Child Abuse

Historical background Tardieu in 1860 (King 1988) described the lesions found during the autopsy of children such as burns and associated these features with “battered children”. In 1946 Caffey (King 1988) reported the association of subdural haematoma and long bone fractures. Reports then became more frequent, but it was only after mainstream use of the definition of Kempe (1962) of the term “battered child syndrome” that the problem started to be debated in public, and legal measures put in place in various countries. Key points •

Child abuse has been reported in the literature since the 1860s but it was not until the 1960s that there was public and legal awareness

Definition The initial definition by Kempe implied direct physical abuse and has since been broadened to psychological and sexual abuse, emotional and medical neglect. If a child is harmed by the lack of appropriate treatment for a specific condition (for example : parents or caretaker who refuse physical therapy and casting for a clubfoot) , it is considered as medical neglect and necessitates the same general approach as direct physical abuse. Key points

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Kempe’s definition has been broadened to include psychological and sexual abuse, emotional and medical neglect.

Epidemiology

 

The exact number of children being neglected or abused is impossible to determine since numerous cases are undiagnosed or unreported. A general estimate is that 1 to 1.5 % of all children are abused (Akbarnia 1996). Child abuse is universal and found in all races and classes. All children can be abused but the majority are small children, especially below the age of one. Boys and girls are equally affected. Stepchildren are at greater risk. Once abused there is about a 35 % of chance of “ relapse” and 5 % of death. Diagnosis Child abuse diagnosis and thus management is often delayed or undiagnosed. Environmental elements The physician Emergency room physicians, paediatricians, general practitioners and orthopaedic surgeons are often in the first line in the discovery of an abused child. To be able to distinguish “normal” physical injuries from neglect or abuse, the physician needs to first of all have a high level of suspicion in all injuries involving young children, especially if the caretaker gives no clear explanation. Less experienced physicians might also feel uncomfortable with these more “general” and “emotional” situations. Some physicians might be more reluctant to report cases from higher social classes. Over diagnosis can bring conflicts in the future patient-doctor relationships. Despite all these examples of the difficulties involved with only “suggesting” the possibility of an abused child, the orthopaedic surgeon must go further than the simple fracture treatment and each fracture needs an

appropriate explanation in a child.

Medical history There is not one simple clue but again physicians need to have a level of suspicion when the trauma history given by the caretaker is vague, changes when repeated, or does not fit the lesions found. The caretaker can also report that he/she did not see the incident or that the child just started to complain. They can also be reluctant to give explanations and delay bringing in the child for medical treatment. Another element of suspicion is if they come from another part of town/country as they may already be known to staff in local hospitals (and not because “this hospital is better” which is the explanation they will give you).

Caretaker Parents are the most common abuser but any caretaker can be involved. Again there is not a single easily recognised pattern. The abuser can be overly aggressive towards the medical staff, raise lots of question, or refuse investigations on the child. They can also look overly protective of the child and very concerned. Difficult social situations, disrupted families, drug or alcohol abuse, and disabilities can be involved but are not always present.

Key points •

Parents are the most common abuser.

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There are no simple patterns to recognize.

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Abusive parents may act over concerned.

Child The child also has different attitudes from very compliant to aggressive. Girls and boys are equally affected. Stepchildren and handicapped children are more at risk. On the other hand the abused child might show “developmental delay” due to the abuse. In one family, all children can be abused but it can also affect only one of them The physician should be able to recognize any inappropriate behaviour in the caretakers or the child.

Clinical findings The orthopaedic surgeon will be confronted to the bony lesions, but will have to look for other “clues” if an abused child is suspected.

Soft tissue lesions Physical examination will reveal bruises, burns, lacerations, and scars. Again some of these have usual, normal explanations but one will have to make the differences between “normal” bruises from falls: elbows, shins, knees and inflicted ones: buttocks, perineum, trunk. The same is true for lacerations and scars. Cigarette burns are quite characteristic. Burns are seen in 10% of abused children, and some reports suggest as high as 20% (Galleno 1982). It is also useful to determine the timing of the bruises and soft tissue lesions: one or more episodes? Photographs and appropriate documentation of these lesions is crucial.

