Initial clinical presentation of children with acute and chronic versus acute subdural hemorrhage resulting from abusive head trauma.

OBJECT At presentation, children who have experienced abusive head trauma (AHT) often have subdural hemorrhage (SDH) that is acute, chronic, or both. Controversy exists whether the acute SDH associated with chronic SDH results from trauma or from spontaneous rebleeding. The authors compared the clinical presentations of children with AHT and acute SDH with those having acute and chronic SDH (acute/chronic SDH). METHODS The study was a multicenter retrospective review of children who had experienced AHT during 2004-2009. The authors compared the clinical and radiological characteristics of children with acute SDH to those of children with acute/chronic SDH. RESULTS The study included 383 children with AHT and either acute SDH (n = 291) or acute/chronic SDH (n = 92). The children with acute/chronic SDH were younger, had higher initial Glasgow Coma Scale scores, fewer deaths, fewer skull fractures, less parenchymal brain injury, and fewer acute noncranial fractures than did children with acute SDH. No between-group differences were found for the proportion with retinal hemorrhages, healing noncranial fractures, or acute abusive bruises. A similar proportion (approximately 80%) of children with acute/chronic SDH and with acute SDH had retinal hemorrhages or acute or healing extracranial injures. Of children with acute/chronic SDH, 20% were neurologically asymptomatic at presentation; almost half of these children were seen for macrocephaly, and for all of them, the acute SDH was completely within the area of the chronic SDH. CONCLUSIONS Overall, the presenting clinical and radiological characteristics of children with acute SDH and acute/chronic SDH caused by AHT did not differ, suggesting that repeated abuse, rather than spontaneous rebleeding, is the etiology of most acute SDH in children with chronic SDH. However, more severe neurological symptoms were more common among children with acute SDH. Children with acute/chronic SDH and asymptomatic macrocephaly have unique risks and distinct radiological and clinical characteristics.

Three-Dimensional Computed Tomography Skull Reconstructions as an Aid to Child Abuse Evaluations.

OBJECTIVES: Skull fractures can be difficult to recognize on radiographs and axial computed tomography (CT) bone windows. Missed findings may delay abuse diagnosis. The role of three-dimensional (3-D) reconstructions in child abuse evaluations was retrospectively evaluated. METHODS: Twelve exemplary cases between August 2006 and July 2009 are described. All, except 2 medical-legal cases, were clinical abuse consultations. With the use of a 1-to-3 scale, ease and accuracy of interpretation of findings between plain films, bone windows, and 3-D CT images were independently assessed by 2 radiologists. RESULTS: In 7 cases, skull fractures were missed on initial review of skull films and/or bone windows. Three children sustained additional abusive injury before 3-D CT reconstructions demonstrated subtle skull fractures, though imaged, were missed on initial readings. Three children with initially unrecognized fractures had timely 3-D reconstructions confirming fractures, allowing protective intervention before additional injury. An unrecognized ping-pong fracture was discovered on 3-D reconstructions with an inflicted subdural hemorrhage, defining the injury as an impact. Two 3-Ds demonstrated communication of biparietal fractures along the sagittal suture. This changed interpretation to single, rather than 2 separate, concerning impacts. Three potential skull fractures were found to represent large sutural bones. In all cases, ease and accuracy of interpretation scores were highest for 3-D CT. CONCLUSIONS: Without increasing patient radiation exposure, 3-D CT reconstructions may reveal previously unrecognized skull fractures, potentially allowing abuse diagnosis before additional injury. They may clarify normal skull variants and affirm accidental injury causes. We now routinely include 3-D reconstructions on cranial CTs for children younger than 3 years.

Additional injuries in young infants with concern for abuse and apparently isolated bruises.

OBJECTIVE: To determine the prevalence of additional injuries or bleeding disorders in a large population of young infants evaluated for abuse because of apparently isolated bruising. STUDY DESIGN: This was a prospectively planned secondary analysis of an observational study of children<10 years (120 months) of age evaluated for possible physical abuse by 20 US child abuse teams. This analysis included infants<6 months of age with apparently isolated bruising who underwent diagnostic testing for additional injuries or bleeding disorders. RESULTS: Among 2890 children, 33.9% (980/2890) were <6 months old, and 25.9% (254/980) of these had bruises identified. Within this group, 57.5% (146/254) had apparently isolated bruises at presentation. Skeletal surveys identified new injury in 23.3% (34/146), neuroimaging identified new injury in 27.4% (40/146), and abdominal injury was identified in 2.7% (4/146). Overall, 50% (73/146) had at least one additional serious injury. Although testing for bleeding disorders was performed in 70.5% (103/146), no bleeding disorders were identified. Ultimately, 50% (73/146) had a high perceived likelihood of abuse. CONCLUSIONS: Infants younger than 6 months of age with bruising prompting subspecialty consultation for abuse have a high risk of additional serious injuries. Routine medical evaluation for young infants with bruises and concern for physical abuse should include physical examination, skeletal survey, neuroimaging, and abdominal injury screening.

Older victims of sexual assault: an underrecognized population.

OBJECTIVE: We performed this study to determine if sexual assault characteristics differ in women presenting for evaluation as women age. STUDY DESIGN: All females 20 years or older presenting after sexual assault to an urban emergency department during a nine year period underwent standardized evaluation. Analysis was performed by chi(2). RESULTS: We evaluated 2399 women: 1743 women 20-39 years, 554 women 40-55 years, and 102 women over 55 years of age. Compared with the other age groups, older women were more commonly assaulted in their own home (36%) or care facility (33%), P < .001, assaulted by a service provider (16.7%) or stranger (18.6%), P < .001, impaired (54.9%), P < .001, admitted to the hospital (15.7%), P < .001, incur genital trauma (35.6%), P = .04, and less likely to have a weapon used (7.8%), P = .003. CONCLUSION: Sexual assault in older women has distinct characteristics, which may be useful in planning intervention and prevention strategies.

