Abstract
A complete differential diagnosis is essential when assessing potential child abuse injuries. The differential diagnosis provides clinicians with the opportunity to compare injuries that might mimic abuse with actual abuse-related injuries. The differential diagnosis should delineate the injury type, injury site, instruments used, patterns, and the appearance of old or repeated injuries. This article discusses differential diagnoses that should be considered when evaluating injuries in infants and young children.
In 1998, the National Center of Child Abuse and Neglect reported 903,000 cases (12.9 per 1,000 children) of child maltreatment. Some 22.7% of these children were victims of physical abuse. The highest victimization rates occurred among children age 3 and younger; the rates declined as the child's age increased.' Among emergency department patients age 12 and younger, 50% of children treated for sexual abuse were age 4 and younger, and 50% of those treated for other violent injuries were age 5 and younger.' Many abuse cases are not reported because child injuries are often misdiagnosed. Reliable statistics on the incidence of children who are falsely identified as having abuse injuries in emergency departments are unavailable.2
Although child abuse reporting programs exist in all 50 states, the standard for what constitutes abuse differs.z Several steps must be taken when abuse is suspected;'' careful management is required to estimate the time of injury and to aid in the investigation. Health care providers often must investigate, report, and testify.
Observation of Interactions
Observation of caregiver-child interaction may provide clues to abuse. The caregiver may seem unaware of the seriousness of the child's injury, indifferent, or unsupportive. The caregiver may belittle the child, try to control the child's communication, or appear inattentive to the pediatric behavioral requests. Child behavioral indicators, such as aggressiveness, passivity, or hypervigilence, should evoke suspicion, as should a child who does not look at the caregivers.5-7
The History
When assessing injuries, the clinician must obtain a complete history, including present illness, review of systems, past medical and psychosocial history, family history (particularly bleeding disorders), and history of injury-related disorders. The caregiver should be permitted to lead the interview with a narrative of the injury. Child abuse should always be suspected when marks or injuries do not match the given history.8
Salient clues to child abuse include a history of minor trauma with extensive physical injury, a history of no trauma with evidence of injury, a history of self inflicted trauma that is incompatible with the child's developmental stage, a history of injury that changes with time, and delays in seeking treatment.9,10 Caregivers may blame siblings or playmates for serious injuries. When a third party, especially a sibling, is blamed, the clinician should determine if that sibling is developmentally capable of performing the alleged act.11 Additionally, the description of the injury mechanism must be consistent with injury type, severity, pain history, and developmental age of the injured child.
The Physical Examination
Bruises
Soft tissue trauma, combined with other trauma findings, may be the most common manifestation of physical abuse." Bruises result from blunt force to the skin surface, which disrupts capillaries and other larger blood vessels. The bruise size and depth are indicative of the force of impact, the size of disrupted blood vessels, the vascularity and connective tissue density, and the fragility of blood vessels. For example, the periorbital area is well vascularized and rapidly shows a black-eye syndrome when impacted.10
Toddlers and young children may have some minor bruising caused by rough play; however, these frequent and minor injuries usually overlay bony prominences such as shins, knees, elbows, forehead, and the dorsum of the hands. Lacerations and scrapes usually accompany rough-play bruises.
Underlying body organs influence the pattern of the bruise. Flat objects that strike underlying bony processes may leave marks as a result of the underlying soft tissue compressed against the unyielding bone.2 Therefore, bruises on relatively protected skin sites, such as cheeks, neck, trunk, genitals, and upper legs, should be considered suspicious for abuse.
On a young infant, multiple bruises of different ages, bruises and marks with geometric shapes, or severe bruising are not consistent with any acceptable history.12,13 Deep injuries to an area such as the thigh may not be apparent for hours or days. For example, when examining bruises, the caregiver may state that the child fell down the stairs. Common sense indicates that a fall down nonpadded stairs causes a series of bruises the size and shape of the stair edge; however, bruises would rarely exist on one body area.
The clinician should measure the bruise, describe the color, and draw pictures of the injury on the patient's chart. Based on the informed consent protocols of the individual institution, standard or instant photographs are made and labeled for placement in the patient's record. Instant photographs allow the clinician to verify the quality of the photo before the child leaves the office.14,15
Although the color of a bruise changes with time, a definitive means of dating bruises by color does not exist. On impact, a lesion commonly becomes deep red, blue, or purple. Swelling may last for approximately 2 days until the serum is reabsorbed. Localized or diffuse bleeding into tissue creates extensive bruising in children, especially loose tissue with poorly supported blood vessels such as around the periorbital area and genitals. Generally, the color changes from greenish to yellowish-brown before hemoglobin in the clot degenerates and is absorbed.
