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Cutaneous Injuries in Child Abuse Lori D. Frasier MD Chief, Division of Child Abuse Pediatrics Penn State Milton S. Hershey Children’s Hospital.

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Presentation on theme: "Cutaneous Injuries in Child Abuse Lori D. Frasier MD Chief, Division of Child Abuse Pediatrics Penn State Milton S. Hershey Children’s Hospital."— Presentation transcript:

1 Cutaneous Injuries in Child Abuse Lori D. Frasier MD Chief, Division of Child Abuse Pediatrics Penn State Milton S. Hershey Children’s Hospital

2 The Skin: l The largest organ in the body l The most visible organ that is injured accidentally and through abuse l Important for thermal regulation, immune functions, maintenance of hydration, protection from the environment (sensory and environmental)

3 n Epidermis- compact firm outer layer; not easily damaged n Dermis- capillaries and fibrous tissue; resistant to damage n Subcutaneous tissue- rich in capillaries and fat, easily deformed; majority of hemorrhage occurs here

4 Types of Injuries due to abuse l Bruises l Burns l Lacerations l Incisions l Abrasions l Avulsions l Strangulation (extremities) l Complications of neglect

5 Bruising is in 1 st place l Earliest form of physical child abuse l Most common form of physical child abuse l Most easily recognized sign of physical abuse l Most common direct sign of physical abuse to be missed

6 Why talk about bruising? The failure to recognize bruising as a sign of physical child abuse is an error in medical, social, and legal decision making that contributes to poor outcomes for children. Bruises are a high risk prognostic indictor for abuse

7 Early Recognition is Prevention 75% of physical child abuse is missed initially

8 The high cost of missed abuse and the risk of failure to diagnose or act The risk of repeat injury: –80% prior injuries –45% prior “odd” bruises –33% prior brain injury 80% of victims of fatal abuse were known to a health care professional who did not act

9 In an older child bruises are Common Innocuous Harmless Meaningless Why bruises are overlooked

10 A bruise can take on a whole new meaning: Uncommon Nocuous Harmful Ominous Change 2 things: age of the child & body region bruised

11 Five Rules of Bruises

12 Definitions l A bruise or contusion: bleeding beneath the intact skin at the site of blunt impact trauma Blunt impact occurred at the site of discoloration l Ecchymosis: blood that has dissected through tissue planes to become visible externally May be visible in an area never subjected to trauma l Hematoma: blood that has extravasated from the vascular system into the body Hematomas may develop in the presence of natural disease process in the absence of trauma l Petechia- small (1-2mm) red or purple spot caused by a minor hemorrhage of capillary blood vessels

13 Rule Number 1 Bruises are injuries Blood vessel disruption from traumatic injuries aka vessel fracture

14 Bruising reflects vessel damage Bruising occurs when injury threshold of vessels are exceeded Vessels are crushed and leak Pressure exceeds the injury threshold and the vessel leaks Petechiae result from tiny vessels that are damaged or leak due to pressure (dot <2mm hemorrhage) Bruising indicates vascular integrity has been compromised u vascular damage, not skin damage

15 Visibility of vessel damage l To bleed, you need vessels l To bleed, you need a blood pressure The child in shock may have damaged vessels but no pressure to result in “visible leaking”…aka a bruise l The depth and extent of bleeding, and tissue vascularity, plays a significant role as to when or even if the bruise will become visible on the surface

16 Factors that influence the occurrence and appearance of a bruise l The body site of impact l The object l The amount of force behind the impact l The rate of force application

17 Rule Number 2 The age of the child matters An infant with a bruise may be abused

18 Bruising and age of the child l Myth: baby’s are delicate and bruise more easily The greater the skin elasticity, the greater the capacity to absorb injury forces and energy without actual damage Injury threshold is thus less likely to be exceeded than in older tissues l Myth: even a little bump will cause a bruise Infants don’t move about enough or with enough force to injure their deep subcutaneous tissues If you don’t cruise, you don’t bruise l Truth: Unexplained bruising in the non-cruising infant predicts future injuries and some will be fatal

19 Bruising and age of the child l Bruises in infants and toddlers: those who don’t cruise rarely bruise. Sugar, et al. Archives of Ped and Adolescent Medicine, 1999 l Bruises in infants: those with a bruise may be abused. Pierce, et al. Pediatric Emergency Care. 2009

