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]

Examiner: The carer says the rib fractures were from CPR. [6]

Strong answer: That is the common defence and it does not hold. Maguire's systematic review shows rib fractures from CPR are rare and usually anterior or lateral; posterior and multiple lateral-arc fractures are not explained by CPR. I would proceed with the full work-up. [6]

Examiner: How do trauma care and safeguarding fit together? [1]

Strong answer: They run concurrently, not sequentially. I resuscitate with the paediatric trauma team and operate for peritonitis or instability, while the child-protection team is notified, the mandatory report is filed, and forensic documentation proceeds. Disposition must guarantee a safe place — never discharge to the index household before the MDT case conference. [1]