Bite marks are common symptoms of abuse, especially in older children. The injury results from the crushing pressure of the teeth cutting and dragging over soft tissue. Bite marks appear ovoid, arched, or round. The mark's endurance depends on the magnitude and duration of the bite and the character of the tissue involved.16,17 Many bite marks are misdiagnosed as simple bruises, which are dismissed as a normal part of childhood.
Because of the physical advantage of the abuser, the entire body of an infant or small child is vulnerable, requiring full examination when one bite is discovered. Certain areas of the body are inaccessible for self-inflicted bites. Animal bites can be differentiated from human bites because they result in deep penetration with accompanying tears and lacerations.11 Suspicious bites should be swabbed for DNA samples, which may detect secretory antigens left by the perpetrator's saliva. If the space between canine teeth marks is greater than 3 cm, the bite is most likely from an adult.6
Many injuries appear to be bruises on initial examination, but are not.10 However, the diagnosis of a common condition should not exclude the possibility of coexisting maltreatment injuries (see Table 1 ).12 If the complete blood count (CBC) is markedly abnormal, salicylate toxicity or anticoagulant ingestion should be considered. Other unusual presentations include collagen synthesis disease (skin hyperextensibility, joint hypermobility, and skin fragility) and osteogenesis imperfecta (a congenital, collagen systemic abnormality).
Many hematologic conditions, metabolic diseases, congenital dermatologic abnormalities, and toxicities present with bruising. When a child presents with questionable bruising, a bleeding assessment with a platelet count, prothrombin time, and partial thromboplastin time is required to rule out these systemic problems.
Burns
Some 80% of burns in children occur in the home, and 10% to 25% of these burns result from abuse.9,12 Burns are most frequent in infants and toddlers under age 3. Four types of burn injuries exist, and the types are based on the cause mechanism: scalds (hot liquid), flame contact (hot solid objects), electrical, and chemical. Burn injuries are classified by the depth of injured skin (superficial, partial, or full thickness); the size of the burn is calculated from the percentage of body surface area involved. Conditions that may resemble burns are listed in Table 2.
Scalding causes the majority of childhood burns and is the most common form of burn found in children admitted to the hospital.13 Intentional burns are caused when liquids are poured on or thrown at a child. When diagnosing this type of burn, the clinician should consider whether the child is capable of pouring hot liquids on himself.
Accidental burns, such as kitchen spills, have typical burn patterns: The worst burn is at the highest point of body contact. For example, a child who has upset boiling water while reaching up to a counter will experience burns on the cheeks, neck, shoulders, upper arm, and upper chest. The most severely burned areas will decrease as spilled liquid runs down the body, cools, and leaves a less severe injury. Clothes may hold the hot liquid in contact with the skin. Rashes of dif ferent infectious etiology, including candida, often mimic scalding to the diaper area.
Abusive immersion burns are common in infants and toddlers. Immersion burns occur when the child falls into or is submerged in hot liquid. Forced immersion shows a pattern suggestive of the restraint used to plunge and hold the child in hot liquid.
Water heaters are typically set between 120 deg. F and 150 deg. F (49 deg. C and 66 deg. C). Water is comfortable for bathing at 101 deg. F (38 deg. C) and becomes uncomfortable at 109 deg, F to 118 deg. F (43 deg. C to 48 deg. C). Burn times for adults and children are similar when the water is below approximately 130 deg. F (54 deg. C). Burn severity is altered by exposure time and body region differences in skin thickness. For example, keratinized skin, such as on the surfaces of feet and palms, does not burn as quickly as the skin on the dorsal surface of the feet or hands. Because a child's skin is commonly thinner on all body areas, the time required for heat to penetrate to the basal layers is shortened, so that burn damage usually occurs more rapidly in a child at temperatures over 130 deg. F (54 deg. C). For example, a preschool child can suffer partial thickness burns after only one second of immersion in water at 140 deg. F (60 deg. C); it would take approximately five times longer for an adult to sustain the same burn.3
Immersion burns of the buttocks and lower extremities of a young child are frequently correlated with attempts to toilet train the child. The caregiver may burn the child while cleaning him or burn the child to punish him for having an accident. When a child is held vertically by the arms or upper torso, toes and feet come in contact with the hot liquid first. The child reflexively withdraws the lower limbs by flexing his knees and hips and assuming a cannonball-like position. The burn leaves a "stocking" appearance on the feet and ankles without splash marks; it spares flexion creases." The caregiver then immerses the child's genitals and buttocks. Depending on the size of the child, the feet and lower legs are burned, the flexed knees are spared, and the buttocks and genitals are burned with distinct lines of demarcation.
