Blunt Abdominal Injuries in Child Abuse Cases
Anatomical Factors that Make Children Vulnerable to Organ Injuries
Sep 18, 2009
Traumatic injuries continue to be the leading cause of death in children, far surpassing other causes. Abdominal trauma accounts for 8-10% of all trauma admissions to pediatric hospitals. More than 80% of traumatic abdominal injuries in children result from blunt mechanisms (National Center for Injury Prevention and Control Fact Sheet, 2005).
Blunt abdominal injury is a relatively uncommon form of child abuse, but the mortality rate from abdominal injury tends to be much higher than other forms of abuse. The U.S. Department of Health Services Administration reported that in 2004 an estimated 1,490 child fatalities were the result of abuse and neglect.
“Just as abdominal trauma is more dangerous than other forms of child abuse, abdominal trauma from child abuse is often more dangerous than other forms of abdominal injury,” says the Journal of Pediatric Health Care in a 2005 article entitled “Physical abuse: Recognition and reporting.” Blunt abdominal trauma in children secondary to violent assault has a greater risk for mortality than abdominal trauma from motor vehicle accidents, falls, and bicycle accidents.
Anatomical Factors
Numerous anatomical factors make a child more vulnerable than an adult to abdominal organ injury. A child’s smaller size, thin abdominal wall, and cartilaginous ribs mean a greater force is placed on the abdominal organs. The close proximity of the abdominal organs also increases the chance of multi-organ injury. Also, the more horizontal position of the diaphragm in a child means that the liver and spleen lie lower and more anteriorly and thus more vulnerable to injury.
Abdominal trauma can be life threatening because abdominal organs, especially those in the retroperitoneal space, can bleed profusely, and the space can hold a great deal of blood. Solid abdominal organs, such as the liver and kidneys, bleed profusely when cut or torn, as do major blood vessels such as the aorta and vena cava.
Hollow organs such as the stomach, while not as likely to result in shock from profuse bleeding, present a serious risk of infection, especially if such an injury is not treated promptly. Gastrointestinal organs such as the bowel can spill their contents into the abdominal cavity. Hemorrhage and systemic infection are the main causes of deaths that result from abdominal trauma (National Center for Injury Prevention and Control).
Abdominal Injuries
The most common abdominal injury in children is perforation of the gut. A blow in the abdomen can crush the gut against the bone at this point and severe it almost as cleanly as a scalpel. Alternatively, the gut may be badly bruised and become non-viable, causing a necrotic rupture some days later, with fatal peritonitis.
The spleen is rarely injured in child abuse. Other organs in the abdomen, such as the kidneys and bladder are rarely injured except in unusual cases. A common organ to be injured is the liver as heavy prodding or blows on the upper abdomen or even lower chest can cause tears in the soft infant liver with consequent hemorrhage.
Damage to the metaphyses and epiphyses (especially at the large joints like elbow and knee) are common. The lateral edges of the bones are chipped and avulsed and present a characteristic appearance to an experienced radiologist. Fractures of long bones occur and transverse and spiral fractures due to twisting and shearing strains are almost pathognomonic of abuse in small infants.
Child abuse is unfortunately very common and is the leading cause of trauma death in infants. Abdominal injury from child abuse carries a mortality rate as high as 45% (National Center for Injury Prevention and Control). These injuries are often the result of a punch or kick. A neglected infant who is the victim of child abuse can present with rupture of intra-abdominal organs.
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