Evaluating Multiple Fractures in Children
Detecting Inflicted Injuries in Child Abuse Cases
Sep 23, 2009
Child abuse injuries, particularly traumatic brain injuries, may result in significant long-term disabilities including learning deficits, attention-deficit/hyperactivity disorder, behavioral problems, seizures, spasticity, blindness, paralysis, and mental retardation (American Academy of Pediatrics, Fact Sheet 2008).
Physical Examination
“The child's alertness and demeanor may reflect neurologic status and degree of discomfort and pain. Spontaneous and symmetrical movement of all extremities should be noted, as well as any of the child's responses that indicate pain when extremities are examined and moved, says a 2006 Committee on Child Abuse and Neglect in an article entitled “Evaluating infants and young children with multiple fractures.” Evidence of spinal cord injury, such as abnormal reflexes, muscle tone, or responsiveness to tactile stimuli, should be carefully pursued.
Evidence of neglect may be seen during the general examination of the infant or child; extensive dental caries, severe diaper dermatitis, or neglected wound care may be noted in addition to injuries that raise suspicion of abuse. Bald areas on the scalp may sometimes be seen with severe nutritional deficits or with traumatic alopecia.
Obscure sites for inflicted injuries include the ears, especially the posterior aspects, the neck and angle of the jaw, scalp, and the frenula of the lip and tongue. Inflicted injuries tend to occur on surfaces away from bony prominences, such as the neck, head, buttocks, trunk, hands, and upper arms. Some deeper bruises may not be readily visible for several hours; areas that are painful to palpate may require further examination in 1 to 2 days, when bruises may become apparent.
Bite marks, recent or healed, should be carefully measured and photodocumented when possible; an intercanine distance of more than 2 cm suggests a human adult-sized bite. Fresh bites should be swabbed with sterile, premoistened cotton-tipped applicators for forensic analysis of potential genetic markers found in saliva.
A fundoscopic examination for retinal hemorrhages should be considered for any infant or young child who is a suspected victim of physical abuse. The ophthalmologist should provide documentation of the retinal hemorrhages by photography or detailed annotated drawings. Location, depth, and extent of retinal hemorrhages may distinguish between abusive and non-abusive causes of head trauma (Committee on Child Abuse and Neglect).
Auscultation, performed before palpation, may reveal decreased or no bowel sounds if the child has sustained intraabdominal injury. If the intestines, liver, or spleen have been ruptured, guarding or abdominal muscle rigidity may be noted on palpation. Abdominal bruising is often not seen, even with severe blows to the abdomen. Liver and pancreatic enzyme tests are helpful in screening children for abdominal trauma, especially when the child presents with acute symptoms or shortly after the incident has occurred. A urinalysis may also lead to the discovery of unexpected trauma to the urinary tract and kidneys.
Palpation of the legs, arms, feet, hands, ribs, and head may reveal acute or healing (callus formation) fractures. If a fracture is suspected, surfaces should be carefully examined for "grab marks" that may indicate restraint or areas that were pulled or twisted to create the fracture; however, absence of such bruising does not exclude abusive mechanisms of injury.
Clinical Presentation
Soft tissue swelling, with or without bruising, may indicate more recent trauma. Many fractures, including rib and metaphyseal fractures, may not be clinically detectable, so a negative clinical examination should not preclude the need for a skeletal radiologic survey when inflicted trauma is suspected, particularly in children younger than 2 years.
Long-bone fractures that should be evaluated carefully for nonaccidental causes include metaphyseal fractures and spiral/oblique fractures, especially in nonambulatory infants; both types of fractures have been associated with accidental mechanisms of injury as well.
Child physical abuse is a common problem of childhood. The physician must be able to recognize suspicious injuries, conduct a comprehensive and careful examination with appropriate auxiliary tests, critically assess the explanation provided for the injury or injuries, and establish the probability that the explanation does or does not correlate with the pattern, severity, and/or age of the injury or injuries.
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