Cutaneous Injuries, Fractures, and Abusive Head Trauma
Author: Kirsten Bechtel, MD, Assistant Professor of Pediatrics, Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT.
Peer Reviewer: Steven M. Winograd, MD, FACEP, Attending Physician, Emergency Department, Uniontown Hospital, Uniontown, PA.
Abuse of the child is a social blight that has been present since the beginning of recorded history, and unfortunately, is still very present in the 21st century. Child abuse can be difficult to recognize, especially in the often chaotic environment of the emergency department (ED). An astute knowledge of the presenting signs and symptoms of child abuse is necessary, as an accurate history may be difficult to discern. Emergency physicians must maintain an index of suspicion for abuse, especially when the mechanism or pattern of a childhood injury is cryptic or out of place. As the leaders of the community and medical safety net that is the ED, emergency physicians play a unique role in detecting, treating, and preventing child abuse. This issue of Emergency Medicine Specialty Reports provides an update on the patterns, diagnosis, and treatment of physical child abuse injuries.—The Editor
Introduction
Child abuse is a pervasive problem in the United States. The central premise of child abuse is that a child’s caregiver, such as a parent, guardian, or foster parent, fails to provide for that child’s health and well-being, either through acts of omission or commission. Such acts can lead to harmful effects on the child’s health, development, and psychological well-being. The Child Abuse Prevention and Treatment Act (P.L. 93-247), which Congress passed in 1974, states that child abuse can be defined as the following:
"The physical or mental injury, sexual abuse, negligent treatment or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances which indicate that the child’s health and welfare is harmed or threatened thereby."
By 1968, mandated reporting laws were passed in all 50 states of the United States. A mandated reporter is an individual who is routinely responsible for a child’s health or well-being, and includes teachers, day care workers, medical personnel, and law enforcement professionals. Such individuals are required to report cases of suspected child abuse to child protective service agencies. A mandated reporter needs reasonable suspicion, not proof, of child abuse to make a report, and such individuals are protected from litigation for libel in nearly all states. In fact, a mandated reporter may be prosecuted for failing to report suspected child abuse in some states.
Epidemiology
In 2000, an estimated 3 million children were reported to child protective service agencies for suspected abuse or neglect.1 Families who are most likely to be reported to child protective service agencies are those with a history of substance abuse; domestic violence; socioeconomic constraints, such as poverty, inadequate housing, and unemployment; and poor parenting skills, such as young parental age, mental health problems, and unrealistic expectations of a child’s development. There also may be racial disparities in reports of suspected child abuse. One study found that young minority children with fractures that ultimately were determined to be accidental were three times more likely to be reported for suspected abuse than Caucasian children.2
Of these reports of suspected child abuse, 32%, or 879, 000, were substantiated as cases of child abuse or neglect. Of these substantiated cases, 63% were due to neglect, 19% were due to physical abuse, 10% were due to sexual abuse, and 8% were from emotional maltreatment. In 2000, 1200 children died from child abuse or neglect. Eighty-five percent of these deaths were in children younger than 6 years of age.
Unfortunately, there are numerous ways in which children are maltreated. This article will focus on the most frequent manifestations of physical abuse, such as bruises, burns, fractures, and abusive head trauma, which also is known as Shaken Baby Syndrome.
Cutaneous Manifestations of Physical Abuse
Bruises. Bruises are the most common injury in abused children, and are a common accidental injury of childhood. There are several historical and physical features that help to distinguish between accidental and abusive bruises, but still there may be considerable overlap. An understanding of the pathophysiology of bruises may be useful to aid in this distinction.
Pathophysiology. A bruise occurs when there is an impact to the skin surface, which results in disruption of underlying capillaries, leading to extravasation of blood into the dermis. The location of the impact and the complexion of the child’s skin can contribute to a bruise’s appearance. Bruises in locations on the body where the supporting tissue is areolar, such as the genitalia and periorbital regions, may appear immediately. Bruises in areas of significant muscle mass, such as the thigh, may not appear until days later, after extravasated blood has traversed the quadriceps or hamstring muscles to reach the dermis. A child’s complexion may affect the appearance of a bruise, as children with darker complexions may not be noted to have bruising unless the skin is inspected very closely.
