The Medical Workup when Differentiating Falls from Abuse
Initial Assessment and Stabilization
The initial clinical assessment of the infant or child presenting to the emergency department with the history of a fall, and the possibility of associated abusive injury, should be similar to that of any pediatric patient presenting for evaluation of trauma. As with all patients, an injured child must be rapidly assessed and medically stabilized before further evaluation is undertaken. A trauma response team and pediatric subspecialists are often involved. Immediate medical assessment and resuscitation are done simultaneously. During this period, a patent airway is established while control of the cervical spine is maintained. The primary survey (Airway, Breathing, Circulation, Disability, and Exposure) with ongoing appropriate resuscitation is followed by a secondary survey. This should include a complete physical examination, complete history of the current episode, past medical history if possible, and appropriate initial laboratory evaluation and imaging. Complete documentation might not be possible initially and must always be second in importance to resuscitation and stabilization of the patient.
Getting the Medical History
Once the child is stabilized, a careful and well-documented history, whether true or not, is a vital element of the medical evaluation. Frequently, infants and children present to medical settings with a history of a fall. Short falls have been shown to result in minor trauma such as bruising, linear parietal skull fractures, and clavicle or extremity fractures, but fatal injuries from short falls are extremely rare. The ability to recognize the possibility of intentional injury is crucial because immediate intervention is necessary to find other injuries and to prevent further harm to the child or to other children in the household. Information should be gathered in a nonaccusatory but detailed manner. Any statements made by the caregiver regarding the injury should be documented accurately and completely using quotes whenever possible. The pediatrician should also document any descriptions of the mechanisms of injury or injuries given by the caretaker. It is also important to document onset and progression of symptoms and the child’s developmental capabilities. , Audio or video recording of the history interview could be of value for quality assurance and education but is not currently required for forensic purposes.
Information regarding the child’s behavior before, during, and after the injury occurred, including feeding times and levels of responsiveness, should be gathered. Victims of significant trauma usually have observable changes in behavior. Access of caregivers to the child, as well as activities before, during, and after the injury occurred, are important to document. , If the child is verbal, it may be helpful to gather parental and patient histories separately. If the child can be interviewed, his or her demeanor should be noted during questioning. Some children display strong nonverbal cues of anxiety and reluctance when answering questions regarding potential abuse, because they are protective of their abuser or they fear retribution for “telling.” Others appear openly fearful of their abuser. Such responses are important to consider when a safety plan for the child is made.
Certain explanations are concerning for nonaccidental trauma, including the following :
- 1
No explanation or vague explanation for a significant injury;
- 2
An important detail in the history changes dramatically;
- 3
The explanation given is inconsistent with the pattern, age, or severity of the injury or injuries;
- 4
The explanation given is inconsistent with the child’s physical and/or developmental capabilities; and
- 5
Different witnesses provide markedly different explanations for the injury or injuries.
Additional information that is important in the medical assessment of suspected physical abuse includes :
Past medical history : Birth and neonatal history trauma, hospitalizations, congenital conditions, chronic illnesses
Family history : Especially history of bleeding, bone disorders, and metabolic or genetic disorders, and history of family violence
Pregnancy history: Maternal age, wanted/unwanted, planned/unplanned pregnancy, prenatal care, postnatal complications, postpartum depression, delivery in nonhospital settings
Developmental history of child: Language, gross motor, fine motor, psychosocial milestones
Social history: Familial patterns of discipline; child temperament; history of past abuse to child, siblings, or parents; substance abuse by any caregivers or people living in the home; social and financial stressors and resources; and violent interactions among other family members, all of which have been associated with an increased risk of abusive injury
Physical Examination
The physical examination should include detailed documentation, either by body diagrams and/or photographs, of any visible findings. Include a thorough search for other signs that may help differentiate an abusive from a nontraumatic cause of injury.
General Assessment
The general appearance of the child must be documented, including the child’s alertness, demeanor, and Glasgow Coma Score (GCS). These can reflect neurological status and degree of discomfort and pain. Evidence of neglect can be seen during the general examination of the infant or child; extensive dental caries, severe diaper dermatitis, or neglected wound care should be noted in addition to injuries that raise suspicion of abuse.
