1. ABUSE & IMAGING PEDS & GERIATRICS
SOME IMAGES MAY BE DISTURBING
YOU HAVE A LEGAL RESPONSIBILITY
TO REPORT POSSIBLE ABUSE

7. CHILD ABUSE MULTIPLE INJURIES COVERS MORE THAN 1 PLANE
DEFENSIVE WOUNDS
BE ALERT

14. Most abused and neglected children never come to the attention of government authorities.
This is particularly true for neglected and sexually abused children, who may have no physical signs of harm.
In the case of sexual abuse, secrecy and intense feelings of shame may prevent children, and adults aware of the abuse, from seeking help.
Therefore, official government statistics do not indicate actual rates of child abuse.
Government statistics are based on cases that were
(a) reported to social service agencies,
(b) investigated by child protection workers
(c) had sufficient evidence to determine that a legal definition of "abuse" or "neglect" was met.

15. Failure to report suspected abuse is against the law and harms children
Every state has laws that require healthcare workers and others to report suspected child abuse to a law enforcement agency or child protective services.
When circumstances suggest a reasonable suspicion that a child could be a victim of abuse, a report is required.
It is not the job of the "mandatory reporter" to investigate the facts in these cases. The law simply directs them to file a report with a law enforcement agency or child protective services whenever facts might suggest a reasonable suspicion of abuse. Mandatory reporters are not permitted to pick and choose which cases they will report based on their personal opinion. Those who may feel that there is nothing wrong with adult-child sex cannot simply pretend child rape is merely consensual sex. By law, an underage girl cannot consent to sex. Nor does the law allow a mandatory reporter to decide whether or not a report should be filed based on the statements of the child, because cover stories are often concocted to cover up cases of abuse.

16. Child neglect, also called psychological abuse
, is a form of child abuse. It occurs when someone intentionally does not provide the child of the necessities of life, or does so with reckless disregard for the child's well being. Such necessities include food and water for healthy growth, shelter, clothing, and medical care. They child may also lack a safe environment, and adult emotional support. The abuser may ignore, insult, or threaten the child with violence.
Some authorities consider witnessing violence or severe abuse between parents or adults another form of psychological abuse.

17. Symptoms of psychological abuse may include
Difficulties in school
Eating disorders, resulting in weight loss or poor weight gain
Emotional issues such as low self esteem, depression, and anxiety
Rebellious behavior
Sleep disorders
Vague physical complaints

18. Battered child syndrome; Physical abuse - children
The physical signs of child abuse used to be called battered child syndrome. This syndrome referred to multiple fractures in different states of healing. The fractures occurred at different times in children too young to have received the fractures as a result of an accident.
The definition of child abuse has since expanded significantly. Physical child abuse or non-accidental child trauma refers not only to multiple fractures at different ages, but it also includes numerous other signs of injury.

19. Physical abuse tends to occur at moments of greatest stress, when someone strikes out in anger at the child. Many of those who commit physical abuse have been abused themselves as children. As a result, they often do not realize that abuse is not appropriate discipline. Those who commit physical abuse also frequently have poor impulse control, which prevents them from thinking about what happens as a result of their actions.
Because adults are so much stronger and bigger than children, an abused child can be severely injured or killed by accident. For example, shaking an infant, especially if the head hits something, even against a soft object like a mattress or pillow, can cause bleeding over the brain (subdural hematoma). This can cause permanent brain damage or death. (See shaken baby syndrome.)

20. SHAKEN BABY SYNDROME
is a severe form of head injury caused by the baby's brain rebounding inside of the baby's skull when shaken.
In this injury there is bruising of the brain, swelling, pressure, and bleeding (intracerebral hemorrhage).
This can easily lead to permanent, severe brain damage or death. If a child has this injury there are usually no outward physical signs of trauma, but there may be a change in the child's behavior such as irritability, lethargy, pale or bluish skin, vomiting, and convulsions.