It previously was thought bruises undergo a predictable sequence of color changes during healing, but this premise recently has been challenged.3 Many of the initial studies evaluating the change in color sequence of bruises were performed in adult cadaver models, and the applicability of these results to living children has been questioned. Stephenson and Bialas performed a prospective analysis of the evolution of color changes in children with bruises.4 They recorded the color of bruises in children who were admitted to an inpatient pediatric unit with accidental trauma. These researchers noted that red was apparent in bruises up to one week after injury, yellow was seen in bruises that were 1-12 days old and green was not present in injuries fewer than 2 days old. Many of the tables regarding the age estimation of bruises printed in textbooks have been adapted from Wilson, who recognized the imprecise nature of dating bruises and recommended that practitioners refrain from stating the precise age of a bruise.5
History and Physical Examination. The location of bruises on a child is helpful in determining whether the mechanism is accidental or inflicted. Typically, children who are not ambulatory rarely have bruises, as their activity does not predispose them to falls unless they are left unattended. A 1999 study prospectively evaluated 973 young children who received care in several pediatric practices and found that bruises rarely were encountered in pre-ambulatory children who presented for routine well-child visits.6 Ambulatory children, such as toddlers, frequently have bruises on areas of bony prominences, such as the forehead, knees, and elbows, as these are the regions that first are impacted during a fall. However, there are regions of the body that are well protected in normal household falls, such as the neck, groin, and inner aspects of the thighs. A history that does not include impact to these regions during a fall should raise the suspicion of inflicted injury.
Bruises that consist of certain highly defined patterns are suggestive of inflicted injury. Frequently, the pattern of the bruise conforms to the implement that was used to strike the child. Implements commonly used include the hand, belts, cords, ropes, and rulers. Cords, belts, and ropes can be looped, leading to U-shaped bruises. Rigid, linear objects, such as rulers or cooking utensils, result in linear bruises. (See Figure 1.) If the implement is applied to the child with high velocity, there may be a negative image of the implement, with skin that is not bruised outlined by a fine rim of petechiae that conforms to the shape of the implement.7
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Bite marks lead to a highly distinctive pattern of bruises. They may appear as an arched pattern of individual tooth prints that conform to the central and lateral incisors and to the canines. Forensic dentistry may be helpful to aid in the identification of the perpetrator based on the pattern of the bite injury. The typical distance between the mandibular canines in children is approximately 2.5 cm, while in adults this distance usually is greater than 3 cm.8 This distance between the canines should be used only as an estimate, as it may increase only 5 mm between childhood and adulthood.7 If bites are recent and the child has not bathed, he can be swabbed with a saline-soaked cotton swab and sent for DNA markers that potentially could identify the perpetrator. Dental impressions also can be taken from alleged perpetrators and compared to the bite mark itself.
Children may be restrained during beatings, leading to bruises around the extremities. If the child is restrained by being held about the extremities with the hands of the perpetrator, there may be isolated, circular bruises of the volar and dorsal surfaces of the arms and legs. If ligatures are used, there may be circumferential, linear bruises around the ankles or upper arms, occasionally accompanied by abrasions and lacerations if the ligature was applied tightly.
Conditions that May Be Confused with Inflicted Bruises. Some conditions may be confused with inflicted bruises. Several religious or folk medicine practices from Southeast Asia may result in a distinctive pattern of bruising.7 One is coin-rubbing, or Cao Gaio, which causes petechial bruising over the paraspinal region of the back. A coin is dipped in hot oil and rubbed vigorously over the child’s back as treatment for medical illness. A second healing method involves heating a glass and applying it to the skin; when removed, there can be circular petechial bruises. While these practices result in injury, the caregiver’s intent was to treat the underlying medical condition.
Mongolian spots are a congenital variation in skin color, most frequently seen in infants and children with darkly pigmented skin. They most commonly appear as slate-blue or brown-black macules on the sacrum, but also can be present on the lower extremities or forehead. Unlike bruises, there is no accompanying tenderness or edema. They fade over a period of months to years, and easily are distinguished from bruises due to the long period over which they resolve.
