Naomi F. Sugar

Cervical spinal cord injury in abused children

Five infants and toddlers who sustained cervical spinal cord injury as the result of child abuse are described. Three cases are previously unreported. Diagnosis was complicated by coexistent brain injuries and their treatments, subtle and/or evolving paralysis, and central cord syndrome, in which arm function is diminished but leg function is preserved. Definitive spinal imaging by magnetic resonance imaging (MRI), computed tomography, and plain radiographs was delayed because of life support efforts. When completed, the MRI was most sensitive to cord injury. Evidence of associated bony spinal injury was often absent or unapparent until healing occurred; 4 children had spinal cord injury without (or with minimal) radiological abnormality. The 3 children presenting to our hospital with cord injury represent 1% of the estimated cases of inflicted head injury seen during a 23-year period.

Additional Injuries in Young Infants with Concern for Abuse and Apparently Isolated Bruises

OBJECTIVE To determine the prevalence of additional injuries or bleeding disorders in a large population of young infants evaluated for abuse because of apparently isolated bruising. STUDY DESIGN This was a prospectively planned secondary analysis of an observational study of children<10 years (120 months) of age evaluated for possible physical abuse by 20 US child abuse teams. This analysis included infants<6 months of age with apparently isolated bruising who underwent diagnostic testing for additional injuries or bleeding disorders. RESULTS Among 2890 children, 33.9% (980/2890) were <6 months old, and 25.9% (254/980) of these had bruises identified. Within this group, 57.5% (146/254) had apparently isolated bruises at presentation. Skeletal surveys identified new injury in 23.3% (34/146), neuroimaging identified new injury in 27.4% (40/146), and abdominal injury was identified in 2.7% (4/146). Overall, 50% (73/146) had at least one additional serious injury. Although testing for bleeding disorders was performed in 70.5% (103/146), no bleeding disorders were identified. Ultimately, 50% (73/146) had a high perceived likelihood of abuse. CONCLUSIONS Infants younger than 6 months of age with bruising prompting subspecialty consultation for abuse have a high risk of additional serious injuries. Routine medical evaluation for young infants with bruises and concern for physical abuse should include physical examination, skeletal survey, neuroimaging, and abdominal injury screening.

Older victims of sexual assault: an underrecognized population

OBJECTIVE We performed this study to determine if sexual assault characteristics differ in women presenting for evaluation as women age. STUDY DESIGN All females 20 years or older presenting after sexual assault to an urban emergency department during a nine year period underwent standardized evaluation. Analysis was performed by chi(2). RESULTS We evaluated 2399 women: 1743 women 20-39 years, 554 women 40-55 years, and 102 women over 55 years of age. Compared with the other age groups, older women were more commonly assaulted in their own home (36%) or care facility (33%), P < .001, assaulted by a service provider (16.7%) or stranger (18.6%), P < .001, impaired (54.9%), P < .001, admitted to the hospital (15.7%), P < .001, incur genital trauma (35.6%), P = .04, and less likely to have a weapon used (7.8%), P = .003. CONCLUSION Sexual assault in older women has distinct characteristics, which may be useful in planning intervention and prevention strategies.

Pediatric Tramadol Ingestion Resulting in Seizurelike Activity : A Case Series

Tramadol has been reported to cause seizures in therapeutic dosing and in overdose. We present a series of 2 infants poisoned with tramadol, both presenting with abnormal neurologic findings: either seizures or seizurelike activity. Tramadol poisoning should be considered in the differential diagnosis of dystonia and seizures.

Diagnosing child abuse

The evidence base is advancing through new areas of research

Three-dimensional computed tomography skull reconstructions as an aid to child abuse evaluations

Objectives Skull fractures can be difficult to recognize on radiographs and axial computed tomography (CT) bone windows. Missed findings may delay abuse diagnosis. The role of three-dimensional (3-D) reconstructions in child abuse evaluations was retrospectively evaluated. Methods Twelve exemplary cases between August 2006 and July 2009 are described. All, except 2 medical-legal cases, were clinical abuse consultations. With the use of a 1-to-3 scale, ease and accuracy of interpretation of findings between plain films, bone windows, and 3-D CT images were independently assessed by 2 radiologists. Results In 7 cases, skull fractures were missed on initial review of skull films and/or bone windows. Three children sustained additional abusive injury before 3-D CT reconstructions demonstrated subtle skull fractures, though imaged, were missed on initial readings. Three children with initially unrecognized fractures had timely 3-D reconstructions confirming fractures, allowing protective intervention before additional injury. An unrecognized ping-pong fracture was discovered on 3-D reconstructions with an inflicted subdural hemorrhage, defining the injury as an impact. Two 3-Ds demonstrated communication of biparietal fractures along the sagittal suture. This changed interpretation to single, rather than 2 separate, concerning impacts. Three potential skull fractures were found to represent large sutural bones. In all cases, ease and accuracy of interpretation scores were highest for 3-D CT. Conclusions Without increasing patient radiation exposure, 3-D CT reconstructions may reveal previously unrecognized skull fractures, potentially allowing abuse diagnosis before additional injury. They may clarify normal skull variants and affirm accidental injury causes. We now routinely include 3-D reconstructions on cranial CTs for children younger than 3 years.

