Skin Findings and Physical Abuse

Shelly Martin, MD

Lt Col, USAF, MC

Child Abuse Pediatrician

Objectives

• Bruises

• Bites

• Burns

History – “Red Flags”

• Inconsistent, changing, conflicting stories• Delay in seeking medical care/lack of

parental concern• Prior incidents of abuse or neglect• Blame another child or pet for injuries• Severe injuries secondary to short falls• Child not developmentally capable of causing

injury

Physical Examination “Red Flags”

• Multiple injuries• Diverse locations

• Different stages of healing

• Different mechanisms of injury

• Signs of other types of abuse or neglect

Bruises

• Shape

• Location

• Pattern

• AGE

When to be Concerned?

•Age of child•Development capabilities•Patterns•Location

Accidental vs Non-accidental Bruises

• Age and development• Arch. Ped. & Adol. Med. 1999, Sugar et al-

• 973 children <36 mo studied retrospectively

• The # and location of bruises were recorded during well child visits

Conclusions

• Increasing developmental stage was significantly associated with more bruises• Walkers > Cruisers > Crawlers > Non-crawlers

• “Those who don’t cruise don’t bruise”

• Uncommon sites for bruises in all ages and stages of development• Trunk, genitals, buttocks, hands, feet, neck, face

BRUISES BY LOCATION

More common Rare

Developmental Milestones

• 3-4 months – rolling over

• 6 months – sitting up

• 8-9 months – crawling

• 9-12 months – cruising

• 10-14 months – walking

When Are Bruises Concerning?• Bruising without explanation in a non-

mobile infant• Those who don’t cruise don’t bruise

• Need a plausible accidental history

• Often do the work-up then decide to accept accidental history

% Injuries by Age

Type of Injury

0-8 Months

9 Months -4 Years

5-9 Years 10-17 Years Total

Bruises 1.2 60.3 80.3 52.7 58.1

Abrasions 1.2 19.8 37.6 30.5 23.7

Scratches 11 26.3 26.6 20.2 23.9

Other* 0 2.1 2.2 2 1.9

# ChildrenExamined

246 1,012 579 203 2,040

Labbe, Pediatrics 2001

*Cuts, bites, burns, etc

Atypical & Unexplained BruisingTEN-4

4 years and younger:

• Torso (trunk)• Chest

• Abdomen

• Back

• Buttocks

• GU

• Ear

• Neck

FACES

• Frenulum

• Angle of jaw

• Cheek (buccal)

• Eyelids – black eye

• Subconjunctival hemorrhage

Bruising ANYWHERE on infant 4 mo or under

TEN-4 FACES• Torso

• A lot of cushion to absorb injury

• Ears• Difficult to bruise

• Not very vascular (minimal or no subcutaneous tissue)

• Neck• Protected

• No superficial bony structure to provide “crush” needed for vascular damage

When Are Bruises Concerning?

Patterned bruising (belt, loop, slap, etc)

Spanking with an Electric Cord

Spanking with a Belt

Spanking with a Belt or Cord

When Are Bruises Concerning?• Bruising in locations not common for

accidental trauma• Accidents more common over bony prominences

(where skin and bone are close together)

When Are Bruises Concerning?

• Bruising with a report by the child that it was caused by a caregiver• Non-specific bruises have significance with a

report they were caused by non-accidental trauma

Medical Evaluation

• Family history

• Photographs

• CBC (Platelets)

• PT, PTT

• Consider other bleeding studies: vWD screen, PFA-100, Thrombin Time, D-Dimer, Factor XIII

Differential Diagnosis of Bruising

• Dermal Melanocytosis

• Ehlers DanlosSyndrome

• Erythema Multiforme

• Allergic “shiners”

• Phytophotodermatitis

• ITP

• Leukemia

• Hemophilias

• VW Disease

• HSP

• Cao Gio

• Pediculosis

• Accidental Injury

• DIC

Coining

PhytophotodermatitisAppearance confusing for burns or bruises. Bizarre shapes such as linear streaks, hand prints.

Seen with Citrus fruits, figs, celery, wild parsnips, rue

Caused by Furocoumarins (psoralen) in the plants that cause the reaction. Produced transiently, usually after rain.

The psoralen, when exposed to sunlight, produces a photodermatitis that leads to blister formation then hyperpigmentation that can last for months.

