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the clinical presentation of child abuse(iatrogenic): various injuries to the skeleton, soft tissues, or organs of a child sustained as a result of repeated mistreatment or beating, usually by the person responsible for the child's care

A group of physical and mental symptoms arising from .long-term physical violence against a child Battered child syndrome refers to injuries sustained by a child as a result of physical abuse, usually inflicted by an adult caregiver. Alternative terms include: shaken baby; shaken baby syndrome; ...(child abuse; and non-accidental trauma (NAT

Symptoms may include a delayed visit to the emergency room with an injured child; an implausible explanation of the cause of a child's injury; bruises that match the shape of a hand, fist or belt; cigarette burns; scald marks; bite marks; black eyes; unconsciousness; lash marks; bruises or choke marks around the neck; circle marks around wrists or ankles (indicating twisting); separated sutures; unexplained unconsciousness; and a bulging .fontanel in small infants Emotional trauma may remain after physical injuries have healed. Early recognition and treatment of these emotional "bruises" is important to minimize the long-term effects of physical abuse. :Abused children may exhibit A poor self-image -1 Sexual acting out -2 An inability to love or trust others -3 Aggressive, disruptive, or illegal behavior -4 Anger, rage, anxiety, or fear -5 Self-destructive or self-abusive behavior -6 Suicidal thoughts -7 Passive or withdrawn behavior -8 Fear of entering into new relationships or activities -9 School problems or failure -10 Sadness or other symptoms of depression -11 Flashbacks or nightmares -12 Drug or alcohol abuse -13

Sometimes emotional damage of abused children does not appear until adolescence or even later, when abused children become abusing parents who may have trouble with physical closeness, intimacy, and trust. They are also at risk for anxiety, depression, substance abuse, medical illnesses, and problems at school or work. Without proper treatment, abused children can be adversely affected throughout their life

Internal injuries, cuts, burns, bruises and broken or fractured bones are all possible signs of battered child syndrome. Emotional damage to a child is also often the by-product of child abuse, which can result in serious behavioral problems such as substance abuse or the physical abuse of others. Approximately 14% of children in the United States are physically abused each year, and an estimated 2,000 of those children die as a result of the abuse. Between 1994-1995, 1.1 million cases of child abuse were recorded in the United States; of that number, 55% of the victims were less than a year old

Prevalence, morbidity and mortality rates

An estimated 2,000 children die each year in the United States from confirmed cases of physical abuse and 14,000 more are seriously injured. The battering takes many form, including lacerations, bruises, burns, and internal injuries. In addition to the physical harm inflicted, battered children are at risk for an array of behavioral problems, including school difficulties, drug abuse, sexual acting out, running away, suicide, and becoming abusive themselves. Dissociative identity disorder, popularly known as multiple personality, is also common among .abused children

Detailed radiographic appearance

Radiologist has legal obligation to report suspected child abuse, usually to the referring physician Appearances of skeletal trauma

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Hallmark of the syndrome are multiple, asymmetric fractures in different stages of healing Separation of distal epiphysis Marked irregularity and fragmentation of metaphyses "Corner" fracture (11%) or "Bucket-handle" fracture = avulsion of a metaphyseal fragment overlying the lucent epiphyseal cartilage secondary to a sudden twisting motion of extremity Isolated spiral fracture (15%) of diaphysis secondary to external rotatory force applied to femur / humerus Extensive periosteal reaction from large subperiosteal hematoma Exuberant callus formation at fracture sites Cortical hyperostosis extending to epiphyseal plate Avulsion fracture at site of ligamentous insertion Frequently seen without periosteal reaction

Battered child syndrome is most often diagnosed by an emergency room physician or pediatrician, or by teachers or social workers. Physical examination will detect injuries such as bruises, burns, swelling, retinal hemorrhages (bleeding in the back of the eye), internal damage such as bleeding or rupture of an organ, fractures of long bones ore spiral-type fractures that result from twisting, and fractured ribs or skull. X rays, and other imaging techniques, such as MRI or scans, may confirm or reveal other internal injuries. The presence of injuries at different stages of healing (i.e., having occurred at different times) is nearly always indicative of BCS. Establishing the diagnosis is often hindered by the excessive cautiousness of caregivers or by actual concealment of the true origin of the child's injuries, as a result of fear, shame and avoidance or denial mechanisms Differential diagnosis of child abuse Normal periostitis of infancy Osteogenesis imperfecta Congenital insensitivity to pain

Infantile cortical hyperostosis Menkes kinky hair syndrome Schmid-type chondrometaphyseal dysplasia Scurvy Congenital syphilitic metaphysiti

Recommended imaging modalities or procedure

CT findings in head trauma

Subdural hemorrhage (most common) Inter hemispheric location most common Subarachnoid hemorrhage Epidural hemorrhage (uncommon) Cerebral edema (focal, multifocal, diffuse) Acute cerebral contusion appears as ovoid collection of intra parenchyma blood with surrounding edema

MR findings of head trauma

More sensitive in identifying hematomas of differing ages White matter shearing injuries as areas of prolonged T1 + T2 at corticomedullary junction, centrum semiovale, corpus callosum

Treatment options
Medical treatment for battered child syndrome will vary according to the type of injury incurred. Counseling and the implementation of an intervention plan for the child's parents or guardians are necessary. The child abuser may be incarcerated, and/or the abused child removed from the home to prevent further harm. Decisions regarding placement of the child with an outside caregiver or returning the child to the home will be determined by an appropriate government agency working within the court system, based on the severity of the abuse and the likelihood of recurrence. Both physical and psychological therapies are often recommended as treatment for the abused child. If the child has siblings, the authorities should determine where they have also been abused, for about 20 percent of siblings of abused children are also shown to exhibit signs of physical abuse

The prognosis for battered child syndrome will depend on the severity of injury, actions taken by the authorities to ensure the future safety of the injured child, and the willingness of parents or guardians to seek counseling for themselves as well as for the child.


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