Abusive Injury Research Articles

Abusive Head Trauma and a Delay in Presentation for Care.

Abusive head trauma (AHT) is the leading cause of death from trauma in children less than 2 years of age. A delay in presentation for care has been reported as a risk factor for abuse; however, there has been limited research on this topic. We compare children diagnosed with AHT to children diagnosed with accidental head trauma to determine if there is a delay in presentation. We retrospectively studied children less than 6 years old who had acute head injury and were admitted to the pediatric intensive care unit at a pediatric hospital from 2013 to 2017. Cases were reviewed to determine the duration from symptom onset to presentation to care and the nature of the head injury (abusive vs accidental). A total of 59 children met inclusion criteria. Patients who had AHT were significantly more likely to present to care more than 30 minutes after symptom onset (P = 0.0015). Children who had AHT were more likely to be younger (median, 4 vs 31 months; P < 0.0001) and receive Medicaid (P < 0.0001) than those who had accidental head trauma. Patients who had AHT were more likely to have a longer length of stay (median, 11 vs 3 days; P < 0.0001) and were less likely to be discharged home than patients who had accidental head trauma (38% vs 84%; P = 0.0005). Children who had AHT were more likely to have a delayed presentation for care as compared with children whose head trauma was accidental. A delay in care should prompt clinicians to strongly consider a workup for abusive injury.

Impact of the 2020 COVID-19 pandemic on the workload of the orthopaedic service in a busy UK district general hospital

IntroductionThe COVID -19 outbreak has had a profound effect on the management of healthcare service provision in the UK. Orthopaedic departments have been no exception to this and have needed to adapt to the changing circumstances by releasing resources and focusing on ‘essential’ activity. The aim of this study is to quantify the reduction in trauma and, in addition, describe any changes in the type of referrals to the trust which may have been affected by the pandemic itself and the social distancing measures employed by the UK government. Methods: The study was performed in a UK District Hospital which is also a Trauma Unit providing trauma and orthopaedic care to a population of 625,000 people.The trust based electronic database of trauma referrals was used to compare the numbers of, and types of referral to our trauma service during the COVID-19 pandemic and the corresponding time periods in the previous 3 years. ResultsThe mean number of referrals per week to the service reduced by 33% in the time period following the confirmation of the outbreak as a pandemic (p<0.0001). Number of operations performed per week reduced by 26% (p = 0.001). There was no change in the number of referrals relating to domestic abuse or non-accidental injury. In addition, numbers of hip fractures, periprosthetic fractures and prosthetic joint dislocations were unchanged. There was a significant reduction in the number of referrals for simple fractures, native joint dislocations, wounds and soft tissue injuries. Within the paediatric population, similarly, a reduction in simple fracture referrals was demonstrated. DiscussionAn association between the outbreak of the pandemic and a reduction in referral numbers to our department has been demonstrated. The direct cause of this may be multifactorial but proposing that it is, in part, due to the social distancing measures introduced by the government is certainly conceivable. The patterns of injury would reflect this also with low energy and fragility trauma persisting whilst injuries associated with younger people have reduced. We would suggest that information such as this could be useful in healthcare planning and resource allocation in future pandemic situations.

Prevalence and Causes of Subconjunctival Hemorrhage in Children

PURPOSE Subconjunctival hemorrhage (SCH) is an easily diagnosed ocular finding that may result from traumatic or medical causes. SCH has been reported as a sign of occult abusive injury, but there are limited published data about SCH during childhood. We sought to determine the prevalence and causes of SCH in children. METHODS We conducted a retrospective cross-sectional study of children seen by pediatric ophthalmologists in an outpatient setting over a 4-year period. Reasons for examination included the wide variety of disorders evaluated by pediatric ophthalmologists, including amblyopia, strabismus, blurry vision, …

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

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. To demonstrate the radiographic features of proximal femoral physeal fractures both with unossified and ossified femoral heads. 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. Eight patients, ages 2.5 to 26months, 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. 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.

Prevalence of Abuse and Additional Injury in Young Children With Rib Fractures as Their Presenting Injury.

