Identifying the Subtle Signs of Pediatric Physical Abuse
Part II: Injuries to the Thorax, Abdomen, and Oral Cavity
Author: Kirsten Bechtel, MD, Associate Medical Director, Child Abuse Evaluation Team, Yale-New Haven Children’s Hospital, CT.
Peer Reviewer: Georges Ramalanjaona, MD, DSc, FACEP, Associate Professor of Emergency Medicine; Associate Chairman for Academic Affairs, Department of Emergency Medicine, Seton Hall University, South Orange, NJ.
In part one of this two-part series, we reviewed the cutaneous findings that are suggestive of abuse and abusive head trauma. In the conclusion of this series, the author focuses on thoracoabdominal trauma and injuries to the ear and mouth region that may indicate abuse. The author discusses suspicious history and physical findings and injury patterns that may suggest abuse. The high incidence of morbidity and mortality associated with abusive abdominal trauma demands that emergency physicians maintain a high degree of suspicion and a low threshold for imaging in an abused child who potentially may have multiple injuries. Failure to diagnose this trauma may result in devastating consequences for the child. The child with the potential for physical abuse will continue to present diagnostic and emotional challenges to emergency physicians. Early diagnosis and timely referral to appropriate agencies may improve the long-term outcome for these children.
— The Editor
Thoracoabdominal Injuries
While inflicted abdominal trauma is a less common form of physical child abuse, it has significant, associated morbidity and mortality. Blunt abdominal trauma due to child abuse has a higher mortality than that caused by accidental blunt trauma, with some studies demonstrating fatality rates as high as 50%.1-3 After head injuries, abusive abdominal trauma is the most common form of fatal child abuse in patients who are beyond infancy.4 Rib fractures are the most common thoracic injuries in physically abused children, but underlying injury to the intrathoracic organs may occur as well.
Epidemiology. Abusive abdominal trauma accounts for a small portion of traumatic injuries in children. One study retrospectively analyzed the medical records of children who presented with traumatic injuries to the emergency departments (EDs) of two urban hospitals during a 15-year period.5 Blunt trauma due to child abuse accounted for 0.5% of 10,000 traumatic injuries. The average age of children with inflicted abdominal trauma was 24 months, and 64% were male. The mortality from inflicted abdominal trauma in this study was 45%.
Ledbetter conducted a retrospective review of 156 pediatric patients with blunt abdominal trauma.3 Of the 156 patients, 139 (89%) had abdominal injuries judged to be accidental, and 17 (11%) had abdominal injuries thought to be caused by abuse. When comparing these two groups, the authors found that abused children were much younger (2 years 6 months vs 7 years 8 months), and that child abuse accounted for 44% of all abdominal trauma in children younger than age 4. The mortality rate was significantly higher for abused children compared to children with accidental injuries (53% vs 21%, respectively). The mortality for children with inflicted intestinal perforation was 71%, while the mortality for those with accidental intestinal perforation was 28%. Sixty-five percent of children who had accidental abdominal trauma died from associated closed head injuries.
Thoracic injuries in physically abused children most are often due to rib fractures. This fracture pattern is highly specific for child abuse, and is most commonly seen in young infants. On rare occasions, there may be associated injury to the intrathoracic organs. When inflicted thoracic injuries are fatal, it often is because there is associated cardiac injury.6,7
Mechanisms and Patterns of Injury. Most inflicted abdominal injuries are either due to a focal, forceful blow or rapid deceleration and impact that occurs when a child is thrown. While children who have accidental abdominal trauma most often present immediately after the injury has occurred, children with inflicted abdominal trauma frequently present for medical attention long after the injury has occurred. This is because the assailant or other unsuspecting caregivers may not appreciate the severity of the child’s injury until shock develops from intra-abdominal hemorrhage or from peritonitis due to intestinal perforation. This statement is supported by data from Ledbetter, who noted that children who sustained accidental trauma most often presented within three hours of injury, while those who sustained inflicted injury presented more than three hours after injury.3 In another series, Cooper and coworkers found that children with abusive abdominal trauma presented an average of 13 hours after injury.5
When a child is struck in the abdomen, the intestines and solid viscera are compressed between the striking object and vertebral column.3,8 Children who are struck in the epigastrium frequently will injure the left hepatic lobe, pancreas, and duodenum as the organs are compressed against the vertebral column. The transverse and descending duodenum particularly are susceptible to injury from such a mechanism, which often results in intramural hematomas.4,9