21. SHAKEN BABY SYNDROME
The tight grasp around the chest that accompanies this shaking may also cause rib fractures (these are also highly specific for abuse). These rib fractures may be incidentally found on chest X-rays performed for other reasons, such as to evaluate for pneumonia.

22. Finally, the shaken infant syndrome may also include throwing the baby down or into a hard surface, like a wall or table.
This will cause swelling at the point of impact and, if the head is the point of impact, may add to brain damage by causing local bleeding and swelling in and on the brain and scalp.
This impact injury often accompanies shaking; this may be refered to as "the shaken-impact syndrome."

23. Rate of child abuse is fairly high.
The most common form is neglect.
Child abuse accounts for at least 1,400 deaths in children each year.
The major risk factors for someone to abuse another person include:
Poverty
Lack of education
Being a single parent
Alcoholism
Other drug abuse

24. Symptoms of physical abuse
Adult may bring an injured child to an emergency room with a strange explanation of the cause of the injury. The child's injury may not be recent.
Symptoms include:
Broken bones that are unusual and unexplained
Bruise marks shaped like hands, fingers, or objects (such as a belt)
Bruises in areas where normal childhood activities would not usually result in bruising
Burn (scalding) marks, seen when a child is placed in hot water as a punishment -- particularly "glove" or "sock" burn patterns
Burns from an electric stove, radiator, heater or other hot objects, usually seen on the child's hands, arms or buttocks

25. Symptoms of physical abuse
Cigarette burns on exposed areas or the genitals
Black eyes in an infant or a similar, unexplained injury in a child
Human bite marks
Lash marks
Choke marks around neck
Circular marks around wrists or ankles (indicating twisting or tying up)
Separated sutures
Bulging fontanelle
Evidence of unexplained abdominal injury (such as bruised or ruptured intestines due to punching)
Unexplained unconsciousness in infant

26. Typical injuries in abused children include:
Bleeding in the back of the eye, seen with shaken baby syndrome or a direct blow to the head
Internal damage, such as bleeding or rupture of an organ from blunt trauma
Any fracture in an infant too young to walk or crawl
Evidence of fractures at the tip of long bones or spiral-type fractures that result from twisting
Fractured ribs, especially in the back

27. Typical injuries in abused children include:
Evidence of skull fracture (multiple fractures of different ages may be present)
Subdural hematoma (collection of blood in the brain) without plausible explanation
Multiple bruises that occured at different times -- especially in unusual areas of the body or in patterns that suggest choking, twisting, or severe beating with objects or hands
Other unusual skin damage, including burns or burn scars

28. The following tests can reveal physical injuries
Bone x-ray -- a skeletal survey is done whenever physical abuse is suspected. All the child's bones, including the skull, are x-rayed to look for unseen fractures or old, healing fractures.
MRI or CT scan of the head or abdomen are done if there is a skull fracture, bleeding in the eye, unexplained vomiting, severe bruising of the face, skull or abdomen, or unexplained neurological symptoms, headaches, or loss of consciousness.

30. There are several types of bone fracture, including:
Oblique - a fracture which goes at an angle to the axis
Comminuted - a fracture of many relatively small fragments
Spiral - a fracture which runs around the axis of the bone
Compound - a fracture (also called open) which breaks the skin

31. Physical abuse of a child can lead to severe brain damage, disfigurement, blindness, crippling, and death. Abused individuals may carry emotional scars for a lifetime.
Children can be removed permanently from the parents' custody if the parents are the perpetrators and the cause is sufficient to warrant termination of parental rights. However, this experience itself can result in significant psychological problems due to feelings of rejection, or if the placement does not result in a strong, long-term attachment to new caregivers.

32. Recognize the warning signs of potential abuse.
For example, a caregiver may:
Previously abused a child
Fail to maintain the child's proper hygiene or care
Appear to lack love or concern
Have alcohol or drug problems
Have emotional problems or mental illness
Was abused as a child
Has high stress factors, including poverty

33. All states require that you report any known or suspected child abuse
All states require that you report any known or suspected child abuse. Call the police and Child Protection Services

34. Sexual abuse - children
Child sexual abuse is the deliberate exposure of minor children to sexual activity.
This means a child is forced or talked into sex or sexual activities by another person. Such abuse includes touching (fondling), sexual intercourse, oral sex, pornography, and other sexual activity.

