PEDIATRIC

NONACCIDENTAL
TRAUMA
Angela Long, BSN, RN

Cheryse Jackson, BSN, RN

Reginald Degrafenreid, BSN, RN

Andre Foster, MSN, BL, RN

OBJECTIVES
Increase Nurse Practitioners awareness of
epidemiology of and risk factors for child physical
abuse
Increase NP recognition of non-accidental
trauma (NAT) based on history, physical exam
findings, and radiologic studies
Increase NPs understanding how to report
suspected abuse and/or neglect

EXTENT OF ABUSE
Approximately 10% of all ED visits for children <5
years old are related to NAT
3 million reports and 1 million substantiated cases
per year incidence of 42 per 1,000 children

Have

you ever reported abuse?

True extent of abuse unknown; many cases go

unreported
Child maltreatment encompasses:

Physical

abuse 23%
Sexual abuse 12%
Neglect 60%
Emotional abuse 4%

WHY NURSE PRACTITIONERS NEED

TO BE AWARE
Very common
High morbidity & mortality
Opportunity to intervene
Responsibility to intervene
Requirement to report

MARYLANDS DEFINITION OF
ABUSE

The physical or mental injury of a child by any

parent or other person who has permanent or
temporary care or custody, or responsibility for
supervision of a child, or by any household or
family member, under circumstances that
indicate that the childs health or welfare is
harmed or at substantial risk of being harmed

NURSE PRACTITIONERS
RESPONSIBILITY

Maryland law mandates that all medical

providers report suspected abuse or neglect to
Child Protective Services (CPS) or other law
enforcement agencies
Medical

Providers may be held liable for failure to

report
Immunity from civil liability and criminal penalty if a
report is made in good faith

RED FLAGS: WHEN TO SUSPECT

ABUSE
Unexplained injury
History and/or developmental abilities inconsistent
with injury
Varying, changing histories
Delay in seeking treatment
Frequent injury/illness

Less common:

Child accuses adult

One parent accuses other parent
Alleged self- or sibling-inflicted injury
Eyewitness
Perpetrator confesses

RISK FACTORS FOR ABUSE

Family stress
Economic

difficulty/unemployment
Poor housing/crowding
Illness

Parents psychology
Impulse

control disorder
Depression
Psychosis
Drug/alcohol abuse
Retardation

Child factors
Provocative

behavior
Illness/disability/ developmental
delay
Multiple children in household

Parenting factors

Lack of preparation
Poor role models
Unrealistic expectations of
child
Use of corporal punishment
Unsupportive spouse/partner
Nonbiologic parent present
(especially Moms boyfriend)
Inconsistent parenting

Social factors

Social isolation
Distant/absent extended family
High expectations for all
parents
Violence considered acceptable
in society

BEFORE ANY EXAM HISTORY,

HISTORY, HISTORY!

Initial Introduction:

Explain the evaluation process

Make the child as comfortable as possible

Caregiver Interview/History of Events:

Allow caregiver an opportunity to describe concerns

(with the child OUT OF THE ROOM)
Let caregiver provide PMHx (especially easy bleeding or
bruising in patient or family), ROS, home
environmental situation, prior abuse history, and relate
any information about the current suspected abuse
Explain the mandatory sharing of information with CPS
and law enforcement

HISTORY FROM THE CHILD

Most NAT in children <2 years old, so history from child
often not possible
If it is
Once rapport has been established, ask the child why they
have come to see the doctor
Use simply worded, open ended questions
Avoid yes or no questions
Glean additional information with a tell me more & and
then what happened approach
Gather specific details regarding the abuse
Use the childs terms for body parts and actions
Finish the interview by encouraging the child and praising
them for disclosing the information
Prepare them for the physical examination

MANIFESTATIONS OF PHYSICAL
ABUSE
Skin: lesions (lacerations, punctures, &
abrasions), burns, hair loss
Skeletal system: fractures, periosteal hematomas
CNS: direct trauma, shaking injures
GI system: mouth injuries, blunt abdominal
trauma
Cardiopulmonary and GU trauma
Unusual: ingestions, drowning, punishment
diets, Munchausen syndrome by proxy (aka:
Factitious disorder by proxy)

BRUISES, BURNS, AND

OTHER
ABUSIVE SKIN FINDINGS

ACCIDENTAL VERSUS SUSPICIOUS

BRUISES

Accidental
Extensor

surfaces of extremities, forehead, bony

prominences
Ambulatory child

Suspicious
Shape:

imprint of object
Location: upper arms, anterior thigh, trunk, genitalia,
buttock, face, ears, neck
Pattern: symmetry or pairs
Multiple locations
Different ages
Not compatible with history, especially non-ambulatory
child children who dont cruise shouldnt bruise

