Bone injuries

A fracture like any other injury, should never be interpreted in isolation, but rather, it must be interpreted and assessed in the context of a child’s medical and social history along with their developmental stage and the explanation given. After bruising, fractures are the second most common type of non-accidental injury occurring in children. Therefore, medical professionals are obliged to be on the lookout for signs of child abuse when they treat children who have sustained broken bones.

Some of the different types of fractures include:

• A metaphyseal fracture refers to an injury to the metaphysis which is the growing plate at each end of a long bone. This type of fracture can also be known as a corner or bucket fracture.
• Metaphyseal fractures are usually associated with non-accidental injury and can be misdiagnosed as an injury resulting from child abuse because it is extremely uncommon for an infant to sustain this type of injury as a result of normal activity or even a fall.
• A greenstick fracture is where the bone simply bends and cracks on one side rather than completely breaking mainly because children’s bones are softer and more flexible than adults as they are still growing.
• A hairline fracture in a child is a fracture that does not go all the way through the bone, ie it can be described as a crack.  Without medical attention, the fracture may get worse.
• Rib fractures are one of the most common types of fractures associated with child abuse.  These types of fractures are caused by compression or squeezing of the ribs.

Head injury

A head injury or skull fracture can be very serious, even if the child initially seems fine. As the skull protects the brain, a skull fracture can also cause a brain injury. A skull fracture is caused by an injury or trauma to the head, for example from a fall from a height or a blow to the head.

There are several signs and symptoms to look out for if your child has hit their head:

• a lump or dent on the head
• bruising or swelling on the head
• headache
• confusion or disorientation
• dizziness
• nausea or vomiting
• loss of consciousness
• clear fluid or blood running from the nose or ears
• bruising around the eyes (panda eyes)

There are four main types of skull fracture:

• Linear fractures are the most common. They are generally straightforward breaks in the skull.
• Depressed fractures are where the skull has been pushed in. Surgery may be needed to lift the bone if it is putting pressure on the brain.
• Diastatic fractures are when a break occurs in more than one of the bones in the skull that are connected together causing the joint to widen. This is usually found in young children because the bones in the skull have not fused together properly yet.
• Basilar fractures are the most uncommon and appear at the base of the skull and can risk damage to the spinal cord.

Brain injuries – Shaken baby syndrome

Shaken baby syndrome is a type of brain injury that occurs when a child is shaken violently causing swelling, bruising, and/or bleeding in and around their brain. Shaken baby syndrome may damage a child’s eyes, neck, and spine as well. Given that infants’ heads are very large and heavy in proportion to the rest of their bodies when a child is shaken, their brain bounces back and forth against the sides of their skull. The resulting injuries can have long-term effects and can lead to brain damage, permanent disabilities, and death. It can be caused by and not limited to:

• Bouncing your baby on your knee.
• Tossing your baby in the air.
• Bicycling with your baby.
• Accidental falls off furniture.

Shaken baby syndrome can cause a child to suffer the following injuries:

• Direct brain trauma: This can occur when your child’s brain strikes the inner surfaces of their skull.
• Brain damage: Brain damage can result from a lack of oxygen if your child stops breathing during shaking.
• Brain cell damage: This can occur when injured nerve cells release chemicals that add to the oxygen deprivation to your child’s brain.
• Retinal hemorrhages: Bleeding in the back of your child’s retinas.
• Neck and spinal cord damage: Injuries to your child’s cervical spinal nerves.
• Fractures: This may include skull fractures as well as fractures to your baby’s ribs, collarbone, arms, and legs.

Severe immediate signs of shaken baby syndrome may include unconsciousness, seizures, and shock. Other symptoms may include the following:

• Not smiling, babbling, talking, or extreme irritability.
• Vomiting.
• Poor appetite or feeding problems.
• Breathing difficulties.
• Lethargy (extreme tiredness, lack of movement, and/or an inability to stay awake).
• Pale/blue colored skin or bruises on their arms or chest.
• A large head or forehead.
• A bulging soft spot on the top of their head.
• Inability to lift their head.
• Widened (dilated) pupils or inability to focus or follow movement with their eyes.
• Tremors.

This is not an exhaustive list, and it is to be noted that sometimes there are no obvious external signs of physical violence or injury.

Skin injuries

There are a number of different types of skin injuries, the most common ones are as follows:

Cuts, lacerations, gashes, and tears. These are wounds that go through the skin to the fat tissue. Caused by a sharp object.

Scrapes, abrasions, scratches, and floor burns. These are surface wounds that don’t go all the way through the skin. Scrapes are common on the knees, elbows, and palms.

Bruises. These are bleeding into the skin from damaged blood vessels. Caused by a blunt object. They can occur without a cut or scrape.

These types of injuries are very common in young children and so will be noted in the context of the child’s previous medical history and the explanation given.