35. Sexual abuse - children
With the exception of sexual abuse among family members (incestuous relationships), child sexual abuse was not clearly described until the late 1970s.
The problem is far more common than had been thought. Indeed, the medical literature up through the mid-1970s contained articles about children and sexually transmitted diseases, such as gonorrhea.
However, there was no discussion of how the children caught such disease. There was great reluctance in society to deal with this issue, but after 30 years of examination worldwide, child sexual abuse is now considered a serious issue.

36. Causes, incidence, and risk factors
   It is difficult to determine how common child sexual abuse is. It is often more secret than physical abuse. Children are often scared to tell someone about the event. According to the American Academy of Child and Adolescent Psychiatry, it is reported up to 80,000 times a year, but the actual number of unreported events is probably much higher.

37. Causes, incidence, and risk factors
Abusers are usually men.
They usually know the person they are abusing.
This is the case in 80 to 90% of cases.
Because the abuser violates the trust of the younger person, it makes the sexual abuse even more psychologically devastating.

38. Causes, incidence, and risk factors
Child sexual abuse occurs in all social and economic classes of people, but it has the same type of risk factors as physical child abuse, including poverty, disordered families, and abuse of alcohol and street drugs.
Abusers often have a history of physical or sexual abuse themselves.
A small group of repeated abusers suffer from the psychiatric disorder pedophilia, in which the preferred sexual contact is with children.

39. Symptoms of child abuse are similar to those seen in depression or severe anxiety and nervousness.
They can include:
Repeated headaches
Stomach aches (vague complaints)
Bowel disorders, such as soiling oneself (encopresis)
Eating disorders, such as anorexia nervosa

40. Symptoms of child abuse are similar to those seen in depression or severe anxiety and nervousness.
Sleep problems
Genital or rectal symptoms, such as pain during a bowel movement or urination, or vaginal itch or discharge
Children may withdrawal from normal activities, have excessive fears, do poorly in school, and display disruptive behaviors such as using alcohol and street drugs or engaging in high-risk sexual behaviors.

41. Signs and tests
If you suspect a child has been sexually abused, the child should be examined as soon as possible by a trained healthcare professional.
A doctor's exam should not be delayed for any reason. Many signs of injury related to sexual abuse are temporary. Ideally, the exam should occur within 72 hours of the event or discovery. A complete physical exam must always be performed, so that the examiner can look for any signs of physical and sexual abuse. The two forms of abuse may co-exist.
Affected areas may include the mouth, throat, penis, anus, and vagina, including the hymen. There are some normal variations to this structure, but it can be affected by abuse.

42. Signs and tests
blood tests to check for sexually transmitted diseases, such as syphilis and HIV, and pregnancy in females. These tests can help determine treatment.
Photographs of injuries may help establish what happened.
Most pediatricians, many family medicine doctors, and most emergency room (ER) doctors have training in examining cases involving sexual abuse.
VCUG may be ordered for recurrent UTI’s
due to possible sexual abuse

43. Treatment  
All children who have been sexually abused or traumatized in any way should receive mental health counseling.
Suspicion of child sexual abuse must be reported to child protective services and the police. Medical professionals, teachers, and child care professionals are required by law to make a report.
TELL YOUR SUPERVISOR
Once a case is reported, child protection agencies and the police must investigate. If the allegation is considered true, the child must be protected from further abuse. Placement with a non-abusing parent, another relative, or a foster home may result.
In physical abuse cases, the goal of child protection agencies is to educate an abusing caretaker and attempt to re-join the family together, if safe

44. 3,500 Number of deaths due to child abuse and neglect in 27 developed nations worldwide. The United States, Mexico, and Portugal have death rates 10 to 15 times higher than many of the other countries.
40-47 Percent of sexual assaults perpetrated against girls age 15 or younger worldwide Percent of United States child abuse fatalities that were in children aged 4 years or younger. More than 1/3 Number of U.S. child abuse fatalities that were associated with neglect, or in other words, the denial of a child’s basic need for food, warmth, clothing, and medical care.