20 Labbé J, Caouette G. Recent skin injuries in normal children. Pediatrics 2001 108:271 - 276 l < 9 months old: 1.2% with bruises l > 9 months old: 76.6% with skin injuries l < 1% 15 or more injuries l all ages: < 2% bruises to thorax & abdomen < 1% bruises to chin, ears, or neck l no difference between boys and girls

21 Sentinel Injuries in Infants Evaluated for Physical Abuse. Sheets et al Pediatrics, April 2013 l Case control, retrospective study of infants under one year evaluated for abuse l 200 infants rated definite abuse: n 27% had a previous sentinel injury l 100 infants rated intermediate confern n 8% had a sentinel injury l 101 non abused infants-0%

22 What is a sentinel injury? A relatively minor injury that preceeds serious physical abuse. l Previous bruising-head, ear, trunk extremity l Minor abrasions l Intraoral injury l 30% of AHT infants had a sentinel injury l 25% of non AHT abused infants had a sentinel injury

23 Rule Number 3 Body region matters ACCIDENTALINFLICTED ShinsUpper arms Lower armsAnterior thigh Under chinTrunk ForeheadGenitalia HipsButtocks ElbowsFace AnklesEars Bony prominencesNeck


25 Body regions: T-E-N l Torso: a lot of cushion to absorb injury forces n Seatbelt sign: marker of high risk for internal injury: why? n Handlebar sign only present in 30% of injuries resulting in splenic, pancreatic, or liver lacerations: why? l Ears: difficult to bruise; not very vascular (minimal or no subcutaneous tissue and floppy) l Neck: protected and no superficial bony structure to provide the crush required for vascular damage/leaking n Usually neck bruising is in the form of petechiae. Check for tracheal damage. Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz D. Bruising characteristics discriminate physical child abuse from accidental trauma in young children. Pediatrics January 2010

26 Distinguishing physical assault from accidental injury: 97% sensitive 84% specific A validation study in 2600 children that began in June of 2011

27 TEN 4 Bruising Model l Question 1: skin findings in children under 4 years of age Trunk/torso bruise Ear bruise Neck bruise l Question 2: is the child non-ambulatory Any infant < 4 months of age: is there a bruise or skin injury to any region/any where on the body l Question 3: confirmed accident in public setting? Are bruises accounted for and consistent?

28 Recommended action l Positive screen Bruising in the non-cruising Bruising in TEN locations in children under 4 years of age l Diagnostic studies include evaluation for trauma and for any other cause of the bruises l Report to CPS if no bleeding issues are identified that explain the bruising, even if other trauma screening tests are negative

29 Thorax

30 Ears

31 Detailed anatomy of the ear

32 Neck

33 Bruising anywhere in an infant less than 4 months old

34 Rule Number 4 The number of bruises matters

35 Body planes front and back - top and bottom l Regular life falls or accidents, even when significant, do not generate the required impacting forces to generate multiple bruises l Even falls from 20 feet rarely produce more than one bruise l Facial bruising in multiple planes doesn’t occur in household injury l Inflicted injury forces result in contact forces with the strike, and then with the landing impact- bruising may therefore occur in 2 planes or more, often opposing l Multiple inflicted strikes can result in multiple contusions

36 Multiple simple impacts do not cause multiple bruises

37 Bruises and stair falls n=29 Plausible Suspicious MC Pierce, GE Bertocci, et al. Pediatrics, 2005

38 Rule Number 5 Patterns matter

39 Factors that influence the occurrence and appearance of a bruise l The body site of impact l The object l The amount of force behind the impact l The rate of force application


41 Oral Injury

42 Differential Diagnosis of Bruising l Accidental l Inflicted l Dermatologic l Coagulation disorders l Folk therapies l Genetic/Metabolic l Miscellaneous

43 Coagulation Disorders Which May Mimic Abuse l Idiopathic Thrombocytopenic Purpura (ITP) l von Willebrand’s Disease l Hemophilia l Ingested anticoagulants l Leukemia l Vitamin K deficiency l HSP