PATTERN BRUISES: HANDSLAP

Pattern: the appearance of the
injury suggests the object used
to cause the injury
Injuries caused by a highvelocity injury such as a slap
mark create a negative imprint
or outline of the object that
contacted the skin with
surrounding confluent
petechiae

PATTERN BRUISES: BELT

PATTERN BRUISES: LOOPED CORDS

PATTERN BRUISES: SPANKING

Notice the linear petechial
confluence just parallel to the
gluteal cleft. In other cases,
this can be seen as frank
isolated bruising in the same
location. This linear injury is
not from being stuck in a
vertical manner; rather, it is
from deformation of the
buttocks, causing more blood
vessel rupture here than
elsewhere. The buttocks are a
common site for disciplinary
trauma, especially after
toileting accidents.

PATTERN BRUISES: FISTS AND

KNUCKLES

OTHER PATTERN BRUISES

Wire brush

Switch

Chip clip

EAR BRUISING

Petechiae

Mastoid bruising

Although accidental injuries to the

pinna occasionally occur, abusive
injuries from direct blows to the side
of the head, pulling, or grabbing are
seen often in abused children. Note
how linear bruises run along the top
of her pinna, where it was crimped
against her underlying scalp by the
blow.

Fingernail marks

BITE MARKS

ATTEMPTED STRANGULATION

Notice the abrasions and

bruises from the cord in
addition to the petechiae about
the face. Petechiae about the
neck and face are common in
these cases because of the
elevated venous pressure
experienced during the
strangulation attempt.

PERIORBITAL ECCHYMOSES
Can be secondary to
accidental forehead
trauma

Non-accidental eye
trauma often causes
subconjunctival
hemorrhage in addition
to bruising

MULTIPLE BRUISES

PATTERN BURNS

PATTERN BURNS

Irons

Space heater

Spatula

PATTERN BURNS: CIGARETTE

LIGHTERS

Smiley-face

PATTERN BURNS: CIGARETTE

LIGHTERS

PATTERN BURNS: CIGARETTES

Cigarette burns are sometimes indistinguishable from healing

contusions and impetigo. One must observe the injuries for
quantity, symmetry, location, and size. Burns are typically about 7
to 8 mm wide, although this depends on the type of cigarette, and
have a deeper, central ulcer or eschar where the most heat from the
cigarette contacts the skin. These injuries have been directly
imprinted and are multiple, not the single, amorphous burn that
usually occurs with an accidental brushing of a lit cigarette.

WATER/SCALD BURNS

Spill and Splash

Burns

Varying depth of burn

Deeper burns in area of
first contact
May see inverted triangle
shape
Multiple areas of burn
Indistinct borders
Splash marks
Accidental or inflicted

Immersion Burns

Uniform depth of burn

Stocking or glove
distribution
Buttocks, lower back &
perineum with sparing of
flexor creases
Unvaried appearance
Distinct borders with
sharply defined water
lines
No splash marks
Usually inflicted

IMMERSION BURNS

Stocking glove appearance

Note sparing of flexural creases

SCALD BURNS

Hand held under hot water

HOT AIR BURN

ABUSIVE MIMICS

Slate gray nevi (aka: Mongolian spots)

ABUSIVE MIMICS
Coining

ABUSIVE MIMICS

Cupping

ABUSIVE MIMICS

Coagulopathy

ABUSIVE MIMICS

Vasculitis (HSP)

ABUSIVE MIMICS

Hemangioma

RADIOGRAPHI
C FINDINGS OF
ABUSE

ANATOMY OF A GROWING BONE

Characteristics of a young childs (<5 yrs old) bone:

-ligaments stronger than bone
-epiphysis is weakest area
-lots of woven bone (tends to wrinkle or bend)
-periosteal membrane loosely attached, increasing risk for subperiosteal
hematomas
-rapid healing

MOST COMMON ACCIDENTAL

FRACTURES IN CHILDREN < 5
YEARS OLD

1.
2.
3.
4.
5.
6.

Guided by developmental milestones

Clavicular fractures (usually midshaft)
Skull fractures: narrow, linear, uncomplicated, do
not cross suture lines, rare neurological sequelae
Toddlers fracture: oblique, hairline fracture of
tibia
Torus fractures, or incomplete distal radial and
ulnar fractures
Complete fractures of both the radius and the ulna
Distal phalanx injury, a soft tissue injury, with or
without a fracture of the distal phalanx

VIRTUALLY PATHOGNOMONIC FOR

ABUSE
Metaphyseal corner fractures
Multiple rib fractures, especially posterior rib
Acromial fractures
Multiple/bilateral skull fractures, especially crossing
suture lines

