Physical Abuse

When to be concerned: The level of concern for abuse is determined through the history leading to presentation, the child’s medical history and development stage, and physical examination of the injuries identified. Any injury can be the result of child abuse, and concordance between history and physical findings should be assessed for all injuries.

Thus, the first steps in developing the appropriate level of concern for abuse are consistent with standard best medical practice:

• a thorough history of events leading to presentation

• a review of the child’s medical and developmental history

• a thorough physical examination

• initiation of a diagnostic workup

Mandatory reporting: Medical providers are mandatory reporters and if, over the course of an evaluation, there is reasonable suspicion for physical abuse, all clinicians have a legal responsibility to report to child protective services (see Legal Mandates for Health Care Providers).

High-Risk Injuries

Although any injury can result from abuse, some specific injury types should consistently raise concern for physical abuse and prompt further evaluation.

Bruising

• Clinical rules: The TEN-4 and TEN-4 FACESp bruising decision rules are useful mnemonics (explained below) for identifying bruising that is at high risk of being caused by physical abuse and warrants additional evaluation for abuse. These rules have been shown to be highly predictive of physical abuse in injuries that are not confirmed as publicly witnessed, accidental events.

  • TEN-4: Any bruising in an infant <4 months or any bruising in the following areas in a child ≤4 years:

    • Torso

    • Ears

    • Neck

  • TEN-4 FACESp: This extended mnemonic includes additional areas, beyond TEN-4, that are also high-risk:

    • Frenulum

    • Angle of the jaw

    • Cheek

    • Eyelids

    • Subconjunctival hemorrhage

    • Patterned bruising

• Location: The location of accidental bruising should match the child’s developmental abilities and stage. For example, active preschoolers are expected to have many bruises on the shins from daily play. However, infants who are not yet mobile should not have bruises, commonly noted as “those who don’t cruise rarely bruise.” Similarly, older children with impaired mobility or global developmental delay are unlikely to incur incidental bruises of childhood from routine play and activities.

  

  (Source: Patterns of Bruising in Preschool Children—A Longitudinal Study. Arch Dis Child 2014.)

• Pattern: Patterned bruises or marks that have sharp edges, especially on fleshy portions of the body (e.g., buttocks, torso, or backs of thighs) should also raise concern for inflicted injuries.

• Evaluation of high-risk bruising in infants and young children should include:

  • photodocumentation (when available) in the electronic medical record of findings from the examination

  • evaluation for occult injury

  • assessment for bleeding disorder:

    • family history

    • complete blood cell (CBC) with platelet count

    • coagulation studies (prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR])

    • evaluation for bleeding disorders in some cases (factor VIII, factor IX, and von Willebrand disease antigen and activity)

Examples of High-Risk Bruising

(Photograph courtesy of Cindy Christian, MD)

(Photograph courtesy of Cindy Christian, MD)

(Source: NEJM Knowledge+)

(Source: Child Abuse and Neglect. N Engl J Med 1995.)

Fractures

Studies suggest that approximately one in four fractures in infants younger than one year is caused by abuse and that the majority of fractures attributed to abuse are diagnosed in children age 18 months or younger. No fracture type is pathognomonic for child physical abuse. Similar to the approach for bruising, all fractures should be compared to the reported history and mechanism by which the fracture occurred for plausibility and consistency.

• High-risk fractures: Some fractures in infants are considered particularly high-risk for abuse. Overall, these fractures are uncommon and, when they do occur, raise concern for child physical abuse in the absence of a specific accidental mechanism or medical predisposition.

  • classic metaphyseal lesions (CMLs): also known as metaphyseal corner fractures or “bucket-handle” fractures

  • rib fractures

  • scapular fractures

  • spinous process fractures

  • sternal fractures

  

  (Radiograph courtesy of Barbara H Chaiyachati, MD, PhD)

  

  (Radiograph courtesy of Barbara H Chaiyachati, MD, PhD)

• Differential diagnosis should include medical conditions that may increase the risk for fracture (e.g., osteopenia of prematurity, demineralization related to decreased use, osteogenesis imperfecta) or medications that impact bone health.

