Physicians have a responsibility to report any suspected child abuse. This is not easy. Identifying non-accidental trauma can be challenging, and is often guided by little more than a suspicion on the side of physician. It can be uncomfortable to think of the patient’s parents or caregivers as the cause of injury. Nevertheless, the physician who identifies abuse can save their patient’s life.
An analogy can be drawn to the way emergency physicians approach other life–threatening diseases: first rule out life threatening causes of symptoms before settling on a more benign cause. Much like it’s important to rule out an MI before diagnosing a patient with costochondritis, we should ask ourselves if the injury at hand is non-accidental. This article outlines a step-wise approach to determining whether a fracture or bruise could be caused by non-accidental trauma.
1. The history
The history of the injury is the first clue to identifying abuse. Make sure to get a complete account of the location, the details (for example, height of the fall, surface of the floor, developmental abilities of the child), when the injury occurred, the evolution of symptoms over time, the individuals involved, and the response of both child and caregiver to the injury. The key with the story is consistency. The injury must be consistent with mechanism and amount of force, consistent with the child’s developmental stage, and consistent across re-tellings.
Start by ensuring that the story you receive is the same as what was told to the triage nurse. The story should be a plausible cause of the injury, and be proportionate to the injuries found. Non-ambulating children generally do not have bruises or broken bones, and those who are ambulating should not have bruises on well cushioned areas (e.g., buttocks). A good way to remember this is: “If you don’t cruise, you don’t bruise”. Injuries in the shape of objects should be suspicious.
Other concerning signs are delay in seeking medical attention and multiple injuries which cannot be accounted for by one mechanism. Make sure to document the story in quotes from the caregivers, and document the injury using a body diagram, with its colour and size, or using medical photography.
2. The physical exam
Inspect the skin for bruising or other signs of trauma, with specific attention to the ears, genitalia, and buttocks. Note all bruises, their size and colour, but know that specific colours don’t correlate with time of injury. Examine the mouth for the frenula — torn frenula may be a sign of trauma to the mouth. Palpate the entire body for tenderness, with special attention to the bones and abdomen.
Perform a neurological exam, identify the fontanelle (where applicable), measure the head circumference, and examine the fundi for retinal hemorrhages. Extensive retinal hemorrhages and abnormal neurological exams could be markers of Abusive Head Trauma, in which infants (usually younger than 12 months of age) have intracranial hemorrhage, brain injury, and retinal hemorrhages as a result of violent shaking, impact, or a combination of both.
It is important to consider the differential diagnosis for bruises and fractures (see below). If you are considering abuse as a cause of a fracture be sure to assess for possible metabolic causes of weakened bones by ordering a calcium, phosphate, magnesium, ALP, PTH, and vitamin D on your workup. If bruising is prominent, assess for possible bleeding disorders by including a CBC with a differential, a blood smear, INR, PTT, fibrinogen, vWF activity and antigen, and clotting factors (factor VIII and IX). Liver enzymes should be included on all trauma workups as they can be elevated in occult abdominal trauma. In some cases, neuroimaging to assess for intracranial hemorrhage and/or an ophthalmology consult to examine the patient for subtle retinal hemorrhages should be considered.
A skeletal survey, containing a series of at least 12 x-rays may identify acute and healing fractures that are not evident on physical exam. Single x-rays of the child’s entire body are insufficient as the resolution does not allow subtle fractures to be detected. Whenever you are worried about abuse in children younger than 2 years of age, always order a skeletal survey. When looking at these x-rays, it is important to not only look for fractures, but also for new bone formation, which would appear bulbous on imaging and could be a sign of an old fracture. It is also important to determine whether the bones appear osteopenic which may suggest an underlying medical explanation for the fracture. Several worrisome locations for fractures should be examined closely: metaphyses, ribs, scapula, vertebrae, sternum, and multiple skull fractures. These areas are unlikely to fracture in common accidental trauma.
4. Differential diagnosis
The differential diagnosis for bruising or fractures is outlined in Figure 1. Be sure to rule out:
• Accidental bruising
• Bleeding disorder
• Connective tissue disease (e.g., Ehlers-Danlos)
• Congenital dermal melanocytosis (Mongolian spots)
• Folk healing practices
• Ink, paint, or dye
• Accidental trauma
• Osteogenesis imperfecta
• Menkes disease
• Bone tumours
Reporting a child’s injuries is difficult: not only in recognizing the injury, but also in its work-up, reporting, and documentation. We will cover the topic of reporting suspected abuse in another post. However, arguably the most important step in advocating for your pediatric patients is being able to recognize when you should be worried. Hopefully this article broke it down into a step wise approach about when to be concerned, and how to go about investigating the issue.
This post was copyedited by Brad Stebner (@stebs444)
Reviewing with the Staff
Identifying and reporting suspected child maltreatment is not an easy task. This article nicely outlines a solid approach to the history, physical exam, investigations, and management of injuries that are suspicious for physical abuse. It is important to remember there are other forms of abuse which can be more difficult to identify: exposure to intimate partner violence, sexual abuse, emotional abuse, and neglect. If physicians need further guidance on identifying whether a presentation is worrisome, they can always seek consultation from pediatricians or child abuse expert pediatricians.