eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect: Physical Abuse

Author: Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Coauthor(s): Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Contributor Information and Disclosures

Updated: Dec 12, 2008

Introduction

Background

Physical abuse, a subset of child abuse, is defined in various ways by different states. However, common to all definitions is the presence of an injury that the child sustains at the hands of his or her caregiver. These injuries are also referred to as inflicted or nonaccidental injuries. Some states use broad definitions that encompass a wide range of injuries; other states use more narrow definitions that include specific signs and symptoms. Physical abuse can produce various injuries and injury patterns in children. This article focuses on several common examples of inflicted injury dealing with the skeleton (eg, fractures), skin (eg, burns, bruises), and CNS (eg, subdural hematoma [SDH], abusive head trauma [AHT], shaken baby syndrome [SBS]/shaking-impact syndrome).

Definitions of physical abuse

The federally funded Third National Incidence Study (NIS-3) defines physical abuse as a form of maltreatment in which an injury is inflicted on the child by a caregiver via various nonaccidental means, including hitting with a hand, stick, strap, or other object; punching; kicking; shaking; throwing; burning; stabbing; or choking to the extent that demonstrable harm results.¹

The advantage to a narrow definition is that it objectively states what is and is not physical abuse; however, such a clear delineation of circumstances likely fails to identify all possible cases of physical abuse (eg, pulling the child's hair, biting the child's skin). Definitions may also attempt to characterize the seriousness of injury; however, characterization is difficult because injuries vary greatly from mild redness on the buttocks that fades over several hours to injuries so severe that the child dies. Recent medical definitions focus more on the effect of the injury on the child and less on the perceived intention of the caregiver because the child presents with an injury in need of care to the health care provider.

Additionally, newer definitions also consider the sociocultural context in which the injury occurs; folk healing practices may cause the appearance of nonaccidental injury to the child. Finally, the effect of the physical abuse may not be limited to just the immediate injury findings. The National Center on Child Abuse and Neglect (NCCAN) estimated that 37% of children with maltreatment injuries developed a disability or special need, directly from the abusive actions or omissions of the child's caregivers.² Furthermore, NCCAN estimated that incidence of disabilities caused by or likely to have been caused by maltreatment was 147 per 1000 maltreated children.

Multifactorial nature of physical abuse

No one single cause has been identified that explains the occurrence of all cases of physical abuse. The multifactorial nature of physical abuse requires a more comprehensive amalgam of models and conceptual frameworks to account for the heterogeneous set of cases classified as physical abuse.

Circumstances that may give rise to the occurrence of a child's injury via physically abusive actions have been organized into a typology having the following 5 subtypes: (1) caregiver's angry and uncontrolled disciplinary response to actual or perceived misconduct of the child; (2) caregiver's psychological impairment, which causes resentment and rejection of the child by the caregiver and a perception of the child as different and provocative; (3) child left in care of a baby-sitter who is abusive; (4) caregiver's use of substances that disinhibit behavior; and (5) caregiver's entanglement in a domestic violence situation.

This typology describes commonly observed circumstances that may result in nonaccidental injury to children; however, it does not shed light on why the circumstance leads to a child's injury.

Ecological model of human development and interaction

The ecological model of human development and interaction is generally regarded as an ideal conceptual framework from which to approach the complex interactions among the caregiver, child, family, social situation, and cultural values leading to the nonaccidental injury or physical abuse of the child.

Environmental stress and caregiver frustration

Helfer builds on this ecological viewpoint and states that physical maltreatment arises when a caregiver and child interact around an event, in a given environment, with the end result being injury to the child.³ Viewing maltreatment in this way allows consideration of the factors that the caregiver, child, and environment contribute to placing the child at risk for injury. The caregiver is viewed as having a personal developmental history, personality style, psychological functioning, and coping strategies. The caregiver often possesses expectations of the child, and a level of ability to nurture the child's development that meets the child's developmental and caregiving needs.

