Gregory Wallace, DO

A 6-month-old girl was brought to the emergency department (ED) of a rural hospital by her mother and father with fever, cough, and irritability. Both parents appeared to be developmentally delayed but acted appropriately under the circumstances.

The child was born prematurely at 34 weeks; she had a long complicated stay in the newborn intensive care unit (NICU). She had required ventilation for several weeks and the parents were certain she had been given “fluid pills” (furosemide) because of lung “problems.” When later questioned, the parents also stated that the child had received CPR on 2 occasions during her stay in the NICU.

The infant’s immunizations were up to date.

The physical examination showed the child to be small for her age. Her heart rate was 155 beats/min; respiratory rate, 48 breaths/min; temperature, 101.3°F. The child appeared well-hydrated, clean, and free of signs of trauma. She was extremely irritable, however. There was concern about lung “congestion” noted on the ED report. The 

 were as shown. The ED physician made a diagnosis of pneumonia. Rib fractures were also noted, of which the parents were unaware.

The ED physician recommended admission overnight.



By the following morning, records obtained from the NICU showed there was no history of any fractures at time of discharge 3 months earlier.

The father was very anxious; his anxiety had escalated to the point that he was asked by security to leave the hospital. He was concerned that he was being accused of child abuse. He was under suspicion at this point, but no one had yet approached him or his wife. 

The child had a head CT scan as well as retinal examination. Results of both were normal.

Child Protective Services was consulted; the mother told the social worker how the father had squeezed the baby’s chest when the baby cried. The father confessed to the police later in the day. The mother lost custody of the child for 6 months while she completed parenting classes and the father served prison time for child abuse.




Without question, this is the most straightforward case of child abuse involving rib fracture with which I have ever been involved. There was eyewitness testimony and a perpetrator confession within less than 12 hours of the clinical presentation.

Rib fractures suggest abuse and are a lone finding in 29% of skeletal injury cases.



Without the father’s confession and the x-ray films from the NICU, this case would have been very difficult to prove. It is commonly accepted that prematurity as well as administration of total parenteral nutrition or furosemide all predispose to fractures.

 The fact that this child had also received CPR would have been a point of contention as well.

 In similar cases, there are claims that rib fractures are the result of birth fractures becuase of the baby’s size or method of delivery.


1. Barsness KA, Cha E-S, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. 

. 2003;54:1107-1110.
2. Amir J, Katz K, Grunebaum M, et al. Fractures in premature infants. 

 1988;8:41-44. http://www.ncbi.nlm.nih.gov/pubmed/3121670.
 3. Dolinak D. Rib fractures in infants due to cardiopulmonary resuscitation efforts. 

2007;28:107-110.
4. Hartmann, RW Jr. Radiological case of the month. 

. 1997;151:947-948.
5. Bulloch B, Schubert CJ, Brophy PD. Cause and clinical characteristics of rib fractures in infants. 

. 2000;105:e4-8. http://www.pediatricsdigest.mobi/content/105/4/e48.full.


 

Articles

Rib fractures suggest abuse and are a lone finding in 29% of skeletal injury cases.

Rib Fractures: A Case of Abuse in a 6-Month-Old

A 6-month-old girl was brought to the emergency department (ED) of a rural hospital by her mother and father with fever, cough, and irritability. Both parents appeared to be developmentally delayed but acted appropriately under the circumstances.

The child was born prematurely at 34 weeks; she had a long complicated stay in the newborn intensive care unit (NICU). She had required ventilation for several weeks and the parents were certain she had been given “fluid pills” (furosemide) because of lung “problems.” When later questioned, the parents also stated that the child had received CPR on 2 occasions during her stay in the NICU.

The infant’s immunizations were up to date.

The physical examination showed the child to be small for her age. Her heart rate was 155 beats/min; respiratory rate, 48 breaths/min; temperature, 101.3°F. The child appeared well-hydrated, clean, and free of signs of trauma. She was extremely irritable, however. There was concern about lung “congestion” noted on the ED report. 

The chest film 

 findings were as shown. The ED physician made a diagnosis of pneumonia. Rib fractures were also noted, of which the parents were unaware.

The ED physician recommended admission overnight.

How strongly do you suspect abuse? What physical cause might mimic these clinical findings?

