Occult Abusive Abdominal Injury

Lurking Injury

 

Numerous trauma related topics have been covered within the Morsels (ex, pneumothorax, c-spine injury, aortic trauma, head trauma), but, unfortunately, not all trauma that children suffer is accidental. Non-accidental Trauma / Child Abuse is a prevalent concern for us as we care for children.  We are all acutely aware of the devastating injuries that are associated with non-accidental trauma.  This Morsel is meant to remind us that once we find one injury, don’t stop looking… as the risk for another is still present.  This is particularly true with respect to an occult abusive abdominal injury!

 

Abusive Abdominal Injury Kills

  • Relatively rare (0.5-11% of cases), but is the 2nd leading cause of child abuse associate mortality (head injury is #1).
  • Mortality rates as high as 45%.
  • Estimated that abdominal trauma contributes ~50% of abusive fatalities. (Maguire, 2013)

 

Anatomy Matters

  • The young patient has several anatomic factors that make him/her more susceptible to blunt abdominal trauma.
    • Less protective covering.
      • Thinner abdominal muscles and less fat.
    • Less protective ribs.
      • The compliant ribs do not dissipate force.
      • That transmitted force now is absorbed by the underlying organs and structures.
    • More exposed solid organs.
      • The diaphragm is more horizontal compared to older patients.
      • The liver and spleen are, thus, more anterior and less protected by rib cage.
  • All abdominal organs are at risk for injury. (Maguire, 2013)
    • Solid Organs
      • Liver injury is the most commonly seen in hospitalized patients (64%).
        • Abuse is reported as being the 2nd or 3rd most common cause of hepatic injury in children, after MVCs.
      • Kidney (19% of hospitalizations)
    • Hollow Organs (12% of hospitalizations)
      • Duodenal perforation, transection, and hematoma have been documented.
      • Often present in delayed fashion (as you’d expect).
      • Duodenal perforation is so rare in kids < 5 years of age, that if found, abuse should be suspected.

 

Age Matters

  • >25% of ALL abdominal trauma in children < 1 year of age has been shown to be due to abuse. (Lane, 2012)
    • Infants have the highest rates for abusive abdominal trauma (17.7 cases / million in 2006).
    • Toddlers also have high rates.
  • Infants and Toddlers cannot communicate well so abdominal complaints can be missed.
  • Abdominal trauma sustained by an infant or toddler should make us consider the possibility of abuse.

 

 It Is Often Occult

  • It is estimated that 6-8% of abused children will have abdominal injury without overt signs.
  • The history can be purposefully deceiving (alternating or evasive stories) and the child cannot communicate well to relay clues.
  • The exam can be deceiving.
    • Difficult to detect because of few external signs.
    • The compliant rib cage will not often fracture.
    • External bruising is not often present – as few as 12% will have it. (Ledbetter, 1988)
    • If there are abnormal findings (tenderness, distention, bruising) then the likelihood of finding abdominal injury is 5 fold greater!
  • Lab Tests can be deceiving.
    • Similar to accidental pediatric abdominal trauma, the utility of a normal set of LFTs and Lipase is low.
    • Abnormal values, however, do warrant imaging (with a CT scan… U/S won’t be good enough as kids are less likely to have free fluid with their intra-abdominal injuries).

 

Stay Vigilant

  • The high mortality associated with this condition demands our respect, despite the fact that it is rare and may be difficult to detect.
  • First of all, stay vigilant, especially AFTER you have already found one injury.
    • Great job catching that rib fracture (which is definitely concerning for abuse in young kids), but don’t get complacent.
    • Abdominal injuries were often found with other associated injuries.
    • Like with other trauma, once you find one injury, look harder for the other one. 
  • Labs?
    • Personally, I have a low threshold for getting LFTs and Lipase and U/A in a child that has a defined abusive injury.
    • But know that normal labs do not rule out the presence of an abdominal injury.
    • They also do not look at possible splenic, adrenal, or small bowel injury.
  • Clinical Vigilance and repeat exams trump labs.

 

References

Maguire SA1, Upadhyaya M, Evans A, Mann MK, Haroon MM, Tempest V, Lumb RC, Kemp AM. A systematic review of abusive visceral injuries in childhood–their range and recognition. Child Abuse Negl. 2013 Jul;37(7):430-45. PMID: 23306146. [PubMed] [Read by QxMD]

Lane WG1, Dubowitz H, Langenberg P, Dischinger P. Epidemiology of abusive abdominal trauma hospitalizations in United States children. Child Abuse Negl. 2012 Feb;36(2):142-8. PMID: 22398302. [PubMed] [Read by QxMD]

Wood J1, Rubin DM, Nance ML, Christian CW. Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma. 2005 Nov;59(5):1203-8. PMID: 16385300. [PubMed] [Read by QxMD]

Ledbetter DJ1, Hatch EI Jr, Feldman KW, Fligner CL, Tapper D. Diagnostic and surgical implications of child abuse. Arch Surg. 1988 Sep;123(9):1101-5. PMID: 3415461. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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4 Responses

  1. October 22, 2015

    […] Unfortunately, must also consider Abuse. […]

  2. June 3, 2016

    […] Highly consider abuse in children with rib fractures! May even want to consider extra thoracic injuries. […]

  3. October 7, 2016

    […] Free intra-abdominal fluid? – Is there occult trauma?? […]

  4. July 21, 2017

    […] “Funny” story that changes? –> Head CT and evaluate for NAT […]

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