45. 2.9 million Number of reports of child abuse and neglect received by U.S. Child Protective Services from concerned teachers, policemen, social workers, day care workers, friends and neighbors (2003). That’s 39 referrals for every 1,000 children % of U.S. child abuse or neglect deaths where one or both parents were involved. Much of the time, the parent is young, without a high school diploma, living in poverty, depressed, and has experienced violence in his or her own life.

47. Injuries Worrisome for Child Physical Abuse
Skin and Soft Tissue Injury
bruises on face, lips, mouth, torso, back, buttocks, thighs
especially if in various stages of healing
degree of bruising is greater than expected for the activity level of the child
bilateral black eyes ("raccoon eyes")
patterned bruise (of inflicting instrument such as belt buckle, hairbrush, or hand)
human bite marks
cigarette burns, especially on palms, soles of feet, back, buttocks
immersion burns
patterned burns (curling iron, clothes iron, stove burner)
rope burns

48. Skeletal Injuries
fractures of ribs, ends of long bones (near growth plates),
spine
multiple fractures
fractures of differing ages
any fracture inconsistent with the developmental capabilities of the child

49. Head Injuries bleeding into/onto brain (subdural hemorrhage)
brain swelling (cerebral edema)
multiple skull fractures ("eggshell" fracture)

50. Abdominal Injuries
small bowel injury (duodenal or jejunal hematoma, bowel laceration)
pancreatitis or pancreatic injury
injury to liver, spleen, adrenal glands

52. Signs of Neglect lack of appropriate hygiene inappropriate dress
bald spots
severe diaper rash
failure to thrive
lack of immunizations
lack of dental care
lack of supervision
abandonment

53. Parental Behavior Patterns Seen in Abuse
lack of concern or detachment about injury
lack of response to child in pain
overly concerned about trivial injuries
has unrealistic expectations of the child (to be behaviorally more mature)
parents themselves may exhibit or have a history of:
drug or alcohol addiction
psychosis
lack of trust in health professionals

54. Radiographic skeletal survey in all children less than 2 yrs suspected of abuse.
The abuse skeletal survey consists of individual frontal X-rays of the following body parts:
chest
skull (also lateral)
upper arms (humeri)
forearms
hands
pelvis
upper legs (femurs)
lower legs (tibia/fibula)
ankles (also lateral views)
feet  
In children 12 months or younger, also perform:
lateral thoracolumbar spine film

55. with mammography or high-detail extremity film (exquisite detail)
NOTE: Expert attention to technique and detail is necessary for quality radiographs that show some of the very subtle injuries of abuse.
These are the radiographs that will go to court - it is imperative that they be well-performed. It is recommended that these films be obtained:
with mammography or high-detail extremity film (exquisite detail)

56. Expert attention to technique and detail is necessary for quality radiographs
during regular duty hours (not in the middle of the night by the on-call technologist)
and submitted to a pediatric radiologist for interpretation
NOTE: some of the injuries of abuse heal very quickly (in less than 2 weeks), so it is imperative that the evaluation of the possibly abused child be accomplished as promptly as possible

57. Abuse imaging
Head CT scan: Perform on all suspected abuse victims 1 year of age or younger.
Nuclear Medicine Bone Scan. Usually not necessary.  Perform this if:
there are equivocal findings on the skeletal survey
there is a high clinical suspicion of skeletal injury but the skeletal survey is normal
Brain MRI scan: Perform if the susupected or confirmed abuse is older (weeks to months or even years), to look for evidence of chronic blood collections (chronic subdural hematoma) and brain damage.

