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11 conditions mistaken for child abuse
11 conditions mistaken for child abuse
11 conditions mistaken for child abuse
11 conditions mistaken for child abuse
11 conditions mistaken for child abuse
11 conditions mistaken for child abuse
11 conditions mistaken for child abuse
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11 conditions mistaken for child abuse

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  • 1. VISUAL DIAGNOSIS OF CHILD ABUSE ON CD-ROM LECTURE SERIES 11. Conditions Mistaken for Child Physical AbuseOutlineAbstract Fractures Osteogenesis ImperfectaLearning Objectives Diagnostic Considerations in DistinguishingConfusing Cutaneous Conditions Osteogenesis Imperfecta From Folk Medicine Inflicted Injuries Burns Temporary Brittle Bone Disease Infantile Cortical HyperostosisIntracranial Bleeding (Caffey’s Disease)Ocular Hemorrhages Other Miscellaneous Conditions Mistaken for Child Abuse References 1
  • 2. Visual Diagnosis of Child Abuse on CD-ROM Lecture Series 11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE Abstract • Dermatitis herpetiformis Numerous conditions exist that can suggest an • Diaper dermatitis etiology of inflicted injury. Strict adherence to • Chilblains evidence based on objective findings and consid- • Drug eruption eration of all diagnostic possibilities help to avoid • Mechanical abrasion mistakes. An organ-system approach is outlined • Chemical burns here. The medical conditions that may mimic child maltreatment are discussed with an eye toward • Staphylococcal scalded skin syndrome distinguishing them from inflicted injury. • Accidental burns Learning Objectives Intracranial Bleeding • To identify conditions, disorders, and syndromes Accidental Trauma—There have been numerous that may be confused with child abuse articles detailing the kinds of falls that produce seri- • To differentiate inflicted injury from preexisting ous intracranial injuries in infants and children.9–32 medical conditions The conclusion of these studies is that children do • To identify cultural practices that may be confused not suffer serious intracranial injuries from short with child abuse (<4 feet) falls. The exception is epidural hematomas, which usually are easily distinguished on computed tomography (CT) scans of the head, appearing as Confusing Cutaneous Conditions lenticular-shaped densities. The impact caused by The process of diagnosing medical conditions is motor vehicle crashes and falls, usually from 2 to organized around gathering information about the 3 stories, is necessary to produce subdural or sub- onset, severity, and duration of the symptoms and arachnoid hematomas. Extensive, multilayered reti- signs; the objective findings on physical examination nal hemorrhages (RHs) are almost exclusively seen of the patient; and collection of additional data from in shaken baby syndrome/shaken impact syndrome the laboratory, special studies, or x-rays. When all of (SBS/SIS). Retinal folds are diagnostic of abusive these are synthesized, a list of diagnostic possibili- head trauma. ties is developed. This list—called the differential Coagulation Disorders—Although bleeding and diagnosis—forms the basis for further thinking about clotting disorders can exacerbate intracranial bleed- the possible etiology of the patient’s disorder. ing when a traumatic event has occurred, the brain It is no different when approaching a case of is not the usual site for such bleeding. In hemo- suspected abuse. There are a number of medical philia, for example, bleeding is usually into joints conditions that may mimic physical child abuse. or soft tissue. Appropriate laboratory tests for bleed- These possibilities must be considered and ruled ing and clotting abnormalities will diagnose a coagu- out in the diagnostic process. lation disorder. Folk medicine Tumors—These are usually diagnosable by radio- graphic techniques such as CT scans or magnetic • Coin rubbing (cao gio)1,2 resonance imaging. • Spooning (quat sha)3,4 Vascular Malformations—Rare in childhood, when • Moxibustion4,5 intracranial bleeding is due to these it is usually in • Cupping4,6 the brain tissue itself. • Maqua5 Caida de Mollera (Fallen Fontanelle)33—In some Burns cultures, a flat or sunken fontanelle is considered unhealthy, although it may be present for a variety • Phytophotodermatitis7 of benign reasons. When caida de mollera is • Impetigo employed to “raise” the fallen fontanelle, the baby • Varicella is held upside down, often shaken in that position, • Epidermolysis bullosa and the head is held over or dipped into boiling liquid. The shaking motion is sometimes extreme 2