Central Nervous System (CNS)
Because CNS injury is the leading cause of death among injured children and is a principal determinant of outcome, a thorough and complete neurological examination must be performed. The GCS is the universal tool for the rapid assessment of the level of consciousness after injury. A modified verbal and motor version, the Pediatric Glasgow Coma Scale, has been developed to aid in the evaluation of consciousness level in infants and young children. The GCS score and its modified version (with scores of 3-15) are based on children’s best response in three areas: (1) motor activity, (2) verbal response, and (3) eye opening. Traumatic brain injury in children is classified as mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS 3-8). It is crucial that the presenting GCS be documented, as well as any significant changes in GCS.
A complete neurological assessment, including reflexes, cranial nerves, sensorium, gross motor, and fine motor abilities, should be conducted. Because the signs and symptoms of intracranial injury can be nonspecific and difficult to recognize, a high index of suspicion for CNS injury must be present at all times. , Evidence of spinal cord injury, such as abnormal reflexes, muscle tone, or responsiveness to tactile stimuli, should be carefully pursued. In addition, abnormalities, when present, might reflect current or past injuries to the central nervous system. Abused children sometimes also have developmental disabilities because of deprivation in the home environment or other causes.
Head, Eyes, Ears, Nose, and Throat
Obscure sites for inflicted injuries include the ears (especially the posterior aspects), the neck and angle of the jaw, the scalp, and the frenula of the lips and tongue. ,
Head
The scalp should be palpated for areas of crepitance, bogginess, or step-off, which may be indicative of an underlying skull fracture. Also of concern for head injury are scalp hematomas, ecchymoses, or in the infant less than 12 months-old, a bulging anterior fontanelle. In addition, bald areas on the scalp could be indicative of traumatic alopecia or malnutrition and should be noted.
Eyes
Pupils should be evaluated for size and reactivity. Extraocular movements should be described. A fundoscopic examination for retinal hemorrhages should be done as part of the initial examination for any infant or young child who is a suspected victim of physical abuse. Then, as soon as possible, an ophthalmologist with pediatric experience should conduct an examination of dilated pupils by using indirect ophthalmoscopy, documenting retinal hemorrhages by photography or detailed annotated drawings. Location, depth, and extent of retinal hemorrhages could help distinguish between abusive and nonabusive causes of head trauma.
Ears
The presence of blood in the tympanic cavity of the middle ear (hemotympanum) is most commonly caused by trauma. Bruising of or behind the pinna should also be noted (see Figure 59-1 in Chapter 59 Supplemental Resources online at www.expertconsult.com ). ,
Nose
Nasal septum deviation and septal hematoma are also concerning for acute or past abuse. Blood in the nose is often a result of injury, especially in infants.
Oropharynx
Oropharyngeal injury represents a complex array of types of trauma. Treatment of dentoalveolar injuries should be referred to a dentist. , Evidence of mid-face instability, malocclusion, suspected injury to the parotid region, or concerns for facial nerve function requires subspecialty intervention.
Neck
Early airway control is paramount and cervical spine injury must be presumed until excluded. Gross laryngotracheal injury, stridor, pulsatile bleeding, or expanding hematoma requires urgent operative treatment. In addition, because abusive caregivers often fail to mention injuries that have been inflicted, special care should be taken during the examination of the child’s neck, which may be fractured and require immobilization until diagnostic radiographs can be performed.
Heart
Inflicted injuries that involve the heart are rare but often severe, including, but not limited to, commotio cordis and cardiac laceration. , Other rare injuries associated with abusive blows or compressive forces to the chest include hemopericardium and cardiac contusions.
Chest
Most rib fractures in infants are caused by child abuse, although the differential diagnosis includes serious accidental injuries, birth trauma, bone fragility, or possibly, resuscitation using pressure on both the front and the back of the chest. Acute rib fractures can cause shallow breathing attributable to pain and splinting; in severe cases, a fractured rib can puncture the lung. Alterations in respiratory patterns might also be a sign of central nervous system damage or response to pain. Rarely, shearing of the thoracic duct results in chylothorax.
Abdomen
The most reliable clinical signs and symptoms of abdominal injury in alert patients are abdominal pain, abdominal tenderness, gastrointestinal hemorrhage, hypovolemia, and evidence of peritoneal irritation. Large amounts of blood, however, can accumulate in the peritoneal and pelvic cavities without any significant or early changes in the physical examination findings. , Bruising of the abdomen often is not seen, even with severe internal abdominal injury. , When present, bruising of the abdominal wall is a significant finding. It is usually the result of a lap seat belt or a restraint device in a motor vehicle crash but can be seen with severe inflicted abdominal trauma. The finding of fluid in the abdomen on CT scan without associated solid organ injury should raise suspicion for hollow viscus injury.
