Non-accidental injuries Profoma

Question 1

Epidemiology of NAI

Answer 1

• 30% of children suffer child abuse.
• Often diagnosed late
• Physical abuse more common in younger children.

Question 2

Presentation of NAI

Answer 2

• History - often very vague, inappropriate & changes occur each time it is told.
• Delayed presentation
• Bruising in a non-mobile child (note that birthmarks can be confused w/ bruise - get second opinion if unsure).
• Facial (except forehead), abdominal or pubic bruising - these are not areas that are common for bruises.
• Injuries to mouth
• Slaps, pinches, bite marks
• Burns - circular burns that are deep = cigarette burns.
• Injuries at sites not commonly exposed to trauma
• Story doesn’t match the injury - no link between proposed & actual mechanism of injury
• Multiple injuries
• Fractures of different ages

-metaphyseal fractures

• Child is withdrawn & shows no attachment to parents - particularly when parents are present.
• Neglect - child looks dirty, unkept & doesn’t have right clothes.
• Weight- look for signs of malnutrition.

Question 3

What are common fractures in NAI?

Answer 3

Spiral fractures- result of twisting forces so cannot be caused by simple falling, highly suspicious of NAI.

Rib or tibial metaphysis fractures.

Mid-shaft fractures of the humerus

Supracondylar fractures are more likely to have non-abusive cause.
- Very common in 5-7 year olds & caused by FOOSH.

NOTE: view x-rays on notes- very important!

Considering age & developmental stage of the child is very important.
- e.g. fractures in children under 2 is uncommon.
- Or rolling off something is suspicious if the child is not old enough to be able to roll…

Question 4

Investigations for NAU

Answer 4

Full body exam - find any other injuries or bruises.

Skeletal survey - a series of X-rays that cover all the bones in the body.
- Involves 20 individual X-rays - lots of radiation so should only be done if indicated.
- A repeat skeletal survey is done in 2 weeks after, because healing fractures can be easier to spot than new ones. Rules out osteogenesis imperfecta, which can be mistaken for NAI.

CT scan head - looks for brain injury & trauma.

MRI - done after CT head.

Ophthalmology exam- identifies retinal haemorrhage or any external trauma such as bruising.
- indicate a high likelihood of abusive head trauma.

FBC to exclude thrombocytopenia & any clotting or blood disorders that might cause bruising.

NOTE: view images on notes

Question 5

Risk factors for NAI

Answer 5

Domestic violence

Parental substance abuse

Mental health disorder in parent.

Social factors - poverty, young parents, social isolation, 3 or more children under 5 yrs.

Child factors - disability, pre-term delivery or multiple pregnancies i.e. twins.

Parental factors- learning difficulties, bad experiences of parenting & personal history of abuse.

Question 6

Management of NAI

Answer 6

• Child should be admitted for protection if NAI is strongly suspected.
• Good record keeping including photographic evidence & verbatim accounts.

-Fracture should be treated in the usual way

• Refer to social services & involve safe guarding lead.

Identify any other related/associated children as they may also be at risk.

Question 7

Prognosis of NAI

Answer 7

• Children who have been abused can participate in high-risk behaviours e.g. binge drinking, drug use & criminal behaviour later on in life.

-Associated w/ increased mental health problems in adulthood e.g. PTSD, substance abuse or anti-social personality disorder.

• Can lead to generational abuse