Case 59

This 10-month-old male was left in the care of his 16-year-old uncle for several hours. When his mother returned home, she changed the baby’s diaper/nappy and noted that he had profuse diarrhoea and bruises around his anus. Upon examination in the emergency centre, he was stable, consolable and had a normal physical examination except for the injuries shown (Image 59a). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig59a.jpg"/>

What injuries are seen?

What was the likely cause of these injuries?

What is the appropriate management?

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In addition to the bruises noted by his mother, the picture shows fissures and perianal tears distributed in a wheel-spoke appearance around the anus. Some appear to be actively bleeding.

These injuries are seen with penetrating and blunt force trauma to the anus, likely secondary to sexual assault. ^1–3

Child Protective Services and the police were notified and the uncle confessed to having penetrated the baby’s anus with his penis. The uncle had a prior history of criminal sexual conduct. A sexual assault evidence kit (‘rape kit’) was used to methodically collect and store samples from the anus. The paediatric surgeons were consulted to evaluate the possibility of deep injuries to the rectum or pelvis.