The child may have certain characteristics that make providing care more complex; however, caution must be used in considering the child's contribution to the abusive interactions because the child needs safe, nurturing parenting regardless of any characteristics that he or she may possess. Specific factors that may place the child at higher risk for physical maltreatment include prematurity, poor bonding with caregiver, medical fragility, various special needs (attention deficit hyperactivity disorder), and the child being perceived as different (owing to physical, developmental, and/or behavioral/emotional abnormalities) or difficult, based on temperament style.

Finally, the environment may contain stressors that may make the caregiving less than ideal and may overextend the coping abilities of the caregiver. While exploring the role of environmental stress and caregiver frustration in the occurrence of child abuse, Straus and Kantor found a complex interaction between the amount of stress present in the family setting and the response of the caregivers.⁴ Not all stressed caregivers responded by inflicting harm on the children in the environment.

Straus and Kantor concluded that human beings have a capacity for acting violently both in and outside the family setting. Physical abuse can result if a specific home situation arises that has a relatively high degree of stress and a baseline amount of violence within it (eg, spanking the children, pushing or slapping a spouse). Thus, risk of child abuse is related to the response of caregivers whose caregiving environment has a certain amount of overall risk for violent behavior. The caregivers' level of social connectedness to nonrelatives seemed to have a role to play in the children's risk for maltreatment. Caregivers under high degrees of stress who did not participate in clubs, unions, and other organizations (ie, socially isolated) had higher rates of abusing children than those who were not as socially isolated. However, children whose caregivers had many family members living nearby did not achieve the same protective effect, as did the nonfamilial social connectedness group.

Domestic violence, intimate partner violence, corporal punishment, and child maltreatment

The relationship of domestic violence or intimate partner violence (IPV) and child maltreatment is receiving increasing attention. Each year, between 3.3 and 10 million children witness episodes of family violence; 30-59% of mothers of abused children are victims of domestic violence or intimate partner violence. Additionally, children whose mothers are victims of domestic violence or intimate partner violence are 6-15 times more likely to be maltreated compared to children living in families in which their mothers are not being battered. The American Academy of Pediatrics (AAP) recommends that pediatricians assess for the presence of domestic violence and intimate partner violence in the child's family and observes that intervening on behalf of the victimized parent (typically the child's mother) may be an effective child-abuse prevention strategy.⁵

No credible evidence in medical literature supports the continued use of corporal punishment; spanking is less effective than time out or removal of privileges for decreasing undesired behavior in children. Discipline, however, is a necessary component for child rearing, and appropriate discipline aims for limit setting, teaching right from wrong, assisting in decision making, and helping the child develop a sense of self-control.

When physical force is used as a discipline technique (as in corporal punishment), the concern arises that if the misconduct continues even after corporal punishment is applied, the caregiver then may become angry and frustrated and reapply the physical force. As the physical force is reapplied while the caregiver is becoming increasingly angry, the potential emerges for the caregiver to lose control and injure the child. Regardless of whether injuring the child was the intended outcome of the corporal punishment, the end result experienced by the injured child is that he or she has been hurt.

Caregivers who use corporal punishment are often angry, irritable, depressed, fatigued, and stressed. They apply the punishment at a time that they "have lost it," and caregivers frequently express remorse and agitation while punishing their children. To avoid this risk of harming the child and in order to model nonviolent behavior for children, many health care professionals advocate child discipline via consistent, nonphysical force based approaches such as time out, loss of privileges, expressions of parental disappointment, and grounding. Approximately one half of US pediatricians report being opposed generally to the use of corporal punishment; about one third are completely opposed to its use (about three fourths of the pediatricians reported having been spanked when they were children).

Pathophysiology

Each form of injury sustained by a child as a result of physical abuse has its own set of biomechanics and pathophysiology. This article looks specifically at the mechanisms of injury for skeletal injury, burns, bruising, and CNS injury observed in AHT, SBS, and shaking-impact syndrome.

