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Thoracic injuries Blows or compression injuries to the thorax may fracture the ribs, and in a few cases damage the lungs, or more rarely the heart or great vessels. Haemothorax, pneumohaemothorax, haemopericardium and intra-pulmonary haemorrhage may be seen although they are rare in abused children, and their immediate diagnosis and treatment is the same as for those conditions following severe accidental injury. Proper attention to the history and to the family situation should help to avoid missing cases of child abuse.

Secondly, the child may be flung against an object. If it is hard like a wall the skull may fracture and there may be an overlying skin bruise. If the head hits a soft surface like a bed or upholstered chair there may not be a fracture or any sign of external bruising to the head. Signs of grasping and metaphyseal injuries should be sought. In sudden deceleration injuries the tiny veins crossing the subdural space from brain to dura are ruptured and slow oozing of blood gradually produces a subdural haematoma, usually bilaterally.

Smothering with a pillow or a plastic bag leaves little evidence, and at autopsy can be difficult to differentiate from the sudden infant death syndrome. Families are on record where more than one child has been dealt with in this way. Poisoning which kills the child may be unsuspected and passed off as a cot death. A very careful immediate history and inspection of the home is needed as well as a careful assessment of all past events to the child and siblings. The nature ofthe parent/child relationship also needs careful study99.

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Count with Tigger!

by Charles

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