Boy am I having a hard time with these posts.  Maybe it’s because I spent 20 years in the trenches as a pediatrician, many of them in the emergency departments of hospitals large and small.  I know I have a hefty case of PTSD from it all, because when I even think of writing these things my stomach goes into a knot and I have an almost uncontrollable urge to bolt.

In today’s post I want to talk about signs of physical abuse that everyone who interacts with children should know about, and be alert for, and know what to do if they see them. I went to my usual source for slides and looked at them, and found that I am no longer capable of looking at color slides of abused children without getting sick.  I guess that’s a good sign, because it means that at least I am no longer capable of dissociating when I look at the patterns of injury.  I had been planning to include some slides with this post, but now I’ve decided I won’t, because they are so heart-breaking that I really don’t want to put them up.

I used to have a slide lecture distributed by my professional organization, the American Academy of Pediatrics, that I took around and showed to teachers, school nurses, volunteer firemen, and anybody else who wanted to hear the talk or who I thought ought to hear it.  I stood up there, brave professional woman, and showed them all these gruesome pictures of inflicted injuries, knowing full well that some of the people in the audience had been abused themselves as children, and that some of them had inflicted injury on their own children.  I must have given that talk well over 50 times, and I never got through one without at least one person in the audience breaking down in tears.  It’s a hard subject.

But even harder is for the subject not to be broached, and for those who are the most likely to be on the front lines of child care to be ignorant of the signs.  How many of us have heard, over and over, about children who have had multiple reports made to Social Services regarding suspected abuse, and the case is neglected, and the child dies?  These children are dying of nothing less than torture.  So if we see or hear something that makes us suspect that a child is being abused, REPORT IT!  Where do we report it?  We usually start with the Department of Social Services, or DSS.  If they don’t act promptly, call 911.  And if you in any way suspect that a child is being abused RIGHT NOW, call 911.

Patterns of Injury

We all know that children run around careening off of every object in their world, including one another, and they all get bruises, cuts, and scrapes; sometimes they even break a bone getting torpedoed off the trampoline or crashing on their bikes.  My own son broke both of his wrists (not at the same time): one by flying over the handlebars of his bike, and the other in an unintentional (on his part) game of roller-derby.  His teacher called DSS on me.  I said, good on her!  Then he broke both of his legs, one getting tackled while playing flag football in sixth grade, and the other playing Varsity football in high school.  Nobody called DSS about those.

There are places that you normally see bruises, scrapes, and cuts: knees, elbows, cheekbones, eyebrows.  Those are the places that stick out and get whacked on inanimate objects.  And the bruises don’t look like anything in particular; they’re usually oval-ish or irregularly shaped.  Cuts are usually jagged and also over bony prominences: how many of you and/or your children have a scar on your eyebrow?  That’s because that’s the part of your face that hits the ground first.  It IS a part that gets hit by a fist first too (besides the nose), but for some reason we see this less in abuse and more in adolescent fights.

So if you see a child who has bruises on the upper arm, as if someone grabbed him, or on her back or the backs of her legs, especially if the marks are linear (as a belt would make) or in loops (electrical cord) or any other pattern, that is very likely inflicted injury.  One interesting exception is the pattern of red marks running parallel to the upper spine that the Oriental folk medicine practice of “coining” makes (rubbing up and down with a coin, usually meant to treat chest congestion), or the circular red marks of cupping, also on the back and sometimes chest.

Babies who are not yet walking, and especially if they are not pulling up on things and falling down, should NOT get bruises.  They don’t do anything that causes bruises!  Bruises can sometimes be accidental, such as a baby rolling off the changing table or couch; in those cases the caretaker is usually frantic with distress over the event and seeks medical care immediately.  That usually (but not always) rules out abuse.  But if you see a slap mark on the baby’s face or anywhere else, that’s abuse.  Bruising on the ears is a red flag for hard slapping.  Bruising over the abdomen can mean internal injuries and must be seen in the emergency department immediately.

Burns

Older kids do get burned, but the cause is always explainable: playing with fire, for instance.  Cigarette burns on an older child signal abuse: that child is probably being abused in other ways also.  Toddlers sometimes get accidentally scalded.  I have seen some horrendous accidental scalds from toddlers pulling electric tea kettles over on themselves.  Since babies’ and toddlers’ skin is so thin, it only takes a moment to produce a full-thickness (third-degree) burn in a small child.  Burns to be concerned about from a child-abuse standpoint are any burn that looks like it has a pattern to it, whether it be the punched-out holes of a cigarette or the “stocking-glove” pattern of a child who is literally dipped into hot water and pushes away with its hands and feet, so that mostly the hands and feet get burned to the same extent.  Some brilliant caregivers get angry with a child who is being potty trained and has an accident, and immerse their bottoms in scalding hot water.  I can’t imagine what goes through these sadists’ minds.  I won’t go through all the varieties of burn patterns, but at this point (if you’re still with me) you get the idea that if there is a pattern to the burns and/or bruises, it’s most likely inflicted injury and must be reported immediately.

Broken bones

It’s hard for a lay person to assess broken bones in patterns of abuse.  One thing that is clear, if you are a caregiver such as a babysitter or a daycare teacher, is that if a baby who was crawling, pulling up, cruising along the furniture or walking, suddenly stops doing this, there’s something wrong.  If the baby simply won’t move a limb or cries when you move it for him, there’s something very wrong.  Report this and don’t be afraid.  Much better to make a report and be wrong than let a baby or child be battered at home.  Amazingly, most small children who come to medical attention for one broken bone are found, on X-ray, to have multiple broken bones in various stages of healing, indicating that this poor child has been repeatedly battered to the point of breaking multiple bones.

One notable exception to the rule that refusal to move a limb means it might be broken is the pesky “nursemaid’s elbow.”  It’s and accidental injury that comes from holding a small child (9 months-3 years) by the hand, and putting tension on the arm, such as swinging the child across puddles (fun!), pulling the child along by the hand because it has suddenly stopped (who has not done this?), or, in the case of my own child, holding the child by the hand and then he suddenly sits down.  Blam!  It pulls the head of one of the two bones in the forearm (the radius) out of its socket, and then it gets stuck and can’t get back in.  My ex-husband was taking my spaghetti-sauce-covered two-year-old son to the sink to wash him off, when my son suddenly sat down, and his screams nearly blew the roof off.  I was an intern at the time, and I had not yet seen a case of “nursemaid’s elbow,” so as we rode to the emergency department I spat all kinds of venom at my ex regarding what I was going to do to him for breaking our child’s arm.  My Pediatrics program director met us at the ER and very kindly explained the innocuous nature of the injury and talked me down from my murderous rage, and showed me how to fix the dislocation (actually it’s a subluxation, but that’s a technicality).  My first case of  subluxation of the radial head, a.k.a. “nursemaid’s elbow.” Some kids have very flexible elbow joints, as did my son: his injury recurred many times, the last time being when he was five years old and was shutting the car door.  The wind caught the door and pulled his radius out and he gave a shriek.  I jumped out and ran around to his side; but by the time I got there he had already fixed it himself.  He was very proud of that, as you may well imagine.

Well, I seem to have managed a few words here on physical abuse.  I may have to take a day or two off now, before I dive back in, as the next topic on the list is sexual abuse; not anything that anyone ever wants to talk about, including me.  But it must and will be talked about.