Physical Child Abuse Clinical Presentation

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 caregiver is a plausible explanation for the child's injury. It is also important to recognize that while developmental milestones provide a general expectation, each child being evaluated has their own developmental pace. Pediatricians and pediatric healthcare providers are generally able to understand the type of injuries associated to child’s developmental capabilities. Injuries that fall outside of the expected norm warrant close consideration in the context of the history provided, and if implausible given the child’s development, should raise concern for possible physical abuse. 

Once the full extent of the injury is determined based on physical examination and pertinent radiology and laboratory workup, the healthcare provider can further assess the plausibility of the explanation offered by the caregiver. At times, when abuse is considered, additional information from community partners, such as law enforcement and child protective services, can aid in clarifying historical details, which in turn can support or negate the provided information. Similarly, a child may, at times, present with a caregiver who was not present at the time the injury was sustained, resulting in incomplete information. When the injury is atypical for the child’s age and development, attempting to obtain a more complete history from the caregiver who was present is strongly encouraged, which may require support from community partners as well.  

Whenever a child is injured, a complete history regarding the circumstances surrounding the injury, as well the injury itself, is essential. As with any medical history, the provider should aim to obtain a history of present illness, past medical history, and review of systems. Basic questions to address the history of present illness include the following:

• When was the child last seen completely well (no symptoms, no caregiver concern whatsoever)?

• What was the date and time of the injury and when was it first noted, and how does it relate to the time of presentation?

• Where did the injury occur?

• Who witnessed the injury?

• What was happening prior to the injury?

• How did the child respond to the injury?

• What did the child do after the injury (ie, did the child resume normal activity)?

• What did the caregiver do after the injury?

• How long after the injury did the caregiver wait until seeking care for the child and how reasonable was that time?

• What prompted the caregiver to seek care?

• What symptoms was the child exhibiting, and what, if any, remedies did the caregiver attempt?

• Inquire about specific details related to the injury, such as distance and landing surface (if a fall) and temperature of water (if scald burn), among others.

In cases of maltreatment, the history is often inaccurate and misleading. The following historical elements should raise concerns for possible physical abuse:

• Details change, or additional scenarios are suggested, as additional trauma is identified or as the cause of the trauma is questioned

• Details are inconsistent among caregivers

• Caregivers provide 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 in a child whose development requires caregiver attention (ie, non-mobile infants)

• Injury described as self-inflicted is not possible given the age and developmental abilities of the child

• Caregivers demonstrate a significant and unreasonable delay in seeking treatment for the child

• Serious injury is attributed to a younger sibling or playmate

The past medical history should be explored for general health as well as previous trauma and hospitalizations. The source of healthcare and the developmental and social aspects of the child's life should also be explored. The following historical elements on review of systems should raise concerns for possible physical abuse:

• History of prior injuries attributed to benign causes, particularly in infants, such as intraoral bleeding, subconjunctival hemorrhages outside of the neonatal period, and bruising (see Physical below)

Physical examination of the child with an injury is crucial 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 often results from an ongoing pattern of unsafe care, ^[27]  performing a thorough head-to-toe examination is essential in order to identify other areas of either current or previous injury. 

Photodocumentation of cutaneous injuries, such as burns, bite marks, bruises, or other injuries, is very important and helpful in cases of child abuse. Quality photodocumentation includes 1) an orienting picture to the adjacent anatomical landmarks, 2) a close-up, focused photograph of the injury, and 3) a photograph of the injury with a measurement standard.

Photodocumentation, when used as an adjunct to standard medical written documentation, allows consulting physicians, child protective services (CPS) workers, law enforcement officials, attorneys, and others to view and better comprehend the injuries. It allows for discussion and peer review as well as for assessment of the finding’s evolution. Furthermore, quality photographs of injuries may be very helpful in legal proceedings. Photodocumentation should be performed in accordance with institutional policies and procedures and should be treated as protected health information under the Health Insurance Portability and Accountability Act (HIPAA).