  • 3. Visual Diagnosis of Child Abuse on CD-ROM Lecture Series 11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE TABLE 11-1. CONDITIONS CONFUSED WITH BRUISING Condition Distinguishing Features Mongolian spots • Slate gray and uniform in color from one side to the other • Seen at time of birth, become less visible slowly • Seen usually on buttocks, lower back, but can be seen anywhere on the body Ehlers-Danlos syndrome • Skin is velvety, hyperelastic, and fragile (India rubber syndrome) • Minor trauma can lead to bruises Erythema multiforme • Splotchy, covering various areas of body Hypersensitivity vasculitis • Often itchy, may be raised (hives) • Recurrent, indolent Phytophotodermatitis • Exposure to psoralens in the juice of certain plants followed by exposure to sunlight (limes, lemons, figs, parsnip, celery, herbal preparations) Millipedes secretions8 • Mahogany-colored lesions from contact to skin Contact dermatitis and allergic reactions • Rubber, face masks, surf boards, squash balls, elastic bands in clothing, plants, chemicals Lice, “crabs” • Can inject anticoagulant under the skin causing deposit of hemosiderin Ink or dye on skin (clothing) • Mimics bruises or abrasions Coagulation defect (hemophilia, von • Coagulation studies—PT, PTT, TT, fibrinogen, Factor VIII, platelets, Willebrand’s, leukemia, ITP, HSP, vitamin special studies K deficiency, ingestion of anticoagulants and can lead to tearing of the bridging veins and Ocular Hemorrhages resultant subdural or subarachnoid hematomas. Periorbital Ecchymoses—Bilateral black eyes are Obstetric Trauma—Cephalohematomas are com- usually from abuse, but they can be caused by blunt mon parturitional injuries, especially in births trauma to the forehead with resultant seepage of involving instrumentation. They occur in 3% to the extravasated blood into the periorbital tissues. 10% of newborns.34 In 25% of cases they are Subconjunctival Hemorrhage—Forceful coughing, associated with skull fractures, usually in the sneezing, vomiting, or other Valsalva maneuvers can posterior parietal region.35 cause subconjunctival hemorrhages. Subdural hemorrhage related to the tentorium is Retinal Hemorrhages—Retinal hemorrhages must be associated with vacuum extraction.36 Chronic sub- described in terms of their characteristics, because dural collections seen in the first months of life may not all RHs are alike.38 Retinal hemorrhages do not be attributed to parturitional events, but examina- occur as the result of cardiopulmonary resuscita- tion of those events will usually clarify whether tion,38–41 seizures,38–42 or thoracic compression in there were factors during the birth that may have childhood (Purtscher’s retinopathy).38,43,44 given rise to the collections seen later. The CT imaging characteristics and the absence of asso- ciated injuries (other fractures, RHs, abusive bruises) and the social history often can help distinguish these conditions from parturitional injuries.37 3
  • 4. Visual Diagnosis of Child Abuse on CD-ROM Lecture Series 11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE Other conditions in which RHs are seen include Rib fractures resulting from birth trauma are almost unknown. Kleinman37 has found only 4 examples Vaginal Delivery—Occurring in 40% of children of rib fractures associated with birth injuries in delivered vaginally, these fine petechial preretinal otherwise normal infants.52–55 hemorrhages usually resolve within 10 to 14 days of delivery leaving no residual.38 Forceful Manipulation—Overzealous passive exercise and chiropractic or other health care providers have Bleeding Disorders—Isolated RHs in coagulopathies been reported to cause fractures.56 have not been described. When they occur in patients with bleeding or clotting disorders, they Metabolic Disorders, Nutritional Deficiencies, and are associated with other sites of bleeding. Infectious Conditions—Preterm