Diagnostic Considerations

The differential diagnosis depends on the type of injury, the age of the child, and the signs and symptoms. Most of the time, injury diagnosis is between accidental and inflicted trauma.

Bruise-related differential diagnoses are as follows:

Accidental bruises
Congenital dermal melanocytosis (Mongolian spots)
Hemangioma
Phytophotodermatitis
Immune thrombocytopenic purpura
Henoch-Schönlein purpura
Petechiae or subconjunctival hemorrhage from vomiting or coughing
Insect bites
Paint/ink on skin
Hemorrhagic disease of the newborn
Bleeding disorder (congenital or acquired)
Birth trauma
Hemophilia
Malignancy
Erythema multiforme
Folk healing practices (eg, coining, cupping)
Nevi

Skeletal fractures–related differential diagnoses are as follows:

Accidental fractures
Malignancy
Osteogenesis imperfecta
Rickets
Osteomyelitis
Bone fragility with chronic disease
Physiological subperiosteal new bone
Scurvy
Hypervitaminosis A
Congenital syphilis
Caffey disease
Birth trauma
Osteopenia of prematurity
Osteopenia

Burn-related differential diagnoses are as follows:

Accidental burns
Phytophotodermatitis
Impetigo
Folk healing practices (eg, coining, cupping)
Atopic dermatitis
Inflammatory conditions of the skin
Sunburn
Chemical burn
Contact dermatitis

Abusive head trauma (AHT)–related differential diagnoses are as follows:

Accidental head injury
Congenital or acquired coagulopathies (eg, hemophilia, vitamin K deficiencies, neonatal alloimmune thrombocytopenia)
Metabolic disease (eg, glutaric aciduria type 1)
Cerebral sinovenous thrombosis
Arteriovenous malformations
Unintentional asphyxia
Birth trauma
Bacterial meningitis
Leukemia
Solid brain tumors
Menkes disease

Workup

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Media Gallery

A 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints.
A 5-year-old girl who presented within 24 hours of being slapped on the leg. The markings are bruises and not erythema. The linear parallel lines are virtually diagnostic of a human handprint.
An 8-month-old infant who is brought into the emergency department by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humeral fracture. This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap.
A 2-month-old infant presented to the emergency department with the history from the father that the child had slipped in the tub the night before. Note the periosteal callus formation, indicating that the fracture is at least 1 week old and, thus, inconsistent with the history being offered.
A 15-month-old whose babysitter told the child's mother that she "lost it" and spanked too hard. This paddle injury is in a protected area rarely bruised accidentally and with gluteal cleft sparing. Note the areas of vertical bruising on either side of the gluteal cleft; this is characteristic of paddling.
A 4-year-old girl brought in by her father who picked her up from her mother's house and found these patterned, whip lashes on her buttocks and lower back. The patient reported her mom would get "really mad" at her.
A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
A 3-month-old presented with the chief complaint of apparent life-threatening event but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 2-month-old brought to the emergency department with 2-day history of congestion, rhinorrhea, and cough. On the day of admission, the patient had poor feeding, lethargy, and episodes of apnea. A skeletal survey showed multiple rib fractures and there were extensive retinal hemorrhages in one eye. The parents denied a history of any trauma. The head CT scan showed multiple foci of subdural hematoma and subarachnoid hemorrhage predominantly over the bilateral convexities.
A 7-day-old boy who presented with unexplained bruises and multiple fractures, including these classic metaphyseal lesions seen at the distal femur. There was no history of birth trauma.

of 13

Author

Julia Magana, MD Assistant Professor of Pediatric Emergency Medicine, Division of Emergency Medicine, University of California, Davis, School of Medicine

Julia Magana, MD is a member of the following medical societies: American Academy of Pediatrics, The Ray Helfer Society

Disclosure: Expert witness for: Yolo and Butte Counties, California.

Coauthor(s)

Marilyn Kaufhold, MD, FAAP Clinical Instructor, Department of Pediatrics, University of California, San Diego, School of Medicine; Senior Medical Staff, Child Abuse Pediatrics, Rady Children's Chadwick Center for Children and Families

Marilyn Kaufhold, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, International Society for the Prevention of Child Abuse and Neglect, San Diego County Medical Society, The Ray Helfer Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Acknowledgements

Ann S Botash, MD Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University

Ann S Botash, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, Helfer Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Dylan M McKenney, MD Resident Physician, Department of Psychiatry, Maine Medical Center, Portland

Dylan M McKenney, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and Phi Beta Kappa

Disclosure: Nothing to disclose.

Lawrence R Ricci, MD Director of Spurwink Child Abuse Program, Assistant Professor, Department of Pediatrics, University of Vermont College of Medicine

Disclosure: Nothing to disclose.