The physical abuse of children by parents affects children of all ages. It is estimated that 1% to 2% of children are physically abused during childhood and that approximately 1500 children are fatally injured each year. Although mothers are most frequently reported as the perpetrators of physical abuse, serious injuries, such as head or abdominal trauma, are more likely to be inflicted by fathers or maternal boyfriends. The diagnosis of physical abuse can be made easily if the child is battered, has obvious external injuries, or is capable of providing a history of the abuse. In many cases, the diagnosis is not obvious. The history provided by the parent is often inaccurate because the parent is unwilling to provide the correct history or is a nonoffending parent who is unaware of the abuse. The child may be too young or ill to provide a history of the assault. An older child may be too scared to do so or may have a strong sense of loyalty to the perpetrator.
A diagnosis of physical abuse initially is suggested by a history that seems incongruent with the clinical presentation ofthe child (Table 22-1). Although injury to any organ systemcan occur from physical abuse, some injuries are more common. Bruises are universal findings in healthy ambulatorychildren but also are among the most common injury identified in abused children. Bruises suggestive of abuse includethose that are patterned, such as a slap mark on the face orlooped extension cord marks on the body (Fig. 22-1). Bruises
A child presents for medical care with significant injuries, and a history of trauma is denied, especially if the child is an infant or toddler.
The history provided by the caregiver does not explain the injuries identified.
The history of the injury changes significantly over time.
A history of self-inflicted trauma does not correlate with the child’s developmental abilities.
There is an unexpected or unexplained delay in seeking medical care.
Multiple organ systems are injured, including injuries of various ages.
The injuries are pathognomonic for child abuse.
Figure 22-3 A, Metaphyseal fracture of the distal tibia in a 3-month-old infant admitted to the hospital with severe head injury. There also is periosteal new bone formation of that tibia, perhaps from a previous injury. B, Bone scan of same infant. Initial chest x-ray showed a single fracture of the right posterior fourth rib. A radionuclide bone scan performed 2 days later revealed multiple previously unrecognized fractures of the posterior and lateral ribs. C, Follow-up radiographs 2 weeks later showed multiple healing rib fractures. This pattern of fracture is highly specific for child abuse. The mechanism of these injuries is usually violent squeezing of the chest.
in healthy children generally are distributed over bony prominences; bruises that occur in an unusual distribution, such as isolated to the torso, ears or neck, should raise concern. Bruises in nonambulatory infants are unusual, occurring inless than 2% of healthy infants seen for routine medical care.Occasionally a subtle bruise may be the only external clue toabuse and can be associated with significant internal injury.
Burns are common pediatric injuries and usually represent preventable unintentional trauma (see Chapter 44). Approximately 10% of children hospitalized with burns are victims of abuse. Inflicted burns can be the result of contact with hot objects (irons, radiators, or cigarettes) but more commonly the result of scalding injuries (Fig. 22-2). Hot tap water burns in infants and toddlers are sometimes the result of intentional immersion injuries, which often occur around toilet training
Figure 22-1 Multiple looped cord marks on a 2-year-old abused child who presented to the hospital with multiple untreated burns to the back, arms, and feet.
issues. These burns have clear lines of demarcation, uniformity of burn depth, and characteristic pattern.