The primary objective of this study was to determine the prevalence of (a) additional injuries, (b) abuse as determined by a standardized scale, and (c) reports to child protective services (CPS) among children younger than 5 years in whom a rib fracture was the first presenting injury concerning for abuse. A retrospective study of children younger than 5 years diagnosed with rib fractures at a tertiary pediatric hospital between 2007 and 2018 was performed. Children in motor vehicle crashes, hospitalized after birth, or with previously diagnosed metabolic bone disease were excluded. We included only those children whose rib fractures were the first presenting injury. Demographic and clinical information was abstracted from the records. Prevalence of additional injuries, a diagnosis of abuse, and a report to CPS were calculated. Associations between patient demographic and clinical characteristics and the outcomes of interest were examined. Of the 67 cases included, additional injuries concerning for abuse were identified in 40 (60%), and 58% were deemed likely or definite abuse. Reports to CPS were filed in 72% of cases. Posterior rib fractures, multiple rib fractures, and presence of rib fractures of multiple ages were all associated with presence of additional injuries and classification as definite or likely abuse (all P ≤ 0.05). The presence of a rib fracture in young children is associated with a high likelihood of additional concerning injuries and should prompt a thorough evaluation for child abuse.

End-of-life medical decision-making for children in custody: A collaborative, multi-stakeholder practical approach

BackgroundParents have a constitutionally-protected, fundamental right to make decisions concerning the health and well-being of their children, afforded by the Due Process Clause of the Fourteenth Amendment. However, parental rights are not absolute, and may be curtailed after a finding of parental “unfitness” including perpetration of egregious child abuse/neglect. Court intervention may be necessary to assert “parens patriae” authority to protect a child’s well-being. Disagreements over medical care for a child (particularly when parent maltreatment resulted in life-altering clinical conditions and parents are suspected of perpetrating abusive injuries) often pose conflicts of interest. End-of-life decision-making involving abuse perpetrators may be influenced by self-interest, due to potential for escalation of criminal charges. ObjectiveDiscuss medico-legal decision-making for children in child welfare custody using a detailed case example involving a child near-fatally, abusively injured by his parents; review of relevant case law/national legal precedents; and clinical policy statements guiding end-of-life decision-making for pediatric patients. Participants/setting/methodsUsing an exploratory, quasi-qualitative approach, perceived experiences of purposefully-selected taskforce members identified key themes that informed a care de-escalation protocol, implemented across the state. ResultsKey themes included coordinated communication, expedited legal proceedings, and balancing child’s best interest (the right not to suffer for a prolonged period of time or sustain complications) with parents’ rights and due process concerns, and informed protocol development. ConclusionsPracticable guidance established in the protocol can be theoretically adapted at the local level to address the complexity inherent in end-of-life decision-making for children in custody.

Integrated Care: Provider referrer perceptions of occupational therapy services for homeless adults in an integrated primary care setting

Occupational therapists have a long history of addressing community performance and participation challenges faced by individuals with complex, chronic conditions, including those with serious mental illnesses (SMI) and cognitive issues that present with a traumatic brain injury (TBI). Healthcare reform has shifted incentives to support practices that promote successful community life for people with complex medical conditions. Community based care models emphasizing integrated primary care, such as Federally Qualified Health Centers (FQHC) are emerging, and a generalist role for occupational therapy is being defined. Those with complex comorbid conditions such as mental illness, substance abuse and traumatic brain injury are at risk for negative health outcomes that are further compounded by homelessness. There is a critical need to understand effective treatment options for this population to reduce the negative effects of chronic health conditions. As occupational therapists further define a role serving traditional clients in less traditional settings, such as the FQHC, it is helpful to explore the perceptions of the utility of OT services on the part of provider referrers. This study explored provider referrer perceptions of a new occupational therapy service for homeless adults in an FQHC to assist effective allocation of scarce resources. Twelve provider referrers at an FQHC were interviewed regarding their perception of the role and utility of occupational therapy in this setting. Interviews were then coded for themes. Providers identified the unique value of occupational therapy, emphasizing critical information gleaned from the performance-based assessment of functional cognition, and the positive impact on team interactions and subsequent care decisions. Occupational therapy provides a distinct perspective on client performance in FQHC settings indicating benefit for inclusion of services.

