Maltreatment

Question 1

Red flags for inflicted trauma in young child w fracture

Answer 1

No history of trauma/unwitnessed
History incompatible w age/development or w injury
History changing w repetition
Delay in seeking medical attn

Age <1y
3 or more fractures
Rib # 
Metaphyseal #
Humeral # < 18 months 
Femur # in nonambulatory children
# of different ages
Presence of other injuries

Question 2

Investigations in suspected inflicted trauma

Answer 2

CBC, Renal fn, liver fn
Serum calcium, phosphate and alkaline phosphatase, Urinalysis

When clinically indicated:
parathyroid hormone, 25-hydroxy-vitamin D serum copper, ceruloplasmin

Anyone w suspected head trauma: ophthalmological assessment

Skeletal survey for all children < 2y

Question 3

Red flags in bruising

Answer 3

Bruises in babies who are not yet cruising
Bruises on the ears, neck, feet, buttocks or torso (torso includes chest, back, abdomen, genitalia)
Bruises not on the front of the body and/or overlying bone
Bruises that are unusually large or numerous
Bruises that are clustered or patterned (patterns may include handprints, loop or belt marks, bite marks)
Bruises that do not fit with the causal mechanism described

Question 4

Investigations for suspicious bruising

Answer 4

CBC+smear
PT/INR 
aPTT
fibrinogen
vW studies
blood group 
FVIII/IX levels
LFTs
RFTs

Question 5

Characteristics of abusive head trauma?

Answer 5

ICH, retinal hemorrhage,brain injury+/- skull, rib, long bone #, may or may not have external evidence of trauma

Question 6

Workup in suspected abusive head trauma

Answer 6

Full physical exam - absence of external injuries does not rule out AHT
Ophthalmologist must perform a dilated retinal exam
CBC + Coags+/- lytes, BG, tox, micro, metabolic screen
CT head to rule out subdural hematoma or cerebral edema
Skeletal Survey - may require follow up in 10-14 days

Question 7

DDX for skeletal fracture?

Answer 7

Trauma

1. Birth-related
2. Accidental
3. Inflicted

Genetic bone disorder

4. Osteogenesis imperfecta
5. Menkes disease
6. Infantile cortical hyperostosis
7. Hypophosphatasia

Nutritional/metabolic disorder

8. Vitamin D deficiency rickets
9. Osteopenia of prematurity
10. Copper deficiency
11. Chronic renal insufficiency
12. Scurvy

Infection

13. Osteomyelitis
14. Congenital syphilis

Toxicity

15. Hypervitaminosis A
16. Methotrexate toxicity

Neoplasc disorder
Leukemia
Langerhans cell hisocytosis

Question 8

Red Flags for inflicted fracture? History and Clinical

Answer 8

Historical:

• No history of trauma/unwitnessed injury
• History incompable with age/developmental stage OR with injury
• History changes with repetition
• Delay in seeking medical attention

Clinical:

• Age < 1 year
• High-risk fractures
• Rib fractures
• Metaphyseal fractures
• Humerus fracture < 18 months
• Femur fracture in a non-ambulatory child
• Multiple fractures
• Fractures of different ages
• Presence of other injuries