Child Abuse

Child abuse most often occurs under 3 years of age, and if it is not recognized and reported, repeat abuse may occur in 40% of the cases. Death can occur in up to 5% of cases.

Risk factors for Child Abuse include:

  • Being the first born child
  • Single Parent
  • Stepchild
  • Disabled Child
  • Parents were abused

It is important to rule out osteogenesis imperfecta and metabolic bone disease.

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Suspect Child abuse if:

  • There is a fractured femur in an infant before walking age
    • The most common orthopaedic injury associated with child abuse is a femur fracture
  • Multiple fractures in different stages of healing
    • Callus and periosteal reaction is seen
  • Unwitnessed spiral fracture
    • Spiral fractures are not a good criteria because most of them are accidental
  • Multiple soft tissue bruising
    • Skin lesions are the most common
    • Bone fracture is the second most common

skin lesions

  • Corner fracture
    • Metapheseal fracture especially in the distal femur and proximal tibia
    • Child abuse should be considered when health care providers see cornercornerfx fractures in children before they are of walking age.
  • Posterior rib fracture from a squeezing injury
  • If there is a transepiphyseal separation in the humerus
    • In Newborns
      • The olecranon moves posteriorly
      • Looks like an elbow dislocation
    • Older Child
      • Separation of the distal humerus usually occurs in younger ages

Discrepancy in the history is a clue. It is hard to explain the injury and match it with the given mechanism of the injury. Injuries in abuse mostly occur at the humerus, tibia, and femur (more in the diaphysis). When child abuse is suspected in a patient it is important to recognize the symptoms, be non-judgmental, and obtain a skeletal survey. If you suspect abuse and a skeletal survey is negative, obtain a bone scan to verify. Then consult protective services. The most frequent cause of long-term morbidity in an abused child is a head injury.

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Lead Poisoning

Lead poisoning can occur when lead builds up within the body, usually over a long period of time. Young children are vulnerable to lead poisoning and it is important to be aware of this due to lead poisoning being a factor in mental and physical development. Lead poisoning is a medical condition caused by increased levels of lead within the body that interferes with the normal processes of the body and is particularly toxic to children. This occurs because lead and calcium compete for the protein that is important for body functions, especially the nervous system. The lead can displace the calcium from that protein so the calcium will not be able to function properly.

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When simplifying the signs and symptoms of lead poisoning, we use the acronym “LEAD”. L represents the lines on the gingiva and long bones; E stands for Encephalopathy and erythrocyte (RBC) basophilic stippling (disease, damage, or malfunction of the brain), A signifies abdominal colic and anemia, and D which stands for drop foot and drop wrist.

Lead inhibits the enzymes that are needed to make Heme—preventing the production of hemoglobin. This causes basophilic stippling of the cells due to lead inhibiting the ribosomal RNA degradation. The red blood cells (RBC) will retain aggregates of ribosomal RNA that causes the stippling of the cells.

RNA

Lead poisoning will present itself with a “lead line” in the gingiva (gums) called the Burton’s line. This gray-blue line is visible at the margin of the gum at the base of the teeth. The long bones will also have lead lines in the metaphysis that appear like white bands on an x-ray because the lead is collected within these white bands. The width and density of these lines reflects chronic exposure.

 

At the RBC level, you will find anemia and basophilic stippling of the red blood cells.

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The patient will also have encephalopathy associated with headache and memory loss. Lead poisoning may also cause abdominal colic—pain, cramps, and constipation. Another condition that may occur due to lead poisoning is “foot drop”. The patient may experience permanent damage to the central nervous system and the peripheral nerves.

 

This condition usually occurs from exposure to lead based paint, typically used in much older homes. Particles from the lead based paint can be inhaled through the air or from contaminated drinking water, as we have seen recently. Extended exposure can cause serious problems, with children being the most vulnerable. They will commonly show signs of: irritability, fatigue, lower IQ, and lack of attentiveness. The child may show signs of encephalopathy, nausea, vomiting, gait disturbances, and seizures. Exposure in adults is usually occupational related. Adults will experience personality changes, headaches, neuropathy, weakness, foot and wrist drop, and stomach aches. Both children and adults will experience pale skin due to anemia because lead interferes with the normal formation of hemoglobin.