• Evaluation of fractures that raise concern for abuse should include:

  • evaluation for occult injury

  • assessment for bone health disorder

    • family history

    • electrolytes (including calcium, magnesium, and phosphorous)

    • 25-hydroxy vitamin D, alkaline phosphatase, and intact parathyroid hormone

    • review of bone mineralization on radiographs

Abusive Head Trauma

Abusive head trauma (AHT) is the leading cause of fatal head injuries in young children. Annual AHT incidence in the United States is estimated at 20 to 30 per 100,000 children. AHT refers to head injury that may result from multiple mechanisms such as shaking or blunt impact. AHT represents an expansion of the previous terminology, shaken baby syndrome.

• Clinical presentation of AHT is varied and may manifest as acute altered mental status, increasing head circumference, seizures, respiratory distress and apnea, vomiting, poor feeding, or death. AHT may also be recognized during the evaluation of children who present with other injuries that raise concern for maltreatment (e.g., bruising or fractures) without specific neurologic signs or symptoms. AHT is most commonly diagnosed in infants younger than 6 months but can also be diagnosed in toddlers and young children.

• Imaging: Children with symptoms that raise clinical concern for intracranial injury (e.g., change in mental status, vomiting, seizures, or facial injuries) should undergo head imaging, most often head CT, completed to assess for acute and clinically actionable intracranial findings. Screening for clinically occult AHT using brain MRI should also be considered in young infants without neurologic signs or symptoms but with other injuries concerning for abuse (see Occult Injury Screening).

  • If imaging confirms suspicion for AHT with the presence of intracranial blood or ischemia without other known explanation, children should undergo ophthalmology evaluation to assess for injuries within the eyes, including retinal hemorrhages.

  

  (Source: NEJM Knowledge+)

• Diagnosis is based on history and clinical findings. Common findings in children with AHT include:

  • subdural hemorrhages (found in 90% of children with AHT)

  • retinal hemorrhages

  • fractures (rib, skull, other)

  • bruising or other skin injuries

  

  (Source: Child Abuse and Neglect. N Engl J Med 1995.)

• Evaluation of intracranial bleeding in infants and young children should include:

  • family history of bleeding disorders

  • assessment for occult injury

  • review of newborn screening results

  • assessment for a bleeding disorder:

    • CBC with platelet count

    • coagulation studies (PT, PTT, INR)

    • VWF antigen, VWF activity

    • factor VIII, factor IX, factor XIII

  • in children with neurological compromise, also obtain:

    • fibrinogen

    • D-dimer

  • Consider factor XIII in certain clinical circumstances

Other Harbingers of Risk

• Lack of history to explain injury: A basic understanding of biomechanics suggests that most fractures or bruises over areas of significant subcutaneous tissue require a substantial, nonincidental amount of force. Such force increases the likelihood that an injury causing event was notable by a caregiver either through observed mechanism or by an acute change in the child’s disposition (e.g., crying or otherwise showing distress), although some exceptions exist.

  • Children and caregivers may be unable to provide a complete history of events leading to an injury for a number of reasons regardless of etiology. For example, injuries of independently mobile children are often unwitnessed by adults, so specifics regarding mechanism will not be known.

  • In cases of intimate partner violence, a caregiver may be unable to access care in a timely manner or may be fearful of revealing the true mechanism of injury due to fear for their own safety.

• Delay in medical care: There are many reasons why parents do not bring children for medical care in a timely manner. In cases of abuse, delay in care for a significant injury may raise concern for medical neglect or a potential attempt to avoid detection of abuse by allowing the injury to heal without medical intervention.

  • Some information about the age of a fracture can be obtained from radiographs. Expected patterns of healing may vary based on factors including the child’s age, mobility, health status, and details of fracture type and immobilization.

  • Bruises cannot be reliably dated based solely on their appearance.

