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11 Conditions Mistaken for Child Abuse

11 Conditions Mistaken for Child Abuse

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Published by Alison Stevens

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Published by: Alison Stevens on Mar 15, 2013
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ISUAL
D
IAGNOSISOF 
HILD
 A
BUSEON
CD-ROM
L
ECTURE
S
ERIES
11.Conditions Mistaken for Child Physical Abuse
Outline
1
AbstractLearning ObjectivesConfusing Cutaneous Conditions
Folk MedicineBurns
Intracranial BleedingOcular HemorrhagesFractures
Osteogenesis Imperfecta
Diagnostic Considerations in DistinguishingOsteogenesis Imperfecta FromInflicted Injuries
Temporary Brittle Bone DiseaseInfantile Cortical Hyperostosis(Caffey’s Disease)
Other Miscellaneous Conditions Mistaken forChild AbuseReferences
 
Abstract
Numerous conditions exist that can suggest anetiology of inflicted injury. Strict adherence toevidence based on objective findings and consid-eration of all diagnostic possibilities help to avoidmistakes. An organ-system approach is outlinedhere. The medical conditions that may mimic childmaltreatment are discussed with an eye towarddistinguishing them from inflicted injury.
Learning Objectives
To identify conditions, disorders, and syndromesthat may be confused with child abuseTo differentiate inflicted injury from preexistingmedical conditionsTo identify cultural practices that may be confused with child abuse
Confusing Cutaneous Conditions
 The process of diagnosing medical conditions isorganized around gathering information about theonset, severity, and duration of the symptoms andsigns; the objective findings on physical examinationof the patient; and collection of additional data fromthe laboratory, special studies, or x-rays. When all of these are synthesized, a list of diagnostic possibili-ties is developed. This list—called the differentialdiagnosis—forms the basis for further thinking aboutthe possible etiology of the patient’s disorder.It is no different when approaching a case of suspected abuse. There are a number of medicalconditions that may mimic physical child abuse. These possibilities must be considered and ruledout in the diagnostic process.
 Folk medicine 
Coin rubbing (cao gio)
1,2
Spooning (quat sha)
3,4
Moxibustion
4,5
Cupping
4,6
Maqua
5
 Burns 
Phytophotodermatitis
7
ImpetigoVaricellaEpidermolysis bullosaDermatitis herpetiformisDiaper dermatitisChilblainsDrug eruptionMechanical abrasionChemical burnsStaphylococcal scalded skin syndromeAccidental burns
Intracranial Bleeding
 Accidental Trauma
—There have been numerousarticles detailing the kinds of falls that produce seri-ous intracranial injuries in infants and children.
9–32
 The conclusion of these studies is that children donot suffer serious intracranial injuries from short(<4 feet) falls. The exception is epidural hematomas, which usually are easily distinguished on computedtomography (CT) scans of the head, appearing aslenticular-shaped densities. The impact caused by motor vehicle crashes and falls, usually from 2 to3 stories, is necessary to produce subdural or sub-arachnoid hematomas. Extensive, multilayered reti-nal hemorrhages (RHs) are almost exclusively seenin shaken baby syndrome/shaken impact syndrome(SBS/SIS). Retinal folds are diagnostic of abusivehead trauma.
Coagulation Disorders
—Although bleeding andclotting disorders can exacerbate intracranial bleed-ing when a traumatic event has occurred, the brainis not the usual site for such bleeding. In hemo-philia, for example, bleeding is usually into jointsor soft tissue. Appropriate laboratory tests for bleed-ing and clotting abnormalities will diagnose a coagu-lation disorder.
Tumors
—These are usually diagnosable by radio-graphic techniques such as CT scans or magneticresonance imaging.
Vascular Malformations
—Rare in childhood, whenintracranial bleeding is due to these it is usually inthe brain tissue itself.
Caida de Mollera (Fallen Fontanelle)
33
—In somecultures, a flat or sunken fontanelle is consideredunhealthy, although it may be present for a variety of benign reasons. When caida de mollera isemployed 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 boilingliquid. The shaking motion is sometimes extreme
 2
Visual Diagnosis of Child Abuse on CD-ROM
Lecture Series
11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE
 
and can lead to tearing of the bridging veins andresultant subdural or subarachnoid hematomas.
Obstetric Traum
a—Cephalohematomas are com-mon parturitional injuries, especially in birthsinvolving instrumentation. They occur in 3% to10% of newborns.
34
In 25% of cases they areassociated with skull fractures, usually in theposterior parietal region.
35
Subdural hemorrhage related to the tentorium isassociated with vacuum extraction.
36
Chronic sub-dural collections seen in the first months of life may be attributed to parturitional events, but examina-tion of those events will usually clarify whetherthere were factors during the birth that may havegiven rise to the collections seen later. The CTimaging characteristics and the absence of asso-ciated injuries (other fractures, RHs, abusive bruises)and the social history often can help distinguishthese conditions from parturitional injuries.
37
Ocular Hemorrhages
Periorbital Ecchymoses
—Bilateral black eyes areusually from abuse, but they can be caused by blunttrauma to the forehead with resultant seepage of the extravasated blood into the periorbital tissues.
Subconjunctival Hemorrhage
—Forceful coughing,sneezing, vomiting, or other Valsalva maneuvers cancause subconjunctival hemorrhages.
Retinal Hemorrhages
—Retinal hemorrhages must bedescribed in terms of their characteristics, becausenot all RHs are alike.
38
Retinal hemorrhages do notoccur as the result of cardiopulmonary resuscita-tion,
38–41
seizures,
38–42
or thoracic compression inchildhood (Purtscher’s retinopathy).
38,43,44
 3
Visual Diagnosis of Child Abuse on CD-ROM
Lecture Series
11. CONDITIONS MISTAKEN FOR CHILD PHYSICAL ABUSE
TABLE 11-1. CONDITIONS CONFUSED WITH BRUISING
Condition Distinguishing Feature
Mongolian spotsSlate gray and uniform in color from one side to the otherSeen at time of birth, become less visible slowly Seen usually on buttocks, lower back, but can be seen anywhere onthe body Ehlers-Danlos syndrome(India rubber syndrome)Skin is velvety, hyperelastic, and fragileMinor trauma can lead to bruisesErythema multiformeHypersensitivity vasculitisSplotchy, covering various areas of body Often itchy, may be raised (hives)Recurrent, indolentPhytophotodermatitisExposure to psoralens in the juice of certain plants followed by exposureto sunlight (limes, lemons, figs, parsnip, celery, herbal preparations)Millipedes secretions
8
Mahogany-colored lesions from contact to skinContact dermatitis and allergic reactions Rubber, face masks, surf boards, squash balls, elastic bands in clothing,plants, chemicalsLice, crabsCan inject anticoagulant under the skin causing deposit of hemosiderinInk or dye on skin (clothing)Mimics bruises or abrasionsCoagulation defect (hemophilia, vonWillebrand’s, leukemia, ITP, HSP, vitaminK deficiency, ingestion of anticoagulantsCoagulation studies—PT, PTT, TT, fibrinogen, Factor VIII, platelets,special studies

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