The Case

A two-year-old girl presents with a rash on her face. This was first noticed when the child was picked up from the babysitter. Per parents, the child is otherwise healthy. She has been fussy and has vomited once.

How would you manage this child? What laboratory and imaging studies, if any, do you order?

Bruising From Abusive Trauma

The diagnosis of abusive trauma in children, particularly very young children, can be extremely challenging. Bruising is the most common presentation of physical child abuse. Certain patterns of bruising should raise the level of suspicion for physical abuse, including patterned bruising, any bruising on a non-ambulatory child, and bruising to the torso, ears, or neck in a child under age four (i.e., TEN-4 bruising).¹ Once child abuse is suspected in a child with bruising, further medical workup, often including imaging and lab testing, may be indicated.

Laboratory Testing

In children with bruising concerning for abuse, the emergency physician should first determine whether bruising is due to trauma or to a bleeding disorder. Laboratory evaluation may not be required in cases where abuse has been witnessed, disclosed or in cases of patterned bruising. The most common bleeding disorders, which mimic nonaccidental trauma, are idiopathic thrombocytopenic purpura (ITP) and von Willebrand disease. Initial laboratory testing should include prothrombin time, activated partial thromboplastin time, von Willebrand factor antigen, von Willebrand factor activity, Factor VIII level, Factor IX level, and a complete blood count with platelet count.²

Radiologic Evaluation

Skeletal survey

The presence of skeletal fractures may support the diagnosis of abusive trauma. A skeletal survey is indicated in all cases of suspected nonaccidental trauma in children under the age of two years. The yield of skeletal surveys drops dramatically in children over the age of five years; whether to obtain a skeletal survey in children between the ages of two and five years should be left to physician judgement.³ Consultation with a child abuse pediatrician, if available, may be useful in making this determination.

A skeletal survey differs from what is commonly referred to as a babygram. While a babygram is composed of only one or two images that encompass the entire child, a skeletal survey consists of multiple views of the appendicular and axial skeleton. Images should include AP views of the arms, forearms, femurs, lower legs, feet, abdomen, lumbosacral spine, and bony pelvis; PA view of the hands; AP and lateral views of the thorax and cervical spine; lateral view of the lumbar spine; and frontal and lateral views of the skull.³ The skeletal survey should ideally be performed by a technician with experience in obtaining these views and interpreted by a pediatric radiologist. If the child is to be transferred to a tertiary care center with a child protection team, the skeletal survey may be deferred until the child is under the care of the child protection team if agreed upon prior to transfer.

CT/MRI

Children with suspected head trauma should undergo CT or MRI. CT is readily available and has high sensitivity and specificity for intracranial hemorrhage. Skull and facial bone fractures may also be seen on CT. MRI is superior to CT in the diagnosis of shear injury and brain edema; MRI should be considered if there are findings on CT imaging or if CT is negative, but there is a high level of suspicion for intracranial injury.³

Case Conclusion

The child has a pattern injury to her cheek consistent with having been struck with an open hand. Given the facial bruising, labs, a CT of the head, and a skeletal survey were all obtained. CT did not show any acute traumatic injury. The skeletal survey showed old rib fractures. Labs were not consistent with a bleeding disorder. The hospital’s child protection team is contacted and an investigation is begun.

DR. RIVIELLO is chair of emergency medicine at Crozer-Keystone Health System and medical director of the Philadelphia Sexual Assault Response Center.

DR. ROZZI is an emergency physician, director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and chair of the Forensic Section of ACEP.