Like other forms of abuse, physical findings alone are not usually diagnostic of physical abuse. Any time there is a lack of history, a history that changes over time, or a history that does not make sense when compared to the injury, the diagnosis of physical abuse is indicated. In addition, there are some constellations of injury that are often associated with intentional injury, including:
Infants may present as "shaken" infants. The finding may include retinal hemorrhages, subdural hemorrhages, rib fractures and/or metaphyseal fractures. Infants who have been shaken may or may not have associated other injuries.
Toddlers may present with scald burns, such as a scald pattern on the buttocks and/or feet with a "doughnut hole" spared area on the buttocks. These injuries may have "tide" marks where the burned skin begins and normal skin ends. Inflicted burns generally do not have splash marks because the child is held in position. Scald burns may or may not be associated with other injuries.
Older children may present with bruises or fractures resulting from excessive corporal punishment. These may be pattern injuries and resemble the outline of the striking object. Bruises commonly occur on the buttocks and extremities.
General Principles of Injury Evaluation
Is the history consistent with the mechanism of trauma?
Is the child developmentally able to self-inflict this injury?
Is there any other medical explanation for the injury or finding, such as illness or genetic condition?
Is there corroborative information?
Findings Suggestive of Physical Abuse
Findings in physical abuse can manifest in any area of the body, although some injuries are more common than others:
Head
May present with external injury (hematoma, laceration, ecchymoses), increased head circumference, bulging fontanelle, and/or change in mental status. Factors that increase the risk of missing or misdiagnosis of acute head trauma:
Younger age
"Intact" family
Caucasian
Asymptomatic
Misinterpretation of radiologic findings
Eyes/ears
Periorbital bruising may suggest a globe injury or orbital fracture. Retinal hemorrhages may occur with significant head injury. Bruising of the pinna may suggest more serious ear trauma.
Oropharynx
May present with torn frenulum, petechiae, dental trauma.
Chest
Note that bruising may not be evident with blunt trauma. May have costochondral tenderness or chest deformity.
Abdominal trauma
Bruising on the abdomen may not always be present with blunt injury. May present with abdominal distention, abdominal tenderness, absent bowel sounds, hematuria.
Extremities
Tenderness or deformity may not always be present. If physical abuse is suspected in a child less than two years of age, perform a skeletal survey. For more information see Skeletal Survey and the table The Specificity of Radiological Findings and Abuse in RADIOLOGY: Injuries Associated with Abuse.
Skin
May present with bruises that are patterned, multiple bruises of different ages, bruising in a non-ambulatory child, burns, and lacerations.
List adapted from Sirotnak A, Krugman R. Physical abuse of children: An update. Pediatrics in Review 1994; 15:394-99.
Physical findings in children can have various causes and the differential diagnosis needs to be considered when diagnosing children who may have been abused. Pathologic or accidental causes of findings are sometimes confused with child abuse. For more information, see Findings That May Be Confused with Abuse, Appendix G, and the
Differential Diagnosis Table, Appendix H.
High Risk Criteria for Abuse in an Infant
Multiple fractures
Rib fractures
Presence of facial injury
An injury in a child less than six months of age
Culture-Based Practices that May Be Interpreted as Abuse
Before making a diagnosis of abuse it is important to consider whether a culture-based practice could have caused the finding. When you recognize signs of bruising or other injury due to a culture-based practice, it is important to offer information and empathetic understanding to the parent. You may approach the situation by indicating that this practice is not acceptable in our culture and that we offer other methods of treatment. You may need to explain that such practices can be extremely harmful and that we expect that the child will not have to experience them again.
Ecchymosis can be the result of
Cupping
A coin is placed on the skin and topped with a candle about the size of a birthday candle. Then the candle is lit and a glass or jar is inverted over the candle. Or, a tissue is burned in a small glass jar. As soon as the flame is out, the jar is placed on the skin. The suction creates a dark circle of bluish skin. The procedure is done to suck out pain and is often used for headaches. It can also be used to create a place for the illness to exit the body.
Pinching
The skin is pinched until a bruise appears. When used as a headache remedy, a narrow bruise appears between the eyes.
Coining
A coin or spoon is rubbed over an area, creating a long, wide mark or an oval bruise with an irregular border. This is done to create an area for the disease to escape. The bruise may also be punctured with a needle to let the toxins escape.
Folk remedies may use substances such as:
Arsenic
Lead
Urine
Feces
Slime mold
Practices that may be interpreted as abuse include:
Co-sleeping
Comfort nursing of older children
Early marriage
Physical punishment
Refusal of treatment for reasons of religious belief
A parent has discretion to use home remedies and culture-based practices to the extent that they are providing a minimum degree of care. Leaving a burn, puncture mark, or other injury, or using arsenic, lead, feces, etc. to remedy a condition does not meet the standard for a minimum degree of care in New York State. Lack of knowledge of New York State law is not a defense or protection.
Cultural practices that cause physical or psychological injury must be reported to the State Central Register. Medical providers are not exempt from reporting incidents where a child has been harmed or is in imminent danger of harm, even when it may be a result of culture-based custom.
Genital mutilation is against New York State law and is reportable. Imminent danger of genital mutilation should also be reported. Committing genital mutilation or allowing it to be committed is a class E felony. (For information on female genital mutilation, see DIAGNOSIS: Female Circumcision or Female Genital Mutilation.)
