Pathology
Symptoms
The affected child is often undernourished, sometimes grossly, and
shows general signs of severe neglect such as dirty skin, nappy
rash, dirty and tangled hair, uncut nails, and other signs of lack
of care and affection. There may be:Multiple bruising
Evidence of old injuries
X-ray indication of old or current fractures
Tearing of the central fold behind the upper lip
Cigarette burns
Bite marks
Sometimes indications of bleeding inside the skull or brain
The child may well be withdrawn with a facial appearance of fear
called ‘frozen watchfulness’.
Baby battering may involve violent shaking, slapping, punching,
throwing or swinging of the baby against a wall, or burning with
cigarettes. The child’s head may be struck with an instrument of
some kind. These assaults most commonly occur in the first six
months of life, and frequently involve an unwanted child. The
assault is often brought on by loss of sleep, family rows, money
worries, alcoholism, marital resentment, further pregnancy,
unemployment, excessive crying by the baby and other stressful
factors. Child abusers come from every background and may show
apparent willingness to co-operate with medical staff.
Fractures
- (From the Silenced Angles website at -
http://www.silencedangels.com/index.html
In infants under 12 months of age,
fractures are highly suggestive
of abuse. Even infants who crawl or are able to walk do not
produce enough force in their own movements to cause a fracture.
Here are various types of fractures
that may be seen in Shaken Baby Syndrome
Avulsion Fractures - These occur when a bone is pulled
or torn away from its connecting tissue. One common site of
avulsion fractures is within an infant’s spine –due to the intense
whiplash movement of shaking, because the vertebrae’s connecting
segments are pulled away from their supports. Avulsion fractures
can also occur in other bones due to pulling, twisting, or shaking.
Bucket-Handle
or Corner
Fractures
- In any given bone, a mineralized portion can appear
on a radiograph to look like a bucket-handle.
This appears on the edge of the bone between the metaphysis
and epiphysis. This
metaphyseal lesion is indicative of abuse.
Radiologists
originally thought that “corner” fractures occurred in the same area
of the bone as “bucket-handle”, but these fractures have been found
to be one and the same depending on the angle at which an X-ray is
taken.
Clavicular Fractures - The clavicle can break during an
episode of shaking if an infant is held by the shoulders and the
perpetrator's thumbs press on these bones. The force of shaking
combined with the pressure of thumbs can result in clavicular
fracture at its midshaft.
Dislocations - A dislocation refers to the abnormal
position, or displacement, of a bone from its joint. In child abuse
and shaking injuries, it is known as traumatic dislocation
Humerus Fractures - A fracture or ring of calcification
around the metaphysis of the humerus, in an infant with a
questionable mechanism of injury, should immediately raise suspicion
for abuse. The humerus is the segment of the upper arm that is one
of the long bones frequently subject to injury. Such injury occurs
in several ways: direct impact; shaking; or pulling of the upper
arm. Shaking injuries affect the humerus in a variety of ways. The
best known is the classic thorax-grasp shake where the long bones
(including the humerus) flail violently. It is in this instance
that the periosteum or metaphysis of the bone can be displaced.
Impact
Fractures - These occur from direct trauma when an
infant is slammed onto a hard surface after an incidence of shaking,
one end of a fractured bone being driven into another.
Rib
Fractures - Infant ribs, as with other growing bones,
are supple and tend to compress with elasticity. Hence, rib
fractures are rarely seen in minor injuries in children. In the
absence of a history of a motor vehicle accident or bone-effecting
disease, rib fractures in infants are usually indicative of abuse.
During a shaking episode, an infant is usually held around the
thorax and shaken. When a perpetrator shakes, their hands can
squeeze the child’s rib cage severely. Ribs, during shaking,
commonly fracture at the posterior (connected to the spinal column)
area, which is structurally their weakest area. They may also
fracture at the lateral (side) areas of the ribs. Rib fractures
also have been reported not to be a direct result of
cardiopulmonary resuscitation (CPR).
Skull
Fractures - Skull fractures, while difficult to
produce, are one of the more common fractures that occur in child
abuse. Significant trauma is needed to cause a simple linear
fracture. Skull fractures are difficult to produce in an infant
because the cranium is not only pliable, but has three lines of
sutures (“soft spots” or fontanelle). Sutures are nature’s way of
protecting the infant during the birth process, which widen or
compress to protect the brain from direct trauma. Studies have
shown that major injuries (including skull fractures) do not occur
when there is a fall two to three feet from a bed or couch;
especially onto a carpeted floor. Falls down stairs have even been
examined in a large group of children, and skull fractures are
rarely produced.
Spinal
Fractures/Lesions - Spinal cord injury to children
occur at a low rate in child abuse, less than 3 percent. Infants
have special anatomical features that help protect them from serious
injury during serious battery and shaking. An infant’s head and
weak neck muscles allow the head to freely “give” during shaking.
Perpetrators’ fingers actually may support the spine of an infant
when shaking occurs, which can diminish spinal injury as well. The
vertebrae within the spinous process (the prominent points of the
posterior ends of each vertebra) are wedge-shaped and freely move,
and the ligaments within the spinal area are supple. These features
prevent the spine from merely snapping during shaking. The trauma
of the event is displaced evenly throughout the entire length of the
spine.
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