Small intestine perforation is a well-known feature of abusive abdominal trauma, and most often occurs from a blow to the anterior abdominal wall. In his review of 22 cases of inflicted small intestinal perforations in children, Kleinman found that 60% percent of perforations occurred in the jejunum, most often just distal to the ligament of Treitz, while 30% occurred in the duodenum and 10% in the ileum.10 Small intestine perforations are thought to be caused by either a rapid increase in intraluminal pressure or shearing of opposing intestinal surfaces.4 Rapid deceleration after a child is thrown against an object also may cause injury to the mesentery and disruption of the intestinal vascular supply.4 Other injuries associated with abuse include lacerations of the hepatoduodenal ligament, pneumatosis intestinalis, and portal venous gas.11,12
Solid organ injury due to child abuse also has been well described. It has been estimated that up to 10% of all cases of traumatic pancreatitis in children result from child abuse.13 Pancreatic fracture also has been attributed to abusive injury.14 Osseous lesions that are coexistent with abusive traumatic pancreatitis have been described and are thought to be due to systemic release of pancreatic enzymes, leading to medullary fat necrosis.15,16
It is estimated that 5% of all liver injuries in children are due to child abuse.17 Forceful inflicted blows to the epigastrium may result in injuries to the left hepatic lobe; in contrast, the right lobe of the liver more often is injured from accidental abdominal trauma. During accidental blunt trauma, the right lobe of the liver usually is injured following impact of the surrounding ribs and spine.15 While serious accidental abdominal trauma often involves the spleen and kidneys, splenic and renal injuries are not often seen in abusive trauma.3
When an inflicted abdominal injury is fatal, it frequently is due to intra-abdominal hemorrhage or peritonitis from unrecognized intestinal perforation. Cooper and associates reported that of the 10 children who died of abusive abdominal trauma in their study, nine of the deaths were due to intra-abdominal hemorrhage and one was due to peritonitis.5 Similarly, Sivit and colleagues found that intestinal and mesenteric injuries were associated with poor outcome.18 In the Sivit et al series, children who were hemodynamically stable on presentation and were thought to have abusive abdominal trauma most often had solid organ injury. Hemodynamically unstable children who subsequently died were more likely to have had injuries to the intestinal tract and mesentery. In some fatal cases in which child abuse is suspected, whether the child died from inflicted abdominal trauma may only be determined at autopsy.4
Rib fractures are the most common type of thoracic trauma in physically abused children. Rib fractures account for up to 29% of all fractures in children who are physically abused, and up to 51% of all fractures in infants who died from physical abuse.19-21 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 vigorously squeezed;21 this fractures the inner cortex of the posterior rib neck and the posterolateral 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. Sternal fractures may be due to direct blows. Without a history of such trauma, they are highly specific for inflicted injury. Rib fractures do not result from routine infant care, chest physiotherapy, or cardiopulmonary resuscitation because of the compliant nature of an infant’s chest.22-24
Despite the high frequency of rib fractures in abuse, clinically significant injury to the lungs and heart is uncommon. Pulmonary contusions, diffuse alveolar damage, pneumomediastinum, and multiple rib fractures have been described in a young infant with intentional, forceful compression of the chest.25 (For an example, see Figures 1a and 1b.) Pneumothoraces may be associated with rib fractures in older children. (See Figure 2.) However, in young infants with highly compliant chest walls, pneumothoraces may be present without associated rib fractures. On occasion, pleural effusions may accompany rib fractures and underlying pulmonary contusions. Inflicted thoracic trauma may cause chylothorax, either from injury to the thoracic duct or from chylous ascites.26,27
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Inflicted cardiac injuries are rare and frequently fatal. Cohle reported fatal inflicted lacerations of the right atrium in children who were 9 weeks to 2 and one-half years old.28 Such injuries were thought to be due to blunt thoracic trauma with associated abdominal compression. Commotio cordis also has been associated with inflicted blunt trauma to the anterior chest. Denton and Kalekar described two cases of fatal commotio cordis in children 14 months and 3 years of age.29 Both children collapsed immediately after having been struck in the anterior chest with a closed fist. On arrival to the ED, both children were in full cardiopulmonary arrest and could not be resuscitated. There was no evidence of external chest trauma in either child.
