Case 29

A 5-year-old boy was brought to the emergency department by the police. They were notified by one of the neighbours, who heard him crying. The child stated he wet his pants and his mother asked her boyfriend to ‘pop’ him on his hands with a comb. The boyfriend also had him stand in the corner without changing his wet pants for hours. His hands are shown in Image 29a. Images 29b, 29c and 29d show additional skin findings. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig29a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig29b.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig29c.jpg"/> 66 https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig29d.jpg"/>

What do the images show?

What is your diagnosis?

68There is bilateral swelling of the child’s hands (Image 29a). There are also multiple pinpoint abrasions on the dorsa of both hands, especially the left. The child stated those were from being hit hard with the comb, which he referred to as ‘popping’. The distance between the abrasions matched the comb that the child described which was found in the home. The child had a full physical examination with a detailed exam of his skin. He had multiple patterned marks on the lateral, medial and posterior aspects of his left leg as shown in the photos. He disclosed he was whipped with a belt as well as with a cord. The patterned marks and loop marks were consistent with his disclosure. Physical discipline involves usually concealed areas of the body such as the buttocks, thus the skin should be examined in detail. This case needs to be properly recognized by the physician and reported to Child Protective Services to prevent further injury and possible death.

Children usually sustain abuse at the hands of a caregiver who misinterprets the child’s behaviour as naughty and responds inappropriately as in this case when the child wet his pants. The American Academy of Pediatrics has proposed that ‘striking a child with an object’ is a type of physical punishment that ‘should never be used’. ¹ Corporal punishment has deleterious side effects as in this case and is of limited effectiveness. It is very important in this case to document all the disclosures made by the child and obtain a thorough history from the child as well as the parent. Physical examination in this child has to be thorough and include a careful skin examination. The physical examination has to accomplish three main objectives: (1) medical – to assess the physical injury and develop an appropriate treatment plan; (2) psychological – to afford the child a sense of safety; and (3) legal – to provide documentation that may be used as evidence of child maltreatment. ²