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11. Conditions Mistaken for Child Physical Abuse

Abstract Learning Objectives Confusing Cutaneous Conditions Folk Medicine Burns Intracranial Bleeding Ocular Hemorrhages Fractures Osteogenesis Imperfecta Diagnostic Considerations in Distinguishing Osteogenesis Imperfecta From Inicted Injuries Temporary Brittle Bone Disease Infantile Cortical Hyperostosis (Caffeys Disease) Other Miscellaneous Conditions Mistaken for Child Abuse References

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Numerous conditions exist that can suggest an etiology of inicted injury. Strict adherence to evidence based on objective ndings and consideration of all diagnostic possibilities help to avoid mistakes. An organ-system approach is outlined here. The medical conditions that may mimic child maltreatment are discussed with an eye toward distinguishing them from inicted injury.

Dermatitis herpetiformis Diaper dermatitis Chilblains Drug eruption Mechanical abrasion Chemical burns Staphylococcal scalded skin syndrome Accidental burns

Learning Objectives
To identify conditions, disorders, and syndromes that may be confused with child abuse To differentiate inicted injury from preexisting medical conditions To identify cultural practices that may be confused with child abuse

Intracranial Bleeding
Accidental TraumaThere have been numerous articles detailing the kinds of falls that produce serious intracranial injuries in infants and children.932 The conclusion of these studies is that children do not suffer serious intracranial injuries from short (<4 feet) falls. The exception is epidural hematomas, which usually are easily distinguished on computed tomography (CT) scans of the head, appearing as lenticular-shaped densities. The impact caused by motor vehicle crashes and falls, usually from 2 to 3 stories, is necessary to produce subdural or subarachnoid hematomas. Extensive, multilayered retinal hemorrhages (RHs) are almost exclusively seen in shaken baby syndrome/shaken impact syndrome (SBS/SIS). Retinal folds are diagnostic of abusive head trauma. Coagulation DisordersAlthough bleeding and clotting disorders can exacerbate intracranial bleeding when a traumatic event has occurred, the brain is not the usual site for such bleeding. In hemophilia, for example, bleeding is usually into joints or soft tissue. Appropriate laboratory tests for bleeding and clotting abnormalities will diagnose a coagulation disorder. TumorsThese are usually diagnosable by radiographic techniques such as CT scans or magnetic resonance imaging. Vascular MalformationsRare in childhood, when intracranial bleeding is due to these it is usually in the brain tissue itself. Caida de Mollera (Fallen Fontanelle)33In some cultures, a at or sunken fontanelle is considered unhealthy, although it may be present for a variety of benign reasons. When caida de mollera is employed to raise the fallen fontanelle, the baby is held upside down, often shaken in that position, and the head is held over or dipped into boiling liquid. The shaking motion is sometimes extreme

Confusing Cutaneous Conditions

The process of diagnosing medical conditions is organized around gathering information about the onset, severity, and duration of the symptoms and signs; the objective ndings on physical examination of the patient; and collection of additional data from the laboratory, special studies, or x-rays. When all of these are synthesized, a list of diagnostic possibilities is developed. This listcalled the differential diagnosisforms the basis for further thinking about the possible etiology of the patients disorder. It is no different when approaching a case of suspected abuse. There are a number of medical conditions that may mimic physical child abuse. These possibilities must be considered and ruled out in the diagnostic process.

Folk medicine
Coin rubbing (cao gio)1,2 Spooning (quat sha)3,4 Moxibustion4,5 Cupping4,6 Maqua5

Phytophotodermatitis7 Impetigo Varicella Epidermolysis bullosa

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Mongolian spots

Distinguishing Features
Slate gray and uniform in color from one side to the other Seen at time of birth, become less visible slowly Seen usually on buttocks, lower back, but can be seen anywhere on the body Skin is velvety, hyperelastic, and fragile Minor trauma can lead to bruises Splotchy, covering various areas of body Often itchy, may be raised (hives) Recurrent, indolent Exposure to psoralens in the juice of certain plants followed by exposure to sunlight (limes, lemons, gs, parsnip, celery, herbal preparations) Mahogany-colored lesions from contact to skin Rubber, face masks, surf boards, squash balls, elastic bands in clothing, plants, chemicals Can inject anticoagulant under the skin causing deposit of hemosiderin Mimics bruises or abrasions Coagulation studiesPT, PTT, TT, brinogen, Factor VIII, platelets, special studies

Ehlers-Danlos syndrome (India rubber syndrome) Erythema multiforme Hypersensitivity vasculitis


Millipedes secretions8 Contact dermatitis and allergic reactions

Lice, crabs Ink or dye on skin (clothing) Coagulation defect (hemophilia, von Willebrands, leukemia, ITP, HSP, vitamin K deciency, ingestion of anticoagulants

and can lead to tearing of the bridging veins and resultant subdural or subarachnoid hematomas. Obstetric TraumaCephalohematomas are common parturitional injuries, especially in births involving instrumentation. They occur in 3% to 10% of newborns.34 In 25% of cases they are associated with skull fractures, usually in the posterior parietal region.35 Subdural hemorrhage related to the tentorium is associated with vacuum extraction.36 Chronic subdural collections seen in the rst months of life may be attributed to parturitional events, but examination of those events will usually clarify whether there were factors during the birth that may have given rise to the collections seen later. The CT imaging characteristics and the absence of associated injuries (other fractures, RHs, abusive bruises) and the social history often can help distinguish these conditions from parturitional injuries.37

