Case 14 - unable to WB and bruising

Question 1

Typical sites of NAI

Answer 1

Head and neck:
* Ears - esp both sides
* Black eyes - esp bilateral
* Soft tissue cheeks
* Intraoral

Torso:
* Triangle of safety - ears, side of face and neck, top shoulders
* Back and side of trunk except over bony prominences
* Chest and abdomen
* Any groin/genital

Limbs:
* Forearms - raise to protect self
* Inner arms/thighs
* Soles feet

Question 2

Child RF for child abuse

Answer 2

• Failure to meet parental expectations and aspirations - eg disabled, wrong gender, difficult
• Born after forced, coercive or commercial sex

Question 3

Parent/carer RF for child abuse

Answer 3

• MH problems
• Parental indifference, intolerance, over-anxiousness
• Alcohol
• Drug abuse

Question 4

Family RF for child abuse

Answer 4

• Step parents
• Domestic violence
• Multiple/closely spaced births
• Social isolation/lack social support
• Young parental age
• Poverty, poor housing

Question 5

Features in history which make suspicious of child abuse

Answer 5

• Plausibility of explanation of injury
• Any background - eg previous child protection concerns
• Delay in reporting injury
• Inconsistent histories
• Inappropriate reaction of caregivers

Question 6

First line investigations for children presenting with signs of physical abuse

Answer 6

• Clotting screen - coagulopathy?
• FBC and blood film - low plt, haem malig eg ALL
• Factor VIIIc - haemophilia A
• Von-Willebrand factor - VW disease

Consider speaking with paeds haem

Question 7

Fractures highly specific to NAI

Answer 7

• Metaphyseal fractures - bucket handle/corner
• Rib fractures - esp posterior ribs (vigorous CPR can cause anterior)
• Skull fractures - non-parietal, multiple bones, crosses sutures, depressed

Question 8

Fractures moderate specific to NAI

Answer 8

• Bilateral fractures with different ages
• Digital fractures when non-mobile
• Vertebral/subluxation
• Spinal humeral fracture
• Seperation of epiphysis

Question 9

First line inv for child who presents with fracture from NAI

Answer 9

• Bone profile - calcium, phosphate, ALP - metabolic disease eg Pagets, OI, hyperparathyroidism
• FBC - malabsorption –> reduced strength
• Skeletal survey
• CRP - ?osteomyelitis

Question 10

If NAI, what steps should be taken?

Answer 10

• Careful and thorough documentation
• Inform on call paeds consultant
• Inform parents
• Involve police
• Referral to social services