Child Abuse =========== þ See Also Sexual Abuse in Children þ AAP "Cheat Sheet" for suspected abuse þ 36% of abused kids have fractures þ suspicious types of fractures for abuse: - metaphyseal + "corner fractures": chip off corner of metaphysis, caused by violent twisting injury + "bucket fractures": thin rim of avulsed bone from all across distal end of metaphysis, looking like a bucket handle, from shaking - ribs, especially posterior (rare in kids, even from MVA, except from abuse)/sternum/scapula - vertebral body + hangman's fracture of C2 + chip fracture of anterior portion of body from violent flexion/extension - occult injuries - inconsistent history - multiple sites/ages þ Head Injury: - shaken baby syndrome: twisting and sudden deceleration + retinal hemorrhages (dilate eyes to see) + skull fractures Hefer T, Pediatrics 1977 Nim Accidental fx almost always unilateral, less than 1 mm in width, didn't cross suture lines; abuse more likely to be more than 3 mm in width, cross suture lines, bilateral, associated intracranial injury. + subdurals - CPR does not cause retinal hemorrhages þ Blunt Abdominal Injury - may also see duodenal or pancreatic injury, suspicious for abuse (or bicycle handlebar injury) þ Unusual - pepper aspiration: + given by parents for "smart mouth" + child aspirated + caused death, + parents convicted of manslaughter - microwave burns - water deprivation - father who hit child in belly with broom handle, transecting pancreas, then threw child off fire escape to "mask" this injury - force feeding safety pins, needles, light bulbs, etc, - Munchausen by Proxy: + high mortality + experienced docs stumped + only symptomatic in caretakers's presence + overattentive but medically-sophisticated caretaker + contaminated specimens + force-feeding ipecac, salt, etc. þ Differential Diagnosis - Mongolian spots vs. bruises - hemophilia - osteogenesis imperfecta (rare) - bullous impetigo - self-inflicted injuries