Pediatric tramadol ingestion resulting in seizurelike activity: a case series.

Tramadol has been reported to cause seizures in therapeutic dosing and in overdose. We present a series of 2 infants poisoned with tramadol, both presenting with abnormal neurologic findings: either seizures or seizurelike activity. Tramadol poisoning should be considered in the differential diagnosis of dystonia and seizures.

Pubic ramus radiolucencies in infants: the good, the bad, and the indeterminate.

OBJECTIVE: The purpose of this study was to examine imaging findings that differentiate inflicted injuries from developmental variants of the superior pubic ramus in healthy and abused infants. CONCLUSION: A superior pubic ramus fracture and a developmental variant can be difficult to differentiate radiographically. A smoothly marginated vertical radiolucency of the superior pubic ramus detected without other features suggesting infant abuse should not be interpreted as a fracture.

Cervical spinal cord injury in abused children.

Five infants and toddlers who sustained cervical spinal cord injury as the result of child abuse are described. Three cases are previously unreported. Diagnosis was complicated by coexistent brain injuries and their treatments, subtle and/or evolving paralysis, and central cord syndrome, in which arm function is diminished but leg function is preserved. Definitive spinal imaging by magnetic resonance imaging (MRI), computed tomography, and plain radiographs was delayed because of life support efforts. When completed, the MRI was most sensitive to cord injury. Evidence of associated bony spinal injury was often absent or unapparent until healing occurred; 4 children had spinal cord injury without (or with minimal) radiological abnormality. The 3 children presenting to our hospital with cord injury represent 1% of the estimated cases of inflicted head injury seen during a 23-year period.

Perineal impalements in children: distinguishing accident from abuse.

UNLABELLED: Perineal impalements are uncommon and potentially life-threatening injuries. Medical providers must evaluate the risk of child abuse in all cases of genital or anal trauma. Determination of abuse depends on medical assessment of the mechanism of injury and statements by the child and witnesses, and may require collaboration with police or child protection agencies for scene investigation. OBJECTIVE: To describe circumstances, medical findings, and child protection issues raised in accidental pediatric perineal impalement injuries. METHODS: Retrospective case series selected from the authors' own practices and from submissions through an international list-serve of child abuse physicians. All cases included were determined to be accidental. RESULTS: Thirty-four cases were identified. Children ranged in age from 13 months to 14 years, 59% were girls. Most injuries occurred in the home (24/34, 71%), and more than one third (13/34, 38%) occurred in the bathroom. Most children had examination under anesthesia (26/34, 77%), many required surgical repair (20/34, 59%), and 4 had bowel perforations. Multidisciplinary assessment regarding child abuse was used in 71% (24/34) of cases. Inspection of the impaling objects or the scene was accomplished by medical providers or police in 50% (17/34) of cases. CONCLUSIONS: Ambulatory children can sustain accidental perineal impalement injuries, and severe internal injuries may accompany minor external findings. History from supervising adults and from other child witnesses, examination of the impaling objects, and investigation of the scene may be required to reach the conclusion of accidental injury.

Oral surgical aspects of child abuse and neglect.

Oral trauma is a frequent manifestation of child abuse. Injuries to the oral hard and soft tissues are common in active children, but any oral injury in a young preambulatory infant should raise concern for abuse. Oral-facial trauma may be the primary presenting injury, or may accompany other severe inflicted injuries such as head injury, fractures, or abdominal trauma. Some congenital or acquired medical disorders may be mistaken for abuse or neglect. The oral surgeon is a critical participant in the collaborative management of child abuse cases.

Into hot water head first: distribution of intentional and unintentional immersion burns.

INTRODUCTION: Experience with several, previously unreported, intentional face-first immersion burns led us to evaluate the distribution of inflicted and unintentional immersion scald burns in a hospital series. SETTING: (1) Authors' clinical and legal practices; (2) Burn center at regional Level 1 trauma hospital. SUBJECTS: : (1) Case series of face-first, inflicted immersion burn victims; (2) Consecutive hospitalized scald burn victims younger than 5 years old, 1/3/1996 to 3/25/2000. METHODS: (1) Individual case reports; (2) Retrospective records review. Simple descriptive statistics, Fisher Exact test and t test. RESULTS: (1) Six cases of inflicted head and neck immersion injury are described. Four were tap water and 2 food/drink scalds. (2) 22/195 hospitalized victims had sustained immersion burns, 13 from tap water and 9 from other fluids. Six (46%) tap water immersions and no (0%) other immersions had inflicted injuries (P = 0.05). Two of the tap water immersions and one other source immersion included burning of the head and neck. Of these, one tap water immersion, but no other immersion, was inflicted. In no patients were head and neck injuries the sole or predominant site of scalding. In all, 9 children sustained inflicted scalds. Bilateral lower extremity tap water immersion scalds occurred in 100% (6/6) of abusive and 29% (2/7) of unintentional injuries (P = 0.02). Buttock and perineal injuries occurred in 67% (4/6) inflicted versus 29% (2/7) unintentional tap water immersion scalds (P = 0.28). Other fluids caused bilateral lower extremity immersion burns in 3/9 (33 %) unintentionally injured patients, but no abused children (NS). CONCLUSIONS: Craniofacial immersion injury, although seen by the authors in legal cases, is infrequent. It was present incidentally in one inflicted tap water burn in the consecutive hospital series. This series affirms the predominance of bilateral lower extremity burns in inflicted tap water immersions. Buttock/perineal immersions were more common with abuse than with unintentional injury.