The differential diagnosis for bruising should include the presence of birth-related cutaneous manifestations, such as mongolian spots. In this case, the provider should question the historian in a non-leading manner. (ie, “How long has the mark been present?”). In cases of significant unexplained bruising, the clinician may need to rule out a bleeding disorder, such as idiopathic thrombocytopenic purpura, Henoch-Schönlein purpura, hemolytic-uremic syndrome, von Willebrand’s disease, or classic hemophilia.

Whether in the ED or pediatric clinic, the primary care provider may observe behavioral indicators that can help to identify abuse. If the child’s caregiver is the suspected perpetrator, the clinician should observe the interaction carefully between the child and the adult. Even though nonspecific, a child’s fear or a caregiver’s hostility may be subtle clues to an underlying problem.

Any part of the child’s body can be an abuse target, so the provider needs to complete a thorough physical examination before determining if a child has been injured. In some cases, internal organs may be affected without any evidence of superficial injury, so more invasive studies may need to be performed to rule out abuse.

Fantuzzo, Weiss, et al. (1998) assessed maltreated children attending Head Start. They found that children with a history of maltreatment had decreased peer play interaction. The researchers interpreted this finding to indicate a decreased ability to respond positively to others. These children also did not show empathy in response to peer distress, were unable to solve social problems, and avoided conflicts. Teachers observed maltreated children to show decreased self-control in social interactions and to display fewer interpersonal skills than their nonmaltreated peers. The maltreated children were identified negatively more often than their peers, and they exhibited more internalizing adjustment problems, such as withdrawal and sadness. Abused children appeared to use approach-avoidance conflicts nondiscriminantly, preventing potentially ameliorative relationships from forming and thus increasing the risk for social isolation and further withdrawal (Fantuzzo, Weiss, et al., 1998).

History taking is essential in determining what may have happened to a child. Beyond the actual event described as the cause of injury, the interviewer needs to assess possible risk factors through general questioning. Topics should include the following:

The diagnosis of physical abuse frequently is based on the presence of injuries to the child, which are apparent through physical examination or radiographs. The pro-vider who encounters a child dressed in inappropriate clothing for the season should investigate the youngster’s physical status thoroughly. An example is a child wearing long sleeves on a hot summer day. The child or family may be using such a shirt to hide a bruise on the arm. Conversely, a child dressed in a snowsuit during the winter should occasion no initial suspicion. When the child is sitting in a warm waiting room still dressed for outdoors, however, the provider needs to be especially vigilant in assessing the child’s status, even if the child is not the patient he or she is treating.

The following discussion describes specific injuries that providers may observe while examining a child who may have been abused.

Most injuries involve the skin, with bruises being the most frequent finding. The following are sites where bruises may be inflicted rather than accidental:

When clinicians note bruises, they should measure them and document findings on the appropriate clinic sheet, with any accompanying “fill-in” anatomic diagrams. Several types of bruises may have a certain configuration or pattern. Human hands can leave a variety of markings, such as oval grab marks from fingertip compression, trunk encirclement marks from the hand grasping the pelvic girdle and abdomen tightly, linear marks on the face from slapping, resulting in the appearance of individual finger marks, and hand prints or pinch marks.

Strap marks may appear as linear bruises from belts or whips or as loop marks from electrical cords. Sometimes the marks may be rather bizarre and in a pattern, as from a blunt instrument, a homemade tattoo, circumferential tie marks, or gag marks.

An indicator of chronic abuse is the presence of multiple bruises at different stages of resolution. Bruises may resolve at different times based on severity, location, and depth of hemorrhage. Classically, bruises are tender, swollen, and purple, red, or blue when they are new, changing from green to yellow to brown as they resolve. Wide variations and differences exist, however, in interpretation of color and age. The provider must differentiate between an old and a more acute injury (Stephenson & Bialas, 1996).

Accidental bruises often occur over bony prominences, such as the forehead, knees, and shins. Children also can scratch themselves and, in rare cases, self-mutilate. Cultural markings may result from folk medical practices or rites of developmental passage. Depending on the mechanism of injury, some of these markings are relatively benign, but clinicians need to evaluate each case individually to determine if the family is neglecting health care or subjecting the child to a harmful practice. An example is cao gio, an Asian remedy for pulmonary illness that involves rubbing a coin on the child’s body, creating a linear, petechial rash. Cupping, a remedy that uses an inverted hot cup to apply suction to the chest and back, produces lesions similar to those of coin rubbing. Providers should instruct parents how to render safe and effective health care, while informing them of possible consequences if they continue these practices.