58. The Child Abuse Homicide
Abuse should be considered when any child dies unexpectedly. The following should be performed on all unexplained childhood deaths:
forensic autopsy
radiographic skeletal survey, preferably at a hospital (try to have this done BEFORE the body is taken to the morgue or medical examiner's office)
A full radiographic evaluation should be considered an integral part of a complete autopsy on a young child!

59. CASE STUDIES OF PEDIATRIC ABUSE

60. Ped injury – corner fx

61. This 2 month old baby girl was brought into the local ER with scalp swelling
Patterns of skull fracture that suggest child abuse are multiple ('eggshell') fractures (as in this case)

64. 1 year old child brought in by ambulance comatose.
This child was violently shaken, causing severe brain injury, evidenced by diffuse cerebral edema.

65. 4 month old with cough, chest X-ray request says "rule out pneumonia."
Posterior rib fracture of the left 7th rib
This fracture is less than 14 days old as there is no visible callus.
This is a case of child abuse incidentally found on CXR because of the detection of the rib fracture, which was unrelated to the child's presenting complaint

66. Healing right posterior 5th-7th and 9th rib fractures, as well as multiple healing right lateral rib fractures
3 MO OLD – BROUGHT IN FOR ABD PAIN AND VOMITING

67. CORNER OR BUCKLE FX
4 month old baby with brain injury suspicious for child abuse. Skeletal survey performed to evaluate for other injuries of abuse. There is a corner fracture of the distal femur

69. This corner fracture (also known as a metaphyseal or bucket handle fracture) is highly specific for abuse
The metaphyseal lesion in abused infants
It occurs when a child is violently shaken, or other forms of torsional stress and shear are applied to a limb (such as severe twisting or wrenching of the limb).
When this occurs from shaking, the shaking causes the arms and legs to flail violently, and shear forces (whiplash forces) are exerted on the distal ends of long bones.
Fractures occur through the most immature (weakest) part of the growing bone, which is immediately adjacent to the metaphyses or growth plate.
This fracture shears off a disc of bone at the end of the shaft; this fracture fragment may resemble a "corner" of bone or a bucket handle depending on the orientation of the fracture site to the X-ray film.
Notice how subtle this fracture is - Visualizing these fractures is very dependent on high detail radiography.

70. 3 mo deceased sibling of a child who is found to have rib and metaphyseal injuries indicative of abuse.
Cause of death of the abused infants sibling listed by coroner's office as "bacterial peritonitis" from an unknown cause; death ruled "natural"
Body exhumed for reevaluation when younger sibling presented with abuse injuries.
This is a specimen radiograph of the dissected limb of the exhumed body
A forensic autopsy does not evaluate the limbs well (especially the metaphyses), and therefore metaphyseal fractures will often be missed.
In this case, the child did die of bacterial peritonitis from an abuse-related traumatic bowel perforation. 
Post Mortem
Of tibia

71. 11 month old female with possible right-sided posterior rib fractures at recent skeletal survey.
Bone scan shows focal increased uptake along multiple posterior right ribs , the left humeral shaft & both humeral heads
Therefore, plain X-rays of the skeleton (in the areas of abnormality identified at bone scan) are almost always still needed to evaluate for the exact nature of the abnormality.
Use of bone scans for when there is an equivocal finding or there is high clinical suspicion but the plain X-rays are normal. Bone scans will detect those difficult to see posterior rib fractures, as in this case.

72. 3 month old child with vertebral abnormality noted on chest X-ray.
Compression injury to the body of L1. Notice the angulation of L1 relative to T12 above it and the defect in the anterior superior margin of the body of L1

73. Injuries to the thoracolumbar junction
are relatively common in abuse, especially in shaken infant syndrome.
Shaking by holding the infant around the chest makes the thoracolumbar junction a fulcrum.
Violent shaking can thus create strong compression forces on vertebral bodies at this area of the spine (very much like the "lapbelt" injuries in motor vehicle accidents).
Compression fractures can occur, and there can even be rupture of intervertebral ligaments and disc herniations, too.

