Medical Care
Treatment for physical abuse is a complex endeavor involving an interdisciplinary team approach. The nature of the injury determines the form of medical therapy, and the details of the caregiving environment determine the psychosocial supports needed to keep the child safe.
For medical issues, skeletal fractures of the long bones may require casting, and orthopedics should be consulted for assistance with diagnosis and management.
If clinical consideration is being given to the possibility of osteogenesis imperfecta (OI), a genetics consultation may also be valuable.
Burns vary in severity and treatments range from cleansing the area to skin grafting. Plastic surgery should be consulted for assistance with management of more serious burns; transfer to a burn unit may be indicated. See Initial Evaluation and Management of the Burn Patient for burn management.
The most severely injured children, such as those with CNS injury, may require resuscitation and will need intensive care. A multitude of specialists may need to be involved in order to correctly evaluate and treat these seriously ill children. Whenever abusive head trauma is suspected, ophthalmology should be consulted for a formal evaluation, including examination of the eyes for retinal hemorrhages.
Psychosocial management that requires a significant amount of coordination among various services providers, including the physician and other healthcare providers, complements the medical management. Recommendations from the American Academy of Pediatrics state that pediatricians are mandated reporters of suspected abuse, and reports to child protective service agencies are required by law when the physician has a reasonable suspicion of abuse. Transferring a child’s care to another physician or hospital does not relieve the pediatrician of his or her reporting responsibilities. In addition, thorough documentation in medical records and effective communication with nonmedical investigators in child protection may improve outcomes of investigations and protect vulnerable children. [25, 26]
The child protective services (CPS) agency in each community is responsible for performing investigations of cases in which physical abuse is suspected and relies on the physicians to provide the details of the medical evaluation. In addition, CPS assesses the caregivers' background, caregiving abilities and potential, environmental safety, risk for repeat abuse, and risk to other siblings. A variety of CPS service plan options are available, ranging from periodic contact with the child and family to removal of the child from the home, either temporarily or permanently, with termination of parental rights. The CPS process for child maltreatment cases typically involves the following steps:
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Intake - Screening of reports and acceptance of case
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Initial risk assessment - Caregiver interviews, medical information gathering, home evaluation, and possibility of contact with law enforcement
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Case planning - Determination of safety for the child with essentially 3 options: (1) the child goes home with the caregiver with or without services depending on the circumstances, (2) the child is removed from home and family with caregivers' consent and offered services to assist them in working towards reunifying with the child, and (3) the child is removed from the home and family without caregivers' consent, involving court action and incorporation of legal steps and processes to determine the ultimate plan for the child.
Surgical Care
In cases of severe or multisystem trauma, involvement of a pediatric surgeon may be necessary for care and surgical treatment of injuries.
Consultations
The following consultations may be warranted:
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Pediatric radiologist expertise is important because many abusive fractures in infants are subtle on radiographs. Routine pediatric radiologist involvement is ideal. In locations where pediatric radiologists are not routinely available, one should be consulted in cases in which dating of bone injuries become central to the maltreatment investigation and when concerns arise regarding osteogenesis imperfecta (OI) or other bone mineralization problems.
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Orthopedists can assist with diagnosis and management in cases of skeletal fractures of the long bones.
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Hematologists can assist with diagnosis and management of bleeding disorders.
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Geneticists may be needed for a detailed workup for OI or other collagen disorders for characterization of the collagen disorder.
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Plastic surgeons may be needed to assist with the management of serious burns.
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Ophthalmologists should be involved whenever abusive head trauma (AHT) is suspected, for a formal evaluation including examination of the eyes for retinal hemorrhages via dilated direct ophthalmoscope examination, ideally with retinal photography to allow for independent peer review.
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Child psychiatrist, behavioral-developmental pediatrician, or psychiatric social worker may be needed to assess the mental health needs of the child and family, as well as to coordinate an overall psychosocial treatment plan.