This section will describe findings on physical examination, as well as radiological findings, that should elicit concern for child physical abuse. These include, but are not limited to, the following: 

• ​​Injury inconsistent with the history provided, especially if incongruent with a patient’s developmental capabilities

• Injuries at various stages of healing, such as multiple fractures 

• Presence of patterned cutaneous injuries, including immersion burns

• Multiple injuries or multiple types of injuries involving different body systems; for example, a constellation of findings involving subdural hemorrhage, retinal hemorrhages, and skeletal or cutaneous injuries

Sentinel injuries ^[28]  are important to recognize and every examination of an infant should include sentinel injury surveillance. Sentinel injuries are typically minor injuries in young non-mobile infants often identified incidentally and commonly dismissed given their perceived harmlessness. However, sentinel injuries have been found to commonly precede more serious, and even fatal, inflicted injuries. Sentinel injuries, when identified, should not be disregarded and, instead, should prompt further evaluation for occult injury and consideration of underlying physical abuse. Sentinel injuries include: 

• Any bruise in a non-ambulatory child, especially infants < 5 months old

• Oral injuries in infants such as frenula tears, lacerations or bruising to the palate or the pharynx, bruising to the lips, gums, or tongue

• Subconjunctival hemorrhages in otherwise healthy infants outside of the neonatal period. Birth-related subconjunctival hemorrhages typically resolve in 2–3 weeks. In healthy infants, subconjunctival hemorrhages do not typically result from infant crying or straining, and instead should raise concern for trauma (See DDx for more detail).

Bruising, particularly over bony prominences (ie, anterior shins, knees, elbows, forehead), is common in childhood once a child becomes mobile and ambulatory. A bruising clinical decision rule, TEN-4 FACESp, has been validated for helping to distinguish concerning bruising or mucocutaneous injuries in young children from typical childhood injuries. ^[29] Specifically, this clinical decision rule highlights that the following distribution of mucocutaneous injuries should elicit concern for physical abuse: 

• Any bruising in infants younger than 5 months, (see sentinel injuries above) 

• Bruising or mucocutanoues injury in children younger than 4 years old involving the following body areas (“TEN-4 FACES”): 

  • Torso

  • Ear(s)

  • Neck

  • Frenulum

  • Angle of the jaw

  • Cheeks (face, fleshy)

  • Eyelids 

  • Subconjunctiva (ie, subconjunctival hemorrhage)

• Bruising in a patterned ("-p") distribution, such as grab/squeeze marks, slap marks, spank marks, human bite marks, and marks consistent with implements (ie, loop marks, belt marks)

• Bruising to the genitals, buttocks, palms, and soles should also elicit significan concern, as well as bruising over body areas that do not overly bony prominences 

Skeletal injuries in children younger than 2 years may not be obvious and many fracture types can be accidental or inflicted. While there is no pathognomonic fracture for abuse, fractures and fracture features that should elicit concern for physical abuse include the following:​

• Any fracture in a nonambulatory infant without clear accidental and consistent mechanism

• Metaphyseal fractures (ie, classic metaphyseal lesions)

• Posterior rib fractures (see image below)

• Multiple fractures in different stages of healing

• Atypical fractures such as spinous process fractures and scapular fractures

Burn injuries that may suggest physical abuse include the following:

• Patterned contact burns in clear shape of hot object (eg, fork, clothing iron, curling iron, cigarette lighter) (see image below)

• Immersion burn pattern with sharp demarcation, stocking and glove distribution, and sparing of flexed protected areas or doughnut-hole sparing of the buttocks

• Splash/spill burn patterns not consistent with history or developmental abilities

• Cigarette burns

• Bilateral or mirror-image burns

• Localized burns to genitals, buttocks, and perineum (especially during a child's toilet-training phase)

• Burns in addition to other concerning injuries (ie, atypical bruising, fractures, etc.)

• Unreasonable excessive caregiver delay in seeking treatment

Other injuries that may prompt concern for child physical abuse include: 

• Intracranial hemorrhage, especially, subdural hemorrhage in the absence of a known underlying medical condition, particularly in infants. Diffuse or interhemispheric subdural hemorrhage in a young child or infant presenting with altered mental status should prompt additional evaluation for occult injury and consideration of inflicted injury. 

• Intra-abdominal solid organ or hollow viscus injuries, particularly in infants or young children, in the absence of a clear and consistent history of trauma.  

• Anogenital injuries are relatively uncommon, but important to recognize. Degloving penile injury, vaginal lacerations, anal lacerations, or colon perforations may require subspecialty evaluation and management (ie, pediatric urology, pediatric gynecology, and pediatric surgery).  Other, relatively minor injuries, such as bruising or superficial lacerations, may also be present and warrant close attention and documentation. Of note, vulvovaginal injury and vaginal penetrative trauma elicits concern for sexual abuse, which is beyond the scope of this article.

No one single cause has been identified to explain the occurrence of all cases of physical abuse. See Background for more detail.