Skeletal fractures are caused by the application of force to the bone. The child's immature skeleton is characterized by more porous bone than in the mature bone. As a result, the less dense porous bone is more at risk for compression injury and accounts for the bending and buckling injuries observed with green stick and buckle injuries. The periosteum (the fibrous membrane that covers the bone) is thicker and more easily elevated off of the bone in children. The child's joint capsule and ligaments are strong and relatively more resistant to stress than the bone and cartilage, which accounts for less joint dislocations in childhood. Finally, bone healing is more rapid in children than in adults.

Types of fractures

Several types of fractures occur in childhood and may be observed in physical abuse. Diaphyseal fractures are breaks in the mid shaft of the long bones. These fractures may be transverse if the force is applied perpendicular to the long axis of the bone; spiral if the force applied is rotational in nature. Metaphyseal fractures are microfractures through the immature part of the bone edge and often appear like chips or corner fractures on radiographs. The metaphysis is an area of rapid bone turnover in the growing infant and toddler. Rapid acceleration and deceleration forces to the extremity generate fractures.

Skull bones may be fractured as a result of direct impact to the head with a solid surface or object. The skull bones are different than long bones in that they develop within a membrane and not from cartilage as do the long bones. Fractures of the skull bones occur, and the healing mechanism observed is different than that observed in the long bones. Rib fractures may be observed in physical abuse as well. Rib fractures occur as a result of direct blows to the chest and via anteroposterior compression. Most abusive rib fractures are posterior, adjacent to the vertebral body, with the rib levering over the transverse process of the vertebra.

Bone healing and dating of injuries

Fractured long bones and ribs heal in a predictable manner, which is divided into the following 4 stages: initial healing, soft callus, hard callus, and remodeling. Orthopedic aspects of bone healing are described in Fractures, Forearm. In young children, bone healing tends to occur more rapidly than in older children and adults. This healing process permits some level of dating of injuries and allows the health care professional to distinguish new and relatively older fractures in the same child.

Dating of injuries is particularly important in the evaluation of physical abuse, because it may assist investigators in determining who had access to the child in the period of time that the injury is estimated to have occurred. Metaphyseal fractures are generally harder to date because of the relative lack of disruption in the periosteum at the time of the fracture. Skull fractures heal differently than do long bones because of their intramembranous nature; they do not heal with a large amount of callus formation and are more difficult to date. The skills and advice of an experienced pediatric radiologist should be consulted if dating of injuries becomes central to the maltreatment investigation.

Burns

Burns arise from the application of heat energy to the child's skin. Various sources such as hot liquids (scalds), hot objects (contact or dry), flame (flash), chemicals, and electricity can generate heat. Three concentric zones of affected tissues have been identified. Coagulation is the most direct contact with the heat source in which the skin undergoes immediate coagulation necrosis as the proteins denature, and no cellular repair is possible. Stasis involves less heat energy exposure than with coagulation, and these cells, though injured, have some potential for repair. Hyperemia is the least direct injury, and these cells have the greatest potential for repair.

Human skin is composed of 3 layers, the epidermis, dermis, and subcutaneous tissue. Burns are classified clinically depending on the depth of the injury and the involvement of the various skin layers. Superficial burns, which injure only the uppermost tissue of the epidermis, present as red, painful areas without blisters. Complete healing is expected from superficial burns. Deeper burns that extend through the epidermis into the upper levels of the dermis are referred to as partial thickness burns and present as painful blistering areas.

Healing varies with partial thickness burns with varying degrees of scarring depending on the level of tissue that is damaged. Finally, the deepest burns, full thickness burns, extend past the epidermis and dermis and involve the subcutaneous tissue. These burns essentially have destroyed the overlying skin, blood vessels, and associated nerves and present as white insensitive areas because of this destruction. A high degree of scarring and disfigurement result from full thickness burns.

Bruising

Bruising occurs when blunt mechanical force is applied to the child's skin to such a degree that capillaries (and potentially larger vessels) become disrupted resulting in the leakage of blood into the subcutaneous tissue. The amount of blood and size and location of the involved area account for the appearance of the bruise. If force is applied via an object, the bruise may reflect the shape and geometry of the object.