Other medical conditions associated with increased skin fragility and subsequent bruising include connective tissue disorders such as osteogenesis imperfecta and Ehlers-Danlos syndrome. Children with these disorders tend to have hypermobility of the joints and skin laxity. Systemic disorders associated with diminished coagulation, such Immune Thrombocytopenic Purpura (ITP), Hemophilia A and B, and von Willebrand’s disease, may result in either extensive petechiae or ecchymosis, but laboratory evaluation can distinguish these disorders from inflicted bruises. Other disorders associated with vascular inflammation, such as Henoch Schonlein Purpura, result in purpuric, palpable lesions of the lower extremities and torso, the pattern of which also can be helpful in distinguishing it from inflicted injury.
Burns. Inflicted burns are a significant cause of morbidity and mortality. Inflicted burns account for 25% of all hospital admissions for children with burns.9 Inflicted burns can be due to scald injury, in which a hot liquid is thrown at a child or a child forcibly is immersed in hot liquid, or due to contact injury, in which a hot implement forcibly is held against the child’s skin.
Pathophysiology. The depth and extent of a burn depends on the temperature of the implement or liquid that contacts the skin, as well as the duration of this contact. Burns can be characterized by the depth to which they penetrate the epidermis, dermis, subcutaneous tissue, muscle, and bone. A superficial thickness burn is characterized by thermal injury to the epidermis. This appears as a "sunburn," with erythema of the skin and minimal pain and tenderness to palpation. A partial-thickness burn can be characterized by the depth of the dermis that is penetrated by the thermal injury. A superficial partial-thickness burn is characterized by injury to the upper half of the dermis and typically forms blisters that have underlying pink skin with brisk capillary refill. In contrast, deep partial-thickness burns penetrate into the lower half of the dermis, and the skin underlying the blisters is paler and drier due to more extensive capillary damage. Partial-thickness burns may heal with or without scarring.10 Full-thickness burns result from thermal injury that results in destruction of both the epidermis and dermis.
Duration of exposure and temperature has been determined to predict the likelihood of a full-thickness burn due to hot water. Young children typically tolerate bath water that is less than 101°F.7 Hot tub temperatures can vary between 104-108°F, while water that is 110°F most often is painful to an adult.7 Water that is 120°F will cause full-thickness burns in approximately 10 minutes, while water that is 150°F will cause full-thickness burns within two seconds.11,12 Similar formulations for duration of exposure and temperature have not been determined for hot objects.
History. There are several aspects of the history as to how the burn occurred that are helpful in distinguishing accidental from inflicted burns. Accidental burns have a clear history of contact with a hot object or liquid. Accidental burns usually are seen in children whose behavior can place them within reach of such objects. Children who can sit well and reach easily can pull containers of hot liquid toward and onto them, especially while seated on a caregiver’s lap. Toddlers can reach up to pull such containers of hot liquid from the table, stove, or microwave down onto themselves. Older children who have the dexterity to play with and ignite matches or lighters may cause contact burns on the hands and face and, more seriously, may ignite clothes or furniture.
Historical hallmarks of inflicted burns include those with no explained mechanism or those purported to have been inflicted by a young child who cannot provide such a history. Victims of inflicted burns tend to lack the behavioral and motor skills that place them within reach of hot objects or liquids. When such children encounter hot objects or liquids, they will try to remove themselves from contact with such by pulling or turning away, or attempting to climb out of a tub or sink filled with hot liquid. The caregive may provide a history that the child performed a task of which the child is not capable, such as a very young infant manipulating a lighter or turning on a hot water faucet.
