Bruises are the most common injury identified in abused children. Factors that may alert the physician to nonaccidental trauma are bruising to infants who are not yet cruising and bruising in an unusual distribution or location, such as the ears, buttocks, chest, or abdomen. Bruises may also demonstrate pattern injuries that demonstrate a specific object that struck the child. It must be remembered that a subtle bruise may be the only external indicator of significant internal trauma. Additionally, severe or even fatal abuse can occur without a single external mark. Any child suspected of being abused needs a full body skin exam.


Skeletal injuries are more common in infants and young children but can be seen in all ages. Patterns of fractures that raise suspicion for abuse include fractures in nonambulatory infants, multiple fractures, and fractures of different ages. Specific locations of fractures listed below can also increase clinical suspicion.

Femoral Fractures

Femoral fractures (spiral or transverse) in children under age 3 years are suspicious. Minor falls, less than 30–60 cm, usually do not result in femoral fractures.

Epiphyseal–Metaphyseal Fractures

Epiphysealmetaphyseal fractures in young infants and children are virtually diagnostic of abuse because they usually do not occur with accidental falls. These fractures usually occur as a result of severe pulling, twisting, or shaking of the child's limbs. These activities produce severe acceleration–deceleration forces on the limbs, resulting in metaphyseal chip or “corner” fractures.

Rib Fractures

Rib fractures in infants under the age of 2 years are extremely uncommon because the infant's rib cage is extremely pliant. Multiple, bilateral posterior rib fractures are virtually pathognomonic for abuse and are caused by significant squeezing pressure to the chest.


Burns sustained by infants and toddlers may be accidental, inflicted, or the result of poor supervision and neglect. Inflicted immersion burns often demonstrate clear lines of demarcation where the child was held in scalding water with areas above spared. Accidental immersion burns typically have indistinct borders, varying depths of injury, irregular margins, and splash pattern burns outside the primary burn area. Burns also may be inflicted by cigarettes, irons, or stoves. Care must be taken in examining the burn area to identify pattern injury.


Head injuries carry the highest incidence of morbidity and mortality. These injuries can occur by blunt impact or shaking with sudden acceleration–deceleration forces. Head injury is most common in patients under 3 years of age, especially infants. Subdural hematomas can occur with resulting cerebral compression. In addition, these forces can cause direct neuronal injury within the brain. Infants who are severely shaken can present with sudden onset of seizure or coma but have no signs of head trauma. Typically, infants who are severely shaken will have bilateral subdural and inter-hemispheric hemorrhages.


Nonaccidental abdominal injury may produce severe injury to the viscera, including intramural hematomas of the small bowel, splenic or hepatic lacerations, traumatic pancreatitis, and renal contusions.



discuss concerns with the parents in a sensitive and compassionate manner,

ensure protection of the child,

perform a complete medial evaluation of the injuries or neglect, including documentation and radiologic imaging if indicated,

report suspicions to child protective services.


Caregiver factors associated with child abuse include the following:2-4

  • Inappropriate parental expectations of the child.
  • Lack of empathy toward the child's needs.
  • The parent's belief in physical punishment.
  • Parental role reversal.
  • Caregiver's personal history:
    • Was abused during childhood.
    • Parents' rearing practices modeled.
    • Mental illness or substance abuse.

Factors specific to the child that are associated with abuse:2

  • Prematurity.
  • Disabilities.
  • Difficult temperament.

Environmental factors associated with abuse:

  • Domestic violence.
  • Financial, family, or work stressors.
  • Housing issues.






Content 9


Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


Content 3

Content 13

A 1-month-old child was seen in the emergency room for bruising. Physical examination revealed bruises to the buttocks, chest, and eye. The parents reported that the child received the buttock bruise (see Figure) after being dropped by the father, that the chest bruise was from the child's seat belt, and the eye bruise from accidentally hitting the child with an elbow while cosleeping.


Image not available.

Bruising to the left buttock noted in a 1-month-old child. Any bruising on an immobile child is highly concerning for child physical abuse. Bleeding disorders must be considered in the differential diagnosis. (Courtesy of James Anderst, MD, MS.)


A skeletal survey, including oblique views of the ribs, at that time showed a healing fracture of the eighth posterior rib (See Figure Below). A head CT and liver function tests were performed to screen for occult trauma, and laboratory tests were done to evaluate for a bleeding diathesis. All were negative. Law enforcement was contacted and coinvestigated with CPS. The child was placed in the home of a relative. Two weeks later, a repeat skeletal survey showed new bone formation over the right femur, indicating a healing fracture.

Image not available.

Healing eighth posterior rib fracture in the same child above. A skeletal survey is indicated in any child younger than 2 years of age where suspicions of physical abuse exist. (Courtesy of James Anderst, MD, MS.)



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