In general, a bruise progresses through a series of colors beginning with deep red, blue, or purple, then changes to a deep blue, then greenish, and, finally, resolves with a yellowish brown color. The various colors emanate from the breakdown of the extravascular blood into the components of hemoglobin. As the extravascular blood organizes itself and is resorbed, certain patterns of color change are expected; however, caution is advised because no clearly predictable chronology can be relied on with absolute certainty. Physicians should be cautious in offering dating information and, at most, only should suggest broad time ranges based on the clinical appearance and stages of healing of the bruise.

CNS trauma

CNS trauma is among the most serious forms of injury that is observed in the context of physical abuse. CNS trauma may result in intracranial hemorrhage, including (1) epidural hemorrhage, which is bleeding into the space between inner skull bone surface and the dura, frequently due to a direct injury to the middle meningeal artery; (2) subdural hemorrhage, which is bleeding into the space between the inner surface of the dura and arachnoid membranes, typically caused by sheering of the bridging vessels that go from the brain surface to the dura; and (3) subarachnoid hemorrhage, which is bleeding into the space between the inner surface of the arachnoid and the brain surface. Other CNS injuries may include contusions (ie, direct injury to the brain tissue) and intraparenchymal bleeding (ie, bleeding directly into substance of the brain).

AHT, SBS, and shaking-impact syndrome

Discussing CNS injury and physical abuse inevitably leads to a discussion of SBS or shaking-impact syndrome, which is now referred to as AHT. SBS (originally referred to as whiplash syndrome) describes a clinical constellation of findings classically described as subdural hematoma, retinal hemorrhage (found in 65-95% of cases), and skeletal fractures, such as metaphyseal fractures and posterior rib fractures (found in 30-70% of cases) sustained while the child is shaken violently back and forth. AHT represents a significant injury pattern in the realm of child maltreatment; although it is associated with the findings listed above, the core injury is to the brain cells themselves, resulting from the application of forces to the child's delicate and developing brain tissue.

AHT has been extended to include cases where the child's head is impacted against a surface, either soft or hard, and may be called either AHT or shaking-impact syndrome. Diffuse, serious brain injuries result from forces that result in rotation of the brain about its center of gravity. Such forces exceed those generated in normal childcare activities and are different from the low velocity translational forces (straight-line movement) that commonly occur in household falls. Immense angular deceleration forces may be generated with sudden striking of the child's head against a surface; these forces act on the brain tissue and cerebral vessels and generate the deleterious effect, which is not specifically from the contact forces applied to the skull.

Frequency

United States

In 2006, approximately 3.3 million reports involving 6 million children were made to Child Protective Services (CPS) agencies. Of these, 61.7% were accepted as needing further investigation, and, once evaluated, the investigations concluded that child abuse and neglect had affected approximately 905,000 children, with 16% of this total representing cases of substantiated physical abuse. The most common form of substantiated abuse in 2006 was child neglect, which accounted for 64.1% of cases, followed by child sexual abuse (8.8% of cases) and emotional maltreatment (6.6% of cases).  

The Third National Incidence Study (NIS-3) reported that, of the approximately 1.5 million estimated annual cases of child abuse, approximately 380,000 cases were identified as physical abuse, which constituted an annual incidence of 5.7 per 1000 children.¹ The incidence of physical abuse in the 1993 NIS-3 (5.7 per 1000 children) rose by 33% from the 1986 Second National Incidence Study (NIS-2) (4.3 per 1000 children). In various clinical series, skeletal fractures are observed in approximately 30% of the children, burns are observed in 9-10%, bruises are quite common and are present in approximately 40% of child maltreatment cases, and inflicted CNS injury is observed in 24% of children treated for head injury.