Physical Examination. Children with accidental scald burns from hot liquids most often have burns that are on the anterior plane of the body and have concentric radiation of the depth of the burn.9 For example, a child who reaches up and pulls a hot liquid down onto himself may have burns of the face, chest, and arm. The point of contact of the hot liquid on the body will have the deepest burn. As the hot liquid travels down the body, it cools, leaving burns that are not as deep.9 The demarcation between normal and burned skin tends to be irregular, depending on the path that the hot liquid travels down the body. Accidental scald burns also can be caused by hot foods, which tend to be more viscous and adherent, prolonging the time of contact with the skin and occasionally causing deeper burns than water at a similar temperature. Clothing does not protect against the degree of burn injury, as hot liquids can soak into the fabric, prolonging contact with the skin.
Scald burns suggestive of inflicted injury include those with clear demarcation lines, especially around the hands and feet, ("stocking-glove"), (see Figure 2) as well as those that involve protected areas of the body, such as the genitalia.7,9,13 A pattern of burn injury that is pathognomic for inflicted injury is one that involves the genitalia and lower extremities. This occurs when a child forcibly is restrained or dunked into a bathtub of hot water. As children are lowered into the water, they reflexively flex their hips and knees, protecting the creases in the groin and popliteal fossa. The resultant burn, therefore, involves the anterior and, to a lesser extent, posterior aspects of the lower extremities and the lower half of the torso. If the buttocks are pressed against the floor of the sink or tub, the area around the gluteal cleft may be spared, resulting in a doughnut pattern of burn.7,13 Similarly, if the soles of the feet are pressed against the floor of the sink or tub, they may be spared as well. If the child struggles, the watermark level (the highest level to which the water immerses the body) may be irregular and wavy on the lower abdomen.7 If any part of the child’s body rigidly is restrained in the hot water, the watermark level will be rather straight.7 Children who accidentally enter a tub of hot water typically will not sit down in the water, and alternately may stand on one leg or the other until removed from the hot water. The resulting burns may involve the lower extremities only, with splash burns scattered elsewhere on the body.
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Accidental contact burns tend to be on the anterior plane of the body and often are solitary. When school-age children experiment with matches or cigarette lighters, there tends to be a single burn on the palmar aspect of the thumb or index finger. When children reach out or up to touch an iron, there may be burns on the palms. If the child reaches up to pull the iron down and the iron falls onto the child, there may be burns on the face, hand, arm, or foot, depending on the trajectory of the iron as it fell. Contact burns on the posterior portions or well-protected areas of the body, such as the genitalia, neck, or axillae, are suggestive of inflicted contact burns.
Medical Conditions that May Be Confused with Abusive Burns. There are a few medical conditions that may be mistaken for abusive burns. Dermatological conditions that cause the formation of bullae, or blisters, include bullous impetigo and epidermolysis bullosa. In bullous impetigo, which most often is caused by Staphylcoccus aureus or Streptococcus pyogenes, bullae that are several millimeters in diameter can form. These bullae may appear in crops and coalesce together. When these bullae rupture, the base may appear as an erythematous, glistening macule that may be mistaken for partial-thickness burns due to cigarettes, which tend to have a smaller diameter. The yellow crust that may appear on top of ruptured impetiginous lesions is easy to remove with water, while that of a partial-thickness burn due to a cigarette is much more adherent.13 In addition, the center of a cigarette burn most often will be deeper than the periphery. Epidermolysis bullosa is a rare, inherited condition in which large bullae can form either spontaneously or over areas of friction. Again, when these bullae rupture, they appear similar to partial-thickness burns. Both impetigo and epidermolysis bullosa are not painful, in contrast to partial-thickness burns. Some forms of candidal and ammoniacal diaper dermatitis may appear as a partial-thickness burn, but can be characterized by diffuse, nontender erythema of the skin surrounding the area of skin sloughing.13
Fractures
Fractures are common injuries in children who have been physically abused. A 1991 study found that of 39 young children with humeral and femoral fractures, 23% were inflicted.14 A subsequent study by these same investigators of 253 fractures in children younger than 3 years of age demonstrated that 24% were due to abuse.15 While there are some fracture patterns that are pathognomic for inflicted injury, such as posterior rib fractures (see Figure 3), there can be overlap among fracture patterns in both inflicted and accidental injuries.
