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When To Suspect Child Abuse

Posted on: 04/30/2009
Over three million young children are victims of child abuse in the United States each year. One-third of all child abuse cases will suffer a bone fracture and need to see an orthopedic surgeon. That's why orthopedic surgeons must be aware of the possibility of child abuse and watch for it. This study provides some added information to help them know what to look for that might raise the suspicion of abuse.

Hospital records of children with physical injuries were used as the basis of this study. Information on two groups of patients was compared: those with injuries caused by known child abuse and those with injuries without the diagnosis of child abuse (accidental injuries). The second group were considered the control (normal) group.

By looking at child demographics, injury pattern, and time periods when injuries occurred, they were able to identify some factors that might predict injuries caused by child abuse. This new information should provide guidance to physicians examining children with physical injuries. The authors note that these predictive risk factors aren't the only way child abuse can be recognized and diagnosed. They are just an added piece of the assessment that can raise the suspicion of abuse-related injuries.

The data collected came from all regions of the United States, making this a nationally-based study. The South and Midwest regions had the largest number of cases. Child abuse appears to be statistically more likely in urban (versus rural) settings. But there's some question that maybe this is because rural health care teams aren't trained to look for and recognize traumatic injuries that occur as a result of abuse.

The strongest predictor of abuse is young age with two groups especially at risk: birth to one year and one year up to two years of age. The second predictive factor was type or pattern of injury. Fractures affecting the bones of the head, neck, and trunk were most common. But fractures of the long bones of the arms and legs must be closely assessed, too. This includes the femur in the thigh, tibia or fibula of the lower leg, humerus of the upper arm, and radius or ulna of the forearm. The one area of fracture that proved to almost always be accidental was a pelvic fracture. More than even fractures, an important physical sign is a contusion. A contusion is a visible bruise or large black and blue mark.

The third predictive factor of abuse-related injury was the specific period of time when the injury took place. Weekdays and during the winter seemed to be a common pattern for child abuse. Weekends might be less stressful with more adult supervision available. Or possibly the attendance of church services influences behavior.

It was thought that perhaps with colder weather and being indoors more in the winter, children would be more likely to spend time with the caregivers who were the abusers. Being outside less during winter months might also lower the risk of accidental injuries making it seem like there are more cases of injuries from abuse than from accidents during the winter.

The researchers also looked at socioeconomic level to see if there was a link there. They couldn't use family income as a marker because it wasn't always reported. So they looked at who was paying for the medical charges. They found that more families on Medicaid than on private insurance were involved in child maltreatment. Medicaid suggests a lower family income.

The authors conclude it isn't always easy to tell when an injury is accidental or the result of child abuse. But physicians examining children with physical injuries must always keep the possibility of abuse in the back of their minds.

Having a few guidelines like those offered in this article can be helpful when looking for any clues to help in making the diagnosis. Using a national data registry made it possible to find common characteristics of child abuse to help raise a red flag during the examination and evaluation.

Hopefully, by recognizing minor injuries caused by child abuse, it may be possible to prevent more serious injuries. Hospitalization to protect the child during investigation and getting Child Protective Agencies involved are two strategies alert physicians can use. These steps can be taken when confronted by any of these predictive factors that point to child abuse as a possible (even probable) cause of physical injury.

References:
Daniel P. Bullock, MD, et al. Hospitalized Cases of Child Abuse in America. Who, What, When, and Where. In Journal of Pediatric Orthopaedics. April/May 2009. Vol. 29. No. 3. Pp. 231-237.

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