PEDIATRIC ABUSE

PEDIATRIC ABUSE

Prepared by Dr. Oguzhan BULUT

This article provides a clinical overview of Non-Accidental Trauma (NAT), commonly referred to as orthopedic child abuse. Recognizing these patterns is critical for healthcare providers, as orthopedic injuries are the second most common presentation of child abuse after skin lesions. Child abuse is the second most common cause of death among children. Children under one year of age are reportedly the most frequently abused age group. Treatment requires reporting the abuse to the relevant authorities and hospitalisation for a multidisciplinary evaluation. Occasionally, surgical treatment of fractures may be necessary.

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EPIDEMIOLOGY

• Incidence: Approximately 1% to 1.5% of children in the U.S. are victims of maltreatment. Orthopedic injuries occur in roughly 30% to 50% of physically abused children.
• Demographics: Infants and toddlers are at the highest risk. Approximately 50% of victims are under 1 year of age, and the majority are under 3 years old. Furthermore, girls are more likely to be abused than boys, with respective rates of 8.2 and 7.1 per 1,000. However, the rate of abuse-related deaths is higher in boys (3.26 per 1,000) than in girls (2.25 per 1,000).

• Social Risk Factors:
  • Child Factors: Premature birth, developmental disabilities, “colicky” or difficult temperament, first-born and unwanted pregnancy.
  • Parent/Caregiver Factors: Substance abuse, domestic violence, young parental age, financial stress, drug use and history of being abused as a child.
• Types of Abuse: Abuse often presents as a combination of physical battery, nutritional neglect, sexual and emotional deprivation.

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PRESENTATION

History & Symptoms

A diagnosis may be suspected in cases involving inconsistent injury patterns, delayed treatment, long bone fractures in non-ambulatory children or unusual fractures.

The history is often the most significant “red flag.” Suspicion should arise if:

• The mechanism of injury is incompatible with the child’s developmental age (e.g., a 2-month-old “rolling off a couch”).
• There is a delay in seeking medical care.
• The story changes between different caregivers or over time.

Physical Exam

A thorough, head-to-toe examination is mandatory.

• Skin: Look for “patterned” bruises (shaped like belts, hands, or bites) and burns (cigarette burns or “stocking-glove” immersion burns).
• Soft Tissue: Multiple bruises at different stages of healing.
• Fractures: Deformity, swelling, or limited range of motion in a non-ambulatory child.
• Orthopedic injuries are the second most common sign of child abuse, with fractures occurring most frequently in the humerus, followed by the tibia and femur. While specific patterns like metaphyseal “corner” fractures are highly suspicious, diaphyseal (shaft) fractures are actually four times more prevalent in clinical practice.

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IMAGING

Radiology is the cornerstone of diagnosis. A Skeletal Survey (a series of ~20 specialized X-rays) is the gold standard for children under age 2.

X-Ray Findings

Certain fracture patterns are highly suggestive of NAT:

• Classic Metaphyseal Lesions (CML): Also known as “Corner” or “Bucket-handle” fractures. These are caused by forceful pulling or shaking of a limb.
• Posterior Rib Fractures: Resulting from the chest being squeezed during shaking.
• Scapular, Sternal, or Spinous Process Fractures: Highly specific for abuse in the absence of high-energy trauma (like a car crash).
• Multiple Fractures in Different Stages of Healing: Suggests a chronic pattern of abuse.

Bone Scan (Scintigraphy)

If X-rays are inconclusive but suspicion remains high, a bone scan may be used to detect very early rib fractures or subtle areas of increased bone turnover that X-rays might miss in the first 7–10 days. It is not useful in cranial and metaphyseal fractures.

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DIFFERENTIAL DIAGNOSIS

It is vital to rule out medical conditions that mimic abuse:

• Osteogenesis Imperfecta (OI): “Brittle bone disease.” Often accompanied by blue sclera and a family history of fractures.
• Rickets: Softening of bones due to Vitamin D deficiency.
• Accidental Trauma: Common toddler fractures (e.g., non-displaced spiral tibia fractures) can occur from simple falls, but the history usually matches the injury.
• Birth Trauma: Healing clavicle or humerus fractures found in newborns.

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TREATMENT & MANAGEMENT

1. Safety First: The immediate priority is the safety of the child. Admission to the hospital is often necessary for protection while an investigation begins.
2. Legal Obligation: Healthcare providers are mandated reporters. You are legally required to report suspected abuse to Child Protective Services (CPS) or the police.
3. Orthopedic Care: Most NAT fractures are treated non-operatively with casting or splinting. Surgical intervention is rarely needed compared to high-energy accidental trauma.
4. Multidisciplinary Approach: Management involves pediatricians, social workers, orthopedic surgeons, and child life specialists.

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PROGNOSIS

The prognosis for the physical fracture is usually excellent; children heal quickly. However, the psychosocial prognosisis guarded.

• Without intervention, there is a 50% risk of repeat abuse and a 10% risk of homicide.
• Long-term survivors often face higher rates of PTSD, substance abuse, and developmental delays.

References

1. Christian CW, Committee on Child Abuse and Neglect. The evaluation of suspected child physical abuse.Pediatrics. 2015;135(5):e1337–e1354.
2. Kleinman PK.Diagnostic Imaging of Child Abuse.Cambridge University Press; 1998.
3. Kocher MS, Kasser JR.Orthopaedic aspects of child abuse.J Am Acad Orthop Surg. 2000;8(1):10–20.
4. Kemp AM, et al.Which radiological investigations should be performed to identify fractures in suspected child abuse?Clin Radiol. 2006;61(9):723–736.
5. Leventhal JM, et al.Fractures in young children: distinguishing child abuse from unintentional injuries.Am J Dis Child. 1993;147:87–92.
6. Barsness KA, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma. J Trauma. 2003;54(6):1107–1110.
7. Jenny C, et al. Evaluating infants and young children with multiple fractures. Pediatrics. 2006;118(3):1299–1303.
8. American College of Radiology (ACR).ACR Appropriateness Criteria®: Suspected Physical Abuse – Child.