When diagnosing lead poisoning, you have to take into consideration the history of exposure, cm lead levels are usually greater than 5—however, some people use higher numbers. If a complete blood count (CBC) test is done, microcytic anemia will be found and in a peripheral blood smear, you will find basophilic stippling (ribosomes). The serum iron will be normal.

basophil

When treating lead poisoning, the first step will be to eliminate the source of lead contamination. Next, a chelating agent will be used. During this step, various drugs may be used to help remove lead from the body. A chelating agent will bind the lead into a form that the body can excrete. It is used if lead levels are higher than 45µg/dL in children, and more than 70µg/dL in adults. Dimercaprol (oral chelating agent) is used in cases where patients present with encephalopathy. Succimer is used when there aren’t any signs of encephalopathy.

It is also possible to be contaminated by lead due to a bullet penetrating a joint or if it is introduced into the cerebral spinal fluid. This may cause severe synovitis and low grade lead poisoning. This condition is rare, however it can occur. Lead toxicity can also occur due to contamination of the ground water and soil. Lead poisoning can occur due to ingesting food grown in contaminated soil.

Salter-Harris Fracture Classifications

The Salter-Harris fracture is a common injury in children, involving the growth plates of the long bones. Approximately 15% to 30% of all childhood fractures are growth plate fractures and are common in the lower leg bones (tibia and fibula). It is important to detect these fractures as they may affect the growth of the bone if not treated properly.

There are five types of Salter-Harris fractures. The higher the type number, the more complications associated with the fracture.

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Type I

Type I

Only 5% of fractures are Type I. It may be difficult to diagnose unless there is obvious displacement and sometimes the diagnosis is a clinical one. Type I fractures occur though the weak zone of the provisional calcification and are known for their fast healing and rare complication rate.

Type II:

typeIIfx
Type II

Approximately 75% of fractures are type II. These fractures occur at the physis (growth plate) and metaphysis – and when the corner of the metaphysis separates (Thurston-Holland Sign). The fragment usually stays with the epiphysis while the rest of the metaphysis will displace. Typically, healing is fast and growth is usually okay; however, distal femur fractures may result in growth deformity.

 

Type III:

10% of fractures are Type III, which are defined as fractures of the growth plate and epiphysis, or even a split of the epiphysis. The fractures extend into the articular surface of the bone and will require reduction of the joint. In distal femur fractures it may result in a growth deformity.

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Type III

Type IV:

About 10% of fractures are Type IV fractures—which pass through the epiphysis, physis (growth plate), and the metaphysis. Type IV fractures can cause complications such as growth disturbance and angular deformity.

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Type IV

Type V:

Type V fractures are uncommon, only occurring about 5% of the time. In type V fractures, compression or a crush injury of the growth plate takes place. This fracture has no association with the epiphysis or metaphysis and an initial diagnosis may be difficult. Despite being uncommon, these fractures have the highest incidence of growth deformity and disturbance.

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Type V

Sever’s Disease

Sever’s disease is a common cause of heel pain in children between the ages of 9 and 12 years. The pain is due to calcaneal apophysitis occurring due to repetitive and continuous traction on the calcaneus from the Achilles tendon. The apophysis is not part of a joint and has muscle or tendon attachments. This traction apophysitis may lead to stress fractures, pain and tenderness over the heel.

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Sever’s disease is similar to Osgood-schlatter disease of the tibial tubercle.

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Patients are usually young athletes presenting with heel pain that increases with activities. Upon examination there could be swelling, tenderness, warmth and/or redness on the back of the heel where the Achilles tendon inserts.

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Plain lateral X-rays may show sclerosis or fragmentation of the calcaneal tuberosity. Sclerosis is not specific for this condition.

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Fragmentation of the calcaneal tuberosity on the other hand, is more common in patients with Sever’s disease relative to the general population.

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Remember that Sever’s disease is a clinical diagnosis. X-rays may show other causes of pain such as tumors, fractures, infections or cysts. MRI is not commonly used, but can help rule out calcaneal stress fractures or osteomyelitis.

Sever’s disease is a self-limiting condition that usually resolves with time. Treatment usually consists of NSAID, Achilles tendon stretching exercises, and activity modifications and in severe condition a short leg walking cast can be used.