Initial clinical presentation of children with acute and chronic versus acute subdural hemorrhage resulting from abusive head trauma

OBJECT At presentation, children who have experienced abusive head trauma (AHT) often have subdural hemorrhage (SDH) that is acute, chronic, or both. Controversy exists whether the acute SDH associated with chronic SDH results from trauma or from spontaneous rebleeding. The authors compared the clinical presentations of children with AHT and acute SDH with those having acute and chronic SDH (acute/chronic SDH). METHODS The study was a multicenter retrospective review of children who had experienced AHT during 2004-2009. The authors compared the clinical and radiological characteristics of children with acute SDH to those of children with acute/chronic SDH. RESULTS The study included 383 children with AHT and either acute SDH (n = 291) or acute/chronic SDH (n = 92). The children with acute/chronic SDH were younger, had higher initial Glasgow Coma Scale scores, fewer deaths, fewer skull fractures, less parenchymal brain injury, and fewer acute noncranial fractures than did children with acute SDH. No between-group differences were found for the proportion with retinal hemorrhages, healing noncranial fractures, or acute abusive bruises. A similar proportion (approximately 80%) of children with acute/chronic SDH and with acute SDH had retinal hemorrhages or acute or healing extracranial injures. Of children with acute/chronic SDH, 20% were neurologically asymptomatic at presentation; almost half of these children were seen for macrocephaly, and for all of them, the acute SDH was completely within the area of the chronic SDH. CONCLUSIONS Overall, the presenting clinical and radiological characteristics of children with acute SDH and acute/chronic SDH caused by AHT did not differ, suggesting that repeated abuse, rather than spontaneous rebleeding, is the etiology of most acute SDH in children with chronic SDH. However, more severe neurological symptoms were more common among children with acute SDH. Children with acute/chronic SDH and asymptomatic macrocephaly have unique risks and distinct radiological and clinical characteristics.

A perplexing case of child abuse: oral injuries in abuse and physician reporting responsibilities

Abstract The following case presents a pediatric patient with an oral foreign body secondary to intentional injury. This patient had presented several previous times for medical care, first with thigh bruises, then mouth bleeding, and finally with the unusual finding of a sharp foreign body embedded in the tongue. This case illustrates the importance of considering physical abuse in the differential of orofacial injuries. Frenulum tears, both in mobile and nonmobile children, are concerning for abuse and should trigger further evaluation. This case highlights the complexity of assessing for physical abuse when examining a patient. Bruising, as seen in this patient, is common in children, and the clinical team must determine if the pattern, location, and history are concerning for a nonaccidental injury. Physicians should strongly consider child abuse in the emergency department when patients present with concerning physical examination findings such as bruises or orofacial injures without corroborating history. Finally, this case reviews mandatory reporting requirements for physicians and other medical professionals and highlights the obligation to report suspected child abuse even when not working in the professional capacity at the time of recognition.

Correlates of physical injury in sexual assault patients

Abstract Objective: To correlate historic and physical examination findings in female sexual assault victims. Methods: All adult women between January 1997 and September 1999 reporting to an urban hospital after sexual assault underwent a standardized history and physical examination by a resident in obstetrics and gynecology (n = 819). Retrospective data abstraction was verified. Logistic regression analyses were used to identify predictors of nongenital and genitoanal trauma. Results: Mean age was 29.3 years (SD = 11.9, range 15–87). Of the women, 35% were nonwhite, 26% had major psychiatric diagnoses, and 10% were homeless. Fifty three percent had recent alcohol or drug (AOD) use. Nongenital trauma was found in 52%. Measures independently associated with nongenital trauma were: age younger than 20 or older than 49 (ref., 20–49, OR 2.0, 3.8), assault by stranger (OR = 1.9), assault by an intimate partner (OR = 1.7), being choked (OR = 3.9), or being anally raped (OR = 1.6). Genitoanal trauma, identified in 194 of 762 patients (26%), was independently associated with age ( 49, OR = 1.2, ref. 20–49), anal rape (OR = 1.8), virginal status (OR = 3.7), and those with general body trauma (OR = 1.8). Relationship, number of assailants, and substance use were not associated with genitoanal trauma. Conclusion: More violent sexual assaults were by strangers or intimate partners, or involved anal rape, but the absence of physical injury is frequent. Prevention and treatment strategies should target vulnerable populations, including those with substance use and psychiatric illness.

Erratum to: Fractures in infants and toddlers with rickets

There was an error in the presentation of ethnicity data in Table 1. The percentages listed in the Nutritional column of Table 1 are calculated based on the total number of included patients with nutritional rickets. Of the 32 such patients included in our study, we had ethnicity data on 27 patients. The numerators in the column add up correctly to 27, but the percentages do not add up to 100% because they were calculated using 32 as a denominator. The authors sincerely regret any confusion caused.