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Injuries from Child Abuse 223
Physical Abuse a delay is common. Finally, repetitive injuries in any child may be
Child abuse is a common cause of childhood death, second only to sud- indicative of child abuse.
den infant death syndrome (SIDS) in the age group under 6 months. The Typical Findings of Physical Abuse
average age of the abused child is 7 years old; the average age of fatal- A constellation of physical findings characterises the injuries seen in
ity is 3 years. Socioeconomic problems often play a role. Although cul- abused children. Some of these are listed in Table 34.1 and explained
ture or socioeconomic status may be associated with child abuse, many in more detail below.
studies indicate that abuse occurs among all income categories and all
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cultures. The smaller the child, the bigger the risk. Younger children Table 34.1: Typical presentations of physical abuse.
are at greatest risk because they are more demanding, defenseless, and • Head injuries
nonverbal. One-third of physical abuse takes place under the age of 6 - - Fractures,-
months, another third at 6 months to 3 years of age, and the remaining - - Intracranial-injuries
third above the age of 3 years. At particular risk are male children, those • Truncal injuries
born prematurely, and stepchildren. - - Fractured-ribs
Modes of physical abuse can be designated as nonaccidental or - - Spinal-cord-injuries
accidental. Nonaccidental injuries are events resulting from deliberate - - Internal-organ-injuries
actions by individuals against themselves or another victim that
intentionally threatens, attempts, or actually inflicts physical harm. • Extremity injuries
- - Fractures-of-long-bones
Accidental injuries result from unforeseen events that cause an external - - Single-fracture-with-multiple-bruises
trauma to the body, without the intent to cause harm.
The exact circumstances surrounding an assault are not always clear, - - Multiple-fractures-in-different-stages,-possibly-with-no-bruise-or-
soft-tissue-injury
but in some cases, the child is used as a shield for an adult under attack. - - Metaphyseal-or-epiphyseal-injuries,-often-multiple
This so-called shielding phenomenon encompasses a large spectrum, •-Superficial injuries
from the scenario where the child is injured as an innocent bystander - - Cuts-and-bruises
to one in which an adult positions the child in self-defence against - - Burns-and-scalds
an attacker. Some injuries, such as knife attacks, are particularly - - Signs-of-hypothermia-and-frostbite
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suggestive of shielding because it is not likely that anyone would
deliberately assault a child with such a weapon. • Suffocation
• Poisoning
Causes of Child Abuse and
Predisposing Factors
There is often an assumption that parents of abused children are Skin
severely psychotic or criminal, but research indicates that more than Lesions can occur everywhere. Bruises on the buttocks and lower back
90% of the parents have no psychological problems or criminal nature. are often related to punishment; bruises on the cheek are usually sec-
Instead, they tend to be lonely, unhappy, and angry adults under tremen- ondary to being slapped. Other typical findings in child abuse are grip
dous stress. Additional stressful factors include a breakdown of family marks, pinch marks, and circumferential bruises. Defining the age of
structure, poverty, financial need, unemployment, being a single parent, the injuries is difficult. Most skin lesions have an initially red colour,
and substance abuse. There is also a very strong correlation with child followed by a reddish-purple period within 24 hours, which then gradu-
abuse of the parents: more than 90% of abusing parents may have been ally progresses to a predominantly purple lesion over the next week.
abused during their own childhoods. Discoloration to yellow/green/brown is due to degradation of haemo-
globin and occurs over a period of 1–3 weeks.
Diagnosing Child Abuse Burns
There are many ways to establish a diagnosis of nonaccidental injury in Approximately 10% of physical abuse involves burns. Typical lesions
children. The first occurs when the child readily cites a particular adult found in child abuse are cigarette burns and so-called stocking/glove
as the assailant. The complaint should always be taken very seriously, injuries in toddlers from hot water immersion.
and every case must be thoroughly investigated. Unexplained injury
should prompt a consideration of child abuse, particularly when parents Head Injuries
are reluctant to explain the nature of the accident. For instance, parents The incidence of abusive head injury ranges from 17 per 100,000 to 40
might claim that they “just found the child like that”, or “the child per 100,000, with the largest group of head injuries seen in infants 0
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might have fallen down”, or “someone else might have hit the child”. to 3 months of age. Approximately one-third of abusive head injuries
The majority of the parents know to the minute where and when the are not recognised at the time of initial visit to a health care provider.
child was hurt. A discrepant history is also suggestive of child abuse. Although nonaccidental head trauma in children younger than 3 years
The suspicion of child abuse increases when the history provided of age is difficult to diagnose, one should maintain a high index of sus-
does not explain the severity of the physical injuries. For instance, a picion. The spectrum of head injury can range from skull fractures to
child who fell from a bed and yet is covered with bruises is unlikely lethal intracranial bleeding and brain atrophy (Figure 34.1).
to have suffered such injuries from the stated mechanism. Another Subdural haematomas may also be the result of shaking. The rapid
is a parental claim that the child “bruises so easily”. This history is acceleration and deceleration of the shaking head appears to tear
usually misleading, especially when no new bruises appear during bridging veins, with resulting bleeding and subdural haematomas, often
hospitalisation. Claims of self-infliction in children should be treated bilaterally. Another common finding is diffuse cerebral oedema with
with suspicion—for example, a report that a small baby had “rolled loss of normal grey-white matter differentiation (Figure 34.2). Retinal
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over her arm and fractured it”. Similarly, shifting the blame for the haemorrhages are nearly always present in these cases (Figure 34.3).
injury to a third party may be an indication of child abuse. Skeletal Injuries
Delayed presentation is a common feature of abuse injuries. In Fractures in small children are rare. In all patients under the age of 3
normal situations, it is uncommon for parents to bring their child to the years, the occurrence of a fracture without an adequate history should
hospital more than 24 hours after an injury. After child abuse, however, prompt the suspicion of child abuse. Approximately one-quarter of