History
Childhood is a time of accidental injuries. 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, radiology, and laboratory workup, the healthcare 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, as well as a detailed injury history, is essential. Basic questions include the following:
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When was the child last 100% well?
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What was the date and time of the injury and when was it first noted?
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Where did the injury occur?
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Who witnessed the injury?
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What was happening prior to the injury?
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What did the child do after the injury?
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What did the caregiver do after the injury?
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How long after the injury did the caregiver wait until seeking care for the child?
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What symptoms was the child exhibiting, and what, if any, remedies did the caregiver attempt?
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Inquire about specific details related to the injury, such as height of the fall, landing surface, and temperature of water (if scald burn), among others.
The past medical history should be explored for general health and previous trauma and hospitalizations, as well as for the source of healthcare and developmental and social aspects of the child's life. In cases of maltreatment, the history is often inaccurate and misleading. The following historical elements should raise concerns for possible physical abuse:
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Details change, or additional scenarios are suggested, as additional trauma is identified or as the cause of the trauma is questioned
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Details are inconsistent among caregivers
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Caregivers give implausible details not congruent with the trauma observed on examination
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Caregivers describe minor trauma, but the child displays major injury on examination
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No history of trauma is offered
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Injury described as self-inflicted is not possible given the age/developmental abilities of the child
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Caregivers demonstrate a significant delay in seeking treatment for the child
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Serious injury is blamed on a younger sibling/playmate
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Caregiver frequently changes healthcare 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, [21, 22] 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:
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Injury pattern inconsistent with the history provided
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Multiple injuries/multiple types of injuries
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Injuries at various stages of healing
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Poor hygiene
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Presence of pathognomonic injuries including loop marks; forced immersion burn pattern; and classic abusive head trauma findings of subdural hematoma, retina hemorrhage, and skeletal injuries
Bruising over bony prominences is common in childhood, but patterns of bruising that raise the concern of possible abuse include the following:
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Involvement of multiple areas of the body beyond bony prominences
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Bruising of ears, facial cheeks, buttocks, palms, soles, neck, genitals (see images below)
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Bruises at many stages of healing (see Bruising, in Pathophysiology)
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Bruises in nonambulatory child
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Patterned markings resembling objects, grab marks, slap marks, human bites, and loop marks (see images below)
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Oral injury, lingular or labial frenula tears
Fingernail scratch in child with acute subdural with shift. Image courtesy of Lawrence R. Ricci, MD.
Example of ear bruising. Ear bruising is a rare accidental injury. This 10-month-old child was intubated for abusive head trauma (AHT) and spiral femur fracture and had this ear bruising in addition to other facial bruising.
Linear inflicted bruising extending from arm to back, inflicted by a belt. Same child shown again with back bruising.
Overlying linear inflicted marks, which the child disclosed came from a belt. Same child is shown in image of arm and back.
Pattern bruising and extensive back bruising. The 4-year-old child was found dead in his home and had no reported history. Autopsy revealed duodenal hematoma and perforation as cause of death.
Skeletal injuries in children younger than 2 years may not be obvious; therefore, a skeletal survey screening is recommended (see Workup for the components of the skeletal survey). [23, 24] Many fracture types can be accidental or inflicted. Fractures that raise a high degree of suspicion for inflicted injury include the following:
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ANY fracture in a nonambulatory infant without clear accidental and consistent mechanism
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Metaphyseal fractures
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Multiple, bilateral, differently aged posterior rib fractures (see image below)
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Multiple and complex skull fractures if only simple impact history
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Spinous process fractures
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Scapular fractures
Radiograph of multiple rib fractures. Radiographs also revealed old radius and ulna fracture. The child presented with a slap mark. Image courtesy of Lawrence R. Ricci, MD.
Burn patterns that may suggest physical maltreatment include the following:
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Patterned contact burns in clear shape of hot object (eg, fork, clothing iron, curling iron, cigarette lighter) (see image below)
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Classic forced immersion burn pattern with sharp stocking-and-glove demarcation and sparing of flexed protected areas
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Splash/spill burn patterns not consistent with history or developmental level
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Cigarette burns
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Bilateral or mirror image burns
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Localized burns to genitals, buttocks, and perineum (especially at toilet training stage)
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Evidence for excessive delay in seeking treatment, and the presence of other forms of injury
Pattern contact burn on buttocks of diapered child. The burn likely came from the metal grate surrounding heater.