Another frequent pattern occurs when the submerged skin of the buttocks is spared by coming in contact with the bottom of the tub, giving a "doughnut" pattern. In this case, the groin may be spared if the thighs are held together. Neither of these patterns is consistent with a child accidentally falling into a tub of water or turning on a hot water faucet. "Stocking" and "glove" burns are circumferential injuries to the distal aspect of the extremity that have a clear line of demarcation separating the uniformly burned area; such injuries are pathognomonic of abuse.
Contact burns are dry injuries that occur when the skin is placed against flames or hot objects such as irons or heating grates. The burned skin may have the full geometric shape of the inflicting object. The shape of the inflicting object would be less defined in an accidental injury because a child quickly retreats from an accidental burn, resulting in a superficial lesion. When burns are intentionally inflicted, the child's body is held in contact with the offending object, and the burns are usually of uniform depth.
Fractures and Skeletal Injuries
Fractures occur in 10% to 50% of abused children, and most fractures occur in infants and children under age 3. 18-20 Skeletal injury may be the first indication of child abuse.18 Young, developing bone is more porous and less dense than adult bone, which is sometimes able to restrain the propagation of a fracture line. A child's bones are more vulnerable to compression (greenstick and torus fractures). The periosteum or porous membrane that covers the surface of a bone is thicker, stronger, and more easily elevated from the diaphysis in a child.
In abuse, single-bone injuries with multiple bruises are most common and suggest a pulling episode.9 Preverbal children may present with irritability, crying on movement of affected areas, or decreased use of the broken limb. Some pediatric fractures, such as metaphyseal and rib fractures in infants, should raise suspicion even if there is no questionable clinical history.20,21
Similar to bruises, fractures heal in a timely sequence in the young. For example, a midshaft femur fracture heals in 3 weeks in an infant and 20 weeks in a teenager. The joint capsules are strong; therefore, dislocations and ligament injuries are less common in young children than adults.12 The goal of dating fractures is the identification of multiple trauma episodes. Fractures that have a high specificity for child abuse are metaphyseal fractures, rib fractures, scapular fractures, clavicular fractures, vertebral fractures, finger injuries in non-- ambulating children, bilateral fractures, and complex skull fractures.22
Full skeletal X-rays were once indicated in all children when abuse was suspected, but this is now debated.2 As an adjunct to X-ray, the radionuclide bone scan can detect new (less than 7 to 10 days) rib fractures, subtle diaphyseal fractures, and early periosteal elevation. Bone scans do not allow injury dating. Four stages of fracture healing that overlap on X-ray are shown in Table 3.
Some 56% to 60% of fractures in infants age 1 and younger are nonaccidental.2,10 Abusive fractures of the long bones of the arms and legs are most common in infants.16 Infants have difficulty propelling themselves and cannot usually exert sufficient force to fracture a bone. Diagnosis is dependent on comparing the injury with the probable force that was applied. For example, spiral (twisting) fractures of the femur or tibia in children are more suspicious for abuse in a nonambula tory infant than in a walking toddler.
Diaphyseal fractures or injuries to the midshaft of the long bones in the arm and leg (humerus, ulna, radius, femur, tibia, and fibula) occur in both accidental and intentional injuries. In infants, however, diaphyseal fractures of the femur require substantial force, which is not typical even in healthy infants. Except when a small child falls on his elbow or outstretched hand, fractures of the humerus are highly suspicious.
Metaphyseal fractures, or those that occur near the growing ends of bones, may indicate abuse.9.20 Tiny fractures through the most immature portion of the growth plate (buckle-handle) may appear as linear transparencies or densities on X-ray. Metaphyseal fractures occur with acceleration-deceleration forces associated with shaken impact syndrome or torsional and tractional forces when an infant is twisted or pulled by an extremity.
Multiple metaphyseal fractures from shaken impact syndrome occur at the proximal humerus, distal ulna and radius, distal femur, and proximal and distal tibia and fibula. Because these are areas of rapid bone growth, injuries do not typically result in significant soft tissue swelling or bruising. Neither the caregiver nor the clinician may recognize the injury and it may heal without treatment because the signs and symptoms are often absent. Growth arrest lines are not specific to abuse and may occur in illness, injury, starvation, or other growth stresses. During periods of slow growth, they cause a thick appearance on X-ray, When the stress is removed, normal longitudinal orientation resumes and the thick area appears as a discrete transverse line.
