Cutaneous Injuries in Child Abuse

Lori D. Frasier MDChief, Division of Child Abuse PediatricsPenn State Milton S. Hershey Children’s

Hospital

The Skin:

The largest organ in the body The most visible organ that is injured

accidentally and through abuse Important for thermal regulation,

immune functions, maintenance of hydration, protection from the environment (sensory and environmental)

Epidermis- compact firm outer layer; not easily damaged

Dermis- capillaries and fibrous tissue; resistant to damage

Subcutaneous tissue- rich in capillaries and fat, easily deformed; majority of hemorrhage occurs here

Types of Injuries due to abuse

Bruises Burns Lacerations Incisions Abrasions Avulsions Strangulation (extremities) Complications of neglect

Bruising is in 1st place

Earliest form of physical child abuse Most common form of physical child

abuse Most easily recognized sign of physical

abuse Most common direct sign of physical

abuse to be missed

Why talk about bruising?

The failure to recognize bruising as a sign of physical child abuse is an error in medical, social, and legal decision making that contributes to poor outcomes for children.

Bruises are a high risk prognostic indictor for abuse

Early Recognition is Prevention

75% of physical child abuse is missed initially

The high cost of missed abuse and the risk of failure to diagnose or act

The risk of repeat injury: –80% prior injuries–45% prior “odd” bruises–33% prior brain injury

80% of victims of fatal abuse were known to a health care professional who did not act

In an older childbruises are

• Common• Innocuous• Harmless• Meaningless

Why bruises are overlooked

A bruise can take on a whole new meaning:

UncommonNocuousHarmfulOminous

Change 2 things:age of the child & body region bruised

Five Rules of Bruises

Bruises are injuries

The age of the child matters

Patterns matter

Body region matters

Number of bruises matters

Definitions A bruise or contusion: bleeding beneath the intact skin at the site of blunt

impact trauma

• Blunt impact occurred at the site of discoloration

Ecchymosis: blood that has dissected through tissue planes to become visible externally

• May be visible in an area never subjected to trauma

Hematoma: blood that has extravasated from the vascular system into the body

• Hematomas may develop in the presence of natural disease process in the absence of trauma

Petechia- small (1-2mm) red or purple spot caused by a minor hemorrhage of capillary blood vessels

Rule Number 1Bruises are injuries

Blood vessel disruption from traumatic injuries

akavessel fracture

Bruising reflects vessel damage

Bruising occurs when injury threshold of vessels are exceeded• Vessels are crushed and leak• Pressure exceeds the injury threshold and the

vessel leaks• Petechiae result from tiny vessels that are

damaged or leak due to pressure (dot <2mm hemorrhage)

• Bruising indicates vascular integrity has been compromised vascular damage, not skin damage

Visibility of vessel damage

To bleed, you need vessels

To bleed, you need a blood pressure• The child in shock may have damaged vessels but no

pressure to result in “visible leaking”…aka a bruise

The depth and extent of bleeding, and tissue vascularity, plays a significant role as to when or even if the bruise will become visible on the surface

Factors that influence the occurrence and appearance of a bruise

The body site of impact The object The amount of force behind the

impact The rate of force application

Rule Number 2The age of the child matters

An infant with a bruise may be abused

Bruising and age of the child

Myth: baby’s are delicate and bruise more easily• The greater the skin elasticity, the greater the capacity to

absorb injury forces and energy without actual damage• Injury threshold is thus less likely to be exceeded than in

older tissues

Myth: even a little bump will cause a bruise• Infants don’t move about enough or with enough force to

injure their deep subcutaneous tissues• If you don’t cruise, you don’t bruise

Truth: Unexplained bruising in the non-cruising infant predicts future injuries and some will be fatal

Bruising and age of the child

Bruises in infants and toddlers: those who don’t cruise rarely bruise. Sugar, et al. Archives of Ped and Adolescent Medicine, 1999

Bruises in infants: those with a bruise may be abused. Pierce, et al. Pediatric Emergency Care. 2009

Labbé J, Caouette G. Recent skin injuries in normal children. Pediatrics 2001 108:271 - 276