If clinicians suspect a medical cause for bruising, they should order coagulation studies, such as prothrombin time, partial thromboplastin time, fibrinogen, fibrin-split products, bleeding time, and platelet count. Refer to Chapter 42 for more information on diagnosis and management of these common problems.

The primary care provider may observe burns in the ED, burn unit, or clinic. In addition to accidental burns caused by scalding, contact, chemical, electrical, and fire sources, burns also may be intentional. Burns comprise 10% to 25% of all cases of child abuse, with scalds from tap water being the most common intentional burn injury (Feldman, 1997). In determining a burn’s etiology, it is important to identify the following:

Whether a burn is circumferential or linear helps to distinguish an immersion burn from a contact burn. Immersion burns usually result from a triggering event that somehow offended, frustrated, or angered the perpetrator. Either because of malicious intent or neglect, the perpetrator places the child in a tub or sink with hot water directly from the faucet. Many adults and most children do not realize the danger of hot water. Stocking-feet and gloved-hand burn configurations are observed in this type of inflicted injury, as are circumferential trunk burns and “doughnut-shaped” burns on the buttocks from contact with the cool porcelain tub surface. A burn located exclusively on the buttocks implies an injury resulting from discipline after a toileting accident. Deeply excavated circular burns on the feet render the image of an angry caregiver repeatedly applying a cigarette to the child’s feet. A pour burn with an arrowhead or triangular configuration will be that shape because, as liquid cools, it does so from the outside to the center. Gravity forces the liquid to move downward, creating the pattern.

In 1997, 24,000 children were seen in EDs for scalds. Hot water directly from the tap accounts for nearly 25% of all scald burns among children (U.S. Health and Human Services, 1999). Children younger than 5 years and adults older than 65 years are at highest risk for scalds because of their age-related inability to make a swift decision about the water’s temperature, decreased ability to ambulate, developmental limitations in the elderly, and decreased sensation.

About 30 years ago, the U.S. Consumer Products Safety Commission and hot water heater manufacturers reached a voluntary agreement to have a normal setting of 120°F. Once out of the factory, however, appliance temperature easily can be increased. Few municipalities enforce 120°F as the safest maximum temperature. Solutions to this problem are obvious. Recently, ordinances have established maximum temperature settings in designated housing, for example, by installing expensive pressure-valve components. These devices prevent sudden bursts of scalding water from diverted flow. More practically, inexpensive heat-sensitive metal alloy fixtures are available, which stop water flow if the temperature exceeds 119°F. Although not directly addressing the housing most in need, including older and poorly maintained units, this type of governmental intervention recognizes the need for child safety and has effectively reduced the incidence of scald-related injuries and deaths secondary to hot tap water (U.S. Health and Human Services, 1999).

Fractures are important components of abuse. Certain types of skeletal injury are of increased concern because they do not occur commonly by simple, short falls. Spiral fractures, although not pathognomonic of abusive injury, are worrisome. These injuries result from a twisting mechanism, leaving a corkscrew configuration of fracture on an anteroposterior and lateral radiograph. This injury can occur when an ambulating child falls because of planted foot, which then twists and breaks or when the child is running and suddenly slips, twisting the leg. In nonambulating infants, this type of injury can occur by a perpetrator grasping and wrenching the femur forcibly during a diaper change (Kleinman, 1998).

Metaphyseal avulsion fractures are of great concern because of the physical mechanism involved in their origin. The lack of mineralization weakens the bone’s integrity at this location, making it very susceptible to shearing forces. The torsion and whiplash effect of a child being vigorously shaken and the isolated twisting above and below a joint cause this type of injury. Metaphyseal avulsion fractures are a highly specific result of maltreatment (Spivak, 1992).

Rib fractures in children most commonly result from child abuse. Sustained, intense compression directed toward the chest, not blunt trauma, causes rib fractures. The mechanism of these fractures is consistent with a young infant being grasped compressively around the chest and then shaken or thrown (Spivak, 1992).