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History. A child who sustains a fracture most often has a change in demeanor. A child may cry, become irritable and difficult to console, and have limited use of the affected extremity. Caregivers may note that handling the infant or child in a particular way caused the child to cry or become irritable. Such a change in behavior helps to localize the time at which the fracture most likely occurred. Children who do not roll, pull to stand, cruise, or walk are least likely to sustain fractures in general because their motor activity typically would not place them in a situation at risk for fracture. Lack of witnesses, no provided mechanism of injury, or a mechanism of injury that suggests a developmental level more advanced than that which is expected are all historical factors that should raise concern of inflicted injury.
Physical and Radiological Examination. The fracture pattern may provide clues as to the mechanism of injury. Spiral fractures typically occur from twisting mechanisms. Such fractures of the long bones in children who are not ambulatory strongly should raise the possibility of inflicted injury. In some cases, these fractures may occur as the caregiver grasped the child’s extremity during a fall, and a consistent history of such should make one less suspicious of an abusive injury. In toddlers and younger children who are ambulatory, accidental spiral fractures of the femur may occur as a child is running, then trips and twists the lower extremity while falling.14 Spiral humeral fractures in young, non-ambulating children historically have been considered to be abusive.14 There have been, however, recent case reports to suggest that such fractures sometimes may be accidental. For example, a case of a witnessed humeral fracture, which incidentally was videotaped, has been reported in an infant who rolled from the prone to supine position, entrapping the upper extremity in the process.16 In addition, linear skull fractures may be seen in short, vertical, household falls from beds, chairs, and changing tables onto firm surfaces, and when children tumble down flights of stairs.17,18
However, there are some fracture patterns that are highly suggestive for child abuse. Posterior rib fractures, such as those close to the rib neck and head, are due to levering of the posterior rib neck over the transverse spinous process as the rib cage is squeezed vigorously.19 This fractures the inner cortex of the posterior rib neck and the postero-lateral arc of the rib. When the thorax undergoes severe anterior and posterior compression, the fracture line may extend to the anterior rib’s articulation with the sternum. In addition, sternal fractures may be due to direct blows, and without a history of such trauma, are highly specific for inflicted injury.19 Metaphysial corner fractures, also known as "bucket handle" fractures, occur due to axial traction on a child’s limbs. As the ligamentous attachments are weaker than the ligaments themselves, the metaphysis may be sheared, leaving the periosteum intact. Such a fracture appears as a "bucket handle" and also is considered to be pathognomic for abuse.20 These fractures most often are seen at the distal regions of the long bones, such as the femur, tibia, and humerus. Multiple fractures in different stages of healing are highly suggestive of repetitive trauma and, therefore, child abuse, but also should prompt one to consider other causes of bony fragility that have a propensity for fractures. However, when multiple, healing fractures are seen with other unexplained injuries, it becomes more likely that these injuries are due to child abuse.
Dating Skeletal Trauma. Fractures undergo a predictable pattern of healing. When fractures occur, there is attendant swelling due to hemorrhage and inflammation in the surrounding tissues. While symptoms of soft-tissue hemorrhage and inflammation may resolve in several days, it can be present on plain radiographs up to 10 days after the fracture occurred. Subperiosteal new bone formation can be apparent on plain radiographs as early as 4-7 days after injury, followed by loss of definition of the fracture line within 10-21 days after injury. The peak of soft callus formation most often is apparent radiographically within 10-21 days after the injury. Hard callus most often is seen within 14-42 days after injury, with complete remodeling evident at three months to one year after the injury.21
Diagnostic Imaging. Occult skeletal trauma most often is seen in children younger than 2 years of age, and in this age group, a skeletal radiographic survey will have the greatest yield of detecting such trauma. A skeletal radiographic survey should not be confused with a baby-gram or body-gram. These previously utilized surveys employed a one- or two-exposure study that captured the child’s entire skeleton and are inadequate to assess for occult fractures, such as metaphysial corner fractures or posterior rib fractures.
It may be useful to repeat the skeletal survey several weeks after the initial study, as some fractures can be detected only when healing. One study found that a second skeletal survey demonstrated additional injuries in 14/23 (61%) young children evaluated for suspected abuse.22 Many of these additional injuries included metaphysial and rib fractures.
