CT identification of abdominal injuries in abused pre-school-age children

A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children

Child abuse is a preventable phenomenon of considerable concern resulting in significant child mortality and morbidity. We analyze various abuse lesions such as radiological (visceral and skeletal lesions and those associated with head trauma) and cutaneous (burns, bruises, bites, etc.) to enhance streamlined identification of injuries in cases of physical child abuse. For effective results, it is essential to remain mindful of all background factors, such as the caregiver setting and the prevalence of child maltreatment in the concerned community while acknowledging the possibility of natural causes (genetic diseases such as osteogenesis imperfecta and hemophilia, or acquired abnormalities) that can mimic NAT and cause confusion in diagnosis and treatment. The margin of error in cases of abuse is negligible, therefore, making its diagnosis a momentous as well as challenging clinical task. An ineffective diagnosis can have detrimental emotional consequences for the family and may even expose the child to future potentially fatal episodes of abuse. Hence, there is a need to direct special focus on the importance of accurate history taking and immediate, responsible reporting to authorities, as well as to child protective services. Therefore, considering the multifactorial approach this subject requires, this review aims to delve into prevalence statistics, various risk factors, and their effect on psychological health to offer a near-complete regulation to ensure an effective understanding of NAT on part of doctors, social workers, and other relevant authorities.

Inferior mesenteric artery laceration associated with blunt abdominal trauma with Casper's sign in a physically abused child: An autopsy case and literature review

There have been few studies of the death of children secondary to child abuse-related abdominal compression, and the detailed pathophysiology of such deaths is therefore unknown. The autopsy findings of a 3-year-old boy who died of hemorrhagic shock due to non-accidental severe blunt abdominal trauma were compared to those of children who died of other non-accidental abdominal injuries. Old and acute subcutaneous hemorrhages, abrasions, and scars were present all over the subject's body. No superficial injuries were found on the ventral midline, but a minor hemorrhage was found in the subcutaneous fat tissue, as well as in the rectus abdominis muscle. The intraperitoneal space contained 450 mL of blood, including coagulated blood. There was a tear in the transverse mesocolon and a crush injury in the small bowel mesentery. The inferior mesenteric artery was transected 0.5 cm from the aortic root. The transverse colon was necrotic, with hemorrhages in the mucosa. Since various organs were ischemic, the cause of death was determined to be blood loss from the inferior mesenteric artery injuries. Blunt abdominal trauma in children usually causes organ damage and intestinal injury, but because it is caused on the posterior surface of the mesentery, vascular injury should also be considered, and an autopsy should be performed. In the case of child abuse-related deaths, damage to the skin surface may not always be present; therefore, imaging tests, histopathological examinations, and biochemical tests should be performed with a focus on the gross anatomy to determine the cause of death and pathology.

Occult child abuse presenting as pneumatosis intestinalis and portomesenteric venous gas - a case report

BACKGROUND

Pneumatosis intestinalis and portomesenteric venous gas are usually caused by necrotizing enterocolitis; however they can occur secondary to abusive abdominal trauma with bone fractures and bruising. It is difficult to recognize initially if there is no bruising on the skin or bone fractures.

CASE PRESENTATION

We report a 1-year-old child with no obvious history of trauma who presented with conscious disturbance. Abdominal computed tomography showed acute ischemic bowel complicated with pneumatosis intestinalis and portomesenteric venous gas. The first impression was septic shock with acute ischemic bowel. Two weeks after admission, brain magnetic resonance imaging showed subdural hemorrhage of different stages over bilateral fronto-parietal convexities and diffuse axonal injury, suggesting abusive head trauma. He was subsequently diagnosed with occult child abuse.

CONCLUSION

Pneumatosis intestinalis and portomesenteric venous gas are rare except in cases of prematurity. Occult abusive abdominal trauma should be considered as a differential diagnosis in patients with pneumatosis intestinalis and portomesenteric venous gas, even without any trauma on the skin or bone fractures.

Characteristics and outcomes of acute pediatric blunt torso trauma based on injury intent

INTRODUCTION

Blunt trauma is a leading cause of pediatric morbidity. We compared injuries, interventions and outcomes of acute pediatric blunt torso trauma based on intent.