44 Dermal Melanosis (Mongolian Spots) l Black 90 - 95.5% l Asian 81.0- >90% l Latin-American 70.1% l White 10% l Rarely on face l Disappear by age 4 - 5 in 95%



47 Bruises take a minimum of 7 days to resolve: F Depth, degree of injury and damage to vessels, body region injured, and circulation all play a role in the rate of both appearance and disappearance of bruising Time for bruise resolution ranges from 12 hours to over 2 weeks

48 The medical condition of the child (such as unconsciousness) will not affect the appearance of the bruise: F A low or absent blood pressure can decrease the amount of leaking of blood and thus the amount of visible damage

49 Bruises can be invisible to the naked eye: T Certain blood proteins absorb wavelengths of light not visible to normal human vision. By supplying an alternative light source with ultraviolet and infrared wavelengths, these blood proteins become visible, making once “invisible bruising” possible to see.

50 Take to Work Points l The site of the bruise matters T-E-N regions for children under 4 yrs of age l The age of the child matters A bruise anywhere on the body if the infant is non-ambulatory l The total number of bruises matters More than 4 bruises in the very young child is concerning l Observation and evaluation coupled with action can lead to prevention of child abuse

51 Good general reference Bruising and Physical Child Abuse. Kim Kaczor, MS, Mary Clyde Pierce, MD, Kathi Makoroff, MD, Tracey S. Corey, MD. Clinical Pediatric Emergency Medicine 7:153-160. 2006


53 Child Abuse by Burning l Abusive burns typically occur in children younger than age 6 and have the greatest percentage of hospitalizations for treatment l Childhood abusive burn victims are more likely to have previous or concomitant signs of abuse/neglect and previous reports to child protective services

54 Incidence and Prevalence l 40,000 children <15 yrs. hospitalized yearly l >2000 children die yearly from burns l Approximately 20% of burns are inflicted l Scald burns - 85% of all burns in children l Flame burns – 13% l Electrical, chemical – 2%

55 Findings Concerning for Abuse or Neglect l Infected burns l Chronic burns l Burns in various stages of healing l Burn appearance is older than stated history l Concomitant cutaneous injuries

56 Characteristics of Abusive Burn Perpetrators l Abusive pediatric burns occur more commonly in families with a single, young, socially isolated parent from a lower socioeconomic class l One study found that most parents of burn abused children were unemployed with incomes of less than $20,000 per year l The abusive burn perpetrator is most frequently the child’s parent or the mother’s boyfriend

57 Necessary History l Date/time the burn injury reportedly occurred l Location of the child at the time of the burn l Presence or absence of clothing l Presence or absence of witnesses to the burn l Time from burn occurrence to presentation for medical care l Child and parent’s reaction to the burn l Developmental level of the child l Prior injury or accidents l Family composition and home environment

58 Classification of Burn Injuries Superficial Partial thickness Full Thickne ss Fourth Degree Superficial layer of the epidermis Characterized by redness only Extends into the dermis causing blistering and tissue loss Entire dermis, appendages. nerves destroyed, no pain Extends into the muscles, bones and joints


60 Scald Burns l The majority of all scald burns are accidental and due to splash/spill injury by fluids other than tap water, such as soups, hot beverages and other cooking liquids and occur in the home environment l Having a child in the kitchen while cooking is one of the greatest risk factors for sustaining a burn injury

61 Burn temperature

62 Abusive Scald Burns l Scalding by immersion in hot tap water is most frequently reported for abusive burns l Up to 14% of all scald burns are secondary to abuse l For suspected immersion scald injury, the pattern of injury greatly assists the medical provider and investigators in analyzing the case for accidental versus inflicted mechanisms

63 Immersion Scald Injury l Burn patterns demonstrating uniformity of burn depth suggest the child was restrained or not moving during the time of injury occurrence l Bilateral burn symmetry in the absence of splash marks suggests forced immersion l Bilateral, symmetric lower extremity burn distribution pattern occurs more frequently in abused children

64 Immersion Scald Injury Immersion burns typically present with patterned injury demonstrating: l Uniform burn depth l Flexion sparing l Linear/sharply defined contour between the burned and unburned skin areas l Absence of splash marks l Can have skin sparing in areas where the skin was in contact with cooler surfaces


66 Child left in comfortable water. Parent returns to find hot running, child burned. To add 3" (11 gal) @ 5.5 gal/min flow = 2 minutes Burn Time @ 125o F= 2 minutes Total Burn Time = 4 minutes 3" 150oF Water 3" 101oF Water 6" 125oF Water

67 Effective investigation of child abuse by burning requires a coordinated effort between the investigators and the medical professionals.