Medical Conditions with Propensity to Fractures. There are several acquired and congenital medical conditions that may lead to bony changes or fractures that could be confused with abusive fractures.23 One such condition is osteogenesis imperfecta, a rare, inherited condition that results in bony fragility and propensity for fractures with routine handling or minor trauma. Children with such medical conditions may present with radiographic findings of multiple fractures in different stages of healing. The hallmark of this disorder is a genetic mutation resulting in the abnormal synthesis of type 1 collagen. Most cases are inherited in an autosomal dominant fashion, though cases due to spontaneous mutation also may occur.7
Nutritional rickets can lead to bony lesions that may be confused with metaphysial fractures. A recent study demonstrated that such infants are African-American, breast-fed, between 5 and 25 months of age, and did not receive supplemental vitamin D.24 All of the infants in this sample had radiological findings of widening of the growth plate; fraying, cupping, and irregularity of the metaphysis; and osteopenia. In addition, all patients were hypophosphatemic as well.
Abusive Head Trauma
While trauma is the most common cause of death in childhood, abusive head trauma is the most common cause of traumatic death in infancy. In 1946, pediatrician Robert Salinger characterized the original "battered babies."25 He described an infant nurse who confessed to killing three infants and injuring many more in her care. She would become angry and frustrated about an infant’s crying and would grab the infant about the chest or the upper extremities and shake him violently until the infant ceased to cry. Autopsies on two of these infants revealed diffuse subdural hemorrhage over both cerebral hemispheres.
Pathophysiology. The biomechanical forces necessary to cause this spectrum of injuries have been understood only recently. In 1972, Caffey described the "Whiplash Shaken Infant Syndrome," which suggested that the pathogenesis of injuries such as subdural hemorrhage and retinal hemorrhage to rotational deceleration forces of the head.26 Such forces cause the dura to slide along the surface of the brain, rupturing the vessels in the subdural space. Similarly, the vitreous humor slides along the surface of the retina, disrupting the vessels that course between the layers of the retina, resulting in diffuse retinal hemorrhage.27
There has been some disagreement as to whether shaking alone or shaking and impact is necessary to cause this spectrum of injuries. In a 1987 study, researchers constructed a biomechanical infant model and demonstrated that the forces necessary to cause concussion and subdural hemorrhage were generated only when this infant model was shaken and impacted on a fixed, hard surface.28 Such evidence of impact injury to the head may not be apparent on initial examination, and may be recognized only when the scalp is shaved or the galea exposed at surgery.29 Other investigators have suggested that vigorous, violent shaking alone generates the force necessary to cause these injuries.
History. Caregivers who inflict these injuries sometimes are unaware that they have injured the child. However, a competent observer to such injuries inherently would realize that the caregiver’s actions would be injurious to the child. Infants and children often are shaken due to a caregiver’s unrealistic expectations of the infant or child or as a disproportionate response to increasing levels of frustration. In some instances, it may be difficult to determine if the caregiver’s intent was to inflict harm or simply to stop the infant or child from crying. Recent studies have demonstrated that perpetrators who injure children in this manner are most likely to be, in descending order, fathers, male paramours, female babysitters, and mothers.30
The histories provided by caregivers may be vague, such as, "I found him like this when he awoke from a nap." There may be suggestion to a remote, poorly defined event, such as, "He may have fallen off the couch yesterday." There is much literature to support the concept that household falls or falls down stairs rarely result in life-threatening brain injury except if a space-occupying lesion, such as an epidural or large intracranial hemorrhage, is present.18,31,32
Children with abusive head trauma can have a wide spectrum of symptoms and signs. Children with milder injuries may have only irritability, vomiting, poor feeding, or sleepiness. These are symptoms that overlap with a myriad of common pediatric illnesses and, thus, these children might not be recognized to have sustained an inflicted head injury. Children with severe injuries often present with more ominous symptoms and signs, such as apnea, unresponsiveness, seizures, or cardiopulmonary arrest. The highest incidence of such injury is in children younger than 6 months of age, due to their proportionally larger head, weak neck muscles, and poor head control, though varying degrees of injury can be seen in children up to 2 years of age.29 Older but physically smaller children with developmental delays also can suffer from these injuries.
