BRUISES

Bruises are the most common injury identified in abused children. Factors that may alert the physician to nonaccidental trauma are bruising to infants who are not yet cruising and bruising in an unusual distribution or location, such as the ears, buttocks, chest, or abdomen. Bruises may also demonstrate pattern injuries that demonstrate a specific object that struck the child. It must be remembered that a subtle bruise may be the only external indicator of significant internal trauma. Additionally, severe or even fatal abuse can occur without a single external mark. Any child suspected of being abused needs a full body skin exam.

SKELETAL TRAUMA

Skeletal injuries are more common in infants and young children but can be seen in all ages. Patterns of fractures that raise suspicion for abuse include fractures in nonambulatory infants, multiple fractures, and fractures of different ages. Specific locations of fractures listed below can also increase clinical suspicion.

Femoral fractures (spiral or transverse) in children under age 3 years are suspicious. Minor falls, less than 30–60 cm, usually do not result in femoral fractures.

Epiphyseal–metaphyseal fractures in young infants and children are virtually diagnostic of abuse because they usually do not occur with accidental falls. These fractures usually occur as a result of severe pulling, twisting, or shaking of the child's limbs. These activities produce severe acceleration–deceleration forces on the limbs, resulting in metaphyseal chip or “corner” fractures.

Rib fractures in infants under the age of 2 years are extremely uncommon because the infant's rib cage is extremely pliant. Multiple, bilateral posterior rib fractures are virtually pathognomonic for abuse and are caused by significant squeezing pressure to the chest.

BURNS

Burns sustained by infants and toddlers may be accidental, inflicted, or the result of poor supervision and neglect. Inflicted immersion burns often demonstrate clear lines of demarcation where the child was held in scalding water with areas above spared. Accidental immersion burns typically have indistinct borders, varying depths of injury, irregular margins, and splash pattern burns outside the primary burn area. Burns also may be inflicted by cigarettes, irons, or stoves. Care must be taken in examining the burn area to identify pattern injury.

HEAD INJURIES

Head injuries carry the highest incidence of morbidity and mortality. These injuries can occur by blunt impact or shaking with sudden acceleration–deceleration forces. Head injury is most common in patients under 3 years of age, especially infants. Subdural hematomas can occur with resulting cerebral compression. In addition, these forces can cause direct neuronal injury within the brain. Infants who are severely shaken can present with sudden onset of seizure or coma but have no signs of head trauma. Typically, infants who are severely shaken will have bilateral subdural and inter-hemispheric hemorrhages.

ABDOMINAL INJURIES

Nonaccidental abdominal injury may produce severe injury to the viscera, including intramural hematomas of the small bowel, splenic or hepatic lacerations, traumatic pancreatitis, and renal contusions.

discuss concerns with the parents in a sensitive and compassionate manner,

ensure protection of the child,

perform a complete medial evaluation of the injuries or neglect, including documentation and radiologic imaging if indicated,

report suspicions to child protective services.

Complications of Injecting Drug Use

• Local problems—Abscess (Figures 240-2 
  

  A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

  and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
  • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
  • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
• IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
  • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.

Bruising to the left buttock noted in a 1-month-old child. Any bruising on an immobile child is highly concerning for child physical abuse. Bleeding disorders must be considered in the differential diagnosis. (Courtesy of James Anderst, MD, MS.)