• Multiple injuries: Accidental injuries represent a leading cause of morbidity and mortality for children in the United States. However, multiple significant simultaneous injuries with similar or different stages of evolution but without a clear timeline and mechanism should raise concern for physical child abuse.

Occult Injury Screening

Infants and young children who are preverbal are typically unable to adequately localize pain and discomfort. Thus, some injuries may be clinically occult, or silent. Occult injuries have significant implications for medical care, recognition of abuse, and appropriate safety planning. Therefore, screening for additional injuries is important when there is concern for abuse in a young child.

• Physical exam: A thorough physical examination should be completed for all children suspected of being abused, including assessment for findings using the TEN-4 FACESp rule. Any marks, including congenital, medical (e.g., eczema), or inflicted should be clearly described in the physical examination and photodocumented if possible, preferably with a size marker (e.g., ruler).

• Laboratory screening tests: Occult abdominal injuries should be considered in any child younger than 4 years with other injuries that raise suspicion for maltreatment. Laboratory tests to assess for intra-abdominal injuries include:

  • CBC

  • hepatic enzymes, amylase, and lipase

• Imaging

  • Skeletal survey: Children younger than 2 years with any injury concerning for abuse should undergo a skeletal survey to assess for presence of fractures.

    • A skeletal survey should include dedicated radiographs of each appendicular anatomic region (e.g., upper arm, forearm, and hand). Additionally, the axial skeleton should be imaged with multiple views, including oblique views of the ribs, to increase detection of rib fractures. One image of the thorax and abdomen, a so-called “babygram,” is not an acceptable means for screening.

    • In one study of 700 consecutively obtained skeletal surveys, approximately 10% revealed a fracture that was not clinically suspected and, among the positive results, a diagnosis of abuse was influenced by the identification of an occult fracture in 50% of cases.

    • A skeletal survey may be indicated in older children with fracture predisposition or particularly high-risk exposures (e.g., children who suffer recurrent maltreatment or are fatally injured).

  • Brain imaging:

    • Occult head injury: All infants younger than 6 months with injuries that raise concern for abuse should undergo brain imaging. The rate of occult brain injury is high in infants with other abusive injuries.

      • MRI offers the highest sensitivity and specificity for identifying occult brain injuries, including subacute and chronic brain changes, subdural hemorrhages, and hypoxic ischemic injury.

    • Symptomatic head injury: As noted in the section on abusive head trauma, patients with neurologic symptoms that raise suspicion for brain injury or intracranial hemorrhage typically undergo CT imaging.

  • Abdominal imaging:

    • A CT scan of the abdomen with intravenous contrast should be considered if clinical concern for injury is present (e.g., abdominal bruising, pain, distention, absent bowel sounds, or vomiting.

    • Imaging to assess for occult injuries is indicated in children with elevated laboratory tests (AST, ALT, amylase, lipase) not associated with clinical symptoms.

  • Psychosocial assessment: If available, all children undergoing nonaccidental trauma evaluations should also undergo psychosocial assessment by a social worker. Although this evaluation will not reveal occult injuries, it will provide important insight on family stressors and social risk factors.

Additional Considerations

• Sibling evaluations: When there is a high index of suspicion for abuse, information about siblings and other children in the shared caregiving environment should be gathered. Siblings of children who are victims of abuse have a high rate of injuries of abuse. These children should be examined and undergo age-appropriate occult injury screening as part of their medical evaluation (including skeletal survey for children who are younger than 2 years).

• Follow-up skeletal surveys: A follow-up or repeat skeletal survey 2−3 weeks after an initial child abuse evaluation should be considered in any young child with a suspected inflicted injury. Follow-up skeletal surveys can identify additional injuries by the presence of healing of occult fractures that were not evident on the initial images. Additionally, follow-up skeletal surveys can help clarify indeterminate findings seen on initial x-rays. For example, fractures are likely to show evidence of healing by presence of a callus, while normal variants would not be expected to change significantly in appearance on repeat imaging.