Child battery syndrome

Question 1

Categories of child abuse

Answer 1

1. Physical abuse
2. Sexual abuse
3. Psychological or emotional abuse
4. Neglect

Question 2

define physical abuse

Answer 2

non-accidental injury

Question 3

may be key to diagnosis of child abuse

Answer 3

External exam – bruises, abrasions, burns may indicate possibility of internal injuries, including underlying fractures

Question 4

Whats something to remember with injuries?

Answer 4

Bone injuries rarely exist in isolation, without some evidence of soft tissue injuries

Question 5

Physical abuse – injury characteristics

Answer 5

1. Injuries in various stages of healing, not only fractures, but also bruises
2. Multiplanar injuries, i.e. injuries that do not make anatomical sense
3. Patterned injuries, e.g. hand marks, belt marks
4. Locations typical of assault – look for injuries in regions normally well protected, e.g. face, neck, upper arms and upper legs, perineum

Question 6

% of childhood fractures result from abuse

Answer 6

30% of childhood fractures result from abuse

Question 7

In children < 1 year old, as much as __% of fractures may be inflicted deliberately

Answer 7

75

Question 8

Most physically abused children are

Answer 8

< 2 years old

Question 9

children are < 1 year old

Answer 9

About 1/3 of physically abused

Question 10

Occult

Answer 10

hidden concealed

Question 11

Children homeside occurances

Answer 11

Most homicides of children occur in first 2 years of life

Question 12

What are the common first year injuries?

Answer 12

First year: mainly (85-90%) head injuries

Question 13

What are the common second year injuries?

Answer 13

Second year: head injuries about 50%, blunt abdominal injuries about 50%

Question 14

What is something to be aware of when it comes to looking at possible child abuse cases?

Answer 14

There may have been multiple episodes so look for other injuires

Question 15

Mimics of child abuse

Answer 15

1. Congenital indifference to pain
2. Congenital sensory neuropathy
3. Congenital conditions such as meningo-myelocoele
4. Acquired spinal cord injuries
5. Acquired cerebral injuries

Question 16

Radiologic evidence

Answer 16

often x-ray examination may yield clues to patterns of abuse
Radiologic skeletal changes may underlie visibly obvious cutaneous injuries, but are evident long after the cutaneous injury has resolved

Question 17

Inconsistency of story and injury

Answer 17

1. injuries may be inconsistent with child’s age
2. injuries may be disproportionate to their purported cause
3. injuries may be inappropriate to the purported mechanism of injury

Question 18

what are pathognomonic clues for child abuse (pathognomonic = specifically distinctive, characteristic)

Answer 18

Multiple fractures at multiple sites in multiple stages of healing seen on X-rays

Question 19

Most common sites of fractures (from most to least frequent):

Answer 19

1. long bones of appendicular skeleton
2. skull
3. ribs

Question 20

Physical abuse of a magnitude sufficient to fracture bones usually occur in what kind of bone?

Answer 20

younger and hence smaller children – smaller bones are easier to deliberately fracture

Question 21

About half of abused children have what kind of fractures and how many and where?

Answer 21

a single fracture, usually a tranverse (direct, angulation, or tension pattern) fracture, or a spiral (twisting or rotatory pattern) fracture – humerus, femur, tibia are most common sites. The direction of a fracture is of less importance than the actual site of the fracture and the age of the child.

Question 22

What are common presentations in an abused child?

Answer 22

Fracture(s) of skull and dehiscence of skull sutures, together with fractured long bone shafts

Question 23

Fractures at ____ (ex.___) should always be questioned

Answer 23

unusual sites (lateral ends of clavicles, ribs, scapula, sternum, spine)`

Question 24

Why is the difference between adult and child bone important?

Answer 24

render children’s bones susceptible to different patterns of fracture

Question 25

Primary agent of endochondral ossification

Answer 25

physis, or growth plate, or epiphyseal plate

Question 26

Injury patterns seen in infants are much different from those seen in older children, as result of

Answer 26

1. mechanism of actual injury in the two age groups 2. different skeletal responses to the applied forces as a result of skeletal differences (changes in bone structure at microscopic and macroscopic level)`

Question 27

Infancy (first year): most common injuries

Answer 27

ribs and metaphyseal regions

Question 28

Childhood (older than one year): most common injuries

Answer 28

long bone fractures, then skull and rib fractures

Question 29

Holding child or infant by thorax and shaking tends to lead to what?

Answer 29

“classic metaphyseal lesions” (CMLs) in arms and legs, usually bilaterally symmetrical

Question 30

Holding infant or child by an arm or leg and shaking or throwing the infant/child may lead to what?

