Non-accidental trauma or child abuse is the leading cause of childhood traumatic injury and death in the United States. It is essential that medical providers recognize non-accidental trauma in order to prevent further morbidity or even mortality. Child abuse can present in a wide spectrum of forms: physical, sexual, psychological and neglect.

According to The Child Abuse Prevention and Treatment Act and the Keeping Children and Families Safe Act, the legal definition of child abuse is defined as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act that presents an imminent risk of serious harm.”

Patient Presentation

The clinical manifestations of child abuse can present in a wide range of pathology. Careful history, physical examination and an appropriate radiographic exam should always be performed.

The history should be detailed and thorough and note any prior injury or diseases that might be associated with bone fragility. The caregiver’s description of when and how the injury occurred should be recorded. Any delays to seeking treatment must be noted. All witnesses to an injury should give their account. A patient’s medical and developmental stage is important when considering the possibility of non-accidental trauma.

A full physical exam must be conducted; all clothes should be removed. The child’s general appearance, weight, nutritional status, affect, and demeanor should be noted. The child’s general appearance, weight, nutritional status, attained or unattained developmental milestones, affect and demeanor should be noted. The affect and demeanor of siblings are also important when considering the mechanism of injury.

The skin exam is used to identify any bruising. Bruises are the most common physical finding of abuse and if found, the size, location, shape and pattern should be recorded. Multiple bruises in various stages of healing are worrisome. Similarly, burns may be a sign of abuse. Burns and bruises in certain shapes or patterns may raise suspicion of abuse (e.g. fork, cigarette, hand, belt). Photo documentation of any bruises or burns should be obtained if possible.

The head of the patient should be carefully evaluated. Skull fractures may present as swelling, crepitus, depression, or bulging of the fontanelles. Head trauma should also be suspected if the child is obtunded or lethargic. A head CT scan and ophthalmologic exam should be performed if head trauma is suspected.

Fractures are common and are a present in about one-third of abused children. On physical exam, fractures may occult or be readily apparent. Gross deformity or angulation is rare. Swelling and bruising may be visible. On palpation, the child may grimace or cry. The limb may be held in a fixed position for comfort.

About three quarters of abused children have multiple fractures. A skeletal survey - total body x-rays - should be ordered for all children suspected of traumatic abuse.

Metaphyseal corner or chip fractures are very suspicious for child abuse and are the result of longitudinal traction and torsion of the affected limb (Figure 1). Posterior rib fractures (Figure 2) and fractures of the hand or foot in non-ambulatory infants are concerning for abuse.

Figure 2: Posterior Rib Fractures.

Femur fractures in a non-ambulatory child (Figure 3) should mandate an abuse evaluation. Fractures in various states of healing are not uncommon in children suffering from abuse.

Epidemiology

Child abuse is both serious and under-recognized despite getting an abundance of attention in medical education, literature, and the news. Reports have estimated that non-accidental trauma is the second leading cause of infant death. According to the Children’s Bureau in 2017, 9.1 per 1,000 children were the victims of child abuse. Often the pediatric orthopaedic surgeon may be the first physician to recognize a child suffering from non-accidental trauma.

Infants are at the greatest risk; incidence of child abuse in the first year of life is 25.3 per 1,000 children. Neglect is the most common form of abuse and physical abuse is the second, accounting for 74.9% and 18.3% of reports, respectively. In 2017, 1,720 children died of abuse/neglect at a rate of 2.32 deaths per 100,000 children.

Differential Diagnosis

Other conditions that may produce “unusual” musculoskeletal findings include osteogenesis imperfecta, congenital pain insensitivity, scurvy, infantile cortical hyperostosis, birth trauma, osteopenia of prematurity, rickets, congenital syphilis, coagulation disorders (von Willebrand, hemophilia, thrombocytopenia), and leukemia.

Red Flags

In all realms of diagnosis, there is usually a sensitive/specificity trade-off: that is, false negatives (missing a case) can be decreased only by increasing false positives (over-diagnosis). In the case of child abuse, the need to protect children demands that the sensitive/specificity thresholds are tilted towards higher sensitivity. Yet recognizing that high sensitivity might lead to more false positives, a two-pronged approach is needed, whereby any worrisome finding will trigger a close and detailed investigation. This investigation can then exclude the false positives.

This two-pronged approach requires a certain equanimity on the part of caregivers and physicians alike: an investigation of suspected child abuse is not to be considered as an accusation.