The Fourth National Incidence Study (NIS-4) is currently underway and is mandated by the US Congress in the Keeping Children and Families Safe Act of 2003 (P.L. 108-36); once completed, it will provide the most up-to-date epidemiologic incidence data.⁶  The NIS methodology views maltreated children who are investigated by CPS agencies as representing only the "tip of the iceberg;" thus, children investigated by CPS are included along with maltreated children who are identified by professionals in a wide range of agencies in representative communities. The NIS-4 uses data gathered from a nationally representative sample of 122 counties. CPS agencies in these counties provide data about all children in cases they accept for investigation during 1 of 2 reference periods (September 4, 2005 through December 3, 2005, or February 4, 2006 through May 3, 2006).

Additionally, professionals in these same counties serve as NIS-4 sentinels and report data about maltreated children identified by the following organizations: elementary and secondary public schools; public health departments; public housing authorities; short-stay general and children's hospitals; state, county, and municipal police/sheriff departments; licensed daycare centers; juvenile probation departments; voluntary social services and mental health agencies; shelters for runaway and homeless youth; and shelters for victims of domestic violence. The final report for the NIS-4 is expected to be available in 2009.

Finkelhor and Jones have analyzed trends in reporting and substantiation rates for child abuse and neglect from the 1990s through 2006 and have identified a decline in the number of substantiated cases of physical abuse.⁷ According to their most recent analysis, the incidence of substantiated physical abuse cases declined 48% from 1992-2006. Between 2005 and 2006, incidence declined by 3%. Cases of child sexual abuse have also declined substantially with a 53% decrease in the number of substantiated cases of sexual abuse observed from 1992-2006. However, child neglect, the most common form of child maltreatment, has not declined; from 2005-2006, substantiated cases of child neglect increased by 2%.

Mortality/Morbidity

Mortality

According to the 1993 NIS-3 study, an estimated 1500 children were known to have died as a result of maltreatment.¹ According to Prevent Child Abuse America's National Center on Child Abuse Prevention Research, in 2006 an estimated 1,530 were known to have died as a result of child maltreatment, which is an average of 4 children each day of the year.⁸ Children aged 0-3 years accounted for 78% of the child abuse and neglect fatalities, with infants younger than 1 year accounting for 44.2% of these maltreatment-related fatalities. When looking at the types of maltreatment that accounted for the fatalities, the breakdown is as follows:

• Child neglect - 43% 
• Multiple forms of maltreatment - 31.4%
• Physical abuse - 22.4% 
• Psychological abuse - 2.9%
• Child sexual abuse - 0.3%

The estimated death rate for child abuse and neglect in the United States is 2.04 per 100,000 children.

Morbidity

Different forms of injury have different risks. For example, CNS injury in younger children is particularly serious. Bruises may be superficial or harbingers of more serious deeper injury. Burns observed in child maltreatment cases tend to be highly severe. Finally, skeletal injuries may be isolated or multiple in nature and may be associated with other injuries. DiScala and colleagues conducted a 10-year retrospective of medical records in the National Pediatric Trauma Registry (NPTR) from 1988-1997; it compared hospitalized, injured children younger than 5 years to determine differences between inflicted (n= 1,997) and accidental injuries (n= 16,831).⁹  

They found that, compared with children who had accidental injury, children who were abused tended to be younger (12.8 mo vs 25.5 mo), were mainly injured by battering (53%) and shaking (10.3%), and were more likely to have a preinjury medical history of a medical problem or condition. The unintentionally injured children were mainly injured by falls (58.4%) and motor vehicles (37.1%)

National Pediatric Trauma Group registry findings.

Looking at potential long-term impacts on health and well being, Felitti et al explored the connection between exposure to childhood abuse and the connection between household dysfunction to subsequent health risks and the development of illness in adulthood in a series of studies referred to as the Adverse Childhood Experiences (ACE) studies.¹⁰ Of 13,494 adults who completed a standard medical evaluation in 1995-1996, 9,508 completed a survey questionnaire that asked about their own childhood abuse and exposure to household dysfunction; the investigators then made correlations to risk factors and disease conditions.