< 9 months old: 1.2% with bruises > 9 months old: 76.6% with skin

injuries < 1% 15 or more injuries all ages:

< 2% bruises to thorax & abdomen< 1% bruises to chin, ears, or neck

no difference between boys and girls

Sentinel Injuries in Infants Evaluated for Physical Abuse. Sheets et al Pediatrics, April 2013

Case control, retrospective study of infants under one year evaluated for abuse

200 infants rated definite abuse: 27% had a previous sentinel injury

100 infants rated intermediate confern 8% had a sentinel injury

101 non abused infants-0%

What is a sentinel injury? A relatively minor injury that preceeds serious physical abuse. Previous bruising-head, ear, trunk

extremity Minor abrasions Intraoral injury 30% of AHT infants had a sentinel

injury 25% of non AHT abused infants had

a sentinel injury

Rule Number 3Body region matters

ACCIDENTAL INFLICTED

Shins Upper arms

Lower arms Anterior thigh

Under chin Trunk

Forehead Genitalia

Hips Buttocks

Elbows Face

Ankles Ears

Bony prominences Neck

Dunstan FD et al.; 2002 - Bruising frequency

0

5

10

15

20

25

30

35

40

Left ear Left face Right face Other head &neck

Anterior chest& abdomen

Back Buttocks Left arm Right arm Left leg Right leg

body regions

% o

f p

atie

nts

Cases (abuse)

Controls (ambulatory outpatients)

Body regions: T-E-N

Torso: a lot of cushion to absorb injury forces Seatbelt sign: marker of high risk for internal injury: why? Handlebar sign only present in 30% of injuries resulting in splenic,

pancreatic, or liver lacerations: why? Ears: difficult to bruise; not very vascular (minimal or no

subcutaneous tissue and floppy) Neck: protected and no superficial bony structure to provide

the crush required for vascular damage/leaking Usually neck bruising is in the form of petechiae. Check for tracheal

damage.

Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz D. Bruising characteristics discriminate physical child abuse from accidental trauma in young children. Pediatrics January 2010

Distinguishing physical assault from accidental injury:97% sensitive84% specific

A validation study in 2600 children that began in June of 2011

TEN 4 Bruising Model Question 1: skin findings in children under 4 years of age

• Trunk/torso bruise• Ear bruise• Neck bruise

Question 2: is the child non-ambulatory• Any infant < 4 months of age: is there a bruise or skin

injury to any region/any where on the body

Question 3: confirmed accident in public setting?• Are bruises accounted for and consistent?

Recommended action

Positive screen• Bruising in the non-cruising• Bruising in TEN locations in children under 4

years of age Diagnostic studies include evaluation for trauma and

for any other cause of the bruises Report to CPS if no bleeding issues are identified

that explain the bruising, even if other trauma screening tests are negative

Thorax

Ears

Detailed anatomy of the ear

Neck

Bruising anywhere in an infant less than 4 months old

Rule Number 4The number of bruises matters

Body planes front and back - top and bottom

Regular life falls or accidents, even when significant, do not generate the required impacting forces to generate multiple bruises

Even falls from 20 feet rarely produce more than one bruise

Facial bruising in multiple planes doesn’t occur in household injury

Inflicted injury forces result in contact forces with the strike, and then with the landing impact- bruising may therefore occur in 2 planes or more, often opposing

Multiple inflicted strikes can result in multiple contusions

Multiple simple impacts do not cause multiple bruises

Bruises and stair falls n=29

0

5

10

15

20

0 bruises1 bruise

2 bruises3+bruises

0 bruises

1 bruise

2 bruises

3+bruises

Plausible Suspicious

MC Pierce, GE Bertocci, et al. Pediatrics, 2005

Rule Number 5Patterns matter

Factors that influence the occurrence and appearance of a bruise The body site of impact The object The amount of force behind the

impact The rate of force application

Oral Injury

Differential Diagnosis of Bruising

Accidental Inflicted Dermatologic Coagulation disorders Folk therapies Genetic/Metabolic Miscellaneous

Coagulation Disorders Which May Mimic Abuse Idiopathic Thrombocytopenic Purpura

(ITP) von Willebrand’s Disease Hemophilia Ingested anticoagulants Leukemia Vitamin K deficiency HSP

