There is always a proof: Not A Happy Household – Fatal Child Abuse

Though it is vital to recognize non-fatal child abuse, because of the need for intervention to prevent the 60 per cent recurrence rate and 10 per cent mortality rate, it can be almost as tragic to falsely accuse landlord convict parents or guardians where the injuries were non-culpable. There has sometimes been perhaps some excess of zeal on the part of pediatricians, radiologists, accident surgeons and pathologists to overinterpret injuries and scenarios that had an alternative and less sinister explanation.

Though it is natural and vital for doctors to protect children and their siblings, medical opinion has to remain free from emotive bias and be confined within the bounds of what can be proved in each individual case, or injustice may be done.

 

The majority of deaths are caused manually, either by hitting or beating with the hands, shaking, throwing, dropping and - less often - by burning or suffocation. It is exceptional for death to be caused by the impact of a blunt instrument, though non-fatal bruises from beating with a strap, for instance, are sometimes seen. Shooting, strangling and stabbing are characteristic of classical homicide, which is distinct from the child abuse syndrome. The most common mode of death is head injury. Next in frequency is rupture of an abdominal viscus, leaving a wide range of miscellaneous injuries to account for the small remainder.

 

Concentrating on autopsy findings, the various types of trauma will be described; though many will not in themselves have caused or even contributed to death. Their recognition is none the less vital as, at the end of the examination, they may well be the decisive factors that may distinguish an accident from deliberate maltreatment.

 

One of the classic aphorisms in the study of child abuse was stated by the forensic pathologists'   ‘The skin and bones tell a story which the child is either too young or too frightened to tell.' Skin bruising is the most common injury and may be seen almost anywhere on the child's body. There are, however, certain sites of predilection which help to strengthen the diagnosis of abuse:

Ø  bruising  around the limbs, especially the wrist and forearms, upper arms, thighs and - in small infants - around the ankles. These places form convenient 'handles' for an adult to grip the child. In the small infant the lower leg bruises may indicate that the child has been held by the leg or ankle in order to swing it - and may be associated with head injuries. The older child, as an adult, may be gripped by the upper arms in order to be shaken.

Ø  The buttocks are a frequent site of bruising from hand smacks or beating with a strap. Bruises on the thigh are less common, but on the outer side may signify slaps and on the inner, possible sexual interference.

Ø  The face is often bruised, especially the cheeks and mouth area, from slaps, which may also be present on the forehead and ears. Associated damage to the mouth and eyes is common. Bruising of the scalp is harder to see because of the hair, but is often part of deeper head injury.

Ø  Bruises on the chest, abdomen and neck are usually from finger pressure rather than slaps or blows. Those on the abdomen and lower chest may be associated with deep visceral injury. Bruises may be of any size or type, but a common variety in child abuse is the small discoid lesion about 1-2 cm in diameter; these were once called sixpenny bruises' from the size of coinage at that time. These are caused by impact or pressure from the finger pads of adults, and may be seen in groups around the limbs and on the neck, chest or abdomen.

Though it is impossible to be accurate about the absolute age of a bruise, those of markedly different colors cannot have been inflicted during the same episode. The interpretation of patterns and the ageing of bruises are more fully considered but any bruise with yellow coloration must be more than 18 hours since infliction.

Skull fractures are common in fatal child abuse, often in association with intracranial hemorrhage, usually subdural, though numerically less than half of infants with subdural hematomata have skull fractures. The most common fracture lies in the occipitoparietal area, but the differentiation from accidental falls is impossible on anatomical or radiological grounds alone, in spite of the dogmatic claims of some radiologists. An infant's skull is more flexible than that of an adult and may absorb some impacts without fracturing. Occasionally, a parietal bone may 'dimple' inwards without cracking, much as a table tennis ball may be dented with a thumb. The skull of a child is much thinner than that of an adult, even though the brain size and weight is greater relative to the postcranial mass. Notwithstanding the flexibility, however, it remains a fact that an infant skull will fracture with the application of much less mechanical force than would be needed to fracture a mature skull. In addition, because the cranium is more easily deformed, a momentary depression of the skull can impinge upon the underlying brain (including membrane), damage it and return to its original shape so that, even in the absence of a fracture, brain damage is more likely to occur. There is now a large literature on infant fractures (especially of the skull) in relation to child abuse, some of it contradictory.

One aspect that arouses much controversy is the height of a passive fall which can (a) fracture a child's skull and (b) cause brain damage. The two injuries are certainly not synonymous, as it is clear that most fractures, both in infants and adults, are not accompanied by any brain damage or neurological effects. However, forces that can cause a skull fracture certainly can - though not must – cause brain or meningeal lesions, and it is impossible to forecast what will happen following a fall of even minor magnitude.