An epidemiology of paediatric cervical spine injuries at the Red Cross War Memorial Children's Hospital over a ten-year period

Background: Paediatric cervical spine injury (CSI) is rare compared to adult CSI. Very little has been published regarding the epidemiology and outcome of CSI in children in South Africa. The objective of this retrospective study is to characterise the epidemiology and report on the outcome of CSI in children <13 years at a tertiary referral centre for paediatric trauma. Methods: We performed a retrospective study of CSI at our hospital over a ten-year period. The Picture Archiving and Communication System (PACS) of our institution was searched for patients with CSIs. Search terms included: cervical spine fracture, subluxation, dislocation, contusion, SCIWORA (spinal cord injury without radiographic abnormality) and retroclival haematoma. Demographic and clinical data were obtained from hospital records. Injury-related variables were compared for children ≤8 and >8 years due to anatomical and biomechanical differences observed. Outcome was assessed using the Frankel grading. Results: Sixty-six children were identified with a cumulative incidence of 0.1%. The median age was 7 years (inter-quartile range 4–8.8) and 65% were male. All injuries were caused by blunt trauma. Passenger motor vehicle injury (MVA) accounted for 52% of injuries. Injuries due to physical abuse, and recreational and sporting activities did not occur. Children ≤8 years of age incurred more injuries than those >8 years (74.2% vs 25.8%). Ninety-eight per cent of injuries occurred in the upper cervical spine (C1–C4) of children ≤8 years. Of the 13 (19.6%) children with neurologic injury, five (7.5%) had complete spinal cord injury, four (6%) had incomplete neurology, and three (4.5%) died. SCIWORA occurred in six (9%) children with variable outcome. Seven patients (10.6%) were operated for instability. An injury severity score (ISS) of 25 (13–34) was associated with poor outcome. The mortality rate was 4.5% and all children who died were ≤8 years with upper CSIs and closed head injuries (CHIs) related to MVA. Conclusion: CSI occurred in 0.1% of patients evaluated following trauma. MVAs, either pedestrian or passenger, were responsible for the majority of these injuries. Children ≤8 years were more frequently injured and sustained injuries to the upper cervical spine. The majority of paediatric CSIs are stable injuries that can be managed conservatively; however, urgent surgical stabilisation is indicated for unstable injuries. CSI with associated CHI caused by MVAs in young children is associated with death. Even though our patients are referred from high violence communities, no CSIs were attributed to physical abuse or penetrating injury. Level of evidence: Level 4

Abuse and Mistreatment of Athletes at US Universities: Legal Implications for Institutional Duty-to-Protect

The recent spate of high-profile cases detailing abuse, mistreatment, and catastrophic injuries, suffered by college athletes have raised concerns regarding their well-being and the quality of care they receive. Post-hoc investigations have often followed in such cases, in an attempt to determine the cause and what preventive actions could have been taken. With disturbing regularity, such investigations have uncovered institutional dereliction of duty to protect and failure to prevent continued misconduct by those with the ability and opportunity to do so. This study presents a documentary investigation into issues college athletes raised during their exit interviews at one university in the United States. This study details the communication chain from athlete to administration and whether athlete concerns received attention commensurate with the gravity of the issues raised. Findings presented here indicate that administrative officials appeared less concerned with athlete well-being than with avoiding attracting attention to potential institutional malfeasance. The congruity of these results with evidence from the broader college athlete population as well as legal implication for institutional duty of care are discussed.

Unrelated male caregiver highly correlated with abuse vs accidental injury

Unrelated male caregiver highly correlated with abuse vs accidental injury

Nursing care of a case of multiple organ dysfunction syndrome caused by child abuse combined with severe soft tissue injury

Objective To explore the nursing experience of a child with multiple organ dysfunction syndrome caused by physical abuse and severe soft tissue injury. Methods In this case, multiple soft tissue injuries and multiple organ dysfunction syndrome were caused by domestic violence abuse. Nursing included strengthening artificial airway nursing, continuous blood purification nursing, skin injury nursing, sedation and analgesia management, nutritional support nursing, psychological nursing and family education. Results After careful treatment and nursing, the child′s condition improved and was transferred to the general ward for further treatment and discharged. Conclusions The nursing of multiple soft tissue injuries and multiple organ dysfunction syndrome includes strengthening artificial airway nursing, continuous blood purification nursing, skin injury nursing, sedation and analgesia management, nutritional support nursing, psychological nursing and family education. Key words: Nursing care; Child abuse; Soft tissue injury; Multiple organ dysfunction syndrome

Trends in US physician diagnosis of child physical abuse and neglect injuries, 2006–2014

