Proximal femoral physeal fractures in children: a rare abusive injury.

BACKGROUND: Proximal femoral physeal fractures are rare in abused children. Recognition may be hampered due to their rarity and lack of an ossified femoral head. Prompt diagnosis and treatment are essential to preventing coxa vara. OBJECTIVE: To demonstrate the radiographic features of proximal femoral physeal fractures both with unossified and ossified femoral heads. MATERIALS AND METHODS: We reviewed our Institutional Review Board-approved 21-year radiology database of 2,206 children who had a skeletal survey as part of their medical evaluation for possible abuse. Cases of proximal femoral physeal fractures were identified. RESULTS: Eight patients, ages 2.5 to 26 months, with 10 fractures were found, yielding a prevalence of 0.4% (8/2,206). In all fractures, there was lateral displacement of the proximal femur. In three fractures, the femoral head was not ossified, simulating a hip dislocation. The intra-articular location of the femoral head was verified by ultrasound or abdomen computed tomography. Subperiosteal new bone formation was present in six fractures, all non-weight-bearing patients. The femoral head was ossified in seven cases, all with medial rotation of the femoral head. Metaphyseal irregularity was present in three of four fractures of the weight-bearing patients; two of three also had metaphyseal scalloping resembling osteomyelitis. The three with metaphyseal irregularity developed coxa vara. CONCLUSION: Proximal femoral physeal fractures are rare in abuse cases. All present with lateral displacement of the proximal femur. With an unossified femoral head, it can simulate hip dislocation, which can be clarified with hip sonogram. Metaphyseal irregularity appears to be a feature in weight-bearing patients.

Pediatric and Adolescent Gynecology Education through Simulation (PAGES): Development and Evaluation of a Simulation Curriculum.

STUDY OBJECTIVE: Develop a Pediatric and Adolescent Gynecology (PAG) curriculum, appropriate pelvic model for teaching examination skills, and an objective structured clinical examination (OSCE) for evaluation. Compare OSCE performance between residents with clinical training in PAG vs those that completed the curriculum vs those without either experience. DESIGN: Prospective cohort study. SETTING: Obstetrics and Gynecology (Ob/Gyn) residency program in an urban academic center. PARTICIPANTS: Senior Ob/Gyn residents. INTERVENTIONS: A simulation-based teaching curriculum was created to teach PAG skills. A pediatric mannequin with anatomic pre-pubertal genitalia was developed for teaching and assessment of skills. MAIN OUTCOME MEASURES: Performance on a PAG-based OSCE as assessed by 2 observers using a 40 point checklist. RESULTS: 17 residents participated in the OSCE; 5 completed the curriculum, 6 completed a clinical rotation, and 6 were controls. The teaching curriculum group had the highest median composite OSCE score (75.0%) compared to the clinical group (73.1%) and control group (55.3%). There was no statistical difference between the scores of the teaching and clinical groups, but the teaching group scored statistically higher than controls (P = .0331). Scores for each OSCE component were compared. The teaching and clinical groups outperformed controls on assessment and procedures. There was no difference in scores on history taking or physical examination. CONCLUSION: An interactive teaching curriculum incorporating simulation and a realistic pediatric pelvic model can be used to teach PAG clinical skills. Using an OSCE to evaluate skills shows that residents completing the curriculum perform as well as those with clinical experience and better than controls.

Aspects of abuse: commercial sexual exploitation of children.

Commercial sexual exploitation of children (CSEC) and adolescents is a serious worldwide problem. It is, in essence, the sexual abuse of a minor for economic gain. In the United States, there is no uniform nationwide database to capture the incidence and prevalence of CSEC. Therefore, there is a great variation in the estimates, but the actual numbers are unknown. Given the clandestine nature of the practice, it is often underreported and underidentified. Healthcare providers will often encounter victims of commercial sexual exploitation due to mental health, physical health, and sexual health consequences, and therefore should be knowledgeable in the signs of possible sexual exploitation. The aim of this article is to educate healthcare providers on how vulnerable children may become sexually exploited, the health consequences involved with sexual exploitation, how to better identify possible victims, and the medical evaluation of a victim of sexual exploitation.

Aspects of abuse: consequences of childhood victimization.

Childhood maltreatment is unfortunately a common occurrence in the United States, affecting 1 in 8 children annually.(1) The consequences of maltreatment can be considerable, and exact a heavy toll on the individual, family, and society. Child abuse and neglect can cause permanent, heritable changes in the body׳s response to stress, which in turn inflicts profound changes in the developing brain. While these changes allow a child to contend with a neglectful, chaotic, or possibly violent environment, they strongly influence an individual׳s behavioral, educational, physical, and mental functioning and well-being throughout his/her lifetime, long after the maltreatment has ended. As the adverse childhood experiences (ACE) studies clearly demonstrate, adult survivors of maltreatment experience significant health harms that can cause significant morbidity and contribute to early death. Further, the lifetime economic cost to society of childhood maltreatment is estimated to be $124 billion dollars.(2) The study of resilient individuals who appear to suffer fewer negative consequences of their maltreatment offers insights into possible interventions for clinical practice as well as advocacy and public policy opportunities that would begin to lessen the significant burdens of childhood maltreatment.

Aspects of abuse: abusive head trauma.

