Ulcerated diaper dermatitis: Child abuse mimicker.

Irritant diaper dermatitis is a common dermatologic problem among infants and young children. Severe erosive presentations, although uncommon, are diagnostically challenging and can mimic non-accidental trauma (NAT). Diagnosing inflicted injury and NAT where it does not exist can cause parental distress, yet failing to diagnose inflicted injury and NAT can result in re-injury. We describe three cases of severe erosive diaper dermatitis in pediatric patients aged 2-6 years that were initially concerning for inflicted scald burn or neglect.

Genetic causes of fractures and subdural hematomas: fact versus fiction.

Genetic disorders are in the differential diagnosis when young children present with unexplained fractures or intracranial hemorrhage. For medical and legal reasons, it is imperative to make the correct diagnosis and provide clear, evidence-based explanations of how alternative diagnoses were ruled out. A genetics consultation in cases of suspected child physical abuse should synthesize the history of present illness, medical history, family history, physical examination, and radiologic and laboratory findings in consultation with other specialists. The medical geneticist highlights how these disorders truly present. When the natural history of a genetic disorder is understood, it becomes clear that genetic disorders are not mysterious or difficult to diagnose. As highlighted in this case-based review, mainstream medical practice allows for differentiation among the intracranial and skeletal manifestations of osteogenesis imperfecta, Menkes disease, glutaric acidemia type 1 and child physical abuse. This review also highlights how a genetic disorder, Ehlers-Danlos syndrome, can be misused in a courtroom. Finally, this review summarizes when genetic testing is appropriate in cases of suspected child physical abuse.

Genetic consultations in cases of unexplained fractures and haemorrhage: an evidence-based approach.

PURPOSE OF REVIEW: When infants and young children present with suspected physical abuse, it is critical to follow standard guidelines and rule out alternative causes of fracture and haemorrhage. A multidisciplinary team involved in the initial evaluation typically includes paediatrics, radiology, child protective services and/or law enforcement, and in complex cases, haematology, neurology, and genetics. A comprehensive genetics consultation includes review of the history of present illness, birth and past medical history, review of growth curves, family history, physical examination, radiological findings, and when indicated, biochemical and/ or genetic testing. RECENT FINDINGS: A number of reports have mischaracterized several genetic disorders as child abuse mimics. There is a difference between a differential diagnosis, which includes every condition that can cause a fracture and/or subdural haemorrhage, and a mimic, so called because it can be difficult to differentiate from child abuse. In this review, we discuss the differential diagnosis for infantile fractures and subdural bleeds, highlight cardinal signs and symptoms of genetic disorders, and demonstrate that these genetic disorders can be readily differentiated and diagnosed using a stepwise approach. Genetic disorders rarely, if ever, are truly mimics of child physical abuse. SUMMARY: In cases of suspected child physical abuse, multidisciplinary evaluations by paediatric specialists, keen clinical judgment, complete physical examinations, and judicious testing provides an evidence-based, time tested approach to excluding genetic disorders and diagnosing suspected child physical abuse.

Proximal femoral physeal fractures in children: a rare abusive injury.

BACKGROUND: Proximal femoral physeal fractures are rare in abused children. Recognition may be hampered due to their rarity and lack of an ossified femoral head. Prompt diagnosis and treatment are essential to preventing coxa vara. OBJECTIVE: To demonstrate the radiographic features of proximal femoral physeal fractures both with unossified and ossified femoral heads. MATERIALS AND METHODS: We reviewed our Institutional Review Board-approved 21-year radiology database of 2,206 children who had a skeletal survey as part of their medical evaluation for possible abuse. Cases of proximal femoral physeal fractures were identified. RESULTS: Eight patients, ages 2.5 to 26 months, with 10 fractures were found, yielding a prevalence of 0.4% (8/2,206). In all fractures, there was lateral displacement of the proximal femur. In three fractures, the femoral head was not ossified, simulating a hip dislocation. The intra-articular location of the femoral head was verified by ultrasound or abdomen computed tomography. Subperiosteal new bone formation was present in six fractures, all non-weight-bearing patients. The femoral head was ossified in seven cases, all with medial rotation of the femoral head. Metaphyseal irregularity was present in three of four fractures of the weight-bearing patients; two of three also had metaphyseal scalloping resembling osteomyelitis. The three with metaphyseal irregularity developed coxa vara. CONCLUSION: Proximal femoral physeal fractures are rare in abuse cases. All present with lateral displacement of the proximal femur. With an unossified femoral head, it can simulate hip dislocation, which can be clarified with hip sonogram. Metaphyseal irregularity appears to be a feature in weight-bearing patients.

Aspects of abuse: abusive head trauma.