ObjectiveTo determine if US child physical abuse and neglect injury rates changed from 2006 to 2014, whether definitive diagnoses of physical abuse and neglect were used more often over time, and what patient factors influenced definitive physical maltreatment diagnoses. MethodsNationally estimated rates of definitive and suggestive physical abuse and neglect injuries for children <10 years were generated using the Nationwide Emergency Department Sample, the National Inpatient Sample, and census estimates. Trends over time were evaluated, including the trend in the proportion of definitive diagnoses to all diagnoses (definitive plus suggestive). Logistic regression was used to evaluate whether patient characteristics and hospital patient volumes were associated with definitive versus suggestive diagnoses. ResultsThe population rates of child physical maltreatment medically treated injuries were unchanged from 2006 to 2014; the trends were not statistically significant for ED or hospitalized patients. Over time, physician definitive diagnoses as a proportion of all physical maltreatment diagnoses (definitive plus suggestive) increased in admitted children from 17.6% in 2006 to 22.0% in 2014 (p = 0.02). Older age, white race, lower income by zip code, and public insurance as well as larger patient volumes increased the odds of definitive rather than suggestive diagnoses of physical abuse and neglect injuries. ConclusionsDefinitive diagnoses of physical abuse and neglect increased over the study period and were associated with hospital volume and patient characteristics which may reflect provider experience and possible bias. The use of electronic medical records may have influenced the coding of definitive diagnoses.

Methods in population study of orofacial injuries in Victorian family violence homicides.

This study standardized the methods used in the determination of orofacial injuries in Victorian family violence homicides and informed potential control selection for an analytic study. Dental service contacts with family violence victims may be intervention avenues due to the presence of abusive injuries in the orofacial region. All Victorian family homicides from January 2000-September 2018 were identified by determining the kinship/relationship and grouped by age. A 20% random sample of adult cases, aged 18-64years was selected. The median number of orofacial injuries in categories of injury mechanisms/age/gender and the nature of abusive orofacial injuries was reported for the sample. Of 357 closed cases of family homicide, 261 were adults aged 18-64years. Offender information and injury mechanism data was available for all closed cases, enabling case selection. Of a random sample of 50 adults, 8 cases were excluded. After 2006, CT scans and photos were present in 20 (91%) and 19 (86.4%) of 22 cases, respectively. The nature and median number of orofacial injuries showed correlation to the reported injury mechanism. Strengths and limitations of the used methods were assessed. Not all cases were compatible for assessment of orofacial injuries, thus serving as an additional criterion for exclusion in our methodology. Further detailed study of the whole population of adults should be limited to the period 2006-2018 where the data is more complete. The mechanism of injury may influence control selection for analytic studies. We present preliminary evidence of the frequent occurrence of orofacial injuries in family violence homicides.

It's 10 o'clock. Do you know who is caring for your child?

State and federal estimates of child maltreatment show that between 700 000 and 1.25 million children in the US are affected annually. Of these children, approximately 18% are victims of physical abuse. Perhaps even more concerning is that the rates of severe injuries that lead to admission or death have not changed substantially since the 1970s when greater emphasis was placed on the development of specific child abuse recognition and prevention strategies (Lancet 2012;379:358-72) (Pediatrics 2013;131:e1796-802). Part of the enhanced recognition of suspected child abuse has hinged on noted associations between high risk environments and caregiver features, but many of these associations have been anecdotal. In this volume of The Journal, Fingarson et al present the results of a prospective, observational, multi-site study designed to evaluate physical and caregiver characteristics associated with abuse vs accidental trauma in a large cohort of children less than 4 years of age. Their findings give credence to what child abuse specialists, general pediatricians, and emergency medicine pediatricians have “known” for years: the risk for injury from abuse is greatest when the infant/child is in the care of a male partner of the mother and that risk is heightened for relationships of shorter durations or when care arrangements are outside of the usual circumstances. These findings, although not surprising, are a wake-up call to those who develop or implement prevention and education projects. If all of those who care for children do a better job of understanding the risks associated with specific caregiver characteristics, we should be able to move the ball forward. Having the evidence with which to modify existing clinic or home-based positive parenting programs that focus on child development and normal behaviors and acknowledge the impact of parental ACES is critical to the prevention of child maltreatment. This study takes an important step in providing that evidence and presents fertile ground for future research. Article page 180▸ Who's Watching the Children? Caregiver Features Associated with Physical Child Abuse versus Accidental InjuryThe Journal of PediatricsVol. 212PreviewTo compare caregiver features and caregiving arrangements of children with physical abuse vs accidental injuries. Full-Text PDF

Lifetime abuse and somatic symptoms among older women and men in Europe.