Highly suspicious:
Vertebrae,

sternum, pelvis, scapulae

Long bone fractures in non-ambulatory children,
especially spiral and oblique fractures
Subperiosteal hematomas
Multiple fractures of different ages
Hand or foot fractures (metacarpals)

CLASSIC METAPHYSEAL LESIONS

(CML)
Usually occurs when
an extremity is pulled,
twisted, or yanked; can
also occur
(symmetrically) with
violent shaking of
thorax
Most commonly seen in
non-ambulatory
infants
Highly specific for NAT
Most common sites:
knee, ankle, distal
humerus

SPIRAL LONG BONE FRACTURES

Isolated, usually oblique long bone
fracture is initial presentation in 15% of
children radiographed for suspected
abuse
Highly suspicious for NAT, especially in
non-ambulatory patient
Most common history: sudden swelling of
the thigh or arm, refusal to bear weight
Mechanism: Rotary/torsional force
Falls from bed, couch, etc. rarely cause
this type of injury
Exception: Toddlers fracture

Spiral or oblique fracture of tibia > femur

due to rotational gait of toddlers, usually
after jumping down from low height

HAND & FOOT FRACTURES

Accidental injuries
usually involve
phalanges, and usually
are reported with
appropriate trauma
history (slammed in
door, etc.)
Metacarpal and
metatarsal fractures
are more suspicious for
NAT

ACROMIAL FRACTURES
Acromion is a curved
protuberance of bone
arising from scapular
spine
Often injured when
upper extremity used
as a lever or handle to
manipulate the childs
body

ABUSIVE HEAD TRAUMA

Injuries to CNS are main cause of death in child
abuse
Two categories:

Direct

trauma

Striking child with hand/object OR dropping/throwing child

against wall/floor
Can cause subdural hematomas
Often given history of child falling off bed or changing table, but
these types of falls only cause even uncomplicated skull fractures
in as little as 1-2% of cases

Shaking

injuries

Characteristically cause CNS damage without evidence of

external trauma
Shearing forces can cause scalp hematomas, subarachnoid
hemorrhages, diffuse axonal injury, and/or brain contusions
(especially frontal and occipital)

SKULL FRACTURES: RACCOON EYES

Often caused by basilar skull fractures

DEPRESSED SKULL FRACTURES

A fracture in which a bone fragment is displaced inward is

called a depressed skull fracture. Depressed skull fractures in
young children are a result of direct trauma with a focal
application of the external force. Carefully consider this when
determining if the history provided adequately explains the
injury.

EPIDURAL HEMATOMAS
Football shaped
(bi-convex)
Often associated with
skull fractures
Can be a surgical
emergency requiring
evacuation of blood
Can occur following
accidental
mechanisms, but
always need to
consider NAT

SUBDURAL HEMATOMAS

Blood collection in potential

space underneath dura
mater (concave)
Result from tearing of
bridging vessels
Acute bleeds appear bright
on CT; chronic bleeds are
darker

CEREBRAL EDEMA
Secondary to direct or
shaking trauma
Causes loss of greywhite differentiation,
flattening of gyri/sulci,
compression of
ventricles, and/or
midline shift
May find bulging
fontanelle in infants

GUIDELINES FOR MEDICAL

EVALUATION OF SUSPECTED NAT

Less than 2 yrs old with suspicious bruise and/or

fracture
Skeletal

survey
Head CT
Trauma labs: CBC, CMP, Amylase, Lipase, T&S, UA,
UTOX, PT, PTT, INR

If + head CT or ocular injury ophtho exam

If older than 2 yrs old: use injuries to guide
imaging, labs
May need MRI and/or radionuclide bone scan to
determine true extent of injuries

REFERENCES

Many images and captions courtesy of

Dr. Forrest Closson, Department of Pediatrics, University of

Maryland, Hospital for Children and Dr. Michelle Chudow ,
Medical Director Baltimore County Child Advocacy Center,
Medstar Franklin Square Hospital Pediatrics, December 2014

Kellogg ND, AAP Committee on Child Abuse and Neglect:

Evaluation of suspected child physical abuse, Pediatrics,
2007; 119: 1232-1241.
Wood, JN and Ludwig, S, Chapter 132: Child Abuse,
Textbook of Pediatric Emergency Medicine, 6th edition,
Philadelphia: Lippincott Williams & Wilkins, 2010.

TEST QUESTIONS
1. Examples of the following are not considered abuse
except :
A. Cupping
B. Pattern pairs
C. Mongolian Spots
D. Coining
2. The physical or mental injury of a child by any parent or
other person who has permanent or temporary care or
custody, or responsibility for supervision of a child, or by any
household or family member, under circumstances that
indicate that the childs health or welfare is harmed or at
substantial risk of being harmed.
A. True
B. False