Causes
No one single cause has been identified that explains the occurrence of all cases of physical abuse.
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Overlap of child maltreatment and domestic violence.
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Handprint on face. Image courtesy of Lawrence R. Ricci, MD.
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Handprint on leg. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with belt. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with switch. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with switch. Image courtesy of Lawrence R. Ricci, MD.
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Switch. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with wooden spoon. Image courtesy of Lawrence R. Ricci, MD.
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Bruises inflicted with belt. Image courtesy of Lawrence R. Ricci, MD.
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Buckle fracture of distal femur shaft. Image courtesy of Lawrence R. Ricci, MD.
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Duodenal hematoma. Image courtesy of Lawrence R. Ricci, MD.
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Burn from car seat. Image courtesy of Lawrence R. Ricci, MD.
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Car seat. Image courtesy of Lawrence R. Ricci, MD.
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Model for femoral neck fracture from being yanked from crib. Image courtesy of Lawrence R. Ricci, MD.
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Femoral neck fracture from being yanked from crib in previous image. Image courtesy of Lawrence R. Ricci, MD.
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Inflicted pinch mark shaft. Image courtesy of Lawrence R. Ricci, MD.
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Burn from being held down on hot cement. Image courtesy of Lawrence R. Ricci, MD.
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Old and new radius fracture. Image courtesy of Lawrence R. Ricci, MD.
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Child with slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Radiograph of old radius and ulna fracture in child with slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Radiograph of multiple rib fractures. Radiographs also revealed old radius and ulna fracture. The child presented with a slap mark. Image courtesy of Lawrence R. Ricci, MD.
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Sunburn. Image courtesy of Lawrence R. Ricci, MD.
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Burn inflicted with lighter. Image courtesy of Lawrence R. Ricci, MD.
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Acute subdural with shift. Image courtesy of Lawrence R. Ricci, MD.
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Fingernail scratch in child with acute subdural with shift. Image courtesy of Lawrence R. Ricci, MD.
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Ecological model for understanding violence.
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US maltreatment trends, 1990-2010.
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Adverse child experiences pyramid.
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National Pediatric Trauma Group registry findings.
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Buckle fracture of distal femur without healing (acute).
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Distal femur buckle fracture, 2-week follow-up film with sclerotic fracture line and periosteal new bone healing.
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Guidelines for the assessment of suspected physical abuse.
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Linear inflicted bruising extending from arm to back, inflicted by a belt. Same child shown again with back bruising.
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Overlying linear inflicted marks, which the child disclosed came from a belt. Same child is shown in image of arm and back.
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CT scan showing liver laceration. Child had severe abdominal bruising (see next image). Caregiver admitted to repeatedly punching the child in the abdomen.
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Abdominal bruising in a toddler who also had a liver laceration (also see previous CT scan).
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Example of ear bruising. Ear bruising is a rare accidental injury. This 10-month-old child was intubated for abusive head trauma (AHT) and spiral femur fracture and had this ear bruising in addition to other facial bruising.
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Mongolian spots on a dark-skinned child.
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Mongolian spots on a light-skinned child. Mongolian spots can have a greenish cast depending on the skin color of the child.
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Faint abdominal bruising. This toddler had elevated liver function test results, liver laceration found on abdominal CT scan, and an upper lip frenulum tear. Note that abdominal injury may be present with little or no bruising of the abdomen.
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Pattern bruising and extensive back bruising. The 4-year-old child was found dead in his home and had no reported history. Autopsy revealed duodenal hematoma and perforation as cause of death.
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Pattern contact burn on buttocks of diapered child. The burn likely came from the metal grate surrounding heater.
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Series of 3 photos of likely accidental hot water scald burn on the leg of an infant. Sparing of skin-to-skin contact areas indicates child was flexed at the knee and ankle at the time of injury, which was consistent with being seated in the kitchen sink. Burn injuries require detailed scene investigation. In this case, investigators confirmed the ease of turning on the faucet and the high temperature of the water from it.
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Example of strangulation/ligature marks on the neck of a toddler. Strangulation/ligature marks are often linear petechiae and may have fingernail scratches from the victim from struggling to free the airway.
