Inflicted abdominal and thoracic injury — branching viva

Stem

A 14-month-old presents with two days of vomiting and a rigid abdomen. The carer calls it a 'tummy bug' and mentions a short fall. ^[1]

Examiner: Which abdominal injuries carry the highest specificity for abuse, and why? ^[1]

Strong answer: Duodenal and jejunal injury, pancreatic injury, and mesenteric injury. These viscera are retroperitoneal or mobile and require substantial, directed force — a direct blow, a crush, or a sudden deceleration — that a short fall cannot generate. A hollow-viscus perforation in a pre-verbal child is abuse until proven otherwise. ^{[1] [4] [7]}

Examiner: The abdomen was soft yesterday. How do you reconcile that? ^[4]

Strong answer: Perforation declares itself late. Enteric contents leak, and peritonitis with sepsis builds over twenty-four to forty-eight hours, so a soft early abdomen does not exclude a transected viscus. Delayed presentation is itself a marker of abuse. ^[4]

Examiner: What laboratory screen do you request, and when do you image? ^[3]

Strong answer: AST and ALT as a liver-injury screen, lipase and amylase for the pancreas, plus FBC, lactate, coagulation and group-and-save. I image a stable child with contrast-enhanced CT of the abdomen and chest, and use FAST in the unstable child to direct emergency surgery. ^{[3] [8]}

Examiner: What about the skeleton? ^[8]

Strong answer: Every child under two with suspected physical abuse gets a high-detail skeletal survey with oblique rib views, repeated at two weeks to reveal callus. Posterior rib fractures carry a positive predictive value for abuse of around 95 per cent in an infant. ^{[5] [8]}