Child Abuse / Non Accidental Injury



Any act or failure to act that

- results in or potentially results in harm / death / physical / emotional / sexual abuse

- by a parent or caretaker who is responsible for the child


4 types



Physical (punch / kick / bite / burn / shake)




Risk factors


Low socioeconomic x25 risk


Single parent

Substance abuse

First child





Parents were abused


Birth parents more likely to abuse


50-80% substance abuse




Abuse second most common cause of death in infants 1-6/12

- SIDS number 1


85% death from child abuse < 5 years


10% trauma < 3 years from child abuse


1962 landmark paper from USA / Kempe

- battered child syndrome

- poor hygiene

- poor nutrition / failure to thrive

- ST / bone injuries

- subdural haematomas




Delay in presenting


History vague, lacking in detail, contradictory

- mechanism of injury insufficient to explain injuries

- history of a fall


Characteristics of child

- less than 3 years old

- poor household environment / drug / physical abuse

- overly aggressive or passive

- behavioral problems

- handicapped child

- stepchild

- premature child

- subnormal growth


Non orthopaedic findings



- bruises (buttocks, perineum and genitalia, trunk, back of head and legs)

- multiple bruises in various stages of healing

- burns (pattern may reflect mechanism of burn)


Head and CNS

- skull fracture (multiple, skull base, crossing suture lines, depressed fractures)

- subdural hematoma, subarachnoid hemorrhage

- retinal hemorrhage, hyphema, retinal detachment

- cognitive disabilities


Chest, abdomen, and pelvis

- rib fractures (posterior, multiple), sternal fractures

- pneumothorax, hemothorax

- rupture of organ (liver, spleen, or pancreas / bowel or bladder rupture)

- intramural bowel hematoma

- kidney contusion, retroperitoneal hemorrhage

- sexual abuse




Musculoskeletal system

- multiple fractures

- fractures in various stages of healing

- metaphyseal corner fracture (pathognomonic)

- femoral fracture in child < 1 (more likely than not)

- humeral shaft fracture child < 3 (almost always)

- vertebral compression fractures, spinous process avulsion

- scapular fracture

- epiphyseal separation




Any obvious injuries


Skeletal survey (< 5 years age)

- AP bilateral arms

- AP bilateral forearms

- AP bilateral hands

- AP bilateral thighs

- AP bilateral lower legs

- AP bilateral feet

- AP and lateral axial skeleton and trunk

- AP and lateral Skull


Bone Scan


Costly / difficult to evaluate / lacks specificity / radiation exposure




Accidental injury




Congenital syphilis


Caffey's disease

- infantile cortical hyperostosis

- < 5 months, fever, pain

- typically mandible

- xrays show hyperostosis

- get periostitis




Failure to Diagnose


30-50% recurrence of abuse

5-10% mortality risk


Reporting is mandatory


Team approach


Paediatrician / social worker / psychologist

General surgeon / Neurosurgeon / Orthopodedic Surgeon / Ophthalmologist / Dermatologist


Notify / discuss with

- primary care provider for background history

- police

- legal counsel

- social services

- child protective services


Hospital admission to treat acute injuries and remove child from dangerous environment


Carefully document all records

Statement regarding level of certainty of abuse


Legal consent still required to treat child or release information from chart

Court custody may be needed if family members not co-operative