Most rib fractures are not detected acutely and are only visualized on plain radiographs after callus formation. When force is applied to the posterior ribs, the bending is against the transverse process, which protects the side of the applied force. Such force causes tensile failure on the rib’s opposite side. The intact posterior cortex prevents displacement and decreases the visibility of an acute fracture, especially on frontal radiographs. In these cases, a bone scan may reveal an otherwise hidden injury (Spivak, 1992).

Skull fractures can be either accidental or abuse-related, but certain features help to delineate the etiology. These features include the velocity or acceleration of impact, height of a fall, presence of any forces other than gravity that increased the velocity or acceleration, and any pathology that may decrease bone strength.

Intracranial injury, the source of the most severe sequellae of abuse, generally is accepted as responsible for at least 50% of deaths in children caused by nonaccidental trauma. Children are anatomically at risk until age 4 years, with most injuries occurring in infants. Severe shaking of an infant has been coined “shaken baby syndrome.” This injury causes sudden accelerative-decelerative forces to shear internal vessels, leading to subdural hematomas and retinal hemorrhages. Duhaime et al. (1992) postulated that blunt head trauma also was required to produce the severe forces needed to cause significant injury, leading to the term “shaken-impact syndrome.”

Important mechanisms that can help the provider to ascertain the presence of subdural hematomas include computed tomography (CT) scan, which can delineate acute hemorrhage. Magnetic resonance imagery (MRI) can be used to discern acute, subacute, and chronic hemorrhage. MRI detects blood breakdown components and, based on particular weighted images, may be able to differentiate blood from cerebrospinal fluid and possibly determine the age of hemorrhage. Ophthalmoscopy can reveal the presence of retinal hemorrhages. If suspicions of abuse are present in a child younger than 2 years, both a skeletal survey and an ophthalmoscopic examination are important tools to help rule out nonaccidental trauma.

A rare but important disease entity that can predispose a patient to having subdural hematomas and retinal hemorrhages with minimal trauma is glutaric aciduria type 1 (GA1). This autosomal recessive, inborn error of metabolism is caused by deficiency of the enzyme glutaryl-CoA dehydrogenase. Macrocephaly, bilateral frontotemporal atrophy or widening of the Sylvian fissure, and subdural effusions are the clinical manifestations of GA1. No skeletal abnormalities have been reported, so GA1 does not predispose a child to fractures. Additionally, if a subdural hematoma is present without coexistent frontotemporal atrophy, GA1 is probably not present. This information is important to consider when confronted with the multiple clinical symptoms of the disease so that in an investigation of suspected child abuse, clinicians can appropriately exclude GA1 (Morris et al., 1999).

Generally abdominal injuries are accepted as the second most common cause of death in physically abused children, with greatest risk between ages 2 and 4 years (Canty & Brown, 1999). Symptoms include abdominal pain, nausea, recurrent vomiting, abdominal distention, absent bowel sounds, and localized tenderness. More severe symptoms on presentation may include ileus, hematemesis, hematochezia, hematuria, peritonitis, and hemorrhagic shock. Because the abdominal wall is flexible, the internal organs usually absorb the force of the blow, so overlying skin typically may be free of bruises. Specific injuries include ruptured liver or spleen, the most common organs injured secondary to blunt trauma. Less common are tears or hematomas of the small intestine at sites of ligamental support, such as the duodenum and proximal jejunum, which can lead to perforation or possible obstruction. Pancreatic chylous ascites and pseudocysts have been reported, and hematuria may occur as a result of blunt trauma to the kidney (Johnson, 2000).

Typically, the caregiver postpones seeking medical attention. Thus, the child presents in an advanced stage of illness. Because the perpetrator denies the event that precipitated the injury, accurate clinical history data are lacking. Frequently, associated central nervous system injury further contributes to the difficulty and delay in diagnosis.

The most practical evaluation of this type of injury is first to obtain a detailed history of any possible blunt injury to the abdomen. The provider should then perform a careful physical examination, noting the presence or absence of skin bruising. A flat plate of the abdomen and a film in the lateral decubitus position may help to show ileus or peritoneal free air but may not reveal a significant acute injury. Better imaging modalities include both ultrasound and abdominal CT. A stool guaiac will reveal occult blood, and helpful laboratory tests include a complete blood count (CBC), amylase, lipase, and liver functions.