74. Upper GI shows a mass in the wall of the descending duodenum
3 1/2 year old with 4 day history persistent vomiting after eating and abdominal pain.
Upper GI shows a mass in the wall of the descending duodenum
This is consistent with a duodenal hematoma.

75. duodenal hematoma
It is a relatively common injury in abuse and is typically seen in older children who are punched or kicked in the abdomen (intentionally or accidentally).
It is an unusual injury in very young children (less than 2 years old).
Of note, abdominal injury, such as this duodenal hematoma, is the leading cause of morbidity and mortality in the older abused child.
Because abdominal injuries are usually seen in older children, who are often quite active, identifying the injury as abuse-related is more difficult.
Correlation with history and other evidence of abuse suggest the diagnosis.

76. This 6-week old male was well until two days prior to presenting to the ED when his left thigh suddenly became swollen.
His mother, who cares for him both day and night, states that there is no history of trauma. She denies any rough play, shaking, or any chance of trauma, such as rolling off the bed or the couch.
Further questioning reveals that sometimes the infant's father, paternal grandmother, paternal grandfather, and paternal aunt, all living in the same household, also care for the infant.
There is also a one-year old female sibling a 2-year old female cousin, and great grandparents all living in the same house, who sometimes play with the infant.
Both mother and father are 18 years of age

77. This radiograph shows an obvious oblique fracture of the proximal shaft of the left femur, with superior and anterior displacement of the distal fracture fragment
Because of the strong suspicion of intentional trauma (child abuse), the infant is hospitalized and a skeletal survey is done

78. The upper extremity radiograph (left image) reveals an old fracture of the right proximal radius. There is some periosteal elevation surrounding the fracture indicating that the fracture did not occur recently. The lower extremity radiograph (right image) reveals a healing fracture of the right tibia with periosteal reaction along the entire shaft of the right tibia. The fracture line itself is not easily identified.

79. The vertebral body of T12 appears much flatter than the other thoracic vertebra. T10 and L2 may also be slightly flattened. Because of the difficulty in diagnosing these as vertebral body compression fractures, a bone scan is done for correlation.

80. This bone scan confirms the long bone fractures.
There is an obvious hot spot
right radius. left femur and right tibia
also the occiput suggesting a fracture or a subperiosteal contusion.
There are no obvious vertebral hot spots suggesting that the flattened vertebral bodies may not represent fractures
After being fitted with an orthopedic harness, child protective services placed the infant in a foster home.
The young children living in the household were also removed and placed in foster homes.

85. The upper extremity radiograph (left image) reveals an old fracture of the right proximal radius
The lower extremity radiograph (right image) reveals a healing fracture of the right tibia with periosteal reaction along the entire shaft of the right tibia.
The fracture line itself is not easily identified.

86. 6-week old male was well until two days prior to presenting to the ED when his left thigh suddenly became swollen.
There is also a one-year old female sibling a 2-year old female cousin, and great grandparents all living in the same house, who sometimes play with the infant.
Both mother and father are 18 years of age.

87. This radiograph shows an obvious oblique fracture of the proximal shaft of the left femur
Because of the strong suspicion of intentional trauma (child abuse), the infant is hospitalized and a skeletal survey is done.
The following positive radiographs are shown:

90. Tachypnea alone may be the earliest sign.
7 WEEK OLD
Wheezing and respiratory distress are a common presentation of CHF in infants.
Tachypnea alone may be the earliest sign.

93. Chest radiograph showing different stages of healing posterior rib fractures (arrows).

95. SIGNS OF ABUSE
Physical abuse most often is a pattern of repeated behavior, with bruises and welts being the most frequent evidence of such.
Typical sites for inflicted bruises include the neck (choke marks), upper lip and frenulum (forceful feeding), ear lobe (pinch or slap marks), cheeks (slap marks), buttocks and lower back (paddling), the genital area and inner thighs.
Human bite marks leave concentric bruises that contain individual teeth marks. If the point-to-point distance between the canines (eye teeth) is greater than 3.0 cm, the injury was inflicted by someone with permanent teeth.