In order to assess exposure to child abuse and neglect, the ACE questionnaire asked about categories of child maltreatment, specifically psychological, physical, and sexual maltreatment. When asking about physical abuse, the questionnaire asked the patients if a parent or other adult in the household had (1) often or very often pushed, grabbed, shoved, or slapped them or (2) often or very often hit them so hard that marks or other injuries resulted.

In order to assess exposure to household dysfunction, the ACE questionnaire asked questions by category of dysfunction, such as having a household member who had problems with substance abuse (eg, problem drinker, drug user), mental illness (eg, psychiatric problem), criminal behavior in household (eg, incarceration) or having a mother who was treated violently. In assessing if their mother was treated violently when the patient was a child, respondents were asked if their mother or step-mother was (1) sometimes or very often pushed, grabbed, slapped, bitten, hit with a fist, or hit with something hard or had something thrown at her or (2) was ever repeatedly hit for at least a few minutes or threatened with or hurt by a knife or gun.

In addition to the questionnaire information, the standardized medical examination of the adults assessed risk factors and actual disease conditions. The risk factors included smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, a high lifetime number of sexual partners, and a history of sexually transmitted disease (STD). The disease conditions included ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis, and skeletal fractures. Once all of the data was collected and analyzed, Felitti et al found that the most prevalent ACE was substance abuse (25.6%), the least prevalent ACE was criminal behavior (3.4%), and the prevalence of physical abuse was 10.8% and the prevalence of the mother being treated violently was 12.5%. 

Overall, 52% of the respondents had one or more ACEs and 6.2% had 4 or more ACEs. The following were findings in respondents who experienced 4 or more ACEs compared with those who had none:

• Risk of alcoholism, drug abuse, depression, and suicide attempt increased 4-12 fold
• Rates of smoking, poor self-rated health, and high number of sexual partners and STDs increased 2-4 fold
• Physical inactivity and severe obesity increased 1.4-1.6 fold

Race

No significant difference in incidence of physical abuse was noted based on race; this is a consistent finding in both the 1993 NIS-3 as well as the 1986 NIS-2. In Child Maltreatment 2006, racial information for 85,324 cases of physical abuse and breakdown is as follows black (12.9%), American Indian/Alaskan Native (6.4%), Asian (14.6%), native Hawaiian/Pacific Islander (11.4%), white (9.8%), multiple racial affiliations (8.1%), Hispanic (9.6%), and unknown/missing information (12.9%).⁷

Sex

Incidence of physical abuse is nearly identical between male and female children and is not statistically different (5.8 cases per 1000 males compared with 5.6 cases per 1000 females). However, boys are at higher risk for serious injury. A specific gender breakdown for physical abuse was not provided in Child Maltreatment 2006, but overall for 882,537 cases of child maltreatment, including all forms of child abuse and neglect in 2006, 48.2% of the substantiated cases were in boys and 51.5% of cases were in girls.

Age

In the NIS-3, the comparison of physical abuse between age groups revealed only one significant difference: children aged 12-14 years had a specific incidence of 7.4 cases per 1000 children versus children younger than 2 years who had an incidence of 3.2 per 1000. The age-specific incidence estimates for the other groups were only marginally different when compared with each other. The fairly low incidence rates for children younger than 2 years may reflect a detection problem; because younger than school-aged children are less observable to community professionals, their abuse may avoid detection. Inflicted brain injuries in infants tend to be particularly severe. In Child Maltreatment 2006, the age break for 142,041 cases of substantiated physical abuse was as follows: age younger than 1 year (10%), age 1-3 years (13.2%), age 4-7 years (23%), age 8-11 years (20.6%), age 12-15 years (24.2%), and age 16 years and older (8.4%).

Clinical

History

Understanding the developmental level and abilities of the child is essential in determining if the history provided by the parent or caregiver is a possible or plausible explanation for the child's injury. Once the full extent of the injury is determined based on physical examination and laboratory workup, the health care provider can further assess the plausibility of the explanation offered by the parent or caregiver. A history that is implausible based on what a child at that level is capable of doing should raise a high degree of concern for possible maltreatment.