Abusive Head Trauma (AHT) is a form of child physical abuse that involves inflicted injury to the brain and its associated structures. Abusive Head Trauma, colloquially called Shaken Baby Syndrome, is the most common cause of serious or fatal brain injuries in children aged 2 years and younger. The American Academy of Pediatrics recommends the term Abusive Head Trauma, as opposed to Shaken Baby Syndrome, as the former term encompasses multiple forms of inflicted head injury (inertial, contact, and hypoxic-ischemic) and a range of clinical presentations and radiologic findings and their sequelae. Children diagnosed with AHT are 5 times more likely to die compared with accidentally head-injured children, yet signs and symptoms are not always obvious, and therefore the diagnosis can be overlooked. Therefore, the American Academy of Pediatrics has tasked pediatricians with knowing how and when to begin an evaluation of children with signs and symptoms that could possibly be due to AHT. Overall, a detailed history of present illness and medical history, recognition of physical and radiological findings, and careful interpretation of retinal pathology are important aspects of formulating the differential diagnoses and increasing or decreasing the index of suspicion for AHT.

Curiosity and critical thinking: identifying child abuse before it is too late.

OBJECTIVE: We reviewed medical records to identify factors contributing to not recognizing child abuse in cases where it was subsequently identified. DESIGN/METHODS: Eighteen cases of delayed diagnosis of physical abuse were reviewed for qualitative themes. Missed abuse was defined by prior medical encounters that revealed findings concerning for physical abuse that were not recognized. RESULTS: Clinical limitations contributing to a delay in diagnosis included inattention to skin and subconjunctival findings, acceptance of inadequate explanations for injuries, no history obtained from verbal children, insufficient exploration of signs and symptoms, nonadherence to the maltreatment pathway, and incorrect diagnoses from radiologic examinations. System-based limitations included limited medical record access or completeness and admission to less-than-optimal settings. CONCLUSIONS: Having a greater index of suspicion for abuse may mitigate missed opportunities. With variability of medical training in child abuse, the factors we identified can be used as learning objectives for continuing medical education.

Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma.

BACKGROUND: In the evaluation of children younger than 3 years with intracranial hemorrhage it can be difficult to determine whether the cause of hemorrhage was traumatic, and if so, whether abusive head trauma (AHT) is a possibility. Cervical spine MRI is not a routine part of the nationally recommended imaging workup for children with suspected abusive head trauma. There is increasing evidence that spinal injuries are found at autopsy or MRI in abused children. However the prevalence of cervical spine injuries in children evaluated for abusive head trauma is unknown. We sought to determine both the incidence and the spectrum of cervical spine and brain injuries in children being evaluated for possible abusive head trauma. We also examined the relationship between cervical and brain MRI findings and selected study outcome categories. MATERIALS AND METHODS: This study is a 3-year retrospective review of children evaluated for abusive head trauma. Inclusion criteria were: children with head trauma seen at our institution between 2008 and 2010, age younger than 36 months, availability of diagnostic-quality brain and cervical spine MRI, and child abuse team involvement because abusive head trauma was a possibility. A child abuse pediatrician and pediatric radiologists, all with board certification, were involved in data collection, image interpretation and data analysis. Statistical analysis was performed using Stata v12.1. RESULTS: The study included 74 children (43 boys, 31 girls) with a mean age of 164 days (range, 20-679 days). Study outcomes were categorized as: n = 26 children with accidental head trauma, n = 38 with abusive head trauma (n = 18 presumptive AHT, n = 20 suspicious for AHT), and n = 10 with undefined head trauma. We found cervical spine injuries in 27/74 (36%) children. Most cervical spine injuries were ligamentous injuries. One child had intrathecal spinal blood and two had spinal cord edema; all three of these children had ligamentous injury. MRI signs of cervical injury did not show a statistically significant relationship with a study outcome of abusive head trauma or help discriminate between accidental and abusive head trauma. Of the 30 children with supratentorial brain injury, 16 (53%) had a bilateral hypoxic-ischemic pattern. There was a statistically significant relationship between bilateral hypoxic-ischemic brain injury pattern and abusive head trauma (P < 0.05). In addition, the majority (81%) of children with bilateral hypoxic-ischemic brain injuries had cervical injuries. CONCLUSION: Although detection of cervical spine injuries by MRI does not discriminate between accidental and abusive head trauma, it can help to distinguish a traumatic from non-traumatic intracranial subdural hemorrhage. Cervical MRI should be considered in children with acute intracranial bleeds and otherwise non-contributory history, physical examination and ophthalmological findings. There is a statistically significant relationship between diffuse hypoxic-ischemic brain injury patterns and abusive head trauma. The high incidence of cervical injuries in children with hypoxic-ischemic injuries suggests a causal relationship. Overall, increased utilization of brain and spine MRI in children being evaluated for abusive head trauma can be helpful.