Historical Information. Stairway falls or simple household falls rarely result in life-threatening thoracoabdominal injury in children. To support this, Huntimer and colleagues conducted an extensive literature search for reports of blunt abdominal trauma that resulted in small intestine perforations, and reports of the types of injuries sustained in stairway falls.30 Of the 28 articles reviewed, motor vehicle accidents, child abuse, physical assaults, miscellaneous blows, non-stairway falls, and bicycle handlebar injuries most often were found to be the cause of small intestine perforations. Falls on stairs were not reported as a cause for any of the 312 cases of small intestine perforation reviewed by these authors. Falls from heights caused seven of the 312 small intestine perforations. These seven cases were among reports of 1000 cases of falls from as high as 17 stories. Many of these falls involved impact onto objects that extended out in one dimension while allowing the patient’s body to continue movement either above or below the object (such as the edge of furniture or a clothesline, chair, or bike saddle).
Joffe and Ludwig also reviewed the spectrum of injuries found in children with stairway falls.31 They postulated that the mechanism of injury in stairway falls consists of an initial impact followed by a series of low-energy falls. In their analysis of 363 children who presented to a pediatric ED after stairway falls, these authors found no difference in the number or severity of injuries in falls of fewer than or more than four steps. Many injuries were isolated and none had associated small intestine perforations. None of the patients had life-threatening injuries or required admission to an intensive care unit.
Physical Examination. The physical examination of children with suspected abusive thoracoabdominal trauma should be thorough and done in a reassuring manner. Subtle alterations in the child’s level of consciousness, heart rate, and capillary refill may be the earliest signs of hypovolemia due to hemorrhage or peritonitis, and most often will be present before any changes in the child’s blood pressure. Not all children with abusive abdominal trauma will have external evidence of trauma. The abdominal wall is compliant and frequently yields to forceful blows without bruising.3,8 The chest and abdomen may be tender to palpation, but the origin of the tenderness can be difficult to localize on physical examination. Some children with other evidence of physical abuse may have occult intra-abdominal trauma, such as liver lacerations, but have few signs or symptoms of such.32
Laboratory Evaluation. Laboratory screening tests, such as liver transaminases, amylase, lipase, and urinalysis, may be helpful for detecting occult intra-abdominal trauma in physically abused children.32 If blunt trauma to the chest is a consideration, and cardiac contusion a possibility, then serial monitoring of the patient’s ECG and cardiac enzymes, such as creatinine phosphokinase-MB fraction, may be useful. Repeated measurement of hemoglobin and hematocrit may be useful in children with suspected intra-abdominal hemorrhage. Leukocytosis, with a neutrophil predominance, may be present in patients with peritonitis from unrecognized intestinal perforation. Microscopic hematuria may be a sign of renal injury.
Diagnostic Imaging Strategies. Abnormalities on plain radiographs from intestinal perforation depend on the location of the perforation and the volume of intraperitoneal air. Most often, free intraperitoneal air will not be identified on supine views of the abdomen. However, an upright view of the abdomen may demonstrate free intraperitoneal air under the diaphragm. If there is a large amount of free intraperitoneal air, it also might be visible on supine views as it outlines the falciform ligament of the liver or the serosal aspect of the gut.4 Intraperitoneal free fluid, such as blood or ascites, most often gives the appearance of either a diffusely increased density overlying the bowel or a central location of the bowel on supine views. Plain radiographs may detect an intramural hematoma if it encroaches on the intestinal lumen and causes obstruction, thereby resulting in a gas-filled stomach with little intraluminal air in the distal intestine. Intramural hematomas, as well as intestinal strictures, are perhaps best delineated by an upper gastrointestinal series.4
Pulmonary contusions most often are due to direct trauma to the pulmonary vessels and manifest as infiltrates on plain radiographs shortly after the injury. When such infiltrates appear days after injury, they often represent acute respiratory distress syndrome (ARDS).33 Pulmonary contusions also can be well-delineated by computed tomography (CT) scan. (See Figure 3.) Rib fractures frequently will not be visible on plain radiographs until there is callus formation, which occurs most often within 7-14 days of the injury.16,34 (See Figure 4.)
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CT scan is perhaps the most rapid and reliable diagnostic modality to detect solid organ injury from abusive thoracoabdominal trauma. CT scans also can detect intramural intestinal hematomas and intraperitoneal free fluid. (See Figures 5a-5e.) Ultrasound may be helpful for detecting small intestinal intramural hematomas if there is not a significant amount of intestinal gas. Ultrasound also may be useful for detecting lacerations of the solid organs and intraperitoneal free fluid, but less helpful for determining the extent of such injuries.
