cell count and erythrocyte sedimentation rate values are normal. What is the most appropriate next step in treatment? Topic Review Topic

1. vitamin D & calcium levels
2. MRI of the knee
3. aspiration of the hip
4. admission and activation of child abuse work-up
5. hip spica cast

(OBQ06.44) What is the second most common presenting sign of child abuse? Topic Review Topic

1. fractures
2. bruises
3. retinal detachment
4. epidural hematoma
5. pulmonary contusion

(OBQ06.98) What is the most common presenting sign of child abuse? Topic Review Topic

1. head injury
2. retinal hemorrhage
3. splenic rupture
4. skin cuts or bruises
5. fractures

(OBQ05.160) All of the following injuries are highly suggestive of child abuse EXCEPT: Topic Review Topic

1. femoral shaft fracture in a nonambulatory infant
2. posterior rib fracture
3. multiple fractures in various stages of healing
4. non-displaced spiral tibial shaft fracture in a toddler
5. metaphyseal corner fractures

(OBQ04.230) A 12-month-old girl is brought to the emergency room by her father. He states that she has not been moving her arm and has been more irritable than usual. A radiograph of the elbow is depicted in Figure A. On examination of her lower extermities, she has mild tenderness and prominence over her left thigh but does not have any bony instability. A radiograph of her left thigh is shown in Figure B. In addition to a complete history and physical, management should include which of the following? Topic Review Topic
FIGURES: A   B        

1. Long arm cast with the elbow in neutral position
2. Bone scan and liver enzymes
3. Notification of hospital child protective services and a skeletal survey
4. Genetic testing to evaluate for chromosomal translocation
5. Sling and discharge home with follow-up in one week

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