1 What four elements should you consider in making a diagnosis of suspected child abuse?

Combining these four elements should help to determine whether you have sufficient grounds to institute a report of suspected abuse.

2 What forms of abuse are defined by most state child abuse laws?

3 Which form of abuse is reported most often? What form occurs most often?

Although physical abuse is most often reported, with sexual abuse a close second, psychological abuse occurs most often and has the most disabling long-term consequences.

Tenney-Soeiro R, Wilson C: An update on child abuse and neglect. Curr Opin Pediatr 16:233–237, 2004.

4 What injury accounts for most deaths due to child abuse?

Head injury accounts for most child abuse–related deaths, including children who suffer direct trauma and shaking-impact injuries. Abdominal trauma causes most other child abuse–related deaths.

5 Abuse occurs most often in which ethnic group?

The rate of abuse by ethnic groups roughly matches the ethnic distribution in the general population. Thus, white children are abused most often.

6 True or false: Most cases of abuse are reported by medical professionals

False. Most cases are reported by nonphysicians and non–health care institutions. Abuse is rarely reported by primary care physicians (probably less than 2% of reported cases nationwide).

7 When did children first gain legal protection against abuse?

In the mid-to-late 1960s and early 1970s. Before passage of the first set of state child abuse laws, children had no legal protection from injury inflicted by parents.

8 What has happened to the incidence of abuse over the past 20 years?

Three national incidence studies have been conducted in the United States during the past 20 years. They show a stepwise increase in the rates of abuse. From the mid-1980s to the present, physical abuse has doubled and sexual abuse has increased threefold.

9 How many abuse victims are killed each year in the United States?

Approximately 1400 children annually. This rate has been fairly constant.

Sirotnak AP, Grigsby T, Krugman RD: Physical abuse of children. Pediatr Rev 25:264–277, 2004.

10 Can the color of bruises on a child’s body be used to date the injury definitively?

Despite findings noted in most standard textbooks, the color of the bruise does not indicate the age. The color of a bruise is determined by location, nature of the traumatic force, amount of subcutaneous tissue, and other factors. Aging of bruises based on color is highly unreliable.

Bariciak ED, Plint AC, Gaboury I, et al: Dating of bruises in children: An assessment of physician accuracy. Pediatrics 112:804–807, 2003.

11 In a child with multiple bruises and normal neurologic examination, is computed tomography (CT) of the head indicated?

At least one study indicated a high yield of positive CT findings, even in children with normal neurologic examinations. CT screening appears to be more helpful than routine ophthalmologic examinations.

Rubin DM, Christian CW, Bilaniuk LT, et al: Occult head injury in high-risk abused children. Pediatrics 111:1382–1386, 2003.

12 What is the most common skin lesion mistaken for abuse?

Mongolian spots, which most commonly occur on the back, at the base of the spine, and on the buttocks. However, they also may occur on other skin surfaces.

13 What conditions may lead to easy bruisability?

Ehlers-Danlos syndrome and other connective tissue disorders may lead to easy bruisability. Hemophilia usually results in deep soft tissue and joint bleeding rather than superficial skin bruises. Idiopathic thrombocytopenia purpura and other platelet abnormalities lead to petechiae and mucous membrane bleeding rather than bruises. Henoch-Schönlein purpura also may be initially confused with bruising.

Bechtel K: Identifying the subtle signs of pediatric physical abuse. Pediatr Emerg Med Rep 6:57–67, 2001.

14 What developmental skill is associated with bruising?

Walking or learning to walk may be associated with bruises. However, bruises found on children who have not yet learned to walk should be considered a sign of possible abuse. Children who do not cruise or walk generally do not bruise.

Sugar NF, Taylor JA, Feldman KW, et al: Bruises in infants and toddlers: Those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med 153:399–403, 1999.

15 A 2-week-old infant, seen in the emergency department (ED) for crying, has several fractures at varying stages of healing. What may you conclude from these findings?

Although this scenario may indicate abuse, the young age of the infant and the possibility that fractures may have occurred in utero make a metabolic bone disease more likely.

16 What findings make osteogenous imperfecta more likely than child abuse?

Blue sclera, dental abnormalities, hearing loss, wormian bones, and radiographs showing osteopenia and healing with abundant callus formation.

17 Which specific fractures have a high probability of being caused by child abuse?

Rib fractures, metaphyseal chip fractures (Fig. 52-1), spine and scapula fractures, and complex skull fractures.

Figure 52-1 Metaphyseal chip fracture.

18 Which specific fractures have a low specificity for abuse?

Linear skull fractures, clavicle fractures, single-bone transverse fractures, and spiral fractures of the tibia (toddler’s fracture).

19 What type of force is consistent with the finding of a metaphyseal fracture?

Metaphyseal fractures occur when an extremity is pulled in the direction of its long axis. Stress on the tight periosteal attachments along the metaphysis results in a chip or corner fracture.

20 A child appears to be tender when his upper humerus is palpated. Plain radiographs fail to show any injury. What other studies may be helpful?

Bone scanning or skeletal magnetic resonance imaging (MRI) scan may be more sensitive at demonstrating bony injury.

Mandelstam SA, Cook D, Fitzgerald M, et al: Complementary use of radiologic skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child 88:387–390, 2003.

21 What criteria should be used to order a skeletal survey for trauma?

22 What tests should be used to differentiate rickets from child abuse as the cause of skeletal abnormality?

The best radiograph to demonstrate rickets is that of the distal radius and ulna (wrist).

23 What history of injury matches a spiral fracture?

A spiral injury is caused by torque or twisting (Fig. 52-2). The extremity is twisted, or the child’s body is twisted while the extremity is held in a fixed position. If the mechanism of injury does not match the nature of the injury, suspect abuse.

Figure 52-2 Spiral fracture of humerus.

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