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Injuries to the Ears, Nose, and Oral Cavity
Injuries to the head and neck are present in more than one-half of all children who have been physically abused.35 Utensils, scalding or caustic substances, or the perpetrator’s hands are commonly used to inflict oral injuries. This can result in contusions, abrasions, or lacerations of the buccal mucosa, hard and soft palate, the gingiva, and the hypopharynx. Trauma to the teeth and jaw can result from direct blows to the face. When objects are forcefully thrust into a child’s mouth, lacerations of the lingual and labial frenulum, and abrasions of the hard palate, can result. Fractures of the maxilla and mandible also may occur from child abuse. 35 Periorbital bruises, nasal contusions and fractures, and scleral hemorrhages can be caused by direct blows to the face.35,36 Similar injuries may result from accidental trauma, and therefore, it is important to exclude such a history. When gags are applied to a child’s mouth, bruises and abrasions can be present at the corners of the mouth.37
Cutaneous injury to the ear, ipsilateral brain injury, and retinal hemorrhage have been described in children who have been physically abused.38,39 This constellation of injuries has been referred to as "The Tin Ear" syndrome. Children are struck on the side of the head with an object, such as the hand. Impact to the ear can cause the apex of the helix to fold onto itself and be compressed against the side of the head during the blow.39 This results in a rim of petechiae along the either the inner or outer aspect of the helix. It has been postulated that when the head is struck in this manner, it undergoes rotational acceleration. That force is thought to cause the ipsilateral subdural hemorrhage, cerebral edema, and hemorrhagic retinopathy.38
ED Management of Children with Suspected Abuse
When an ED clinician suspects that a child’s injury is due to maltreatment, it is helpful to have an objective approach and to have clear, concise documentation. When obtaining a history from the caregiver, it is important to be thorough and deliberate. For verbal children, it also is helpful to question them separately.
Clear, concise, and legible documentation of the history, physical examination, and radiological and laboratory findings should be part of the ED medical record. It also is helpful to document the caregiver or child’s statements as to how the injury occurred, putting quotation marks around the exact words of their statements. In many jurisdictions, any statements made to medical personnel during the course of evaluation and treatment of a medical condition are exempt from hearsay laws. When possible, all physical examination findings should be clearly documented, with attention to the shape, color, and dimensions of the injury. It also is helpful to note the child’s growth parameters and when possible, to review primary care records, noting any delays in immunizations or missed well-child care appointments.
Medical photography also is helpful to accurately depict injuries at the time of the ED evaluation. The photograph should include identifying information of the child, such as name, date of birth, and date of the photograph. A size standard, such as a ruler, or a well-recognized object, such as a coin, is helpful to depict the size of an injury in the photograph.
When child abuse is thought to be the most likely cause of a child’s injury, the ED clinician must make a determination, in conjunction with child protective service workers, about the child’s safety and the likelihood of further injury if the child returns home. In some cases, when immediate placement into foster care, either with a family relative or designated foster care placement, is not possible, it may be necessary to admit the child to the hospital until a safe environment is secured for the child. Such decisions as to imminent risk of injury should the child remain with the caregiver thought to have caused the injuries and appropriate placement of the child into a safe environment should be concisely documented in the ED medical record.
Summary
Child abuse continues to be a significant problem in the United States. When children present to the ED with injuries, one must consider child abuse as part of the differential diagnosis. The diagnosis of child abuse can be difficult to make, as the history of the mechanism of injury may be false or misleading, especially in young children who are not capable of providing such history themselves. The spectrum of inflicted injury is large, but the most common inflicted injuries are bruises, burns, fractures, and head injuries. In rare instances, some medical conditions share clinical features with inflicted injuries, and evaluation to exclude such conditions should be undertaken when necessary. Documentation in the ED medical record of the history and physical examination in cases of suspected child abuse must be legible and complete. Photographic or diagrammatic representation of injuries should be done, with attention to size, location, and color of injuries. As mandated reporters, ED clinicians must have reasonable suspicion, not proof, of child abuse to make a report to child protective service agencies. It is easy to fail to recognize child abuse if one does not consider it as part of the differential diagnosis of a child’s injuries.
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