Ocular Hemorrhages
Periorbital EcchymosesBilateral black eyes are usually from abuse, but they can be caused by blunt trauma to the forehead with resultant seepage of the extravasated blood into the periorbital tissues. Subconjunctival HemorrhageForceful coughing, sneezing, vomiting, or other Valsalva maneuvers can cause subconjunctival hemorrhages. Retinal HemorrhagesRetinal hemorrhages must be described in terms of their characteristics, because not all RHs are alike.38 Retinal hemorrhages do not occur as the result of cardiopulmonary resuscitation,3841 seizures,3842 or thoracic compression in childhood (Purtschers retinopathy).38,43,44

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Other conditions in which RHs are seen include Vaginal DeliveryOccurring in 40% of children delivered vaginally, these ne petechial preretinal hemorrhages usually resolve within 10 to 14 days of delivery leaving no residual.38 Bleeding DisordersIsolated RHs in coagulopathies have not been described. When they occur in patients with bleeding or clotting disorders, they are associated with other sites of bleeding. Arteriovenous MalformationsArteriovenous malformations are extremely rare in infancy and, when present, are seldom associated with RHs. Increased Intracranial PressureThis is present in most cases of SBS/SIS, but current thinking is that if this caused RHs, it would be present in all cases of increased intracranial pressure secondary to all causes. This is not supported by medical literature about accidental head trauma with increased intracranial pressure.24,4549 MeningitisIncreasingly rare in pediatrics, it is not likely this diagnosis would be overlooked after clinical assessment, culturing, and examination of cerebrospinal uid. Accidental Head TraumaRecent literature on the incidence of RHs in accidental head trauma indicates they are seldom seen in cases of accidental origin. Thromboembolic Phenomena (eg, subacute bacterial endocarditis)These conditions would be diagnosed based on numerous other ndings.

Rib fractures resulting from birth trauma are almost unknown. Kleinman37 has found only 4 examples of rib fractures associated with birth injuries in otherwise normal infants.5255 Forceful ManipulationOverzealous passive exercise and chiropractic or other health care providers have been reported to cause fractures.56 Metabolic Disorders, Nutritional Deciencies, and Infectious ConditionsPreterm or very low birth weight babies (neonatal osteopenia), Menkes kinky hair syndrome, rickets, scurvy, and altered vitamin D metabolism due to drugs (phenobarbital, phenytoin) may cause fractures.

Osteogenesis Imperfecta
Osteogenesis imperfecta is a disorder of collagen synthesis.

Type I: 70% of all cases

Normal stature Little or no long bone involvement Blue sclerae Dentinogenesis imperfecta uncommon Osteoporosis often found on plain radiograph Autosomal dominant positive, family history usually positive

Type II: Severe bone disease evident prior to birth

At birth, severe shortening and distortion of limbs ~ Large head ~ Striking blue sclerae ~ Severe generalized skeletal dysplasia ~ Poor mineralization of calvarium with wormian bones ~ Fractures and crumpling of long bones, beading of ribs, distortion of vertebral bodies ~ Early death in perinatal period or infancy ~ Autosomal dominant

Birth InjuriesFracture of the clavicle is the most common obstetrical fracture with an incidence of up to 7 per 1,000 term deliveries.37 This fracture usually occurs in large babies. Callus formation is present by 11 days of age and if not present then, excludes the diagnosis of birth injury. Fracture of the humerus occurs in a small number of births (7/15,435).50 This fracture occurs in difcult deliveries and breech extractions. Fracture of the femur occurs even less frequently than humeral fractures (2/20,409).51 Subperisoteal new bone formation is present by 10 to 12 days of age and mature callus by 2 to 3 weeks.

Type III: Unlikely to be confused with inicted injuries

Large head Severe bowing and shortening of extremities Normal or slightly blue sclerae Severe skeletal dysplasia Presence of fractures at birth common Severe deformities of extremities and spine Autosomal recessive pattern of inheritance family history often is negative

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Type IV
Variable degree of short stature, some deformity Fractures may begin prenatally, deformities at birth Most affected infants are short in stature Triangular heads, prominent foreheads Normal sclerae Osteoporosis, with variable deformity of long bones Dentinogenesis imperfecta common Autosomal dominant, family history typically positive
Cerebral palsy Osteopenia secondary to nutritional problems, Down syndrome, chronic pulmonary disease Prostaglandin therapy for patent ductus arteriosus Methotrexate therapy Hypervitaminosis A Congenital syphilis Congenital indifference to pain

Family history is positive in Types I and II. Clinical features help distinguish. If in doubt, cultured skin broblasts to detect collagen abnormalities yield a denitive diagnosis in 90% of cases tested.

colleagues suggest the underlying problem in TBBD is a temporary deciency of an enzyme, perhaps a metallo-enzyme, involved in the posttransitional processing of collagen. Several investigators58 have challenged these assertions on the basis that there is no scientic evidence to support their theory.

Infantile Cortical Hyperostosis (Caffeys Disease)

This rare idiopathic disease of young infants causes painful subperiosteal new bone formation and cortical thickening in multiple bones. It usually involves the mandible, clavicle, and ulna. Onset after 6 months of age is very rare. Complete healing is the rule in Caffeys disease. Familial distribution is common.

Temporary Brittle Bone Disease (TBBD)

Paterson and colleagues57 described 39 patients older than 10 years who seemed to have selflimiting osteogenesis imperfecta. These patients had fractures in infancy, and the fractures occurred at home in 32 cases and in hospital in 7. This entity has stirred intense controversy in the medical community because of its citation in abuse cases by legal representatives of alleged perpetrators. Most of the features of temporary brittle bone disease (TBBD) are those seen in inicted injury or normal variants in normal children. Paterson and

Other Miscellaneous Conditions Mistaken for Child Abuse

Hair tourniquet syndrome Alopecia areata Hypogammaglobulinemia Mental retardation in parent(s)

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