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Non-Accidental Trauma

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by

Nicole Nikolic

on 10 September 2013

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Transcript of Non-Accidental Trauma

The Differential Diagnosis
Non-Accidental
Trauma

Bruises
Ophthalmic Findings
Clinical findings:
- Accidental vs non-accidental bruising

-Bleeding disorders

- Slate grey nevi (Blue Mongolian spots)

- Henoch-Schönlein purpura (IgA vasculitis)


- Salicylate ingestion

- Very rare mimickers
Fractures
- Accidental vs non-accidental trauma

- Metabolic bone disease

- Neoplasm, bone cyst

- Osteogenesis Imperfecta

- Periosteal reaction from infxn or meds

- Congenital insensivity to pain
- Retinal hemorrhage


- Retinal folds and retinoschisis

- Vitreous hemorrhage


- Papilledema
Burns
Bruises
Fractures
Ophthalmic findings
Subdural hematomas

Burns
Shaken Baby Syndrome
- Triad of exam findings:





- Retina with:
1) Intracranial hemorrhage
2) Cerebral edema
3) Retinal hemorrhage
- large retinal heme in all quadrants and all layers
(subretinal, intraretinal, preretinal)

- Retinoschisis cavities (split between retinal layers)
Accidental:
Non-accidental:
- Hemophilia and other coagulation factor deficiencies, von Willebrand disease, ITP, leukemia
- Erythema multiforme, phytophotodermatitis, post-inflammatory hyperpigmentation, cultural remedies (cupping, coining, caida de mollera, salting)
Erythema multiforme: advanced lesion, clue= central bulla
Phytophotodermatitis
Post-inflammatory hyperpigmentation
Coining
Often linear pattern of bruising
Mongolian Spot
Phytophotodermatitis
Phytophotodermatitis
Subdural hematomas
- Clinical presentation: AMS, vomiting, unstable vitals (apnea, bradycardia), nl or abnl neuro exam



- Ddx:






- Much more common in abuse (vs. accidental), especially if bleeds on imaging with mixed densities
- Retrospective study found up to 37% dx'd with head trauma had normal neuro exam
- Intentional

- Unintentional

- Phytophotodermatitis


- Impetigo
- Usually shallow d/t reflex from painful stimuli
- Congenital insensitivity to pain
- In up to 20% of abused children

- Types:
Branding
Cigarette burns
Immersion burns
Microwave oven burns
Stun gun burns
Intentional Burns
- Burn-like lesion with bullae
- Occurs from rxn with sunlight and photosensitizing compounds (found in limes, lemons, figs, parsnips, celery)
- Occurs hours to days after contact
Staph aureus
Strep pyogenes
"honey crust"
- Palpable purpura (without thrombocytopenia or coagulopathy), arthritis, abdominal pain, renal disease
- Purpura from breakdown of capillary walls
- Bruising from decreased platelet adhesion and increase in capillary permeability
Metabolic Bone Disease
- Rickets

- Vitamin C deficiency

- Copper deficiency

-Renal disease
- Hyperoxaluria, autosomal dominant distal RTA, Lowe oculocerebrorenal
- Xray with metaphyseal changes (cupping, fraying and metaphyseal spurs)
-Large periosteal calcium deposits 2/2 subperiosteal hemorrhage & central epiphyseal lucency
- Osteopenia, metaphyseal cupping, physeal widening, enlarged costochondral junction, and Looser zones (pseudofractures)
Fraying and cupping of distal ulnar and radial metaphyses
Periosteal Reactions
- Infection: congenital syphillis, osteomyelitis

- Drugs:
Vitamin A megadoses
Methotrexate
Prostaglandin
Interleukin-11
- Presents as absent red reflex
- Ddx: neoplasm (retinoblastoma), cataracts
- High ICP
- Cerebral edema, tumor, hematoma, hydrocephalus (non-obstructive after meningitis)
- Abuse, accidental trauma, severe coagulopathy, sepsis, myeloid leukemia
- Abuse, cultural (moxibustion)
Shaken Baby Syndrome
Heme in all 4 quadrants
Fracture Patterns
Abuse:





Accidental:
Metaphyseal corner fractures
Rib fractures
Fractures of sternum, scapula or spinous processes
Multiple fractures in various stages of healing
Bilateral long bone fractures
Skull fractures in kids < 18 months
Isolated long bone fractures
Suspect abuse if midshaft (diaphyseal), spiral or oblique fx
Skull fractures in kids > 18 months
Clavicle fractures
Occur when limb pulled or twisted
Caused by series of planar microfractures through the primary spongiosa
Metaphyseal corner fracture
Get skeletal survey!
- Blue sclera, scoliosis, growth retardation, hearing loss, osteopenia, wormian bones, dentinogenesis imperfecta
extra bones in between sutures
Fever, hepatosplenomegaly, lymphadenopathy, jaundice and rash, with laboratory findings of histiocytosis,[2] and the pathologic finding of hemophagocytosis.


Pancytopenia (anemia, neutropenia, and thrombocytopenia), markedly elevated serum ferritin levels, and abnormal liver enzymes are frequently present.
- Non-accidental vs. accidental trauma, birth trauma
- Bleeding disorder
- Metabolic [glutaric aciduria type 1, galactosemia]
- Meningitis
- Cerebral malaria
- Hemophagocytic lymphohistiocytosis (HLH)
Full transcript