Head injuries The head and face are often injured since they

are quite easy targets. The usual weapon is the human hand. Violent shaking of a baby or young child can be particular deleterious with cerebral oedema or subdural haematoma and is known as the “ shaken baby syndrome”. Thus in any child where abuse or neglect is suspected, a good neurological examination is necessary. On the other hand, in any child with unexplained neurological signs, abuse has to be suspected. Skull X-ray are part of the general skeletal survey, but quite often there is no skull fractures, only internal lesions. In the acute phase, CT scans will help and MRI will show later on the chronic neurologic damage.

Internal injuries Internal injuries are often the cause of death in child abuse. Younger children are more often affected. Death is due to the gravity of these lesions and the fact that the child is brought late to the emergency room. Any internal organ can be injured.

Bony lesions Although some fracture type or pattern are more often seen in child abuse, there is not one “absolute” sign of abuse, it will have to be added to the other clinical and general findings.

Fracture Patterns- Radiological Findings Multiple age fractures and an unclear history will raise suspicion. However King (1988) reported that one single fracture was found in 50 % of his series of abused children. Bone scintigraphy as well as X-rays of the entire skeleton need to be done to look for fractures (healed or not). These tests will be very helpful

in the young child unable to express himself (Akbarnia 1976). One has to suspect abuse in lower extremity fractures in non-weight-bearing children, in the association of posterior ribs fractures with long bone fractures, in the metaphyseal “corner fracture” (Kleinman et al 1986). All other combinations are possible. Some fractures are more specific: for example a metaphyseal corner fracture is caused by pulling forceful on an extremity. They need good quality X-rays to be seen. The following list gives an overview on the degree of suspicion based on the type of fracture. Again any of them can be seen, even the regular common fractures (but then with a suspicious history) (Kleinman 1987)

Highly suspicious fractures: •

Metaphyseal fractures

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Posterior rib fractures

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Scapular fractures

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Spinous process fractures

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Sternal fractures

Suspicious fractures: •

Multiple fractures

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Different age fractures

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Epiphyseal separations

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Vertebral body injuries

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Complex skull fractures

Regular common fractures:

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Clavicular fractures

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Long bone shaft fractures

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Linear skull fractures

Fracture Dating Although variations are of course present, it is quite helpful to date fractures. The following table gives a timetable of radiographic changes (Kleinman 1987)

 

Lesion Soft tissue

Early Peak 2-5 days 4-10

Late 10-21 days

Periosteal

4-10

days 10-14 14-21 days

new bone Loss of

days 10-14

days 14-21

fracture line

days

days

definition Soft callus

10-14

14-21

Hard callus

days 14-21

days 21-42 42-90 days

 

days days Remodelling 3 months 1 year 2 years till epiphyseal closure  

  Differential Diagnosis Child abuse will have to be differentiated from a long list of a possible other underlying pathology: milder forms of osteogenesis imperfecta (Sillence 1981), scurvy, rickets, leukaemia, septic arthritis, osteomyelitis, neurological disorders (osteoporosis in cerebral palsy, myelomeningocele , polyomyelitis) , metastatic neuroblastoma, congenital indifference to pain, stress

fractures, osteopetrosis, and congenital syphilis.

Treatment Physical treatment The child needs to be hospitalised for thorough work-up. The physical treatment of the different injuries is similar to the general practice for the same lesions. For example, fracture care is similar, as with regular fractures, nevertheless the situation might be more complex with the legal and social issues that will have to be raised. Legal and social issues The management of child abuse involves the diagnosis, the medical treatment and the appropriate social and legal measures. To be able to address the legal issues it is mandatory to document the lesion: good medical records with descriptions of the clinical examinations, social workers reports, photographs, X-ray, CT-scan, bone scan. Legal issues vary from country to country, nevertheless the primary goal is to protect the child from further abuse. Hospital stay will thus not only be necessary for the full work-up but also to give time to work out the situation with the social workers and the appropriate “ teams” and local legal system. If possible the child will be returned to his family with counselling to the abusive caretaker, but this will not always be possible and if necessary the child will be placed in a foster home Key points •

Legal issues vary from country to country, nevertheless the primary goal is to protect the child from further abuse

Conclusion

The role of the physician and orthopaedic surgeon is to think of the possibility of child abuse in specific clinical conditions, to hospitalise the child for work-up and treatment, and to alert the appropriate authorities.