96. Dating bruises is also important, and multiple colors suggest multiple times of injury.
Child abuse is a common cause of burns.
Scald or immersion burns are the most common, bearing the characteristic glove or stocking pattern that is observed on physical examination.
With a water temperature of degrees or greater
Contact burns from a hot metal object or cigarette are another type of burn seen with child abuse.

97. Head injuries are the most common cause of death from child abuse
Abdominal injury is the second most common cause of death among battered children. Ruptures of the spleen, liver or bowel caused by a punch or kick can result in the above with no visible bruises or marks on the abdomen in over half the cases.
Rupture of the bladder may also occur.

98. multiple fractures at multiple sites and in various stages of healing should be considered abused until proven otherwise
Epiphyseal-metaphyseal injury is virtually diagnostic of physical abuse in an infant, since an infant cannot generate enough force to fracture a bone at the epiphysis.
Fractures secondary to abuse are more commonly seen in children less than 3 years of age.
Conversely, less than 10% of children over 5 years of age who are abused sustain fractures.
In general, a complete skeletal survey should be done on all children less than 2 years of age who are possible abuse victims.

99. FRACTURES
A spiral or oblique fracture of long bones is produced by a twisting mechanism.
Whether accidental or non-accidental, a large amount of force is required to produce a fracture of the femur.
A direct blow causing a transverse fracture can also be seen with major violence.
Young children who are not ambulatory cannot produce enough force to fracture their femur. A history of getting his/her leg "caught in the crib" should be viewed with suspicion.

100. FRACTURES
Rib fractures are highly suggestive of abuse in infants and young children.
Squeezing usually produces fractures of the posterolateral aspects of the ribs.
Shaking or choking a child has been shown to produce fractures anteriorly in the first or second ribs.
Rib fractures secondary to trauma that is NOT child abuse tend to occur in the middle or anterior part of the rib cage.

101. FRACTURES
Spinal fractures are infrequently seen in child abuse cases. The mechanism is usually one of compression, as a child is forcibly seated into a chair or onto a tabletop.

102. There are several radiologic signs suggestive of abuse.
These include healing fractures, multiple fractures, fractures of unusual locations, and metaphyseal fractures.
The typical radiographic appearances have been described as: a) "corner fractures", b) "bucket handle" fractures, and c) subperiosteal hematoma with new bone formation.
Other radiographic findings suggestive of abuse include posterior rib fractures, spinous process fractures, sternal fractures, complex skull fractures, and diaphyseal spiral and oblique fractures.
Fractures showing different stages of healing are almost signs of abuse.
Any fracture which already shows signs of healing suggests that the fracture is at least ten days old.

103. Review- signs of abuse Just because a child has bruises does not mean that he or she is abused. The most important thing is to look for is a pattern of abuse. Here are some of the signs to look for:
Physical Abuse
Injuries to eyes or both sides of the head or body (accidental injuries typically only affect one side of the body);     
Frequently appearing injuries such as bruises, cuts and/or burns. These may appear as grab marks, human bite marks, cigarette burns.
Destructive, aggressive or disruptive behavior.
Fear of going home.  

104. Review- signs of abuse Sexual Abuse
Symptoms of sexually transmitted diseases
Injury to genital area
Difficulty and/or pain when sitting or walking
Sexually suggestive, inappropriate behavior or verbalization
Sexual victimization of other children       

105. Review- signs of abuse Maltreatment
Obvious malnourishment, listlessness or fatigue
Stealing or begging for food
Poor personal hygiene, torn and/or dirty clothes
Need for glasses, dental care or other medical attention
Frequent absence from or tardiness to school
Child inappropriately left unattended or without supervision

106. 1 YO IN ER
NO FEVER
RIBS FX SEEN
NO HX OF TRAUMA

109. CHILD ABUSE & ELDER ABUSE

115. Healthcare workers are responsible for their patients’ safety
Healthcare workers are responsible for their patients’ safety. This would include treating the patients according
to their own age level. Treating their patients within their age development will assist the healthcare worker to
deliver proper care.