• Whenever a child is injured, a complete history of the circumstances surrounding the injury is essential. Basic questions include the following:
  • What was the date and time of the injury and when was it first noted?
  • Where did the injury occur?
  • Who witnessed the injury?
  • What was happening prior to the injury?
  • What did the child do after the injury?
  • What did the caregiver do after the injury?
  • How long after the injury did the caregiver wait until seeking care for the child?
• The past medical history should be explored for general health and previous trauma and hospitalizations, as well as for the source of health care and developmental and social aspects of the child's life. The following histories raise concerns for possible physical abuse:
  • Inconsistent details that change over time are offered.
  • Caregivers give implausible details not congruent with the trauma observed on examination.
  • Caregivers describe minor trauma, but the child displays major injury on examination.
  • No history of trauma is offered (so called "magical injuries").
  • Injury is described as self-inflicted and is not compatible with the age or developmental abilities of the child.
  • Caregivers demonstrate a significant delay in seeking treatment for the child.
  • Serious injury is blamed on a younger sibling/playmate. In cases of maltreatment, the history is often inaccurate and misleading.
  • Caregiver frequently changes health care facilities, pediatricians, or emergency departments.

Physical

Physical examination of the child with an injury obviously is important, and the order of the complete examination is determined by the presenting condition of the child. Children with less severe injuries in stable condition can have the injured area examined last, since that area is most likely to be uncomfortable. Severely injured children in critical condition require life saving measures first, following the standards of care for trauma life-support; other components of the examination follow from that point.

• Because physical abuse is often an ongoing pattern of unsafe care, performing a thorough head-to-toe examination is essential in order to find other areas of either current or previous injury. Physical indicators that should raise suspicion for maltreatment include the following:
  • Injury pattern inconsistent with the history provided
  • Multiple injuries/multiple types of injuries
  • Injuries at various stages of healing
  • Poor hygiene
  • Presence of pathognomonic injuries including loop marks, forced immersion burn pattern, and classic shaken baby findings of subdural hematoma, retina hemorrhage, and skeletal injuries
• Skeletal injuries in children younger than 2 years may not be obvious; therefore, a skeletal survey typically is recommended (see Workup) for the components of the skeletal survey. Fractures that raise a high degree of suspicion for inflicted injury include the following:
  • Metaphyseal fractures
  • Multiple, bilateral, differently aged posterior rib and scapular fractures
  • Multiple and complex skull fractures
  • Spinous process fractures
  • Spiral fractures in nonwalking infants
• Burn patterns that may suggest physical maltreatment include the following:
  • Patterned burns
  • Classic forced immersion burn pattern with sharp stocking and glove demarcation and sparing of flexed protected areas
  • Splash/spill burn patterns not consistent with history or developmental level
  • Cigarette burns
• Additionally, other concerning aspects to the burn physical examination that should raise the concern for possible abuse include the following:
  • Incompatible history and physical examination
  • Incompatible burn and developmental level
  • Bilateral or mirror image burns
  • Localized burns to genitals, buttocks, and perineum (especially at toilet training stage)
  • Evidence for excessive delay in seeking treatment, and the presence of other forms of injury
• Bruising over bony prominences are common in childhood, but patterns of bruising that raise the concern of possible abuse include the following:
  • Involvement of multiple areas of the body beyond bony prominences
  • Bruises at many stages of healing
  • Bruises in nonambulatory child
  • Markings resembling objects, grab marks, slap marks, human bites, and loop marks
• A child with CNS injury often is seriously ill, presenting in a life-threatening condition with seizures and respiratory arrest.
  • For serious life-threatening injury, no data support the existence of a lucid period between the time of injury and the onset of symptoms; rather, for acute subdural hematoma with severe neurologic sequela, clinical deterioration would be expected immediately around the time of injury.
  • Finally, traumatic acute subdural hematomas, especially those that lead to the death of child, do not occur in a subclinical or insidious manner in an otherwise healthy infant.

Causes

No one single cause has been identified that explains the occurrence of all cases of physical abuse.

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