Diagnostic Considerations
Determining whether an injury was inflicted by a caregiver or caused by accidental means is more than a medical determination, and the current and future safety and well being of the child and family are at stake. Many medical conditions may mimic some of the findings observed in physical abuse, and the differential diagnoses to consider differ depending on the types of physical, laboratory, and radiographic findings observed. Differential diagnoses should be worked through carefully in cases of suspected inflicted injury so that suspected physical abuse can be diagnosed confidently and caregivers are not inappropriately accused of abuse.
In all injuries, the major differential diagnosis is between accidental and inflicted injury. Determination of accident versus abuse is best accomplished by pairing thoughtful, thorough medical evaluation with information gathered through a multidisciplinary investigation, often involving child protective services (CPS) and law enforcement agencies.
Child physical abuse guidelines from the American Academy of Pediatrics (AAP) were updated in 2015 and include new information on the lasting effects of abuse and highlight risk factors for abuse and abusive injuries that are frequently overlooked. [25, 26]
Bruises
For bruises, the differential diagnoses include the following:
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Mongolian spots (collection of melanocytes producing a bluish color present at birth in 80% of black children and in many other ethnicities); see images below
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Hemangiomas (overgrowth of capillaries)
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Eczema
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Phytophotodermatitis (cutaneous phototoxic cutaneous eruption)
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Erythema multiforme (multishaped red lesions believed to be a sensitivity reaction)
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Idiopathic thrombocytopenic purpura (ITP)
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Bleeding disorders (eg, hemophilia)
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Malignancy
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Ehlers-Danlos syndrome
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Osteogenesis imperfecta (OI) type I
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Folk-healing practices (eg, coining, cupping; see Burns, below)
Mongolian spots on a light-skinned child. Mongolian spots can have a greenish cast depending on the skin color of the child.
Skeletal fractures
For skeletal fractures, the differential diagnoses include normal variants of bone structure (may appear as suspicious findings on radiographs), congenital syphilis (leads to periosteal elevation), rickets or other mineralization deficits (cause bone fragility), and OI. OI is frequently raised as a possibility in cases of an unexplained fracture and possible physical abuse. Four types of OI are recognized, as follows:
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Type I is the most common form, has autosomal dominant inheritance, and is responsible for 80% of patients. Other major findings of type I OI include mildly to moderately severe bone fragility with occasional fractures at birth, easy bruising, short stature, and blue sclera. Type I OI may be associated with a family history of hearing impairment. Type I may easily be confused with maltreatment, especially if all of the injuries are skeletal in nature. A thorough medical history and family history are essential.
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Type II is a perinatal lethal form. Death typically occurs by age 1 month, with multiple fractures at birth. This type of OI is generally readily distinguishable from child physical abuse.
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Type III is rare and is easily distinguished from maltreatment because of severe bone fragility and osteopenia, triangular facies, ligamentous laxity, skeletal deformity, and abnormal appearance of teeth.
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Type IV is the most difficult to distinguish from maltreatment because bones may appear normal when the first fracture develops but are usually characterized by mild-to-moderate bone fragility, osteopenia, wormian bones, birth fractures in approximately one third of cases, and normal sclerae. Genetic consultation is necessary to pursue a more detailed workup for OI and the characterization of the collagen disorder.
The incidence of OI (all types) is estimated at 1 case in 20,000 live births; OI is much rarer than child abuse.
Burns
The differential diagnoses for lesions that appear as burns include, but is not limited to, hypersensitivity reaction with blistering, friction blisters, impetigo (may appear circular and be confused with cigarette burns), phytophotodermatitis (reddened areas and erosions that result from sun exposure of skin that has psoralen residue), dermatitis herpetiformis (immunobullous skin condition characterized by blisters that may erode), and folk-healing practices such as coining (rubbing of coin or spoon repetitively over the skin), cupping (application of heated cup over skin with resultant vacuum action as it cools), and moxibustion (application of heated incense to skin). The physician should look for a history supporting this diagnosis over a diagnosis of suspected physical abuse.
CNS injuries
The differential diagnoses for the altered mental status findings observed in CNS injuries include various serious disorders such as meningitis, neurologic conditions that have seizures as a component, and ingestions that may simulate the serious clinical features of CNS injury.
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. 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.
Abusive head trauma (AHT)
In considering the differential diagnoses for the findings in AHT, the differential diagnosis subdural hematoma and retinal hemorrhages needs to be considered. For subdural hematoma, the differential diagnoses include accidental trauma, coagulation disorders, vascular malformations, the rare amino acid inborn error of metabolism glutaric aciduria type I (associated with acute encephalopathy and chronic subdural hematoma), and the folk-healing practice caida di mollera, in which a child with a sunken fontanel is inverted, held upside down by the ankles, and shaken.
Retinal hemorrhages
For retinal hemorrhages, the differential diagnoses include vasculitis, vascular obstruction, and toxic febrile states associated with serious infection. Again, in working through a differential diagnoses, the workup should reveal history and physical examination findings supportive of such a diagnosis over 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.