BackgroundResearch suggests that survivors of interpersonal violence have an increasing experience of bodily symptoms. This study aims to scrutinise the association between lifetime abuse and somatic symptoms among older women and men, considering demographics/socio-economic, social support and health variables.MethodsA sample of 4,467 community-dwelling persons aged 60–84 years (57.3% women) living in seven European countries (Germany, Greece, Italy, Lithuania, Portugal, Spain, Sweden) was recruited for this cross-sectional study. Lifetime abuse (psychological, physical, sexual, financial and injury) was assessed on the basis of the UK study of elder abuse and the Conflict Tactics Scale-2, while somatic symptoms were assessed by the Giessen Complaint List short version.ResultsWomen reported somatic symptoms more frequently than men. Multiple regression analyses revealed that lifetime exposure to psychological abuse was associated with higher levels of somatic symptoms among both women and men, while experiencing lifetime sexual abuse was associated with somatic symptoms only among older women, after adjusting for other demographic and socio-economic variables. Country of residence, older age, and low socio-economic status were other independent factors contributing to a higher level of somatic symptoms.ConclusionsThe positive association between the experience of abuse during lifetime and the reporting of higher levels of somatic symptoms, in particular among older women, seems to suggest that such complaints in later life might also be related to the experience of mistreatment and not only to ageing and related diseases. Violence prevention throughout lifetime could help to prevent somatic symptoms in later life.

Photography Improvement Project

Program Goals: Child Abuse medical evaluations of children suspected of being maltreated often involve photo-documentation of skin findings. These photographs are important for medical documentation, peer review, investigations by Child Protective Services and law enforcement, as well as court proceedings. It is essential that medical photographs are of excellent quality. While there are published guidelines about how to photograph injuries, there is no published tool to assess the quality of photographs of physical abuse injuries. Such a tool would be necessary to use in a …

Impact of Project ECHO on Community ED Providers' Perceptions of Child Abuse Knowledge and Access to Subspecialists for Child Abuse and Neglect

Problem Identification: Victims of child abuse and/or neglect (CAN) are frequently cared for in emergency departments (EDs) where providers must recognize and report injuries suggestive of CAN to prevent additional injury or death. Almost 90% of pediatric visits occur in community EDs with limited access to subspecialty CAN consultation.1 Abusive injuries are missed more frequently in these EDs compared to pediatric EDs.2,3 Efforts to improve CAN care in EDs have been limited to screening instruments and sporadic educational interventions.

The "New Science" of Abusive Head Trauma.

Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.

Who's Watching the Children? Caregiver Features Associated with Physical Child Abuse versus Accidental Injury

To compare caregiver features and caregiving arrangements of children with physical abuse vs accidental injuries. Data came from a prospective, observational, multicenter study investigating bruising and psychosocial characteristics of children younger than 4years of age. Using logistic regression, we examined how abuse vs accidental injury and severity of injury were associated with caregiver sex, relation to the child, whether caregiving arrangements were different than usual at the time of injury, and length of the main caregiver's relationship with his/her partner. Of 1615 patients, 24% were determined to have been physically abused. Abuse was more likely when a male caregiver was present (OR 3.31, 95% CI 2.38-4.62). When the male was the boyfriend of the mother (or another female caregiver), the odds of abuse were very high (OR 169.2, 95% CI 61.3-614.0). Severe or fatal injuries also were more likely when a male caregiver was present. In contrast, abuse was substantially less likely when a female caregiver was present (OR 0.25, 95% CI 0.17-0.37) with the exception of a female babysitter (OR 3.87, 95% CI 2.15-7.01). Caregiving arrangements that were different than usual and caregiver relationships <1year were also associated with an increased risk of abuse. We identified caregiver features associated with physical abuse. In clinical practice, questions regarding caregiver features may improve recognition of the abused child. This information may also inform future abuse prevention strategies.

Latin American Pediatric Neurosurgery Society declaration against abusive head injury

Latin American Pediatric Neurosurgery Society declaration against abusive head injury