Dermal Melanosis(Mongolian Spots)

Black 90 - 95.5% Asian 81.0- >90% Latin-American 70.1% White 10% Rarely on face Disappear by age 4 - 5 in 95%

Bruises take a minimum of 7 days to resolve: F

• Depth, degree of injury and damage to vessels, body region injured, and circulation all play a role in the rate of both appearance and disappearance of bruising

• Time for bruise resolution ranges from 12 hours to over 2 weeks

The medical condition of the child (such as unconsciousness) will not affect the appearance of the bruise: F

A low or absent blood pressure can decrease the amount of leaking of blood and thus the amount of visible damage

Bruises can be invisible to the naked eye: T

Certain blood proteins absorb wavelengths of light not visible to normal human vision. By supplying an alternative light source with ultraviolet and infrared wavelengths, these blood proteins become visible, making once “invisible bruising” possible to see.

Take to Work Points The site of the bruise matters

• T-E-N regions for children under 4 yrs of age The age of the child matters

• A bruise anywhere on the body if the infant is non-ambulatory

The total number of bruises matters• More than 4 bruises in the very young child is

concerning Observation and evaluation coupled with action can

lead to prevention of child abuse

Good general reference

Bruising and Physical Child Abuse. Kim Kaczor, MS, Mary Clyde Pierce, MD, Kathi Makoroff, MD, Tracey S. Corey, MD. Clinical Pediatric Emergency Medicine 7:153-160. 2006

Child Abuse by Burning

Abusive burns typically occur in children younger than age 6 and have the greatest percentage of hospitalizations for treatment

Childhood abusive burn victims are more likely to have previous or concomitant signs of abuse/neglect and previous reports to child protective services

Incidence and Prevalence

40,000 children <15 yrs. hospitalized yearly

>2000 children die yearly from burns Approximately 20% of burns are

inflicted Scald burns - 85% of all burns in

children Flame burns – 13% Electrical, chemical – 2%

Findings Concerning for Abuse or Neglect

 Infected burns Chronic burns Burns in various stages of healing Burn appearance is older than stated

history Concomitant cutaneous injuries

Characteristics of Abusive Burn Perpetrators

Abusive pediatric burns occur more commonly in families with a single, young, socially isolated parent from a lower socioeconomic class

One study found that most parents of burn abused children were unemployed with incomes of less than $20,000 per year

The abusive burn perpetrator is most frequently the child’s parent or the mother’s boyfriend

Necessary History

Date/time the burn injury reportedly occurred Location of the child at the time of the burn Presence or absence of clothing Presence or absence of witnesses to the burn Time from burn occurrence to presentation for

medical care Child and parent’s reaction to the burn Developmental level of the child Prior injury or accidents Family composition and home environment

Classification of Burn Injuries

Superficial

Partial thickness

Full Thickness

Fourth Degree

Superficial layer of the epidermis Characterized by redness only

Extends into the dermis causing blistering and tissue loss

Entire dermis, appendages. nerves destroyed, no pain

Extends into the muscles, bones and joints

Scald Burns

The majority of all scald burns are accidental and due to splash/spill injury by fluids other than tap water, such as soups, hot beverages and other cooking liquids and occur in the home environment

Having a child in the kitchen while cooking is one of the greatest risk factors for sustaining a burn injury

Burn temperature

Abusive Scald Burns

Scalding by immersion in hot tap water is most frequently reported for abusive burns

Up to 14% of all scald burns are secondary to abuse

For suspected immersion scald injury, the pattern of injury greatly assists the medical provider and investigators in analyzing the case for accidental versus inflicted mechanisms

Immersion Scald Injury

Burn patterns demonstrating uniformityof burn depth suggest the child was restrained or not moving during the time of injury occurrence

Bilateral burn symmetry in the absence of splash marks suggests forced immersion

Bilateral, symmetric lower extremity burn distribution pattern occurs more frequently in abused children

Immersion Scald Injury

Immersion burns typically present with patterned injury demonstrating:

Uniform burn depth Flexion sparing Linear/sharply defined contour between the

burned and unburned skin areas Absence of splash marks Can have skin sparing in areas where the skin

was in contact with cooler surfaces

Child left in comfortable water. Parent returns to find hot running, child burned.