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Overlap of child maltreatment and domestic violence.
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Handprint on face. Image courtesy of Lawrence R. Ricci, MD.
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Handprint on leg. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with belt. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with switch. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with switch. Image courtesy of Lawrence R. Ricci, MD.
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Switch. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with wooden spoon. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with belt. Image courtesy of Lawrence R. Ricci, MD.
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Buckle fracture of distal femur shaft. Image courtesy of Lawrence R. Ricci, MD.
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Duodenal hematoma. Image courtesy of Lawrence R. Ricci, MD.
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Burn from car seat. Image courtesy of Lawrence R. Ricci, MD.
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Car seat. Image courtesy of Lawrence R. Ricci, MD.
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Model for femoral neck fracture from being yanked from crib. Image courtesy of Lawrence R. Ricci, MD.
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Femoral neck fracture from being yanked from crib in previous image. Image courtesy of Lawrence R. Ricci, MD.
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Inflicted pinch mark shaft. Image courtesy of Lawrence R. Ricci, MD.
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Burn from being held down on hot cement. Image courtesy of Lawrence R. Ricci, MD.
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Old and new radius fracture. Image courtesy of Lawrence R. Ricci, MD.
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Child with slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Radiograph of old radius and ulna fracture in child with slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Radiograph of multiple rib fractures. Radiographs also revealed old radius and ulna fracture. The child presented with a slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Sunburn. Image courtesy of Lawrence R. Ricci, MD.
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Burn inflicted with lighter. Image courtesy of Lawrence R. Ricci, MD.
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Acute subdural with shift. Image courtesy of Lawrence R. Ricci, MD.
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Fingernail scratch in child with acute subdural with shift. Image courtesy of Lawrence R. Ricci, MD.
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Ecological model for understanding violence.
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US maltreatment trends, 1990-2010.
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Adverse child experiences pyramid.
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National Pediatric Trauma Group registry findings.
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Buckle fracture of distal femur without healing (acute).
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Distal femur buckle fracture, 2-week follow-up film with sclerotic fracture line and periosteal new bone healing.
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Guidelines for the assessment of suspected physical abuse.
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Linear inflicted bruising extending from arm to back, inflicted by a belt. Same child shown again with back bruising.
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Overlying linear inflicted marks, which the child disclosed came from a belt. Same child is shown in image of arm and back.
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CT scan showing liver laceration. Child had severe abdominal bruising (see next image). Caregiver admitted to repeatedly punching the child in the abdomen.
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Abdominal bruising in a toddler who also had a liver laceration (also see previous CT scan).
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Example of ear bruising. Ear bruising is a rare accidental injury. This 10-month-old child was intubated for abusive head trauma (AHT) and spiral femur fracture and had this ear bruising in addition to other facial bruising.
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Mongolian spots on a dark-skinned child.
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Mongolian spots on a light-skinned child. Mongolian spots can have a greenish cast depending on the skin color of the child.
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Faint abdominal bruising. This toddler had elevated liver function test results, liver laceration found on abdominal CT scan, and an upper lip frenulum tear. Note that abdominal injury may be present with little or no bruising of the abdomen.
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Pattern bruising and extensive back bruising. The 4-year-old child was found dead in his home and had no reported history. Autopsy revealed duodenal hematoma and perforation as cause of death.
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Pattern contact burn on buttocks of diapered child. The burn likely came from the metal grate surrounding heater.
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Series of 3 photos of likely accidental hot water scald burn on the leg of an infant. Sparing of skin-to-skin contact areas indicates child was flexed at the knee and ankle at the time of injury, which was consistent with being seated in the kitchen sink. Burn injuries require detailed scene investigation. In this case, investigators confirmed the ease of turning on the faucet and the high temperature of the water from it.
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Example of strangulation/ligature marks on the neck of a toddler. Strangulation/ligature marks are often linear petechiae and may have fingernail scratches from the victim from struggling to free the airway.