Stomach Injuries
Consider injury to the stomach if the child has peritoneal signs and/or bloody nasogastric drainage. Abdominal x-ray films sometimes show pneumoperitoneum.
Duodenal and Pancreatic Injuries
Most pediatric duodenal and pancreatic injuries are from deep, indenting blunt trauma and are often associated with child abuse. , In most cases, diagnosis of pancreatic injury is suggested by an elevated amylase level. However, the amylase level has been demonstrated to be neither sensitive nor specific in the evaluation of pancreatic trauma, particularly within 3 hours after trauma occurs.
Hepatic Injury
In a review of 646 cases of severe abdominal trauma, hepatic injury was the most common intraabdominal injury (40.5%), followed by splenic (26%), hollow viscous (17.9%), and pancreatic (8.6%) injuries. Hepatic injuries are associated with right upper quadrant abdominal pain, abdominal wall guarding, rebound tenderness, and hemodynamic instability.
Splenic Injuries
Splenic injuries are relatively common in major pediatric traumatic events and are associated with left upper quadrant abdominal pain, guarding, and often, rebound tenderness. Significant blood loss may be associated with splenic injury. Thus, hemodynamic instability is concerning for splenic or hepatic injury.
Renal Injury
The kidney is the urogenital organ most frequently injured in the pediatric patient. Contusion is the most common renal injury. Further injuries include disruption of the ureteropelvic junction from transient axial torsion and parenchymal injury.
Anorectal Injuries
Anorectal injuries may range from rectal mucosal or superficial anal injuries to full-thickness injuries or internal sphincter injury. Rectal injuries most often result from accidental impalement, sexual abuse, or blunt trauma. , If rectal trauma is evident on initial examination, further evaluation should be performed under anesthesia.
Musculoskeletal Evaluation
Careful palpation of the legs, arms, feet, hands, ribs, and head is mandatory, and the possibility of deformity or associated fracture must be excluded. If a fracture is suspected, surfaces should be carefully examined for “grab marks” that could indicate restraint or areas that were pulled or twisted to create the fracture. Soft tissue swelling, with or without bruising, indicates more recent trauma. Many fractures, including rib and metaphyseal fractures, might not be clinically detectable, so a negative clinical examination should not preclude the need for a skeletal radiological survey when inflicted trauma is suspected, particularly in children younger than 2 years.
Skin Injuries
Location, size, and shape of any bruises, lacerations, burns, bites, or other skin injuries should be documented in a medical chart as well as with high-quality photographs. Inspection for injuries should be thorough and involve all aspects of the neck and head, mouth, extremities (including feet and hands), genitals, anus, buttocks, torso, and back. Some deeper bruises might not be readily visible for several hours; areas that are painful to palpate require further examination in 1 to 2 days, when bruises might become apparent. Measurement of skin injuries assists in determining the mechanism of injury and/or object used to inflict the injury.
Bite marks can yield important forensic information; referral to professionals who can gather such information and maintain a chain of custody of evidence is advisable (see Chapter 60 , “Forensic Dentistry”). Bite marks, recent or healed, should be carefully measured and photographed. An intercanine distance of more than 3 cm suggests a human adult-sized bite. In some jurisdictions forensic odontologists are available who use special examination and photographic techniques to analyze bite marks. Fresh bites should be swabbed with sterile, premoistened cotton-tipped applicators for forensic analysis of potential genetic markers found in saliva. ,
A reliable method for determining the exact age of a bruise has not yet been developed. Soft tissue swelling is seen more commonly with recent trauma but can persist for several days. The age and developmental capabilities of the infant or child also determine the frequency of bruising.
Burn injuries can be chemical, thermal (including exposure to scalding liquids or hot objects), or electrical. The child’s clothing worn during the burn should be collected to preserve information regarding the cause of the burn. Burns inflicted with hot objects can be difficult to differentiate from accidental mechanisms, because both burns can be patterned. The history, number of burns, and continuity of the burn pattern over curved body surfaces often indicate a greater probability of inflicted trauma (see Chapter 28 , “Abusive Burns”).
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