When the clinical signs are nonspecific, abusive head trauma may be more difficult to diagnose than extremity injuries.23 In young children, accidental linear fractures may occur from falls of less than 4 feet. If the fracture has a complex depressed character, it is more likely from intentional trauma. Multiple skull fractures, bilateral fractures, and those crossing sutures are strongly associated with abuse.10
Skull fractures do not always preclude cerebral injury. For example, shaking does not usually create fractures. An X-ray of the skull is more sensitive than computed tomography (CT) scans for skull fractures. CT scans show soft tissue injury in the first 24 hours, but age identification of older skull injuries is imprecise. Magnetic resonance imaging (MRI) may be the best choice to rule out child abuse in a child who has unexplained neurologic signs.24
Rib fractures in young children are unusual. Most rib fractures result from major trauma such as an automobile accident or abuse,zs or are associated with shaking injuries.zo Direct blows to the ribs are commonly seen in injuries of older children. Violent chest compression, such as squeezing the chest, usually fractures multiple bilateral ribs located posteriorly. The immature compliancy of a young child's rib cage often prevents the rib fractures that occur in older children and adults as a result of cardiopulmonary compression.
Vertebral or spinous process fractures may be caused in infants and young children from hyperflexion or hyperextension of the torso. Most vertebral or spinous fractures are occult and are best diagnosed with X-ray Accidental clavicle fractures are usually associated with other skeletal injuries. Birth trauma, direct injury, or falling on an outstretched arm may fracture the clavicle of an infant. However, involvement of the acromioclavicular joint is associated with violent traction of the arms and shaking injuries; proximal and distal injuries should arouse suspicion.19.20 Fractures of the hands and feet may result from "knuckle beating;' which is repetitive direct blows with the bony prominences of the adult hand. Many skeletal conditions may mimic child abuse injuries (see Table 4).
Abdominal, Thoracic, and Internal Organ Injuries
Internal injury of abdominal organs and thoracic cavities are an underreported but significant cause of physical abuse mortality. Because trauma sustained by internal organs is not visible, the caregiver often delays seeking treatment for the child. Children with internal injuries are generally younger than children who experience accidental abdominal trauma, with the majority being between ages 6 months and 3 years. Most abdominal and chest injuries are caused by blunt trauma and penetrating wounds; gunshot wounds are relatively infrequent. The physiologic mechanisms for abusive abdominal injuries are provided in Table 5.
An abusive caregiver will often suggest that abdominal injuries were caused by falling down stairs or falling from furniture. Necessary laboratory work includes a CBC with differential, bleeding studies, liver studies, and urinalysis. Anemia due to blood loss and infection may be indicative of abuse. Skin marks, such as from a fist, may exist when the liver or spleen is ruptured or when the bowel is obstructed.z A CT scan of the abdomen and an ultrasound facilitate the diagnosis of abdominal injuries and enhance clinical correlation.
Organ injuries to the gastrointestinal system include liver lacerations and subscapular hematomas from blows to the upper abdomen. Although abusive spleen injuries are infrequent because of the organ's position under the ribs, abuse is the leading cause of pancreatic trauma in children.12 Crushing injury may result in pancreatitis, which is often secondary to the release of pancreatic enzymes. Pancreatitis can also be caused by biliary tract disease, congenital anomalies, cystic fibrosis, infection, and certain drugs.
Kidney, bladder, and urinary tract injuries may be associated with both abusive and accidental trauma. Abuse injuries to the oropharynx and esophagus are caused by foreign body aspiration, traumatic perforation, and burns from caustic ingestion. Gastric perforation is infrequently reported as abuse but is more likely to occur if the child has a full stomach at the time of trauma. A distended abdomen may show pneumoperitoneum on X-ray. The duodenum is frequently damaged from abuse because it is in a fixed position in the upper mid-abdomen, where crushing injuries create rupture of duodenal blood vessels, forming a hematoma and obstruction. The colon is impaired by penetrating rectal trauma in sexual abuse; retroperitoneal vascular injuries result from shearing.
Children who die as a result of beating may have extensive muscle hemorrhages. Crush injuries lower the hemoglobin and hematocrit, release creatinine phosphokinase and myoglobin, and cause renal failure." Abnormal myoglobin-- urea and hemoglobinuria levels are possible results of abuse that must be tested without delay, because the levels rapidly return to normal.12 Injuries to the heart and lungs are less common than abdominal injuries because these organs are protected by the ribs.