Physical Examination. On physical examination, there may not be obvious signs of trauma to the head, neck, or chest. Scalp contusions may be seen only when the head is shaved or when the scalp is exposed during craniotomy.29 The extent of brain injury largely determines the signs and symptoms a child may have. There may be focal neurological signs, such as hypertonicity or flaccidity, gaze palsies, or unequal pupils. The child may be irritable or unresponsive to pain. Focal or generalized seizures may be apparent. Cardiopulmonary arrest may be due to significant brain injury, either from direct deceleration injury to the brain stem and upper cervical cord or due to subsequent hypoxia and ischemia from cerebral edema.29
Retinal hemorrhages are present in 60-95% of patients with abusive head trauma.27,29 They sometimes may be appreciated on direct ophthalmoscopy without mydriatics, but often the true extent of such may be appreciated only with dilated, indirect ophthalmoscopy. Typically, retinal hemorrhages seen in those children with abusive head trauma are multiple and often extend to the periphery.27,29 They can occur in multiple layers of the retina, most often in the nerve fiber and ganglion cell layers, and appear to be flame-shaped. Intraretinal and preretinal hemorrhages are more often dot-, blot-, or boat-shaped hemorrhages.27,29 Retinal hemorrhages may be either unilateral or bilateral. Retinoschesis, internal splitting of the retina, macular folding, and vitreous hemorrhage are other retinal abnormalities often associated with abusive head trauma.27,29
On occasion, retinal hemorrhage may be seen in head injuries associated with accidental mechanisms. A recent case series documented three cases of accidental falls and found that retinal hemorrhages were present on the same side as the subdural hemorrhage.33 However, the retinal hemorrhages noted in this case series were isolated to the posterior pole of the retina, did not cover a significant surface area of the retina, did not extend to the periphery, and were not accompanied by retinal folds or detachment.
Cardiopulmonary resuscitation typically does not cause retinal hemorrhages. Odom and colleagues performed dilated indirect ophthalmoscopy on hospitalized children who underwent at least one minute of closed chest compressions during cardiopulmonary resuscitation. Of the 43 patients studied, only one patient had retinal hemorrhages, which were few in number. This patient also had evidence of activated coagulation at the time of the ophthalmoscopic examination.34 Retinal hemorrhage may be seen in up to 30% of infants shortly after birth, but typically resolve after 6 weeks of age.35,36
Radiographic Evaluation. Computed tomographic (CT) scanning is the most rapid, reliable tool in the diagnosis of abusive head trauma. Acute subdural and subarachnoid hemorrhage, the most common brain injuries seen in children with abusive head trauma, can be appreciated readily on CT by experienced clinicians. Typically, a subdural hemorrhage can be thin and extensive, but occasionally may be large enough to cause mass effect.37 There is a high propensity for subdural hemorrhage to involve the interhemispheric fissure, but it also can involve the convexities, and can be unilateral or bilateral.28,37 Subarachnoid hemorrhages are usually multifocal and can be seen most often along the falx or the tentorium.38 Skull fractures, as well, can be detected by CT scan, suggesting impact of the head onto a fixed, hard surface. Skull fractures most often are linear, but can be stellate or diastastic as well.
Children with more severe deceleration injury to the brain may have evidence of diffuse cerebral edema and diffuse axonal injury. This may appear as a reversal of the differentiation between the gray and white matter, also known as the reversal sign.39 The gray matter therefore will appear less dense than the deeper gray matter structures of the basal ganglia and brain stem, as well as the white matter. Diffuse axonal injury arises from shearing injuries to the structures along the gray-white matter interface. Acute, punctate hemorrhage may be present along the gray-white matter junction of the gyri , the corpus callosum, or the basal ganglia.39
Magnetic resonance imaging (MRI) may be useful to detect small extra-axial fluid collections not appreciated on CT scans, diffuse axonal injury, and to narrow the window of time in which the injury occurred.39 MRI can be difficult to obtain in children requiring mechanical ventilation and inotropic support, and should be considered as an adjunct to CT scans.