Answer 30

unilateral metaphyseal lesions or focal long bone injuries

Question 31

Diagnosis of child abuse by skeletal indicators

Answer 31

1. Highly specific fractures | 2. Specific combinations of fractures

Question 32

More often, rather than a finding of a highly specific fracture, it is the combination of what that allows diagnosis of abuse?

Answer 32

a (1) the fracture type, (2) the history, and (3) the developmental stage of the child

Question 33

Shaking of infant/child may lead to multiple CMLs. Most common sites for this injury is?

Answer 33

knee, ankle, distal humerus

Question 34

What occurs in a CML fracture?

Answer 34

Actual lesion is a mineralized disc of metaphyseal bone that has been fractured from primary spongiosa of metaphysis.

Question 35

Twisting, either deliberate or accidental, of femur or humerus may lead to what?

Answer 35

transverse, oblique, or spiral diaphyseal fractures

Question 36

What is very important when determining accident from abuse

Answer 36

history of injury

Question 37

Relationship in frequency between shaft and CML fractures?

Answer 37

Shaft fractures are more commonly seen in abuse than are CMLs, but are less specific for abuse

Question 38

Femoral shaft fracture < 1 year of age?

Answer 38

very suggestive of abuse

Question 39

Humeral shaft fracture < 1 year of age

Answer 39

considered diagnostic of abuse

Question 40

In absence of any history of trauma, presence of what is suspicious for abuse, particularly in infant not yet walking?

Answer 40

oblique or spiral shaft fracture of femur or humerus

Question 41

Children who are shaken violently are often held by arms or legs – accounts for most of classic radiologic long bone hallmarks of child abuse:

Answer 41

1. metaphyseal fractures 2. epiphyseal separation 3. subperiosteal new bone formation along shafts of long bones

Question 42

Rib fractures and child abuse?

Answer 42

3rd most common type of fracture in abused children; tend to be multiple in number

Question 43

Why is it rare for ribs of infants and young children to be fractured in everyday play?

Answer 43

thoracic cage is quite elastic – usually requires severe direct impact type of trauma

Question 44

Rib fracture < 2 years of age is considered what until proven otherwise?

Answer 44

abuse

Question 45

What is not a valid excuse when discussing rib fractures in kids?

Answer 45

CPR

Question 46

Describe torus fractures in the ribs

Answer 46

buckling of cortex due to compression; amount of buckling may be subtle; microfractures allow buckling to occur without overt fracture line

Question 47

Lateral rib fractures usually are due to what?

Answer 47

anteroposterior compression of chest, often by a punch or blow with a blunt object when infant or child is on a flat surface, or slamming chest of child into an inanimate object - rib is flattened anteroposteriorly

Question 48

Sternal and chondral fractures

Answer 48

significant blow to anterior central chest may fracture sternum and/or costal cartilage, as well as cause a separation of costochondral junction; rare to see these injuries in children otherwise, except in high impact trauma, e.g. MVA

Question 49

Common skull fracture patterns in abuse?

Answer 49

1. depressed fractures 2. complex fractures 3. wide fractures 4. multiple fractures

Question 50

Common skull fracture patterns in accidents?

Answer 50

linear skull fractures

Question 51

Relationship between brain and skull injuries?

Answer 51

Skull can be fractured without an underlying brain injury, and brain can be injured without an overlying skull fracture; lack of skull fracture therefore does not have any predictive value as far as deciding whether an infant has sustained a brain injury as a result of abuse

Question 52

Most forensic pathologists feel that a child falling from a distance of _____ will not sustain a brain injury

Answer 52

about 1 metre or less

Question 53

Extent of brain injury sustained by child relates to what?

Answer 53

amount of energy absorbed by brain, not by skull

Question 54

How can you get brain injuries without skull injuries?

Answer 54

Brain and skull each have their own inertial properties – hence when head is either suddenly struck with a moving object, or stuck against an immoveable object, brain moves independently within the cerebrospinal fluid of the skull

Question 55

Linear skull fracture occurs how?

Answer 55

when tensile strength of skull is exceeded – begins at inner table in inbent area (impact point) and at outer table of outbent area (increased tensile strength)

Question 56

Linear fractures are created how?

Answer 56

by relatively low velocity forces of high mass

Question 57

Coup injury

Answer 57

direct injury to brain by inward bending of skull

Question 58

Contrecoup injury:

Answer 58

injury of brain on side opposite to site of external impact injury – can be due to focal cavitation as well as direct contact of opposite side of brain with skull

Question 59

How can a depressed skull fracture be caused?

Answer 59

High velocity forces with small mass may actually exceed tensile of skull at impact point