Childrens Hospital Foundation

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3 things that every child protection
professional needs to know about the medical
aspects of Child Abuse
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Bruises in Babies are (nearly always) Bad
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What is a Bruise?

• An injury to tissue caused by blunt force which
  did not lacerate the surface

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A Bruise?

• Blunt force causes disruption of blood vessels,
  causing bleeding into surrounding tissue

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The Evaluation of Bruises

• Where is it located?
• What does it look like?
• Does the history provided by the caregiver
  explain the injury?
• Is the injury explained by the history?

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Size Of Bruise Depends On

• Force of impact
• Size of damaged blood vessels
• Location of injury
• Coagulation mechanism

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LOCATION
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Lazoritzs A Rule of Biomechanics

• In low velocity accidents
• Babies do not bounce!

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Liver
Pancreas
Duodenum
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Visceral Injuries

• Occur in less than 3 of abused children
• High mortality
• Caused by blunt trauma
• May injure liver, spleen, pancreas or hollow
  viscus

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DistributionLocal or Diffuse
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Estimation of Age of Bruises
Fresh Red Recent Dark Purple, Dark
Blue Older Green,
Greenish-Yellow Yellowish, Brown
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Morphology (Shape)
IF IT LOOKS LIKE AN OBJECT, IT IS NOT LIKELY
ACCIDENTAL LINEAR LOOPS IMPRINTS CHARACTERISTIC
BRUISES
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Bite marks
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The History

• Is There A History?
• Is There A Magical Injury?
• Could The Injury Have Been Prevented?
• Is There A Delay In Seeking Medical Care?
• Does The History Reflect The Injury?

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Normal Bruises

• Facial Scratches in Babies from Long Fingernails
• Knee and Shin Bruises
• Forehead Bruises
• Bruises over Bony Prominences

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Think head injury in infants with vomiting,
irritability and lethargy
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The Spectrum of Head Injury
Shaking and Impact
Impact
Shaking
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Skull Fractures of Abuse

• Posterior
• Diastatic
• Branching (Stellate)
• Cross suture lines

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Diffuse Brain Injury
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Prior ED or Clinic Visit
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Symptoms at Prior Visit
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Retinal Hemorrhage
No
Yes
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Long Bone Fractures
23 of 71 had fractures (32.4) 20 of 23 had
multiple fractures
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Fractures
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Cerebral Edema
All deaths had cerebral edema 48 who had
Massive or diffuse cerebral edema died 35 of
cases had no cerebral edema (all lived)
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Age Distribution in SIS
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Low Birth Weight or Premature
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Neurological Outcome
14.3
8.6
25.7
5.7
45.7
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Prepubertal children who have been molested
usually have a normal exam
so when and why should they be examined
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85-95 of children giving a history of sexual
abuse have a normal physical examination
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The History from the child is the most important
part of any evaluation for suspected sexual abuse
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Do No Harm
Calling a normal finding abnormal
Missing an abnormal finding
Doing an inappropriate exam
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Most vaginal discharges in prepubescent girls
are NOT STDs!
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Summary of STD s
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Most children who allege sexual abuse have a
normal exam There are few diagnostic findings to
verify sexual abuse Sexually transmitted disease
in a child usually means sexual abuse A
multidisciplinary approach is vital to dealing
with child sexual abuse
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Take home messages
The younger the baby, the more questions to ask
Vomiting, lethargy and irritability may mean
brain trauma
Most children who give a history of sexual abuse
have a normal exam