Elements of the history and physical that should prompt a closer look include the following:

• Vague or inconsistent history from the caregivers.
• Delayed presentation of the injury.
• Abnormal interactions between the caregiver and patient.
• A history of other injuries.
• A mechanism of injury that is insufficient to explain an injury or inconsistent with the developmental level of the child.
• A history of domestic abuse.
• Premature infants or those with low birth weight are at higher risk (as are those with chronic medical conditions).
• Metaphyseal fractures.
• Scapula fractures.
• Spinous Process fractures.
• Sternal fractures.
• Rib fractures.
• Any fracture or bruise in a non-ambulating child.
• Detection of a previously undiagnosed healing fracture.
• Bruising on the torso, ear, or neck for a child younger than four years of age.

Treatment Options and Outcomes

Treatment for non-accidental trauma is focused on the presenting problem, includes a thorough evaluation to avoid missed injuries, and prioritizes preventing another injury or problem. The safety of the child and children within the household is a priority.

A multi-disciplinary approach is best used. Sub-specialists should be consulted as the evaluation dictates. Social workers should be notified to help with care and the transition of care to home.

All US states have mandatory reporter laws that dictate that medical providers must report child abuse if it is suspected. The rules established by these laws differ by state. Providers should be familiar with their responsibilities under the law.

The patient should remain under medical care and only be discharged once a plan has been determined that ensures the patient’s safety.

Outcomes from non-accidental trauma are largely determined by the extent of injury.

Figure 4 demonstrates the routine healing response of a femur fracture. Acceptable alignment has been maintained and abundant callus is present at 16 days after initial diagnosis.

It is important to mention that unrecognized child abuse can be disastrous. In one series of 54 children with head injuries caused by non-accidental trauma but not initially recognized as such, 15 were reinjured after the missed diagnosis and five children ultimately died of further abuse.

Holistic Medicine

Care of the abused child and family should be thorough and thoughtful. A non-accusatory discussion with the patient’s caregivers is essential. The history and physical should be focused on the care of the patient. Objective findings should be well documented in the Electronic Medical Record and conjecture or accusations should be avoided.

Caring for a victim of child abuse requires a multi-disciplinary team. Social workers and child protection teams should be contacted once suspicion has been raised to coordinate care. Sub-specialists in neurosurgery and ophthalmology should be consulted if there is evidence of head trauma. Good communication among team members helps to ensure quality care for the patient and family.

Risk Factors and Prevention

Child abuse affects all races, religions, and classes of society, but epidemiology studies have elicited that some populations are a greater risk. It is important to remember that each case must be taken on an individual basis and the absence of risk factors does not preclude abuse.

Risk factors can be categorized into three groups.

1. Risk factors intrinsic to the child.
2. Risk factors intrinsic to the perpetrator.
3. Risk factors intrinsic to family structure and society.

(I)

The risk of non-accidental trauma is inversely related to age with the majority of victims younger than two years of age. First born and step children are at an increased risk of abuse. In addition, any condition that makes the child more difficult to care for predisposes them to maltreatment. Examples include children with behavioral issues, chronic illness, and premature delivery.

(II)

Factors which are intrinsic to the perpetrator of abuse are many. Parents with limited knowledge of child development, low sense of parental competence, or inconsistent parenting may predispose a caregiver to abuse children. Having been a victim of child abuse or in an abusive relationship are predisposing factors as well.

Drug or alcohol abuse, mental illness, low income, unemployed parents, and a lack of social support increase the risk of Non-accidental trauma within the household.

(III)

Looking within the family and societal structure reveals many risk factors. Abuse is more common when families perceive a lack of community support and lack of connection to the community. Abuse is more common in communities of lower socioeconomic status, as well. Within the US, the rate of abuse varies amongst race and culture. According to the 2017 Child Maltreatment Report, African American children are at an increased risk of abuse. The rate of African American child fatalities due to non-accidental trauma is more than double the rate of Caucasian children and three times greater than the rate of Hispanic children.

Miscellany

Here are some helpful memory aids:

• If you don’t cruise, you don’t bruise.
• TEN-4 (Bruises on Torso, Ears, Neck before the age of 4 raise concern).
• 3 S’s: Scapula, Spinous Process & Sternal fractures.

Key Terms

Non-accidental trauma, Child abuse

Skills

Perform a thorough history and physical exam on infants suspected of experiencing abuse. Recognize the history and physical exam “Red Flags” of non-accidental trauma. Be able to clearly and objectively document findings in writing. Communicate clearly with family in a non-accusatory manner, focusing on care and safety of the child.