# Clinical Cases: Child Abuse and Neglect

## Case 1: Abusive Head Trauma

### Patient Demographics
- **Age:** 4-month-old male
- **Sex:** Male

### Chief Complaint
"He's been really fussy and not eating well."

### History of Present Illness
A 4-month-old male infant is brought to the emergency department by his mother and her boyfriend because the baby has been irritable and feeding poorly for the past day. The mother reports the baby has been "different" since yesterday evening, crying more than usual and not wanting to take his bottle. She denies any trauma, fever, vomiting, diarrhea, or other symptoms. When specifically asked, the boyfriend mentions he was caring for the baby yesterday afternoon while the mother was at work, and the baby was "fine" but "cried a lot." The infant was born full-term without complications. There is no significant past medical history.

### Physical Examination
- **Vital Signs:** Temperature 36.9C, HR 145 bpm, RR 32/min, BP 85/50 mmHg
- **General:** Lethargic infant, intermittently irritable, weak cry
- **HEENT:** Anterior fontanelle full and tense; no external head trauma visible
- **Eyes:** Left retinal hemorrhages noted on fundoscopic examination (dilated exam pending)
- **Chest:** No external bruising; lungs clear
- **Cardiovascular:** Tachycardic, regular rhythm
- **Abdomen:** Soft, non-tender
- **Extremities:** No swelling or deformity; no bruising
- **Skin:** No visible bruises or marks
- **Neurologic:** Lethargic, decreased tone, poor suck reflex, sunset eyes noted

### Imaging and Laboratory Findings
- **CT head:** Bilateral subdural hematomas of varying ages (acute and subacute); mild cerebral edema
- **Dilated fundoscopic examination:** Extensive multilayered retinal hemorrhages bilaterally, extending to the ora serrata
- **Skeletal survey:** Healing posterior rib fractures (right ribs 6-8, approximately 2-3 weeks old); acute classic metaphyseal lesion of left distal tibia
- **CBC:** Hemoglobin 9.8 g/dL
- **Coagulation studies:** PT, PTT, fibrinogen, platelets - all normal

### Diagnosis
**Abusive head trauma (previously termed shaken baby syndrome)**

### Clinical Reasoning
This infant presents with the classic triad of abusive head trauma: (1) subdural hematomas of varying ages, (2) extensive multilayered retinal hemorrhages, and (3) encephalopathy (lethargy, poor feeding, irritability). The absence of external trauma is common in abusive head trauma. The skeletal survey reveals highly specific injuries: posterior rib fractures (from squeezing the chest during shaking) and a classic metaphyseal lesion (from shearing forces across the growth plate). Multiple injuries of different ages indicate repeated trauma. The normal coagulation studies exclude bleeding disorders. The history of non-specific symptoms without explanation for severe intracranial injury, combined with the boyfriend being the sole caregiver during the time symptoms began, raises significant concern.

### Management
1. **Medical stabilization:** ICU admission, neurosurgery consultation for ICP monitoring/management
2. **Seizure prophylaxis:** Levetiracetam or phenobarbital if clinical or subclinical seizures
3. **Report to Child Protective Services:** Mandatory; contact CPS and law enforcement immediately
4. **Full skeletal survey:** Already completed; follow-up skeletal survey in 2 weeks to detect additional healing fractures
5. **Documentation:** Detailed, objective documentation of all findings with photographs
6. **Social work involvement:** Complete social assessment of the family
7. **Sibling evaluation:** Any other children in the home should undergo medical evaluation
8. **Safety planning:** Infant should not be discharged to the care of the suspected perpetrator

### Clinical Image
![CT head showing bilateral subdural hematomas](case_01_image.jpg)

**Image Description:** Axial CT scan of the head demonstrating bilateral subdural hematomas (mixed density suggesting different ages) characteristic of abusive head trauma in an infant.

**Source:** Radiopaedia
**URL:** https://radiopaedia.org/cases/abusive-head-trauma-1
**License:** CC BY-NC-SA 3.0

---

## Case 2: Inflicted Burns

### Patient Demographics
- **Age:** 2-year-old female
- **Sex:** Female

### Chief Complaint
"She burned herself in the bathtub."

### History of Present Illness
A 2-year-old girl is brought to the emergency department by her mother with burns to her buttocks and feet. The mother states that the child climbed into the bathtub while the mother was answering the phone and turned on the hot water. She says she found the child in the tub screaming after "a few minutes." The burns were sustained yesterday, and the mother applied butter to the wounds and waited until today to seek medical care because she "thought it would get better." The child has had previous ED visits for a forearm fracture 6 months ago (attributed to a fall from a chair) and a head laceration 3 months ago (attributed to falling against a table).

### Physical Examination
- **Vital Signs:** Temperature 37.5C, HR 125 bpm, RR 22/min
- **General:** Quiet, withdrawn toddler; avoids eye contact; minimal crying despite painful wounds
- **Burns:**
  - Buttocks: Symmetric, full-thickness burns with clear lines of demarcation bilaterally; flexural creases (skin folds) are spared
  - Feet: Circumferential "stocking" distribution burns to both feet up to the ankles with sharp demarcation; uniform depth
  - No splash marks or drip patterns visible
- **Skin (other):** Fading linear bruise on right upper back; healing circular lesion (0.8 cm diameter) on left forearm
- **Genitalia:** Spared (protected in flexed position)
- **Extremities:** Old healing abrasions on shins
- **Neurologic:** Appropriate for age but very withdrawn

### Diagnosis
**Inflicted immersion burns (non-accidental trauma)**

### Clinical Reasoning
Several features indicate these are inflicted rather than accidental burns: (1) Symmetric, well-demarcated burns without splash marks indicate the child was forcibly held in hot water; accidental immersion would show irregular borders and splash patterns from struggling to escape; (2) Spared flexural creases suggest the child was held in a flexed position with skin folds protected; (3) Stocking-pattern burns to both feet with uniform depth and sharp demarcation are inconsistent with accidental contact; (4) The described mechanism is implausible - a 2-year-old cannot generate water hot enough for full-thickness burns from a standard water heater, and the distribution is inconsistent with the described accident; (5) Delay in seeking care is concerning; (6) History of multiple prior injuries raises concern for pattern of abuse; (7) The circular lesion on the arm may represent a cigarette burn.

