Non-accidental injury

Introduction

• 75% of cases under 12mo
• 60% of cases under 6mo (peak crying)
• 80% of maltreatment does not involve physical injury
• 80% have soft tissue injuries
• 20% have non-trauma related presentations e.g crying, abnormal behavior
• Children returned to families with unrecognized NAI have 11-50% chance of second event

Bruises

• Grab marks, pinching, circumferential, slap, bites (canine-canine distance >3cm = adult)
• Location: Torso, ear or neck <4 yo
• Non-bony prominence
• Head
• Cheeks
• Perineum
• Upper arms
• Highly suspicious: Any bruise <6mo, multiple sites, multiple ages

Burns

• NAI in 60% of burns where pattern does not match history
• Immersion
• Branding

Fractures

• 35% of children with NAI have fractures
• Highly suspicious
  • Multiple sites and ages
  • Inconsistent history: <1yo = 75% of fractures are NAI
  • Bucket handle fractures at metaphyses (nearly 100% if <18mo)
    • Due to violent torsion or traction with resultant metaphyseal microfractures
  • Salter-Harris I or II due to jerking movement
  • Spiral long bone: Humeral shaft, femur, tibia, radius <2yo
  • Scapula, rib, spinous process, sternal
• Skull fractures
  • Multiple, complex, occipital or depressed
  • Non-parietal suspicious

Head injury

• Abusive head trauma (new term for shaken baby – only one mechanism of many)
• Acute subdural
  • Tearing of bridging veins
  • Often bilateral
  • 60% due to NAI
  • Frontal parafalcine SDH are highly predictive
• Retinal haemorrhages
  • Due to sudden increase in ICP
  • Present in 80% of cases of abusive head trauma
  • Rare in accidental head injury

Abdominal trauma

• Intramural duodenal haematoma
  • Duodenum squashed against vertebrae due to handlebar or abuse
  • Presents with gastric outlet obstruction
• Liver/spleen injury

Neglect

• General signs of neglect
  • Hygiene
  • Severe nappy rash
  • FTT
  • Failure to provide adequate clothing, schooling, nourishment, social interaction
  • Inappropriate healthcare i.e. not presenting

Investigations

• Clotting screens – For multiple bruises/bleeding
  • FBC, Coags, vWF activity, Factor levels if required
• Ophthalmology for retinal haemorrhages
• CT brain
  • <6mo with suspected abuse
  • 6-12mo if evidence of head injury or a fracture suggestive of abuse
  • Child of any age with evidence of intracranial injury
• FTT workup
• Abdominal screen
  • AST/ALT/L:ipase if <6mo or older child with trunk injuries. If >80 or lipase >100  CT abdomen with contrast
• Skeletal survey
  • All children <2yo:Discovers occult fracture in 10% of cases
  • Use selectively if 2-5yo if neuro impairment, distracting injury or suspicious index fracture
  • Hidden fractures rare if >5yo

Principles of management

• Suspect in all 
• Establish correct diagnosis
• Manage injuries
• Address safety issues
• Report
• Document findings
• Follow-up

Last Updated on October 27, 2021 by Andrew Crofton