1. VISUAL DIAGNOSIS OF CHILD ABUSE ON CD-ROM LECTURE SERIES
11. Conditions Mistaken for Child Physical Abuse
Outline
Abstract Fractures
Osteogenesis Imperfecta
Learning Objectives
Diagnostic Considerations in Distinguishing
Confusing Cutaneous Conditions Osteogenesis Imperfecta From
Folk Medicine Inflicted Injuries
Burns Temporary Brittle Bone Disease
Infantile Cortical Hyperostosis
Intracranial Bleeding
(Caffey’s Disease)
Ocular Hemorrhages
Other Miscellaneous Conditions Mistaken for
Child Abuse
References
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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
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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
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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
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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)
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6. Visual Diagnosis of Child Abuse on CD-ROM Lecture Series 11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE
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