Abuse and Assault

1. Abuse and Assault CCFP EM Core Lecture March 26, 2015 Dr. Jo-Ann Talbot Department of Emergency Medicine Dalhousie University Saint John Regional Hospital

2. Abuse and Assault CCFP EM Core Lecture March 26, 2015 Dr. Jo-Ann Talbot Department of Emergency Medicine Dalhousie University Saint John Regional Hospital

3. Learning Objectives Define abuse and assault Discuss the extension of abuse to all ages Sexual assault in adults and in children Risk factors for abuse, red flags Principle of the chain of evidence Consent for blood ethanol testing for legal purposes The role of the medical expert witness Preparation for provision of evidence in court

4. Abuse and Assault • Definition of abuse : • Maltreatment of another individual • A pattern of coercive control • Definition of Assault : • Any act or threatened act of violence

5. Case 1 4 month old with fever, cough, runny nose, for past 3 days Increased irritability, decreased po intake, no vomiting or diarrhea Bruise noted on right ear which mom states is from banging his head on the crib and he bruises easily Discussion

6. Bruising in Children Bruising is often overlooked because it is usually clinically insignificant, and requires no immediate treatment. Are there patterns of bruising that raise a suspicion of child abuse? Discuss

7. Bruising in children Systematic review in 2005 by Maguire et al Patterns of bruising suggestive of abuse 23 observational studies 7 looked at bruising in normal children 14 looked at abused children (13 case series, 1 cross sectional) 2 looked at both abuse and non abuse

8. Bruising in children • Bruising must be assessed in the context of • medical, social, and developmental history • explanation given • patterns of non-abusive bruising Maguire, Mann, Sibert and Kemp. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review Arch Dis Child. 2005;90:182-86.

9. Bruising in Children Conclusions Bruising in infants who are not moving independently is rare less than 1%. In infants starting to mobilize 17% have bruises In walking toddler 54% Most preschool and school age children have bruises Maguire et al Arch Dis Child 2005

10. Bruising suggestive of physical abuse Bruises in children not independently mobile Bruising in babies Bruises away from bony prominences Bruises to face, trunk arms, ears and hands Multiple bruises in clusters Multiple bruises of uniform shape Bruises that carry imprint of implement Maguire et al Arch Dis Child 2005

11. Bruises Bruising characteristics discriminating physical child abuse from accidental trauma. Pierce, Kaczor, Aldridge et al. Pediatrics. 2010;125:67-74.

12. Bruises Objective to develop a bruising CDR. Case control study of children 0 to 48 months old admitted to PICU for trauma, retrospective as all participants identified through the trauma registry 42 cases physical abuse 53 controls children admitted with accidental trauma over the same time period

13. Bruises • Conclusions Pierce et al • Number of bruises • Abuse cases median of 6, as many as 25 • Accidental controls median of 1, all had ≤ 4 • Regions predictive of abuse • Ear, neck, hand, right arm, chest, buttocks and torso • All genitourinary and hip bruising were found in abuse cases but too few for significance • Bruising in child less than 4 months old rare

15. Bruises • Sugar N, Taylor JA, Feldman KY. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Arch Ped Adol Med. 1999;153(4):399-403 • Landmark study of 1000 children less than 36 months old well child care visits at clinic • Bruises on pre-cruisers rare • Bruises on the hands and buttocks were not observed at any age

16. Bruising Blunt Object

17. Bruise Patterns

18. Bruise Patterns

19. Bruise Patterns

20. Bruise Patterns

21. Bruise Patterns

22. Bruise Patterns

23. Bruise Patterns

24. Case 2 18 month old female with pain in right leg, refusing to walk, father states that she was playing on picnic table, fell off Injury happened about 20 minutes prior to presentation Discussion Xray

25. Spiral Fracture Tibia (Toddler’s)

26. Fractures in Children Fractures are very common in children 60% of boys and 40% of girls will have a fracture by their 15th birthday. Children who are abused represent a very small number of childhood fractures. Are there characteristics of fractures that may represent abuse? Discuss

27. Fractures Kemp, Dunstan, Harrison et al from Cardiff, Wales, published a systematic review in BMJ 2008 on patterns of fractures in child abuse Questioned what features differentiate fractures sustained from abuse from those sustained from other causes. Included 32 studies

28. Fractures • Kemp et al conclusions • Most common abuse fractures were in infants and toddlers • 80% of all fractures from abuse were seen in < 18 month old children • Multiple fractures were more common in abuse • After excluding major trauma rib fractures had the highest probability of abuse

29. Fractures • Fractures due to abuse in children • Age < 18 months 1 in 9 fractures • Age 19 months and 5 yrs 1 in 250 fractures • Age > 5 years old none • When infants and toddlers present with a fracture consider abuse • No fracture on its own can distinguish abuse from non abusive causes

30. Fractures • Metaphyseal fractures (bucket handle) thought to be strong predictors of abuse. This systematic review did not find any evidence to support or refute this hypothesis. • The most comprehensive studies on metaphyseal fractures were descriptions of radiologic findings of metaphyseal lesions in case series of a group of fatally abused children.

31. Fractures • Kleinman PK, Marks SC Jr. A regional approach to the classic metaphyseal lesion in abused infants: the proximal humerus. AJR Am J Roentgenol 1996;167:1399-403. • Kleinman PK, Marks SC Jr. A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol 1996;166:1207-12. • Kleinman PK, Marks SC Jr. A regional approach to the classic metaphyseal lesion in abused infants: the distal femur. AJR Am J Roentgenol 1998;170:43-7. • Kleinman PK, Marks SC Jr. A regional approach to the classic metaphyseal lesion in abused infants: the proximal tibia. AJR Am J Roentgenol 1996;166:421-6.

33. Metaphyseal Fracture Shoulder

35. Metaphyseal Fracture Elbow

37. Metaphyseal Fracture Distal Femur

39. Metaphyseal FractureS Tibia

41. Rib Fractures

42. Fractures Old and New

43. Fracture callus in Radius, Ulna

44. Case 3 2 year old female with burn to buttocks from exposure to hot bath water See image Discuss

46. Burns James-Ellison, Barnes, Maddocks et al. Social health outcomes following thermal injuries: a retrospective matched co-hort study. Arch Dis Child. 2009 Sep;94(9): 663-7 Swansea Wales Retrospective Cohort study 145 children age of 3 years admitted for burns Matched against controls for age, sex, enumeration district.

47. Burns Followed until age of six Results: 89% of burns were deemed accidental and 2.8 % non accidental at initial event By 6th birthday burn cases were more likely to be referred to social services with 9.7% of cases vs 1.4% of controls having been abused or neglected. 32% of cases vs 18% of controls were defined as in need (Social services referral)

48. Burns Children with a burn requiring admission appear to be at higher risk of further abuse or neglect compared with controls.

49. Case 4 • 5 year old girl presents with itching and foul discharge in the vaginal area for past two days. No dysuria or hematuria. • How do you approach the history and physical exam in this child? • Discuss

50. Child Sexual Abuse • 85% Child sexual abuse cases presenting to ED are for: • disclosure of the abuse • or because of other GU tract symptoms • Behavioral Disturbances • Excessive masturbation, genital fondling, regression, nightmares, encopresis, or other sexually oriented or provocative behavior