° A forensic odontologist or pathologist should evaluate the size, contour, and color of the bite marks, as well as make molds of the suspected abuser’s teeth and of the bite itself, if possible. Each individual has a characteristic bite pattern. Burns/Scalds ° Immersion burns have a “water line” or sharp demarcation border. Symmetrical burns with sharp edges (e.g., sock-shaped burns of the same height on each leg) are very suspicious. Clinicians should document an absence of splash marks, which may indicate that the child did not fall into the liquid and try to get out. ° Doughnut-shaped burns can occur when a child is forced into a bathtub. This causes parts of the body, usually the buttocks, to rest on the bottom of the tub, where they will not burn. ° Splash burns can occur when the offender throws hot liquid at the child. Unintentional splash burns are usually on the head or top of the chest and run downward and may be caused by a child reaching upward to grab a pot handle. Liquids that are thrown at a child hit at a horizontal angle, causing the burns to be concentrated on the child’s face or chest and run toward the back of the body. Splash burns on the back or buttocks are highly suspicious. ° Cigarette burns usually appear on the trunk, external genitalia, or extremities. They also often appear on the palms of the hands or soles of the feet. Cigarette burns usually are symmetrical in shape. Impetigo blisters (caused by a bacterial infection) are irregular and can be ruled out by testing for signs of strep. When there are intentional cigarette burns on a child, there often are multiple burns in various stages of healing (i.e., indicating that the burns occurred at various times). ° Chemical burns are caused by household products. Some parents or caretakers force children to drink lye derivatives (toilet bowl cleaner, detergents, or oils), which causes chemical burns of the mouth and throat, vomiting, and esophageal damage. Fractures and Dislocations ° Fractures usually are inflicted by an abuser on non-ambulatory children. ° Ninety percent of all abusive fractures in children 2 years of age or younger include the ribs. ° The following types of fractures and dislocations may indicate abuse: − Metaphyseal fractures can only occur
when a jerking force is applied to the extremities (e.g., by shaking or swinging a child by the arms or legs). − Spiral fractures are common in children because they have more pliant bones. Spiral fractures can occur in small children by twisting their own leg or ankle in an accidental injury (e.g., getting their feet caught in the slats of a crib). Thus, spiral fractures are not always indicative of abuse. − Periosteal elevation occurs when an infant’s extremities are twisted or shaken, causing the periosteum to be separated from the bone and blood to collect in the new space. − Rib fractures can be caused by a caretaker forcefully squeezing the baby. Victims may present with signs of respiratory distress, but they are usually asymptomatic. Neurological Damage (Skull Fracture, Brain or Spinal Cord Damage, and Intracranial Hemorrhage) ° Serious life-threatening skull injuries, with the exception of epidural hematomas, do not result from a child falling from a short height, such as a bed or crib. ° Skull fractures are more likely in young children. Any pressure from cerebritis or hemorrhage can separate fontanelles. ° Brain injury in young children is more likely due to their having an increased subarachnoid space. ° Subgaleal hematoma is often a sign of skull fracture. Diagnostic images of the skull should be taken. It may be caused by jerking or twisting a child’s hair —especially in girls with pigtails—and may be indicated by a bald spot. ° Alopecia (a partial or complete loss of hair) may be caused by neglect if the child lies on his back for long periods of time. Shaken Baby Syndrome ° This occurs when a child has been held around the upper thorax (under the arms) and shaken back and forth with great force. It also occurs when the child is held upside down by the feet and is shaken up and down. ° Many infants die from shaken baby syndrome, especially if there is a delay in getting treatment. Those who survive often have permanent brain damage and may be paralyzed, be developmentally delayed, or develop cerebral palsy. ° There is often an absence of externally visible injuries, but retinal bleeding may occur. Subdural hematoma and metaphyseal lesions are common effects of shaken baby syndrome.
Consequences of Child Physical Abuse Physical abuse affects every aspect of a victim’s development: cognitive, physical, social, and emotional. 7 Victims are more likely to have suicidal thoughts, learning impairments, conduct disorder, a poor self-image, abuse drugs or alcohol, act out sexually, and/or show signs of depression. 8 Adults who were physically abused as children often have problems establishing intimate personal relationships. They are at higher risk for anxiety, depression, substance abuse, medical abuse, medical illness, and problems with school or work. 9 Adults abused as children may also end up repeating the pattern. Research suggests that adults abused as children are 26% more likely to abuse their own children compared to adults who were not abused. 10 Physically abused children are also more likely to be arrested for a violent crime than children who suffered from other forms of maltreatment. 11 One in four female prisoners and one in ten male prisoners were physically abused before the age of eighteen. 11 Clinical Testing and Documentation of Physical Abuse If a clinician suspects an injury may be the result of abuse, he or she may conduct tests to screen for other injuries and/or underlying medical causes to support the finding or be considered in the differential diagnosis. 12 The extent and nature of the testing depends on the severity and type of injury, and the age and developmental level of the child—the younger the child and the more severe the injuries the more extensive and important are the diagnostic tests to be considered. Child abuse pediatricians and/or pediatric subspecialists can be consulted to help determine appropriate testing or procedures. Whenever one child is identified as a suspected victim of abuse, siblings, other young children in the household, or other child contacts of the suspected abuser should be assessed, if possible, for injuries (particularly important for twins). 12 Thorough medical documentation (written, photographic, or orally described) of suspected physical abuse can be critical for protecting and intervening early in cases of suspected abuse. Documentation that includes specific levels of concern, alternative diagnostic possibilities and the results of additional testing can be important for later review or to assist child protective services or legal investigations. BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1 ON THE NEXT PAGE.
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