Inflicted fractures occur more commonly in infants and young children. Although diaphyseal fractures are most common in abuse, they are nonspecific for inflicted injury. Fractures that should raise suspicion for abuse include fractures that are unexplained; occur in young, nonambulatory children; or involve multiple bones. Certain fractures have a high specificity for abuse, such as rib, metaphyseal, scapular, vertebral, or other unusual fractures (Fig. 22-3). Some metabolic diseases can be confused with abuse and should be considered in the differential diagnosis when appropriate.
Abdominal injury is an uncommon but serious form of physical abuse. Blunt trauma to the abdomen is the primary mechanism of injury, and infants and toddlers are the most common victims. Injuries to solid organs, such as the liver or pancreas, predominate and hollow viscus injury occurs more commonly with inflicted trauma than accidental. Even
Figure 22-2 A 1-year-old child brought to the hospital with a history that she sat on a hot radiator. Suspicious injuries such as this require a full medical and social investigation, including a skeletal survey to look for occult skeletal injuries and a child welfare evaluation.
Figure 22-4 Acute subdural hemorrhage in the posterior interhemi-spheric fissure in an abused infant.
in severe cases of trauma, there may be no bruising to the abdominal wall. The lack of external trauma, along with the usual inaccurate history, can cause delay in diagnosis. A careful evaluation often reveals additional injuries. Abdominal trauma is the second leading cause of mortality from physical abuse, although the prognosis is generally good for children who survive the acute assault.
Abusive head trauma is the leading cause of mortality and morbidity from physical abuse. Most victims are young; infants predominate. Shaking and blunt impact trauma cause injuries. The perpetrators are most commonly fathers and boyfriends, and the trauma typically is precipitated by the perpetrator’s intolerance to a crying, fussy infant. Victims present with neurologic symptoms ranging from lethargy and irritability to seizures, apnea, and coma. Unsuspecting physicians misdiagnose approximately one third of infants, and of these, more than 25% are reinjured before diagnosis. A common finding on presentation is subdural hemorrhage, often associated with progressive cerebral edema (Fig. 22-4). Hypoxic-ischemic injury is a significant contributor to the pathophysiology of the brain injury. Associated findings include retinal hemorrhages (seen in many, but not all, victims) and skeletal trauma, including rib and classic metaphyseal fractures. At the time of diagnosis, many head-injured infants have evidence of previous injury. Survivors are at high risk for permanent neurologic sequelae.
The extensive differential diagnosis of physical abuse depends on the type of injury (Table 22-2). For children who present with pathognomonic injuries to multiple organ systems, an exhaustive search for medical diagnoses is unwarranted. Children with unusual medical diseases have been incorrectly diagnosed as victims of abuse, emphasizing the need for careful, objective assessments of all children. All infants and young toddlers who present with suspicious
Genetic diseases Ehlers-Danlos syndrome Familial dysautonomia (with congenital indifference to pain) Vasculitis Henoch-Schönlein purpura
Dermatologic Phytophotodermatitis Stevens-Johnson syndrome Fixed drug eruption Epidermolysis bullosa Severe diaper dermatitis, including Ex-Lax ingestion
Hematologic disorders Vitamin K deficiency (hemorrhagic disease of the newborn) Hemophilia
Glutaric aciduria type I, Menkes kinky hair syndrome
From Christian CW: Child abuse physical. In Schwartz MW, editor: The 5-minute Pediatric Consult, ed 3, Philadelphia, 2003, Lippincott Williams &