We invite you to leave your comments below; then 

Rib fractures suggest abuse and are a lone finding in 29% of pediatric skeletal injury cases.

Rib Fractures in a 6-Month-Old With Pneumonia: Abuse-or Mimic?

A 4-year-old girl presented to her primary care physician with these lesions that had been present for several weeks. The child’s mother was increasingly concerned that the lesions were not of an innocent nature. The first lesion had started on the anterior aspect of the child’s leg; new lesions were now spreading to the other leg and toward the groin. The mother was worried that these were sexually transmitted or abuse-related.

The mother had 2 other children and neither had any rash. The only variable between this child and her siblings was that she attended daycare.

The physician was certain of the cause of the rash, but uncertain of its relationship to child abuse.

Please click here for the answer and discussion.

This child's mother was worried that these lesions were sexually transmitted. What's your suspicion?

Progressive Rash on Child’s Leg and Groin: Child Abuse-Or Mimic?

Telephone consultation with local child abuse center provided the following reassuring information. This was a case of molluscum contagiosum, unrelated to abuse.

There were no allegations of abuse in this case. The interview provided no reason to suspect abuse and the social worker found no risk factors in the family for abuse.

After the social concerns were ruled out, the issue became a medical one. The diagnosis was molluscum contagiosum. The highest incidence of this very common viral skin infection occurs in children under 5 years old; however, the disorder is increasingly seen in sexually active teens and in immunodeficient individuals.

Molluscum spreads through direct contact from playing, sports contact, fomites, sexual activity, and breast feeding.

 The incubation period is 2 to 7 weeks, but may be as long as 6 months. Common locations for the lesions are legs, abdomen, genitals, and eyes. Coitus is not a necessary precursor to genital infection, which can occur by self-inoculation if the lesions are present elsewhere on the body. If lesions are present only on the genitals, however, it is prudent to rule out abuse.

Molluscum is self-limited; lesions generally resolve within 6 to 12 months. Nevertheless, multiple treatment regimens are available.

 Spread of the infection can be limited by covering lesions with clothing or a light bandage. Molluscum does not exclude the child from school or public swimming pools.

In this patient’s case, once the family was reassured that the lesions were not the result of abuse, no treatment was sought. After checking at the daycare and with neighborhood friends, the family found other children with the same lesions.

As with many conditions, abuse needs to be considered in the differential diagnosis of molluscum just to be complete. A through history will eliminate many possible considerations.




1. Feigen RD, Cherry JD, Demmier GJ, Kaplan SL. 

Textbook of Pediatric Infectious Diseases.

 5th ed. Philadelphia: Saunders; 2003:587;3347-3348.
2. American Academy of Pediatrics. Molluscum contagiosum. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. 

Red Book: 2009 Report of the Committee on Infectious Diseases. 

28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:466.
3. Silverberg NB. A practical approach to molluscum contagiosum. 

The mother of this 4-year-old girl was concerned that these lesions were sexually transmitted. The physician recognized them as molluscum, but was uncertain of the potential relationship of this rash to child abuse.

Molluscum Contagiosum in a 4-Year-Old Girl

A 4-week-old girl was brought to the emergency department while she was actively convulsing. The child was afebrile, but had repeated bouts of emesis. Her parents reported that she had been irritable and that her appetite had been diminished for several days. The baby had been breast-fed exclusively until a week before the ED visit. 

 Except for the fact that the family lived near an area in which western equine encephalitis was endemic, there was no other pertinent clinical history.

After seizure activity stopped with lorazepam administration, clinical evaluation was initiated. A CBC count and renal panel were ordered and the child was prepared for a lumbar puncture to rule out encephalitis.

Fundoscopy was performed before the lumbar puncture; an adult ophthalmologist confirmed the presence of retinal hemorrhages. There was no evidence of increased intracranial pressure. Findings similar to those in the 

were noted. 

 CT scans of the head were normal, as were results of the lumbar puncture. The CBC count results were normal for age. Tests of renal function were as follows: sodium, 148 mmol/L (normal, 132-141); chloride, 110 mmol/L (98-107); carbon dioxide, 13 mmol/L (normal, 16-25); potassium, 3.2 mmol/L (normal, 3.3-4.7). The glucose level was 35 g/dL.

