Nurses play a vital role in identifying suspected child abuse cases. In the more evident cases of abuse, the signs may be visible — broken bones, bruising and bleeding. More frequently, however, identifying child abuse comes only after reviewing patterns of injuries over time.
Recognizing child abuse can be challenging for even seasoned professionals, but missing a case can have devastating consequences. Advanced practice registered nurses (APRNs) are among the professionals who have legal and ethical obligations to report suspected abuse to authorities and understand how child abuse assessment tools are utilized.
In a recent Journal of Radiology Nursing article, Angela Karakachian, MSN, RN, et al., said nurses should have a basic understanding of the mechanisms associated with common fractures and must remain vigilant when collecting information from caregivers.
“Nurses working with pediatric patients play a large role in recognizing and preventing child abuse because the nurse is often the first to assess the patient, gather a story and triage the patient,” said Karakachian, a visiting instructor at the Duquesne University School of Nursing. The article, “Understanding the Importance of Radiology Screening When Suspecting Child Abuse,” is co-authored by Kathleen Sekula, PhD, PMHCNS, FAAN, a Duquesne University School of Nursing professor, and Dr. Adelaide Eichman of the Children’s Hospital of Pittsburgh.
For registered nurses who are pursuing higher degrees, including Master of Science in Nursing (MSN) degrees, learning about the appropriate child abuse radiology screenings is crucial for doing their work. As family nurse practitioners (FNPs), APRNs may diagnose fractures that are later determined to be child abuse.
Common Bone Fractures Attributed to Child Abuse
Medical experts say bone fractures are among the most common types of injuries to result from child abuse. The most frequently seen types and locations of abuse-related fractures include:
- Classic metaphyseal lesion (CML)
Also known as the corner or bucket-handle fracture, the CML is a long-bone fracture that often occurs as a result of pulling or twisting and is common in children who have been violently shaken. CMLs often occur in the proximal tibia (just below the knee).
- Diaphyseal fracture
Diaphyseal fractures occur in the double-bone area of the forearm. They are an indicator of child abuse when they occur in non-mobile children.
- Rib fracture
Posterior rib fractures in children are typically associated with abuse because they are frequently caused by the child’s chest being squeezed. In the Journal of Radiology Nursing article, researchers said posterior rib fractures are “essentially never caused by accidents.” Lateral rib fractures are also concerning but can be a result of accidental trauma.
After a physical assessment of possible injuries, medical staff will often order child abuse radiology tests. Because bone growth differs between children and adults, professionals recommend imaging screening tools in cases of suspected child abuse.
Radiological Screening Tools
Because bone fractures make up a majority of physical abuse injuries, healthcare providers should understand the detection mechanisms used, researchers said. Skeletal surveys, also known as bone surveys, are the most commonly employed and recommended child abuse assessment tools. With high-quality X-rays, healthcare providers can examine each bone individually to determine if a child has new or healing fractures.
Pediatric imaging scans use special equipment designed to reduce exposure to radiation. Through the skeletal survey, providers take images of at least 15 areas in the body, including arms, legs and ribs. In the case of areas of concern, a second skeletal survey is used for further determination.
“The skeletal survey is widely available and inexpensive in comparison with alternative imaging modalities. Other important advantages of the skeletal survey include a high sensitivity for most acute and healing fractures and a relatively low radiation burden,” the authors of “Imaging in Child Abuse” on Medscape.com said.
Because skeletal surveys are considered the gold standard for diagnosing bone breaks in nonverbal children, other radiological tests are used to supplement the survey, including the following:
- Radionuclide bone scan
Also known as a skeletal scintigraphy, this nuclear medicine imaging test is known to reveal subtle fractures and the formation of new bone after a fracture. Although the test uses low doses of radiation, medical providers recommend limiting the child’s exposure.
Researchers said scintigraphy can be an important diagnostic tool but has some flaws when being used on children. Due to the variation in bone structure and appearance throughout childhood, having a physician who is well-versed in interpreting the results is critical.
Ultrasound is sometimes used to detect long-bone and skull fractures in children. While it is not a replacement for bone surveys, it can be used as a complement to X-ray studies. The American Academy of Pediatrics (AAP) said the ultrasound is not appropriate for identifying small subdural hematomas and should not be used in suspected child abuse in an emergency setting.
- CT and MRI
Most medical professionals order CT scans in suspected child abuse, particularly if the injuries might include skull fractures. The CT, also known as a CAT scan, is excellent at detecting epidural, subarachnoid, subdural and intraparenchymal bleeding as well as facial, skull and soft tissue injuries.
“Anytime an acute head injury is suspected, CT scan should be the imaging of choice to determine the severity and consequences of the trauma,” Karakachian, et al., said in the Journal of Radiology Nursing article.
At the same time, the MRI is better at detecting old injuries and can be used as a secondary test to identify head injuries. An MRI is good for providing information about brain trauma, including edema and hemorrhaging.
The Nurse’s Role in Protecting Child Abuse Victims
APRNs and other healthcare providers are in a position to identify cases of abuse and report their suspicions. While remaining vigilant to any suspected cases of abuse is important, nurses should be cautious about presenting quick accusations. Some bone fractures may be a result of bone disease such as rickets.
In determining child abuse, providers should follow AAP guidelines for gathering information, which includes taking a detailed medical history of the child, noting the location and types of fractures, and noting any other injuries.
As FNPs, APRNs work as primary care providers in a number of settings, including hospitals, doctor’s offices and private practice. In performing their duties, FNPs, like other providers, must be able to identify possible child abuse, the severity of the injuries and the required medical interventions.
About Duquesne University’s Online MSN Family (Individual Across the Lifespan) Nurse Practitioner Degree Program
Duquesne University’s online MSN FNP program prepares APRNs for a career working alongside physicians and in private practice. The coursework is presented entirely online so nurses can continue their careers and personal lives while pursuing their educational goals. APRNs take part in coursework and clinical experiences that help them better understand child abuse and the related screenings.
The online MSN FNP program prepares APRNs for the American Academy of Nurse Practitioners Certification Board (AANPCP) and American Nurses Credentialing Center (ANCC) Family Nurse Practitioner certification examinations. For more information, contact Duquesne University today.