METHODS

We analyzed de-identified data from a prospective, multi-center emergency department (ED)-based observational cohort of children under age eighteen. Injuries were classified based on intent (unintentional/inflicted). We compared demographic, physical and laboratory findings, ED disposition, hospitalization, need for surgery, 30-day mortality, and cause of death between groups using Chi-squared or Fisher's test for categorical variables, and Mann-Whitney test for non-normal continuous factors comparing median values and interquartile ranges (IQR).

RESULTS

There were 12,044 children who sustained blunt torso trauma: Inflicted=720 (6%); Unintentional=9563 (79.4%); Indeterminate=148 (1.2%); Missing=1613 (13.4%). Patients with unintentional torso injuries significantly differed from those with inflicted injuries in median age in years (IQR) [10 (5, 15) vs. 14 (8, 16); p-value<0.001], race, presence of pelvic fractures, hospitalization and need for non-abdominal surgery. Mortality rates did not differ based on intent. Further adjustment using binary, logistic regression revealed that the risk of pelvic fractures in the inflicted group was 96% less than the unintentional group (OR: 0.04; 95%CI: 0.01-0.26; p-value=0.001).

CONCLUSIONS

Children who sustain acute blunt torso trauma due to unintentional causes have a significantly higher risk of pelvic fractures and are more likely to be hospitalized compared to those with inflicted injuries.

Are There Hallmarks of Child Abuse? II. Non-Osseous Injuries

Certain conditions have been considered hallmarks of child abuse. Such pathognomonic conditions have led to an inevitable diagnosis of inflicted injury. Forensic pathologists are faced with complex analyses and decisions related to what is and what is not child abuse. In this review, we examine the literature on the specificity of five conditions that have been linked to inflicted injury to varying degrees of certainty. The conditions examined include tears of the labial frena (frenula), cigarette burns, pulmonary hemorrhage and intraalveolar hemosiderin-laden macrophages as markers of upper airway obstruction, intraabdominal injuries, and anogenital injuries and postmortem changes. Analysis of the literature indicates that frena tears are not uniquely an inflicted injury. Cigarette burns are highly indicative of child abuse, though isolated cigarette burns may be accidental. Pulmonary hemorrhage is seen more commonly in cases with a history suggestive of upper airway obstruction, but is not diagnostic in an individual case. Hemosiderin-laden macrophages may be seen in cases with inflicted injuries and in natural deaths. Abdominal injuries may be seen in accidents and from resuscitation, though panreatico-duodenal complex injuries in children under five years of age are not reported to be seen in falls or resuscitation. The understanding of anogenital injuries is increasing, but misunderstanding of postmortem changes has led to miscarriages of justice.

Role of the surgeon in non-accidental trauma

Non-accidental trauma (NAT) represents a significant cause of morbidity and mortality in the pediatric population. The management of these patients often involves many care providers including the surgeon. Victims of NAT often present with multiple injuries and as such should be treated as trauma patients with complete trauma evaluation including primary, secondary and tertiary surveys. Common injury patterns in NAT include extremity fractures, closed head injury and intra-abdominal injury. Brain imaging is of importance to rule out acute or sub-acute intracranial hemorrhage. Children under the age of 5 years with acute intracranial pathology should also be evaluated by an ophthalmologist to rule out retinal hemorrhages, which are considered pathognomonic for child abuse from violent shaking. In instances when abdominal injury is suspected, prompt evaluation by a surgeon is recommended along with CT imaging. Finding of extremity fractures should prompt evaluation by an orthopedic surgeon. At our institution, all patients with suspected NAT are admitted to the pediatric surgery service for complete evaluation and management. We encourage other pediatric trauma centers to employ a similar approach so that these complicated patients are managed safely and effectively.

A systematic review of abusive visceral injuries in childhood--their range and recognition

OBJECTIVES

To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children.

METHODS

We searched 12 databases, with snowballing techniques, for the period 1950-2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0-18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome.

RESULTS

Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5-3.7 years vs. 7.6-10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with 'negative' screening tests were not consistently investigated.

CONCLUSIONS

Visceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged<five years warrants consideration of abuse as an etiology. In the absence of clear evidence for a screening strategy, clinical vigilance is warranted in any young child with suspected abuse for the presence of abdominal injury, where the absence of abdominal bruising or specific symptoms does not preclude significant injury.