 The ophthalmologist was not able to rule abuse in or out based on his examination because of the number of retinal hemorrhages seen on the exam. 

 Two additional lab tests were requested because of the acidosis and hypoglycemia. The lactic acid was normal; the serum ammonia was 300 mmoL/L (normal, 0-32). The hypoglycemia was treated and the child was transferred to a tertiary care center.  

 Do you suspect abuse--or do the physical symptoms suggest an underlying medical explanation? 

  

Please click here for the answer and discussion...

Answer: These symptoms were the result of a urea cycle disorder-not abuse.



 The CT scans were confirmed as normal. A bone survey was also negative. A pediatric ophthalmologist confirmed the presence of hemorrhages but felt that they were in the range of “normal” and noted that 3% of all newborns have hemorrhages as a result of the birth process. 

 The acidosis, hypoglycemia, and elevated ammonia level were ultimately determined to be the result of a urea cycle disorder. The parents were later found to be fourth cousins. There was no evidence of abuse. The family was followed for years and the issue of abuse never arose again. 

 Birth-related hemorrhages were first recorded in 1861.

 Their incidence ranges from 2.6% to  50%.

 Evidence of birth hemorrhages may be evident for up to 6 weeks. There is no evidence that seizures are related to hemorrhages.

1. Baum JD, Bulpitt CJ. Retinal and conjunctival haemorrage in the newborn. 

1970:45:344-349.
 2. Emerson MV, Pieramici DJ, Stoessel KM, et al. Incidence and rate of disappearance of retinal hemorrhage in newborns.

2001;108:36-39.
 3. Tyagi AK, Scotcher S, Kozeis N, Willshaw HE. Can convulsions alone cause retinal hemorrhages in infants? 

The ophthalmologist was not able to rule abuse in or out based on his examination because of the number of retinal hemorrhages seen.

Child Abuse-or Mimic? Retinal Hemorrhages in an Infant

A 13-year-old boy and his father presented to an emergency department (ED) stating that something was lodged in the teen’s rectum. The father, who was the boy’s primary care giver, stated that the teen had spent the weekend with his mother and her boyfriend. After the teen arrived at his father’s home, he divulged that he had had something in his rectum for 3 hours or more. The father immediately alluded to concerns of abuse by the mother’s boyfriend.

The teen stated in his father’s presence that he had been showering and then slipped on something and fell. He reported that something had gone into his rectum when he fell. He thought it was a toothpaste dispenser. His story changed a few seconds later. This time he said that when he got out of the shower he inadvertently sat on a toothpaste dispenser that was on the toilet seat. The teen gave yet another account to the radiologist when x-rays films 

 were being obtained and when his father was not present. That version of the story was equally unbelievable.

Multiple attempts to remove the object failed in the ED. Surgery was consulted.

As the hospital social workers began their investigation, the father recalled that his son had stated multiple times over the years that he did not want to go to his mother’s home. Child Protective Services was notified. 

Has this teen been abused, or is there another possible explanation?

Answer: This is not a case of sexual abuse: the foreign body was an attempt at self-stimulation. 


The teen was taken to the operating room and a toothpaste dispenser was recovered from his rectum. After interviewing the parents, the mother’s boyfriend, and the teen, there were no red flags in their interviews. The story as relayed by the mother and boyfriend fit the timeline in the teen’s disclosure. The teen’s final statement was that this had been an attempt at self-stimulation. The case was closed as non-abuse. The teen was discharged to his mother’s home for convalescence.

A review article surveyed the world literature of anorectal trauma and autoeroticism.

 One of the primary complications in a scenario like the one described in this case is perforation or pressure necrosis causing sigmoid perforation and its many ramifications. Anal stimulation is performed for sexual gratification in 60% to 78% of cases; however, up to 40% of those cases were related to sexual assault.

Of the cases reviewed, 99.1% were in males aged 16 to 80 years. In one study reviewed, only a third of the men who presented for medical care stated that they had inserted an anal foreign body. The other two-thirds of patients had only vague complaints of rectal or abdominal pain. 

As with most cases of abuse or mimics, a high index of suspension is necessary to make the diagnosis.


 1. Yacobi Y, Tsivian A, Sidi AA. Emergent and surgical interventions for injuries associated with eroticism: a review. 

This is a case of non-abuse: the foreign body was an attempt at self-stimulation.