Abusive Head Trauma (AHT) is a form of child physical abuse that involves inflicted injury to the brain and its associated structures. Abusive Head Trauma, colloquially called Shaken Baby Syndrome, is the most common cause of serious or fatal brain injuries in children aged 2 years and younger. The American Academy of Pediatrics recommends the term Abusive Head Trauma, as opposed to Shaken Baby Syndrome, as the former term encompasses multiple forms of inflicted head injury (inertial, contact, and hypoxic-ischemic) and a range of clinical presentations and radiologic findings and their sequelae. Children diagnosed with AHT are 5 times more likely to die compared with accidentally head-injured children, yet signs and symptoms are not always obvious, and therefore the diagnosis can be overlooked. Therefore, the American Academy of Pediatrics has tasked pediatricians with knowing how and when to begin an evaluation of children with signs and symptoms that could possibly be due to AHT. Overall, a detailed history of present illness and medical history, recognition of physical and radiological findings, and careful interpretation of retinal pathology are important aspects of formulating the differential diagnoses and increasing or decreasing the index of suspicion for AHT.

Aspects of abuse: recognizing and responding to child maltreatment.

Child maltreatment is a public health problem and toxic stress impacting at least 1 in 8 children by the age of 18 years. Maltreatment can take the form of physical and sexual abuse, neglect, and emotional maltreatment. While some children may experience only one form of maltreatment, others may survive multiple forms, and in some cases particularly complex forms of maltreatment such as torture and medical child abuse. When considering maltreatment, providers should be adept at obtaining a thorough history not only from the parent but when appropriate also from the patient. The most common form of child maltreatment is neglect, which encompasses nutritional and medical neglect, as well as other forms such as physical and emotional neglect. Talking with caregivers about stressors and barriers to care may give insight into the etiology for neglect and is an opportunity for the provider to offer or refer for needed assistance. Familiarity with injury patterns and distribution in the context of developmental milestones and injury mechanisms is critical to the recognition of physical abuse. While most anogenital exam results of child victims of sexual abuse are normal, knowing the normal variations for the female genitalia, and thereby recognizing abnormal findings, is important not only forensically but also more importantly for patient care. Pattern recognition does not only apply to specific injuries or constellation of injuries but also applies to patterns of behavior. Harmful patterns of behavior include psychological maltreatment and medical child abuse, both of which cause significant harm to patients. As health professionals serving children and families, pediatric providers are in a unique position to identify suspected maltreatment and intervene through the health care system in order to manage the physical and psychological consequences of maltreatment and to promote the safety and well-being of children and youth by making referrals to child protective services.

Frequency of skeletal injuries in children with inflicted burns.

BACKGROUND: It is estimated that inflicted burn injuries in physically abused children occur with a prevalence of approximately 6-20%. Identification of burns of a nonaccidental nature is oftentimes difficult. Underlying skeletal injuries in abusive environments are often overshadowed by the acute burn injury. OBJECTIVE: We assessed the prevalence of inflicted burns and the frequency of associated skeletal injuries in a population from a large children's hospital. MATERIALS AND METHODS: From a database of nearly 3,000 children who were assessed for possible abuse from 1997 to 2012, we identified 142 children with burn injuries. We included only those who had undergone skeletal surveys as part of the diagnostic workup. The final diagnosis, based on the burn, was categorized as nonaccidental, accidental or indeterminate by a child abuse pediatrician. We excluded children with no skeletal survey (n = 18), children in whom the final diagnosis could not be found (n = 6), and other conditions misdiagnosed as burn (n = 6). The resulting cohort consisted of 112 children. RESULTS: Of the 112 children with burns, 54 were girls and 58 boys with ages ranging from 1 month to 110 months, mean age of 15 months. Forty-five (40%) were determined to be nonaccidental, 36 (32%) were indeterminate and 31 (28%) accidental. The most common causative mechanism was scalding and the most common location was the perineum and lower extremity in all three diagnostic categories. Skeletal surveys were positive for fractures in 15/45 (33%) of the nonaccidental group; 2/36 (6%) in the indeterminate group, and 0/29 (0%) in the accidental group. Fractures in the nonaccidental group included healing rib fractures in seven, classic metaphyseal lesions in three, healing shaft fractures in six, skull fracture in one and clavicle fracture in two children. Fractures in the indeterminate group included shaft fractures in two, one of which was healing. CONCLUSION: Intentional burns in children appear to be more common than previously known, occurring in 40% of the children in our series, a greater percentage than has been reported in the literature. In addition, nearly one-third of these children with inflicted burns had associated skeletal injuries, most commonly healing rib fractures. Thus young children with concern for nonaccidental burns should undergo a skeletal survey.

Curiosity and critical thinking: identifying child abuse before it is too late.

OBJECTIVE: We reviewed medical records to identify factors contributing to not recognizing child abuse in cases where it was subsequently identified. DESIGN/METHODS: Eighteen cases of delayed diagnosis of physical abuse were reviewed for qualitative themes. Missed abuse was defined by prior medical encounters that revealed findings concerning for physical abuse that were not recognized. RESULTS: Clinical limitations contributing to a delay in diagnosis included inattention to skin and subconjunctival findings, acceptance of inadequate explanations for injuries, no history obtained from verbal children, insufficient exploration of signs and symptoms, nonadherence to the maltreatment pathway, and incorrect diagnoses from radiologic examinations. System-based limitations included limited medical record access or completeness and admission to less-than-optimal settings. CONCLUSIONS: Having a greater index of suspicion for abuse may mitigate missed opportunities. With variability of medical training in child abuse, the factors we identified can be used as learning objectives for continuing medical education.