### Management
1. **Medical treatment of burns:** Wound care, pain management, possible burn unit consultation
2. **Report to Child Protective Services:** Mandatory; this is a medical emergency requiring immediate safety intervention
3. **Complete physical examination:** Document all injuries with photographs and measurements
4. **Skeletal survey:** Age-appropriate (child is under 2 years)
5. **Detailed documentation:** Verbatim history from caregiver including timeline; document all inconsistencies
6. **Multidisciplinary team:** Involve social work, child abuse pediatrician if available
7. **Safety planning:** Child should NOT be discharged to the care of the perpetrator
8. **Law enforcement notification:** Criminal investigation warranted

### Clinical Image
![Immersion burn pattern on lower extremities](case_02_image.jpg)

**Image Description:** Characteristic immersion burn pattern showing stocking-distribution burns to the feet with clear lines of demarcation, uniform depth, and absence of splash marks, indicative of inflicted injury from forcible immersion.

**Source:** Radiopaedia - Child Abuse
**URL:** https://radiopaedia.org/articles/child-abuse
**License:** CC BY-NC-SA 3.0

---

## Case 3: Physical Abuse with Sentinel Injuries

### Patient Demographics
- **Age:** 5-month-old male
- **Sex:** Male

### Chief Complaint
"His leg seems swollen."

### History of Present Illness
A 5-month-old infant is brought to the pediatric clinic by his mother who noticed swelling of his right thigh this morning. She reports he has been fussier than usual for the past 2 days but has no fever, vomiting, or change in appetite. When asked about possible injury, she says she "doesn't know" what happened but wonders if his 3-year-old sister may have stepped on him. The infant was seen in this clinic 3 weeks ago for a "bruise on his ear" that the parents attributed to the baby hitting himself with a toy. He is not yet rolling over independently.

### Physical Examination
- **Vital Signs:** Temperature 37.0C, HR 128 bpm, RR 28/min
- **General:** Fussy infant, cries with movement of right leg
- **HEENT:** Small fading bruise (0.5 cm) on right ear pinna
- **Right thigh:** Swelling of mid-thigh, tender to palpation, decreased spontaneous movement
- **Left leg:** Normal
- **Skin:**
  - Fading yellow-green bruise on right ear pinna
  - Two small (0.5 cm) round bruises on left upper arm
  - Small bruise on right cheek
- **Abdomen:** Soft, non-tender
- **Neurologic:** Moves left arm and leg normally; guards right leg

### Imaging Findings
- **Right femur radiograph:** Acute spiral fracture of the mid-diaphysis
- **Skeletal survey:** In addition to right femur fracture: healing left clavicle fracture (approximately 3-4 weeks old); healing right 7th rib fracture posteriorly (approximately 2-3 weeks old)

### Diagnosis
**Non-accidental trauma (physical child abuse) with multiple fractures and sentinel injuries**

### Clinical Reasoning
This case demonstrates several critical findings of physical abuse:

**Sentinel injuries** (minor injuries that precede more serious abuse):
- Ear bruise at prior visit - bruising to the ear in a non-mobile infant is highly concerning; the ear is a protected location (TEN-4: Torso, Ear, Neck in children under 4)
- Multiple bruises in a 5-month-old who is not yet rolling: "Those who don't cruise rarely bruise"

**Current findings:**
- Spiral femur fracture in a non-ambulatory infant - requires significant rotational force inconsistent with a sibling stepping on the leg
- Unexplained mechanism with changing story
- Multiple fractures at different stages of healing indicating repeated trauma over weeks

The prior "ear bruise" was a sentinel injury that, had it been recognized as concerning at the time, might have prompted earlier intervention and prevented subsequent injuries.

### Management
1. **Report to Child Protective Services:** Mandatory; immediate report required
2. **Full skeletal survey:** Completed; demonstrates pattern of repeated abuse
3. **Follow-up skeletal survey:** Schedule for 2 weeks to identify additional healing fractures
4. **Orthopedic consultation:** For femur fracture management
5. **Complete laboratory evaluation:** Coagulation studies, calcium, phosphorus, alkaline phosphatase to exclude metabolic bone disease
6. **Head CT and ophthalmologic examination:** Even without neurologic symptoms given pattern of abuse
7. **Detailed documentation:** Complete, objective record with photographs
8. **Safety planning:** Child requires protective custody; cannot be discharged to home
9. **Sibling evaluation:** 3-year-old sister requires medical and safety evaluation

### Clinical Image
![Metaphyseal corner fracture on radiograph](case_03_image.jpg)

**Image Description:** Radiograph demonstrating a classic metaphyseal lesion (corner fracture), a fracture pattern highly specific for non-accidental trauma resulting from shearing forces across the growth plate.

**Source:** Radiopaedia
**URL:** https://radiopaedia.org/cases/classic-metaphyseal-lesion
**License:** CC BY-NC-SA 3.0