Tx with moderate steroid ointment

Mongolian Spots

Estimation of Age of Bruises

• Bruises cannot be dated by color

• If red and swollen can say it’s acute

• Studies show that bruises can be any color at any stage

Frenulum Tears

• Sentinel injury – often a precursor to more significant abuse.

Frenulum Tears

• In premobile infants often the result of a bottle, pacifier, or eating utensil being shoved in the mouth

• Rarely accidental• Consider accidental injury in mobile infants

Bites• Suspect a bite mark when you have

ecchymoses, abrasions, or lacerations in a elliptical or ovoid pattern

• May have a central area of ecchymoses caused by:• Positive pressure from the closing of the teeth

with disruption of small vessels

• Negative pressure caused by suction and tongue thrusting

Bites

• Typically easy to differentiate human and animal bites

• Size matters• <3-3.5 cm suggests a child

• >3-3.5 cm suggests an adult

• DNA• Saliva may be present = DNA

• May be able to match bacterial profile

• Forensic dentists helpful

Does Size Matter?

• A intercanine distance (linear distance between the central point of the cuspid tips) measuring more than 3 cm is suspicious for an adult bite

The numbers on the bite mark are labeled according to standard tooth

numbering. The 2 red arrows point to teeth # 22 and 27, the mandibular

canines. The distance between these teeth is 4.0cm, as is the distance between the impressions from the

maxillary canines, teeth # 6 and 11.

Classification of Burns

• Classified by their depth and extent (%BSA)

• Superficial (1st degree)

• Partial Thickness (2nd degree)• Superficial

• Deep

• Full Thickness (3rd degree)

Reference Temperatures (oF)

• 101 Comfortable Infant Bathing• 106-108 Hot tub• 109-113 Painful for adults• 113 2nd degree burn; 6 hours• 120 2nd degree burn; 10 minutes• 127 2nd degree burn; 1 minute• 130 2nd deg; 10 sec (child), 30 sec (adult)• 140 2nd deg; 1 sec (child), 3 sec (adult)• 156 3rd degree burn; 1 second child

Burn Types

• Immersion• sharply demarcated edges

• paucity of splash marks

• flexion creases can be spared

• commonly bilateral

Burn Types

• Splash • Difficult to distinguish from accident

• Commonly on the face, arms and legs

• Consider child’s development

Flow Burn

Burn Types

• Contact• Recognized by geometric pattern

• Consider the depth

Clues to Abuse - History

Is the history consistent with the developmental level of the child??

Burn Profile Checklist

• Attributed to sibling

• Unrelated adult seeking medical attention

• Differing histories

• Treatment delay >24hr

• History of injuries

• Inappropriate affect-parent or child

• History incompatible with injury or development

• Mirror image burns

• Localized to perineum, genitalia, buttocks

• Older than history

• Other injuries

Differential Diagnosis of Burns

First Degree

• Cellulitis, erysipelas

• Sunburn

• Contact dermatitis

• Diaper rash

• Drug reaction

Differential Diagnosis

Second Degree

• Bullous impetigo

• Staphylococcal scalded skin syndrome (SSSS)

• Toxic epidermal necrolysis

• Epidermolysis bullosa

• Phytophotodermatitis

• Psoriasis

ex-lax Burn

Staph Scalded Skin Infection

Cultural Practices

• Moxibustion – ritual burning of moxa on skin

• Cao Gio – hot coin rubbing

• Cupping – cup placed on skin after rim is swabbed with alcohol and ignited creating vacuum

Moxibustion

Cupping

Sexual Abuse

• Genital Warts• Most common concern in a Derm clinic

• Is SUSPICIOUS for sexual abuse

• No typing needed (for abuse)

• Should be reported to CPS and/or Law Enforcement for investigation

• Key is a forensic interview

• If all else is negative, warts themselves is not diagnostic of abuse

• Multiple modes of transmission

• Molluscum is not an STD

• Herpes is in the same category as warts• SUSPICIOUS for sexual abuse

• Report for an investigation

• Key is confirming it is Herpes• Again typing not needed

Sexual Abuse

Legally Defensible Evaluations

• Document in three ways• Words• Photos• Drawings

• Be thorough, complete, non-judgmental• Direct quotations of parent’s statements• Write everything as if you will have to

defend it in court later• Use consultants

Contact Info

Shelly Martin M.D.

Lt Col, USAF, MC

San Antonio Military Medical Center

O: 210-916-9145 DSN: 429-9145

BlackBerry: 210-262-9387

shelly.d.martin.mil@mail.mil

Questions?