or very low birth weight babies (neonatal osteopenia), Menke’s kinky Arteriovenous Malformations—Arteriovenous mal- hair syndrome, rickets, scurvy, and altered vitamin D formations are extremely rare in infancy and, when metabolism due to drugs (phenobarbital, phenytoin) present, are seldom associated with RHs. may cause fractures. Increased Intracranial Pressure—This is present in most cases of SBS/SIS, but current thinking is that Osteogenesis Imperfecta if this caused RHs, it would be present in all cases Osteogenesis imperfecta is a disorder of of increased intracranial pressure secondary to all collagen synthesis. causes. This is not supported by medical literature about accidental head trauma with increased Type I: 70% of all cases intracranial pressure.24,45–49 • Normal stature Meningitis—Increasingly rare in pediatrics, it is not • Little or no long bone involvement likely this diagnosis would be overlooked after • Blue sclerae clinical assessment, culturing, and examination of • Dentinogenesis imperfecta uncommon cerebrospinal fluid. • Osteoporosis often found on plain radiograph Accidental Head Trauma—Recent literature on • Autosomal dominant positive, family history the incidence of RHs in accidental head trauma usually positive indicates they are seldom seen in cases of acci- dental origin. Type II: Severe bone disease evident prior to birth Thromboembolic Phenomena (eg, subacute bac- • At birth, severe shortening and distortion of limbs terial endocarditis)—These conditions would be ~ Large head diagnosed based on numerous other findings. ~ Striking blue sclerae ~ Severe generalized skeletal dysplasia Fractures ~ Poor mineralization of calvarium with wormian bones Birth Injuries—Fracture of the clavicle is the most ~ Fractures and crumpling of long bones, beading common obstetrical fracture with an incidence of of ribs, distortion of vertebral bodies up to 7 per 1,000 term deliveries.37 This fracture ~ Early death in perinatal period or infancy usually occurs in large babies. Callus formation is ~ Autosomal dominant present by 11 days of age and if not present then, excludes the diagnosis of birth injury. Fracture of Type III: Unlikely to be confused with inflicted injuries the humerus occurs in a small number of births • Large head (7/15,435).50 This fracture occurs in difficult deliver- ies and breech extractions. Fracture of the femur • Severe bowing and shortening of extremities occurs even less frequently than humeral fractures • Normal or slightly blue sclerae (2/20,409).51 Subperisoteal new bone formation is • Severe skeletal dysplasia present by 10 to 12 days of age and mature callus • Presence of fractures at birth common by 2 to 3 weeks. • Severe deformities of extremities and spine • Autosomal recessive pattern of inheritance— family history often is negative 4
  • 5. Visual Diagnosis of Child Abuse on CD-ROM Lecture Series 11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE Type IV • Variable degree of short stature, some deformity Other Causes of Fractures • Fractures may begin prenatally, deformities at birth • Cerebral palsy • Most affected infants are short in stature • Osteopenia secondary to nutritional problems, Down syndrome, chronic pulmonary disease • Triangular heads, prominent foreheads • Prostaglandin therapy for patent ductus • Normal sclerae arteriosus • Osteoporosis, with variable deformity of • Methotrexate therapy • Hypervitaminosis A long bones • Congenital syphilis • Dentinogenesis imperfecta common • Congenital indifference to pain • Autosomal dominant, family history typically positive colleagues suggest the underlying problem in TBBD DIAGNOSTIC CONSIDERATIONS IN DISTINGUISHING is a “temporary deficiency of an enzyme, perhaps OSTEOGENESIS IMPERFECTA FROM INFLICTED INJURIES a metallo-enzyme, involved in the posttransitional • Family history is positive in Types I and II. processing of collagen.” Several investigators58 have • Clinical features help distinguish. challenged these assertions on the basis that there is no scientific evidence to support their theory. • If in doubt, cultured skin fibroblasts to detect collagen abnormalities yield a definitive diagnosis Infantile Cortical Hyperostosis (Caffey’s Disease) in 90% of cases tested. This rare idiopathic disease of young infants