VISCERAL INJURIES IN BATTERED CHILDREN.

Abstract

The “battered-child” or the “unsuspected trauma syndrome” is well known since the publication of the initial articles of Caffey (3) and Silverman (9). The term refers to an infant or child who has sustained physical abuse, usually repeatedly, from a parent or guardian. A complete review of this subject is found in the excellent papers of Gwinn et al. (5), Kempe et al. (7), and Woolley and Evans (10). This study is concerned with 10 infants or small children suffering initially unexplained visceral trauma (Table I). All patients presented as acute abdominal crises. The history given by the parents was usually vague and obscure or sometimes purposely misleading. No history could be obtained from the children. Seven of the children were male and 3 female. Their ages ranged from five to thirty months. Visceral Rupture Or Laceration Rupture of the small bowel, the most common visceral injury, was found in 7 of the 10 children. Two sustained laceration of the liver, and 1 a perforation of the stomach. Laceration of the lung occurred in 1 child, and subpleural hemorrhage in another. Multiple viscera were traumatized in 5. With rupture of the intestinal tract, the radiographic findings were pneumoperitoneum, hemoperitoneum, and/or ileus (Figs. 1 and 2). In 1 patient with a perforated duodenum there was a considerable delay in seeking medical care and multiple peritoneal abscesses were found (Fig. 3). In the 2 children with a ruptured liver, hemoperitoneum was a striking finding (Fig. 4). Other Systemic Injuries Various combinations of skeletal, craniocerebral, and soft-tissue injuries were found in these children (Table II). 1. 1. Skeletal Fractures. Five patients had evidence of injury to the skeleton exclusive of the skull. In 2, there were a large number of fractures. The radiographic characteristics of skeletal injuries have been described in detail by Fisher (4), Jones and Davis (6) and Silverman. Metaphyseal fractures are common because the metaphysis is least resistant to trauma in this age group (Fig. 5). Periosteal elevation follows with abundant subperiosteal new bone formation. Often noted are fractures in various stages of healing, a sign of repeated trauma. Multiple fractures in the growing bone with subsequent repair cause marked deformities with blunted ends and twisted shafts (Fisr. 5) Numerous fractures in infants and children may be simulated by (a) vitamin C and D deficiency, (b) leukemia, (c) metastatic neuroblastoma, (d) syphilis, (e) osteogenesis imperfecta (f) hypophosphatemia, (g) osteomyelitis, and (h) cortical hyperostosis. 2. 2. Craniocerebral Injuries. Old or recent craniocerebral damage was found in 3 of the 10 children. A fractured skull was present in 1 child on a prior admission. At the time of entry, 1 had bilateral subdural hematomas and another exhibited radiographic evidence of increased intracranial pressure.