Head Injury and Trauma
Head injury is the leading cause of mortality in abused children.19,26-28 Some 25% of hospital admissions for head injuries in infants and young children are abuse injuries.12
Bruising of the head is caused by blunt trauma that compresses and distorts cutaneous blood vessels, resulting in rupture. The abuser often states that the bruise was self-inflicted during play.15 The skin and underlying tissue that covers the skull may exhibit bruises, hematomas, and lacerations. Such injuries are sometimes overlooked because they are concealed by hair. A subgaleal hematoma represents intracranial hemorrhage in the space between the scalp and skull; it is associated with blunt injury or hair pulling and underlying skull fracture. Fatal head injuries often involve subdural or subarachnoid bleeding, brain swelling, and retinal hemorrhages.26,27,29
More than 50% of abused children have facial injuries. Oral and dental injuries are the most common facial injuries;11 agitated caregivers may target these areas in crying children. Common oral injuries include contusions, abrasions, laceration; burns, bites, fractures, and broken or missing teeth. The majority of these injuries occur in children age 4 and younger, and the incidence increases again in adolescence. The mouth may show tears of the labial or lingual frenum from a blow to the mouth, forced feeding, or forced oral sex.17
Shaken impact syndrome, also known as shaken baby syndrome, exists when there is blunt trauma to the head: After shaking a child, the head is thrust down or toward an object. 30,31 This behavior most often affects children age 2 and younger. The presentation includes a baby who is irritable, poorly feeding, lethargic, and experiencing seizures, apnea, or unresponsiveness. The history is often vague or not given, or the caregiver may claim shaking the child to resuscitate him. In abuse cases, bloody fluid is present in lumbar puncture.
Tin ear syndrome is a triad of unilateral external ear bruising, ipsilateral cerebral edema, and retinal hemorrhages. The abusive mechanism is blunt trauma to the ear with significant rotational acceleration of the head. The child frequently dies of cerebral herniation. The absence of external trauma evidence in combination with intracranial and intraocular pathology is suggestive of shaken impact syndrome.26
Initial assessment of a brain injury includes the Glasgow coma scale, a consciousness evaluation, documentation of lucid intervals, and a CT scan of the brain noting epidural hematomas. Brain swelling can be detected as early as 1 hour and 17 minutes post injury but may not be helpful in estimating the time of injury.32
Other Patterns of Abuse Injury
Sudden infant death syndrome (SIDS) incidence has decreased as a result of the infant sleep recommendations by the American Academy of Pediatrics, although the etiology of SIDS remains controversial.4
In an attempt to elevate the fontanel in a dehydrated infant, caregivers may practice a folk remedy, caida de la mollera, that entails holding the child upside down, consequently causing retinal hemorrhages 33 Other injuries can result from self inflicted injuries associated with mental retardation, temper tantrums, and self exploration.
Poisoning causes vomiting and gastrointestinal symptoms. Parental poisoning syndromes include impulsive poisoning by the parent; the use of sedatives, alcohol, or paregoric to quiet a child; neglect (an unsupervised child ingests drugs or alcohol); toxic doses of vitamins, minerals, herbs, water, or salt administered to a child; Munchausen syndrome by proxy; and the use of psychoactive drugs and alcohol to alter a child's behavior.
In Munchausen syndrome by proxy, recurrent disease symptoms are fabricated or deliberately induced by someone other than the patient. The child receives unnecessary and sometimes painful physical examinations and treatment, often resulting in diagnosis of an unusual disease." In the past, likely signs of Munchausen syndrome by proxy included a mother or caregiver who appears loving and caring; is familiar with medical terminology, procedures, and health care staff; is eager for invasive testing; and may have worked in health care.34 More recent studies indicate that these maternal indicators are not sensitive enough to aid in diagnosis; the researchers recommend covert video surveillance of suspected cases and positive clinical data.35
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ABOUT THE AUTHORS
Betty Wendt Mayer, RN, ARNP, MSN, is an emergency department family nurse practitioner, Florida Emergency Physicians, Inc,, Florida Hospitals of Orlando, Fla.
Patricia Burns, RN, ARNP, PhD, FAAN, is dean and professor, University of South Florida College of Nursing, Tampa.
Copyright Springhouse Corporation Oct 2000
Provided by ProQuest Information and Learning Company. All rights Reserved
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