causes Temporary Brittle Bone Disease (TBBD) painful subperiosteal new bone formation and cor- tical thickening in multiple bones. It usually involves Paterson and colleagues57 described 39 patients the mandible, clavicle, and ulna. Onset after 6 months older than 10 years who seemed to have “self- of age is very rare. Complete healing is the rule in limiting osteogenesis imperfecta.” These patients Caffey’s disease. Familial distribution is common. had fractures in infancy, and the fractures occurred at home in 32 cases and in hospital in 7. Other Miscellaneous Conditions This entity has stirred intense controversy in the Mistaken for Child Abuse medical community because of its citation in abuse • Hair tourniquet syndrome cases by legal representatives of alleged perpetra- tors. Most of the features of temporary brittle bone • Alopecia areata disease (TBBD) are those seen in inflicted injury or • Hypogammaglobulinemia normal variants in normal children. Paterson and • Mental retardation in parent(s) 5
  • 6. Visual Diagnosis of Child Abuse on CD-ROM Lecture Series 11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE References 21. Mayr JM, Seebacher U, Lawrenz K, et al. Bunk beds—a still underestimated risk for accidents in childhood? Eur J 1. Yeatman GW, Shaw C, Barlow MJ, Bartlett G. Pseudo- Pediatr. 2000;159:440–443 battering in Vietnamese children. Pediatrics. 1976;58: 616–618 22. Musemeche CA, Barthel M, Cosentino C, Reynolds M. Pediatric falls from heights. J Trauma. 1991;31(10): 2. Bryan C. Vietnamese coin rubbing. Ann Emerg Med 1987; 1347–1349 16:602 23. Nimityongskul P, Anderson L. The likelihood of injuries 3. Leung A. Ecchymoses from spoon scratching simulating when children fall out of bed. J Pediatr Orthop. 1987;7: child abuse. Clin Pediatr. 1986;25:98 184–186 4. Look K, Look R. Skin scraping, cupping and moxibustion 24. Reece RM, Sege R. Childhood head injuries: accidental that may mimic physical abuse. J Forensic Sci. 1997;42: or inflicted? [see comments]. Arch Pediatr Adolesc Med. 103–105 2000;154(1):11–15 5. Feldman KW. Pseudoabusive burns in Asian refugees 25. Reiber GD. Fatal falls in childhood. How far must children [letter]. Child Abuse Negl. 1995;19(5):657–658 fall to sustain fatal head injury? Report of cases and review of the literature. Am J Forensic Med Pathol. 1993;14(3): 6. Asnes RS, Wisotsky DH. Cupping lesions simulating child 201–207 abuse. J Pediatr. 1981;99:267–268 26. Reider MJ, Schwartz C, Newman J. Patterns of walker use 7. Coffman K, Boyce WT, Hansen RC. Phytodermatitis simu- and walker injury. Pediatrics. 1986;78:488–493 lating child abuse. Am J Dis Child. 1985;139:239–240 27. Selbst SM, Baker MD, Shames M. Bunk bed injuries. 8. Shpall S, Frieden I. Mohagany discoloration of the skin Am J Dis Child. 1990;144(6):721–723 due to the defensive secretion of a millipede. Pediatr Dermatol. 1991;8:25–27 28. Smith GA, Dietrich AM, Garcia CT, Shields BJ. Injuries to children related to shopping carts. Pediatrics. 1996;97(2): 9. Barlow B. Accidents in childhood. Nurs Mirror Midwives J. 161–165 1977;144(8):39–40 29. Smith GA, Bowman MJ, Luria JW, Shields BJ. Babywalker- 10. Billmire ME, Myers PA. Serious head injury in infants: related injuries continue despite warning labels and accident or abuse? Pediatrics. 1985;75:340–342 public education. Pediatrics. 1997;100(2):e1 11. Chadwick DL, Chin S, Salerno C, Landsverk J, Kitchen L. 30. Smith MD, Burrington JD, Woolf AD. Injuries in children Deaths from falls in children: how far is fatal? J Trauma. sustained in free falls: an analysis of 66 cases. J Trauma. 1991;31(10):1353–1355 1975;15(11):987–991 12. Chiaviello CT, Cristoph RA, Bond GR. Infant walker-related 31. Williams RA. Injuries in infants and small children resulting injuries: a prospective study of severity and incidence. from witnessed and corroborated free falls. J Trauma. Pediatrics. 1994;93:974–976 1991;31(10):1350–1352 13. Chiaviello C, Christoph RA, Bond GR. Stairway-related 32. Williams AF. Children killed in falls from motor vehicles. injuries in children. Pediatrics. 1994;94:679–681 Pediatrics. 1981;68(4):576–578 14. dos Santos AL, Plese JP, Ciquini Junior O, Shu EB, Manreza 33. Hansen KK. Folk remedies and child abuse: a review LA, Marino Junior R. Extradural hematomas in children. with emphasis on caida de mollera and its relationship to Pediatr Neurosurg. 