Eye findings related to SBS have been researched in greater detail in recent years. Therefore it is particularly important that physicians and ophthalmologists educate themselves appropriately on the implications of intraocular injury, because of the possibility of child abuse. Through keeping themselves up to date on the latest medical research, performing recommended examinations by the American Academy of Pediatrics and ruling out all differential diagnoses, ophthalmologists will be able to make a significant contribution as part of the interdisciplinary team that is needed to work with families and young victims.
BODY FRACTURES
When a child is shaken, it may be an isolated incident or he or she could be caught up in a cycle of abuse. Fractures are seen approximately one third of the time, depending on the type of fracture. Two of the most common are skull and rib fractures.
Skull fractures come about from impact after shaking. When a perpetrator shakes an infant, he or she may slam the infant down on a hard floor, against a wall, etc. Besides the trauma to the brain that is caused by shaking and impact, a skull fracture may occur.
There are different types of skull fracture. The most basic type of fracture is a linear one, which is a simple straight line that crosses through the full thickness of the bone. Infants and young children may sustain a depressed, or “ping-pong,” fracture due to the immaturity of the elastic skull.
The depressed skull fracture occurs when a small area of skull is displaced inwardly (much like a ping-pong ball that stays depressed when pressed upon). These types of fractures can occur when a child is hit with something or impacts against an object. Depressed fractures have also been seen when a child accidentally falls onto an object, such as a small toy. The shape of the fracture can even take on the shape of the object that has made the injury.
A comminuted fracture is one where a section of the child’s skull breaks into small pieces. This is caused by a major blow to the head. In newborns, comminuted fractures have been produced from vacuum extractions at birth, but this is a very rare event.
Growing skull fractures are associated with underlying trauma in the brain. When a mass is formed and grows, it can press against a simple linear fracture and cause it to expand. This is a rare complication of head trauma and is generally seen only in infants and young children. Growing skull fractures are considered an emergency, since the brain can herniate (or extrude) through the fracture site.
In the case of shaking, there may be signs of both old and new skull fractures, where an infant or child has been caught in a cycle of abuse.16
Skull fractures in infants and young children occur in accidental situations, but any fracture must be thoroughly evaluated by medical and law enforcement professionals to rule out abuse. Several issues must be addressed, including: timeline of injury, nature of injury, height of fall (if this is reported), hardness of impact surface, plausibility of story, underlying brain trauma (significant for abuse), type of fracture, witnessed fall, etc.
Rib fractures present a different problem for the caregiver reporting the injury, because these fractures are highly associated with child abuse. Because infants and young children’s ribs are supple, it requires a great deal of force to cause breaks in the rib bones. Typical abusive fractures of the ribs are lateral (on the sides) and posterior (in the back), because of the way that a perpetrator’s fingers grasp the child. There have been few reports of accidental rib fractures in cases of CPR, and these have occurred in the anterior (front) portion of the infant rib. There have been no reported cases of CPR-induced posterior rib fractures.
Rib fractures occur (as previously noted) in approximately 30 percent of SBS cases. During a shaking event, the perpetrator often squeezes an infant or child hard, which can cause rib fractures. When a medical exam (chest x-ray) finds rib fractures and there is no reasonable story presented by the parents or caregivers, then child abuse should be the first line of thought among medical professionals. Laboratory tests can rule out other types of medical conditions from which a child may suffer (e.g., osteogenesis imperfecta, rickets and other bone deficiencies), but abusive acts are the number one cause of rib fractures in infants and young children.
Radiologists can also determine if new or old rib fractures are present based on x-ray images. Older, healing fractures appear to have globs surrounding them, which are actually calcium deposits that formed in the healing process.
The final type of fracture that shaken babies can develop is the metaphyseal lesion. Infants and children have growth plates (epiphyseal plates) at the end of their long bones (elbows, wrists, ankles, etc.). These plates are actually growing tissues and help determine the length and shape of the mature bone when the child reaches adolescence. Growth plates are fragile and can be “fractured” by abusive acts. When a child is violently shaken, his or her arms may flail in the air, which can lead to injury of the growth plates. These types of fractures may not be seen immediately after a shaking event, so a series of x-rays may help diagnose the injuries as calcium begins to form. Metaphyseal lesions (occurring in the metaphysis [wide part] of the long bone) are also known as “bucket-handle” or “corner” fractures depending on the angle of the x-ray image. Growth plate injury can also occur from pulling or twisting arms and legs. Injuries to growth plates, depending on severity, can cause premature growth arrest and deformity.
DIFFERENTIAL DIAGNOSES IN FRACTURES
There are many diagnoses of problems, diseases and injuries in infants and young children that are known to cause fractures, including diseases such as osteogenesis imperfecta, copper insufficiency, rickets, osteomyelitis and others. These conditions can be diagnosed through lab testing and medical work-ups. When fractures are present in infants and young children (especially pre-mobile infants), the frontrunner diagnosis to be considered is child abuse. If the fracture is accidental, then the history of the injury should be appropriate for the present fracture. Was the injury witnessed? Or was it suddenly discovered? As in any potential child abuse investigation, it is vital that story of the accident be well described. A lump on the back of a five-month-old’s head, which turns out to be a skull fracture and was “just found” makes no sense. The infant’s head needed to have impacted something, or something impacted it.
CONSEQUENCES OF SHAKEN BABY SYNDROME
It is a sad and alarming fact that between 60 and 70 percent of infants identified as having been shaken are faced with dire consequences, including death. The rest may seem to recover well from being shaken but still have residual effects. Truly, the lives of not just the victims, but their entire families change as a result of a brief act of violence. Millions of dollars are spent each year in the rehabilitation of shaken infants and toddlers. The expenses include costs for equipment and services, costs for daily care and, even more importantly, emotional costs.
In the next chapter, some of the main consequences that a shaken infant may face will be discussed.
ATTENTION PROBLEMS
Because the brain has some resiliency in response to traumatic injury, there are children who experience minimal after-effects following an incident of shaking. One such effect might be an Attention Deficit Disorder (ADD) with or without hyperactivity. With an attention disorder, children may appear to ignore what a parent or caregiver is saying to them. They may also be easily distracted and need careful monitoring and clear instructions on adult expectations.
Certain stimulant medications can help a child experiencing attention problems to focus by counterbalancing the overproduced stimulating chemicals of the brain. Parents and caregivers should consult their physicians to discuss behavioral or medical options to assist with their child’s needs. Before a diagnosis of ADD is formally made, the child should also receive psychological testing and evaluation. School personnel should be made aware if a child is diagnosed with ADD, so that special programs or consideration can be arranged.
BALANCE PROBLEMS
Balance