To add 3" (11 gal) @ 5.5 gal/min flow = 2 minutes

Burn Time @ 125o F= 2 minutes

Total Burn Time = 4 minutes

3" 150oF

Water

3" 101oF

Water

6" 125oF

Water

Effective investigation of child abuse by burning requires a coordinated effort between the investigators and the medical professionals.

Scene Investigation

All suspicious burns should be investigated by individuals experienced with scene assessment and evidence collection

In cases of hot water burn injury,a detailed scene investigation is necessary to assist with the critical analysis of the injury by a multidisciplinary team

Knox B, Starling SP. Inflicted burns. In, Jenny C, ed. Medical Evidence In Child Maltreatment. Elsevier Press 2009.

Hot Water Splash Burns

Splash burn injury requires a minimum temperature of 140 degrees F(60 º C) in order to produce tissue injury

Lower water temperatures will coolto a point where burns will not occur

Scald patterns due to splash or flowing liquid can be altered based on the presence/absence of clothing

Scald Injuries Resulting from Liquids Other than Water Hot beverages, foods, grease, oils,

or wax can reach temperatures much greater than the boiling point of water (212 F)

Greater viscosity Result in deeper, more significant

burn due to higher heat source and prolonged contact with the skin

Contact Burns

Result in thermal injury to the skin secondary to prolonged contact with the hot or smoldering source

Typically produce a injury characterized by Distinct margins Grouped burn lesions Clearly inscribed patterns Injuries on parts of the body normally covered

The pattern left on the skin can help in differentiating accidental from abusive injury mechanisms

Other Types of Burns

Radiation burns – commonest is sunburn Chemical burns – acid, alkali, peppers,

garlic, household chemicals Electrical burns – combination of heat

and electrical forces Microwave burns

Chemical Burns Chemical burns resulting from caustic

ingestions can be the result of neglectful child supervision as well as intentional acts

Can result in deep burns and the agent continues to damage tissue until properly removed from the skin

Alkali burns are associated with deeper penetration and more extensive burns than acids

Chemical Burns

Adult drug use is a risk factor for pediatric chemical burns and caustic ingestions

Concentrated bleach does not immediately produce pain and therefore causes skin lesions that develop slowly and worsen with prolonged contact

Laxative-induced buttock dermatitis frequently is confused with abusive immersion burns of the buttocks

2 yo presents with burn to buttocks. Mother says she ate a box of Ex-Lax and then went to bed in a diaper. She woke up soiled and was given a bath. After the bath she c/o pain and later in day blisters appeared.

Flame Burns

Most often secondary to house fires in the pediatric population

Abusive flame burn injury secondary to holding a child’s skin in contact with flame or to ignition of clothing as a consequence of abuse or neglect also occurs

~10% of abusive pediatric burns were caused by fire or flames

Electrical Burn Injury

Represents ~2-3% of all burns requiring treatment in the emergency department

Most occur in the home setting and involve children less than age 5

Most due to lack of supervision Low-voltage injuries are more common in

younger children while high-voltage injuries are seen more frequently in the older pediatric population

Stun Guns

Electrical burns from stun guns have been reported as a pair of small (0.5 cm) superficial circular burns

Microwave Oven Burns

Microwave radiation heats the living tissue Induces heat in tissues with higher water

content to a greater extent than other tissues and produces burns most severe on the skin followed by muscle

Results in asymmetric burns on biopsy

Microwave Oven Burns Microwave ovens heat food and liquids

unevenly Reports of accidental partial and full-

thickness scald burns to the oropharynx and palate of infants drinking formula heated in a microwave

Accidental microwave related scald burns most commonly result from children pulling over-heated food/liquids onto themselves

Outcomes

Children with abusive burns Require longer hospital admissions

than those with accidental burns Increased morbidity Consume more resources during

treatment and follow-up More likely to die from their injuries

Differential Diagnosis of Burns

Accidental Inflicted Dermatologic conditions Chemical burns Folk therapies