1994;21:50–54 shaken baby syndrome. Child Abuse Negl. 1997;22(2): 15. Helfer RE, Slovis TL, Black M. Injuries resulting when small 117–127 children fall out of bed. Pediatrics. 1977;60:533–535 34. Gresham EL. Birth trauma. Pediatr Clin North Am. 1975; 16. Joffe M, Ludwig S. Stairway injuries in children. Pediatrics. 22:317–328 1988;82:457–461 35. Kendall N, Woloshin H. Cephalohematoma associated 17. Lehman D, Schonfeld N. Falls from heights: a problem not with fracture of the skull. J Pediatr. 1952;41:125 just in the Northeast. Pediatrics. 1993;92:121–124 36. Hanigan WC, Morgan AM, Stahlberg LK, Hiller JL. Tentorial 18. Lyons TJ, Oates RK. Falling out of bed: a relatively benign hemorrhage associated with vacuum extraction. Pediatrics. occurrence. Pediatrics. 1993; 92:125–127 1990;85:534–539 19. Mayr J, Gaisl M, Purtscher K, et al. Baby walkers—an 37. Kleinman PK, ed. Diagnostic Imaging of Child Abuse. underestimated hazard for our children? Eur J Pediatr. 2nd ed. St Louis, MO: Mosby; 1998 1994;153:531–533 38. Levin A. Ocular manifestations of child abuse. In: Reece 20. Mayr JM, Seebacher U, Shimpl G, Fiala F. Highchair R, Ludwig S, eds. Child Abuse: Medical Diagnosis and accidents. Acta Pediatr. 1999;88:319–322 Management. Baltimore, MD: Lippincott, Williams and Wilkins; 2001 6
  • 7. Visual Diagnosis of Child Abuse on CD-ROM Lecture Series 11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE 39. Fackler J, Berkowitz I, Green R. Retinal hemorrhages in 50. Rubin A. Birth injuries: incidence, mechanisms and end newborn piglets following cardiopulmonary resuscitation. results. J Obstet Gynecol. 1964;23:218–221 Am J Dis Child. 1992;146:1294–1296 51. Camus M, Lefebvre G, Veron P, Darbois Y. Traumatismes 40. Gilliland MGF, Luckenbach MW. Are retinal hemorrhages obstetricaux du nouveau-ne. Enquete retrospective a found after resuscitation attempts? A study of the eyes of propos de 20,409 naissances. J Gynecol Obstet Biol 169 children. Am J Forensic Med Pathol. 1993;14:187–192 Reprod. 1985;14:1033–1044 41. Kanter R. Retinal hemorrhage after cardiopulmonary 52. Barry P, Hocking M. Infant rib fracture-birth trauma or non- resuscitation or child abuse? J Pediatr. 1986;108:430–432 accidental injury [letter]. Arch Dis Child. 1993;68:250 42. Sandramouli S, Robinson R, Tsaloumas M, Willshaw H. 53. Hartmann R. Radiological case of the month. Rib fractures Retinal hemorrhages and convulsions. Arch Dis Child. produced by birth trauma. Arch Pediatr Adolesc Med. 1997;76:449–451 1997;151:947–948 43. Morgan O. A case of crush injury to the chest associated 54. Rizzolo P, Coleman P. Neonatal rib fracture: birth trauma with ocular complication. Trans Ophthalmol Soc UK. or child abuse? J Fam Pract. 1989;29:561–563 1945;65:366–369 55. Thomas P. Rib fractures in infancy. Ann Radiol. 1977;20: 44. Tomsai L, Rosman N. Purtscher retinopathy in the battered 115–122 child syndrome. Am J Dis Child. 1975;129:1335–1337 56. Helfer R, Scheurer S, Alexander R, Reed J, Slovis T. Trauma 45. Johnson D, Braun D, Friendly D. Accidental head trauma to the bones of small infants from passive exercise: a factor and retinal hemorrhage. Neurosurgery. 1993;33:231–235 in the etiology of child abuse. J Pediatr. 1984;104:47–50 46. Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury 57. Paterson CR, Burns J, McAllion SJ. Osteogenesis imperfecta: in very young children: mechanisms, injury types, and the distinction from child abuse and the recognition of a ophthalmologic findings in 100 hospitalized patients variant form [see comments]. Am J Med Genet. younger than 2 years of age. Pediatrics. 1992;90:179–185 1993;45(2):187–192 47. Duhaime AC. Head trauma. Thousand Oaks, CA: Sage 58. Ablin D, Sane S. Non-accidental injury: confusion with Publications, Inc; 1997 temporary brittle bone disease and mild osteogenesis imperfecta. Pediatr Radiol. 1997;27:111–113 48. Betz P, Puschel K, Miltner E, Lignitz E, Eisenmenger W. Morphometric analysis of retinal hemorrhages in the shaken baby syndrome. Forensic Sci Int. 1996;78:71–80 49. Elder JE, Taylor RG, Klug GL. Retinal haemorrhages in accidental head trauma in childhood. J Paediatr Child Health. 1991;27:286–289 7

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