116. ELDER ABUSE
Each person is moving through the life cycle at all times from birth to death.
The patient’s life cycle stage can generally be identified by physical attributes, psychosocial tasks, common fears or stressors.
As healthcare workers, you can deliver appropriate care to each patient by identifying the life cycle the patient
is currently in and modify the delivery of your treatment to be more effective and best treat the patient.
Abuse is any intentional or unintentional hurt of a person. Elder abuse is any intentional or unintentional hurt of a person who is approximately 60 years of age or older.

117. ELDER ABUSE
Abuse can be Domestic (in their home) or Institutional (in a facility).
Healthcare abusers can be doctors, nurses, hospitals, caregivers, unlicensed “professionals”, and
nonprofessional healthcare providers. Abusers may be family members, visitors or intruders.
Never assume why someone may abuse an elder.
Report all instances of abuse to your immediate on-site supervisor and your staffing specialist.
Be able to report specific information about the incident.

118. SIGNS & SYMPTOMS OF ELDER ABUSE
Warning Signs
are frequent arguments between elder and caregiver or changes in personality or behavior of elder.
If you suspect elderly abuse, but aren't sure, look for clusters of the following physical and behavioral signs

119. PHYSICAL ABUSE 􀂃 Unexplained bruises, pressure marks, black
eyes, welts, lacerations, cuts, or burns
Bone fractures
􀂃 Sprains or dislocations
􀂃 Bite marks or restraint marks
􀂃 Broken glasses
􀂃 Underutilization of medication or overdose
(via lab findings)
􀂃 Elder is not left alone with visitors
􀂃 Elder reports physical abuse

120. EMOTIONAL ABUSE 􀂃 Upset or agitated 􀂃 Withdrawn, depression or
non-communication
􀂃 Sucking, biting or rocking
(usually with dementia)
􀂃 Caregiver belittling or
controlling elder
􀂃 Desertion at an institution
(hospital, nursing home, etc
or public locations)
􀂃 Physical or chemical
restraints
􀂃 Elder reports emotional abuse

121. ELDER NEGLECT Dehydration, malnutrition, or hunger Physical weakness
Hazardous or unsafe living
conditions
Unsanitary & unclean living
Clothing unsuitable for
weather
Poor hygiene, foul body or
household odor
Lack of medical aids

122. SEXUAL ABUSE 􀂃 Bruises around breasts or genitals
􀂃 Unexplained VD or infections
􀂃 Unexplained vaginal or anal bleeding
􀂃 Torn, stained or bloody underclothing
􀂃 Elder reports sexual abuse

123. HEALTHCARE ABUSE Duplicate billings for services
Pill counts are under or over the number the patient was prescribed
Lack of inadequate medical care even though bills are paid

124. ABUSERS
Most abuse occurs in the home, and usually by a family member. Most commonly the perpetrators of elderly abuse are
spouses or partners of elders. Next most frequent abusers are the adult children of elders.
Abusers can be men or women. Men ages thirty-six to fifty are the most common perpetrators.
In nursing homes & other long-term care facilities, abusers may be employees, visitors, or intruders.
Anyone associated with an elder may abuse them: friends, relatives, doctors, lawyers, bankers, accountants, clergy,caregivers, or strangers.

125. Taking care of the elderly, whether at home or in an institution, can be very stressful.
The incidence of depression isvery high among caregivers.
Caregivers habitually lack exercise and outdoor time, have inadequate nutrition, and need more sleep.
Many people with dementia have trouble sleeping so caregivers are kept up caring for them.
Caregivers have a high level of anxiety.

126. HOW TO REPORT ELDER ABUSE
If an elder is in danger:
Notify your on-site supervisor