NAI

Unfortunately, nonaccidental trauma is common.  More than 1 million children are seriously injured and 5000 killed secondary to abuse each year in the U.S. alone.  Most children are younger than 1 year, and almost all are younger than 6 years.

In a child younger than two years of age, any suspicion of child abuse requires a skeletal survey and a head CT.  In a child older than 2, symptom-specific imaging is recommended; brain MR or head CT can also be considered to evaluate for remote injury.  Bone scan is sometimes useful, usually in the setting of equivocal radiographic findings or delayed workup.  Bone scan is more sensitive for rib fractures, but less sensitive for skull and metaphyseal fractures.

Certain clinical findings should raise the suspicion of child abuse.  These include multiple fractures, especially of different ages, bruising greater than expected for the patient's age, burns (often in the shape of common objects), bite marks, retinal hemorrhage, injury inconsistent with history, and delay in seeking care.

Fractures have varying levels of specificity for child abuse.  The most common fracture in abuse is a long bone shaft fracture, which is not specific for abuse, except in infants younger than 9 months.  Metaphyseal "bucket handle" or "corner" fractures have a high specificity for abuse.  These occur most frequently at the knee (distal femur or proximal tibia and fibula), ankle (distal tibia) and shoulder (proximal humerus).  Posterior rib fractures also have a high specificity.  Rib fractures occur in 5-27% of abuse victims; 90% of all rib fractures occur in patients younger than 2 years.  Other high specificity fractures include scapular and sternal fractures.  Skull fractures are not well-correlated with abuse, as they are common in accidental trauma.  Skull fracture findings concerning for abuse include multiple fractures and stellate fractures.

Brain injury is the leading cause of morbidity and mortality in nonaccidental trauma.  Injury patterns include subarachnoid, subdural, and intraparenchymal hemorrhage.  Diffuse cerebral edema and diffuse axonal injury can also be seen.  An interhemispheric subdural hematoma is very concerning for abuse.

Abdominal injury related to child abuse primarily occurs in children older than 2.  It is usually the result of blunt force trauma.  It accounts for approximately 20% of the fatalities related to abuse.  The most common finding is injury to the duodenum and proximal jejunum; mural hematoma may be seen.  Another injury worthy of mention is pancreatitis; traumatic pancreatitis is the second most common etiology in kids.  Other abdominal findings include solid organ lacerations and contusions, adrenal hematoma, and bladder rupture.


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