Other hallmarks of shaking injury include posterior and anterolateral rib fractures and metaphyseal fractures. When children present acutely with brain injury due to shaking, these injuries may not be detected readily on plain radiographs at the time of initial presentation to the ED. At the time of the acute injury, such fractures may not have overlying tenderness, edema, or crepitus, and there may not be loss of function of the involved extremity. Such fractures may be detected only with skeletal scintigraphy, which can be difficult to obtain in children who have significant brain injury that requires mechanical ventilation and inotropic support. Plain radiography obtained within 10 days of initial presentation may be the only modality to demonstrate these fractures in this sicker group of patients with abusive head trauma.39 When these fractures are present with the previously described CNS and retinal findings, this constellation of injuries is pathognomic for abusive head trauma.
Outcome. Long-term outcome of survivors of abusive head trauma tends to be poor, and is dependent on the severity of symptoms on initial presentation.40-42 Children who present with apnea, seizures, and coma are more likely to have long-term neurologic sequelae such as developmental delay, seizures, and static encephalopathy. The overall mortality from such injuries can be as high as 25%.40
Closed Head Trauma that May Be Confused with Abusive Head Trauma. Some children who have contact injuries to the head, either from short vertical falls or blows to the head, may sustain epidural hemorrhage, subdural hemorrhage, or cerebral contusion. When there is a contact injury to the head, the point of impact causes the inner table of the skull to bend inward, putting it under compression, which may injure blood vessels within the epidural or subdural space, as well as the parenchyma of the brain itself.43 These focal injuries may be accompanied by a skull fracture as well. At the same time of this inbending of the skull, there also is simultaneous outbending of the skull around the site of impact.43 This puts the outer table of the skull under tension, and a skull fracture may result, either proximate to or remote from the site of impact. As the skulls of infants are somewhat more elastic, the tension on the outer table of the skull as it bends outward from an impact site may not always result in a fracture.43 These children typically do not present with significant alterations in mental status, unless the EDH or SDH is large enough to cause mass effect and focal cerebral edema.43 In contrast to children who have head injury due to shaking, the outcome of children with subdural hemorrhage due to impact injury typically is good, as most often the hemorrhage is not extensive and spontaneously resolves within 48 hours after injury, with little neurological sequelae.44
References
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3. Schwartz AJ, Ricci L. How accurately can bruises be aged? Pediatrics 1996;97:254-256.
4. Stephenson T, Bialas Y. Estimation of the age of bruising. Arch Dis Child 1996;74:53-55.
5. Wilson EF. Estimation of the age of cutaneous contusions in child abuse. Pediatrics 1977;60:750-752.
6. Sugar NF, Taylor JA, Feldman KW, et al. Bruises in infants and toddlers: Those who don’t cruise rarely bruise. Arch Peds Adolesc Med 1999;153: 399-403.
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Physician CME Questions
1. Which of the following fractures in a 12-month-old child is most suggestive of child abuse?
A. Clavicle fracture
B. Linear skull fracture
C. Tibia fracture
D. Bilateral anterolateral rib fractures
2. Which of the following most often is seen in children with abusive head trauma?
A. Epidural hemorrhage
B. Subdural hemorrhage
C. Cerebral contusion
D. Hydrocephalus
3. Which of the following individuals is mandated to report child abuse?
A. Biological parent
B. Girlfriend/boyfriend of a parent
C. School crossing guard
D. School teacher
4. Which is the most useful modality to detect injuries due to abusive head trauma?
A. Plain radiography
B. Ultrasound
C. MRI
D. CT scan
Child abuse can be difficult to recognize, especially in the often chaotic environment of the emergency department. As the leaders of the community and medical safety net that is the ED, emergency physicians play a unique role in detecting, treating, and preventing child abuse. This issue of Emergency Medicine Specialty Reports provides an update on the patterns, diagnosis, and treatment of physical child abuse injuries.
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