Safeguarding: Non-accidental Injury

Question 1

What are some risk factors for non-accidental injury (NAI)? (5)

Answer 1

1) History of intimate partner violence and abuse: physical, sexual, psychological, emotional, verbal, or financial

2) Substance abuse or mental health condition in one or both caregivers

3) Excessive crying

4) Unintended pregnancy

5) Developmental problems (2x more likely)

Question 2

How can excessive crying lead to non-accidental injury?

Answer 2

Excessive crying, especially aged 0-4 months old, has been identified as a trigger for shaking of infants (a common cause of NAI).

Question 3

How may NAI present?

Answer 3

1) Bruises

2) Bites

3) Lacerations/abrasions

4) Thermal injuries

5) Fractures

6) Intracranial injuries

7) Eye trauma

8) Other e.g. spinal injuries or visceral injuries

Question 4

What to note when a child presents with a bruise?

Answer 4

1) Shape

2) Pattern

3) Age

Question 5

What are some worryingly shaped bruises?

Answer 5

• Shaped like hands
• Linear bruises
• Ligatures
• An identifiable implement

Question 6

When should you ALWAYS be suspicious of bruises in a child?

Answer 6

In a child who cannot mobilise

Question 7

When should a high index of suspicion should be present when lacerations or abrasions are seen in children?

Answer 7

• In non-mobile children
• Symmetrically
• Around the face
• Around the ankles or wrists, in the position a ligature could be applied

An adequate explanation should always be sought for the injuries described above.

Question 8

Suspect NAI where thermal injuries are in locations you would not expect to come into contact with a hot object.

Give some examples

Answer 8

• Soles of feet
• Buttocks/back
• Backs of hands

Question 9

What should you note about any thermal injury?

Answer 9

1) Location of affected area

2) Shape of the burn/scald:
- shape of conceivable implement e.g. a cigarette or iron
- scalds with sharply delineated borders (consider immersion injury)

Question 10

What is an immersion injury?

Answer 10

A peripheral nonfreezing cold injury resulting from exposure to water, usually at temperatures just above freezing.

Question 11

When should fractures in children be investigated for NAI?

Answer 11

1) Fractures, single or multiple, in children without a medical condition predisposing them to fragile bones.

2) Fractures of different ages, especially where there is no documentation of caregivers seeking medical attention.

3) Metaphyseal corner fractures

4) Evidence of occult rib fractures

5) Spiral fractures

Question 12

What are metaphyseal corner fractures?

Answer 12

Pathognomonic of NAI.

It refers to an injury to the metaphysis which is the growing plate at each end of a long bone –> caused by excessive shaking of child.

Question 13

Mechanism of NAI of occult rib fractures in children?

Answer 13

A common finding in infants/children who have been grabbed by the chest and squeezed/shaken.

Question 14

What are spiral fractures?

Answer 14

Spiral fractures are a result of twisting forces so cannot be caused by simple falling, and are highly suspicious of NAI

Question 15

What are 3 types of fractures that are highly suspicious of NAI?

Answer 15

1) Metaphyseal corner fractures

2) Occult rib fractures

3) Spiral fractures

Question 16

When should you suspected NAI with intracranial injury?

Answer 16

• Without an adequate explanation
• In a child under 3 years old
• In the presence of:
  Retinal haemorrhage
  Rib or long bone fractures
  Other associated injuries
• With multiple subdural haemorrhages

Question 17

What type of eye trauma with no medical explanation is highly suspicious for NAI?

Answer 17

Retinal haemorrhage

Question 18

What are 2 key differentials for NAI?

Answer 18

1) Coagulopathy –> can lead to excessive bruising and haemarthrosis

2) Osteogenesis imperfecta

Question 19

Xray finding in osteogenesis imperfecta?

Answer 19

Decreased bone density –> skeletal survery would rule this out

Question 20

What imaging is indicated in suspected NAI?

Answer 20

1) Skeletal survey:
- head/chest (including AP and lateral skull)
- spine/pelvis
- upper limbs
- lower limbs

2) Follow up imaging

3) Neuro imaging: CT or MRI head

Question 21

When should a skeletal survey be repeated in suspected NAI? Why?

Answer 21

Repeated at 11-14 days.

This is to ensure that injuries too new to appear on the initial skeletal survey are detected.

11-14 days is used as this is the maximal time take for the periosteal reaction to occur, allowing fractures to be visualised on X-ray.

Question 22

Neuro imaging modality in NAI depends on the timing of the presentation.

What imaging is indicated in acute presentation?

Answer 22

CT head –> should be performed as soon as the patient has been stabilised, on the day of presentation.

Question 23

Neuro imaging modality in NAI depends on the timing of the presentation.

What imaging is indicated in non-acute presentation?

Answer 23

MRI head –> should be performed as soon as possible, within a week of presentation.

Question 24

What are 2 alternative skeletal imaging options? When might they be used?

Answer 24

1) CT –> more sensitive in diagnosing rib fractures (but higher radiation dose).

2) US –> can be used to diagnose metaphyseal and rib fractures as well as identifying subperiosteal fluid.

Question 25

If abusive head trauma is suspected, what should the child be referred for?

Answer 25

ophthalmology review to identify possible retinal haemorrhages.

Question 26

Criteria for immediate request for CT scan of the head (children): (12)

Answer 26

1) Loss of consciousness lasting more than 5 minutes (witnessed)

2) Amnesia (antegrade or retrograde) lasting more than 5 minutes

3) Abnormal drowsiness

4) Three or more discrete episodes of vomiting

5) Clinical suspicion of non-accidental injury (NAI)

6) Post-traumatic seizure but no history of epilepsy

7) GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department

8) Suspicion of open or depressed skull injury or tense fontanelle

9) Any sign of basal skull fracture

10) Focal neurological deficit

11) If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

12) Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 m, high-speed injury from a projectile or an object)