 

Though the immature skull has more flexibility, once its elastic limit is exceeded during deformation, it will fracture. The pattern of fracturing is similar to that in the adult, but there are some variations because of the presence of open sutures and fontanelles. Fracture lines tend to end at sutures, but if they cross them there is frequently a lateral displacement so that the two limbs of the fracture are not in line. Most instances where what appears to be a fracture line crossing a suture with a 'side-step' are really two independent fractures either approaching or receding from each other, the origins or terminations being slightly offset. The most common example is seen in a child who has been dropped on the vertex of the head. Both parietal bones may then deform and crack transversely from the vertex anterior to the point of impact, the bilateral fracture lines running downwards towards the parietal bosses. The upper ends of both fractures terminate in the sagittal suture, but may be 'staggered' by a centimeter or so. Another common fracture is a horizontal crack running backwards from the frontoparietal suture, which courses across the parietal bone, often turning down towards the base of the skull. This can be caused by a blow or fall on the side or top of the head. Such fractures can occur bilaterally, which is then an indication of an impact on the vertex of the skull, which causes marked depression of the top of the skull with crack fractures along the lines of maximum stress. These are then more marked on the outer aspect than the inner table - though the diploe of infants' skulls are absent or only partially formed, according to the age. Of course, such bilateral fractures can also be caused by two separate impacts on each side of the head; here multiple bruises on or under the scalp may assist in interpretation.

Limbs fractures provide some of the most characteristic signs of child abuse, as injuries are common around the metaphyses and epiphyses of growing bones, as well as being the cause of periosteal lesions. Most of the limb injuries are indirect, that is, the bone damage is caused by stresses from abnormal angulation, torsion or traction, rather than from a direct impact upon the bone. Swinging the child by the wrists or ankles, dragging it by an arm or shin and violent shaking using the limbs as 'handles', are the usual mechanisms. Avulsion of the metaphysis or chipping of the edges of the metaphyses or epiphyses may occur, with small fragments seen isolated on radiographs. Swinging, wrenching or twisting actions can fragment the metaphysis. Small pieces of the adjacent cortex and parts of the provisional zone of calcification may be avulsed from the shaft. The epiphysis may even separate from the metaphysis.

In early infancy it must be appreciated that some breech deliveries have legs that radiologically show long, smooth periosteal thickening secondary to subperiosteal bleeding caused by handling during delivery. It is also accepted that mere growth can produce faint subperiosteal calcification, but this is symmetrical and limited to the central' parts of the shaft, keeping clear of the metaphyses. In child abuse, ribs are commonly fractured, often several consecutive bones being affected on one or both sides. The damage may be fresh or old, giving different radiological appearances. The most characteristic picture of old fractures is of sequential callus formation seen in a vertical line down one or both paravertebral gutters.

Damage to internal organs is almost always confined to the abdomen, as the heart and lungs are rarely injured. As stated earlier, rupture of an abdominal viscus is the second most common cause of death in child abuse.after head injury. Forcible impacts on either the lower chest or the abdominal wall are responsible. Direct punching or heavy 'prodding' are the usual mechanisms rather than being dropped or thrown, which is a common cause of head injury. Often there will be an excuse that the child fell or tripped upon some protruding obstruction, such as a toy or piece of furniture; occasionally this may be true and it is a matter of fact and interpretation as to whether the circumstantial evidence is compatible with the medical findings. The liver is frequently injured, the most common lesion being a deep tear in either lobe, sometimes being a complete penetration or, more rarely, actual detachment of hepatic tissue. A haemoperitoneum results and in fatalities, may be the proximate cause of death. A heavy blow over the lower ribs or xiphisternal area is the most likely site of impact. The small intestine is the other common target organ, the duodenum or jejunum being the most frequent site of damage. The second part of the duodenum is vulnerable to blows in the central abdomen, as beneath this area, the duodenum crosses the midline and is liable to be 'sandwiched' between the compressed anterior abdominal wall and the promontory of the lumbar spine. As the tissue thickness is small in a child, the gut can be virtually 'guillotined' at this point and may be completely transected, appearing almost as clean-cut as if it had been done with a surgical knife.

Unfortunately, thermal injuries are by no means uncommon in abused infants. These may be moist scalds, dry burns or, exceptionally, electrical injuries. Scalds result from dipping in hot fluid and often involve over-hot bath water. The line between accident and abuse may be blurred in some cases, but it can occur as a form of chastisement. In one case, a child was deliberately held in water at over 80°C as a punishment for persistently complaining about being cold. Other scalds may be from boiling water from a kettle or saucepan deliberately being poured over the child. Dry  burns can be inflicted in innumerable ways as a deliberate and sadistic act. Children have been forcibly sat on electric cooking rings and hotplates, branded with hot shovels and electric soldering-irons, or pressed against the bars of a fire. A particular type of burn seen relatively often in abused children is never the cause of death but may be found incidentally. This is the cigarette burn, seen most often on skin not normally covered by clothing, such as the hands, arms, neck and head. Such burns are usually circular, but not always; if the cigarette has been held obliquely against the skin, the mark may be triangular. The regular shape and size usually indicate the nature of the burn, though some skin diseases may simulate an old burn, such as a small patch of impetigo. Fresh cigarette burns are red, sometimes with a narrow rim of a deeper red. When healing, they become pink and later have a silvery sheen on the surface.

A variety of injuries, some bizarre and sadistic, occur from time to time in battered children. The hair may be pulled out in clumps (epilation), leaving pseudo~lopecia on the scalp. Fingers may be broken by hyperextension and fingertips crushed by blows or other means. Patterned marks from straps and ropes may be seen on the skin, usually on buttocks, thighs and abdomen. 'Pinch' or 'tweaking' marks are not uncommon, made by the skin being nipped between adult fingernails. These appear as two small opposing semi-circular or triangular bruises, often with a clear zone between them.

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