68 Scene Investigation l All suspicious burns should be investigated by individuals experienced with scene assessment and evidence collection l In cases of hot water burn injury, a detailed scene investigation is necessary to assist with the critical analysis of the injury by a multidisciplinary team

69 Knox B, Starling SP. Inflicted burns. In, Jenny C, ed. Medical Evidence In Child Maltreatment. Elsevier Press 2009.

70 Hot Water Splash Burns Splash burn injury requires a minimum temperature of 140 degrees F (60 º C) in order to produce tissue injury Splash burn injury requires a minimum temperature of 140 degrees F (60 º C) in order to produce tissue injury l Lower water temperatures will cool to a point where burns will not occur l Scald patterns due to splash or flowing liquid can be altered based on the presence/absence of clothing

71 Scald Injuries Resulting from Liquids Other than Water l Hot beverages, foods, grease, oils, or wax can reach temperatures much greater than the boiling point of water (212 F) l Greater viscosity l Result in deeper, more significant burn due to higher heat source and prolonged contact with the skin

72 Contact Burns l Result in thermal injury to the skin secondary to prolonged contact with the hot or smoldering source l Typically produce a injury characterized by n Distinct margins n Grouped burn lesions n Clearly inscribed patterns n Injuries on parts of the body normally covered l The pattern left on the skin can help in differentiating accidental from abusive injury mechanisms

73 Other Types of Burns l Radiation burns – commonest is sunburn l Chemical burns – acid, alkali, peppers, garlic, household chemicals l Electrical burns – combination of heat and electrical forces l Microwave burns

74 Chemical Burns l Chemical burns resulting from caustic ingestions can be the result of neglectful child supervision as well as intentional acts l Can result in deep burns and the agent continues to damage tissue until properly removed from the skin l Alkali burns are associated with deeper penetration and more extensive burns than acids

75 Chemical Burns l Adult drug use is a risk factor for pediatric chemical burns and caustic ingestions l Concentrated bleach does not immediately produce pain and therefore causes skin lesions that develop slowly and worsen with prolonged contact l Laxative-induced buttock dermatitis frequently is confused with abusive immersion burns of the buttocks

76 2 yo presents with burn to buttocks. Mother says she ate a box of Ex-Lax and then went to bed in a diaper. She woke up soiled and was given a bath. After the bath she c/o pain and later in day blisters appeared.

77 Flame Burns l Most often secondary to house fires in the pediatric population l Abusive flame burn injury secondary to holding a child’s skin in contact with flame or to ignition of clothing as a consequence of abuse or neglect also occurs l ~10% of abusive pediatric burns were caused by fire or flames

78 Electrical Burn Injury l Represents ~2-3% of all burns requiring treatment in the emergency department l Most occur in the home setting and involve children less than age 5 l Most due to lack of supervision l Low-voltage injuries are more common in younger children while high-voltage injuries are seen more frequently in the older pediatric population

79 Stun Guns Electrical burns from stun guns have been reported as a pair of small (0.5 cm) superficial circular burns

80 Microwave Oven Burns l Microwave radiation heats the living tissue n Induces heat in tissues with higher water content to a greater extent than other tissues and produces burns most severe on the skin followed by muscle l Results in asymmetric burns on biopsy

81 Microwave Oven Burns l Microwave ovens heat food and liquids unevenly l Reports of accidental partial and full- thickness scald burns to the oropharynx and palate of infants drinking formula heated in a microwave l Accidental microwave related scald burns most commonly result from children pulling over-heated food/liquids onto themselves

82 Outcomes l Children with abusive burns l Require longer hospital admissions than those with accidental burns l Increased morbidity l Consume more resources during treatment and follow-up l More likely to die from their injuries

83 Differential Diagnosis of Burns l Accidental l Inflicted l Dermatologic conditions l Chemical burns l Folk therapies


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