Child abuse is a hidden epidemic. More than 1 million children are abused in some form every year in the United States. Thousands will die annually from abuse.¹ Many more go undetected and are unrecognized in offices, clinics, hospitals, and emergency departments throughout the country. Emergency physicians are on the front lines and may be the last (or only) safety net for an abused child.

Presentations to the emergency department are sometimes obvious, but many are subtle and go unrecognized. Failure to detect or investigate potential abuse can lead to catastrophic consequences. Children who are physically abused once are likely to be abused again. Studies have shown that unrecognized abuse has up to a 50% chance of recurrence and up to a 10% chance of leading to death.^2-4

Even when investigated or detected, disastrous outcomes might occur if the child is not removed from the potentially harmful environment. With a high index of suspicion and a low threshold for reporting and intervention, emergency physicians can save a life by identifying child abuse and stopping it from happening again.

The History and Physical

There are many challenges when considering the diagnosis of abuse. As most abuse occurs in children who have limited or no verbal skills, the history is often entirely dependent on the caregiver.^5-9 Two common scenarios take place. First, the caregiver may be unaware there has been harm done to the child. They may be bringing in their child after they observed something nonspecific at home, such as respiratory distress or vomiting, after a babysitter, friend, or family member took care of the infant.

The other situation, which is often more challenging, is when the caregiver committed or witnessed the abuse. In such cases, the caregiver will frequently mislead the clinician and/or omit information.

Because subtle presentations for physical abuse are common, especially in the preverbal infant or child, performing a thorough history and physical examination and being alert for suspicious findings are essential for detecting abuse. Injuries that are implausible, inconsistent with mechanism, or accompanied by a changing or vague history should raise suspicion and be investigated further.

Any injury that is inconsistent with developmental capabilities is suggestive of nonaccidental trauma. Examples include a femur fracture in a nonambulatory child or a head injury in a 2-month-old infant who “rolled out” of the crib. Undue delays in seeking care for a significant injury are also concerning.

Soft Tissue Injuries: Bruises and Burns

Bruises may be the first, or only, visible sign of physical abuse. Careful inspection of the head, scalp, face, ears, and neck is crucial to detect nonaccidental bruising. With rare exceptions, nonambulatory infants should not have any bruising.

“Those who don’t cruise rarely bruise” is quoted in the 1999 landmark article by Dr. Sugar and colleagues. This cross-sectional study looked for bruises in nearly 1,000 children younger than 3 years of age. Their outcome measures were the “presence and location of bruises as related to age and developmental stage.” Bruises were rarely found in those younger than 6 months of age, and uncommonly seen in those younger than 9 months of age (1.7%).

The researchers concluded that bruises in this age group should be investigated further for nonaccidental trauma or medical illness.¹⁰

It is also important to know that estimation of the age of bruising by color has been shown to be highly inaccurate in multiple retrospective studies.¹¹

Suspicious history and patterns include but are not limited to (1) bruising in children who are not independently mobile; (2) clusters of bruises; (3) multiple bruises with a uniform imprint; and (4) bruises seen away from bony prominences, i.e., on the face, back, abdomen, arms, buttocks, ears, and hands.¹²

Pattern recognition for concerning burns is also essential. Patterns specific to abuse include glove and stocking distribution, localization to perineum and buttocks suggesting submersion, signs of forced immersion including absence of splash marks, and inflicted contact burns, such as from cigarettes, causing outlines of the contacted surface. The severity of the burns also tends to correlate with likelihood of abuse.¹³

Fractures

Fractures are common findings in abused children. A majority of abuse-related fractures occur in children under 1 year of age and should raise suspicion for abuse. Additional risk factors of concern for abuse are multiple fractures, bilateral long bone fractures, fractures that are in different stages of healing, and fractures in children with developmental disabilities.14,15 One study found that up to 20% of abuse-related fractures in children are missed on first presentation to a clinician.⁴

Fractures of the humerus, femur, and tibia are commonly seen in abused children. The younger the age, the more likely abuse is the etiology. The arms and legs serve as a “handle” so the infant can be easily thrown or shaken.

It is important to note that fractures in these regions may also occur accidentally, especially in the ambulatory child. Therefore, an understanding of childhood developmental expectations, mechanisms of injury, and fracture patterns is vital.

Metaphyseal corner fractures, often called “bucket handle fractures,” imply a forceful shaking, pulling, or twisting injury to the child. They cause a periosteal elevation of the metaphysis. While significant force is needed to produce these fractures, the child may not have obvious symptoms unless the injury is severe.¹⁶

Fractures involving the hands and feet should also raise suspicion, especially in nonambulatory patients. Buckle fractures of the proximal phalanges and torus fractures of the metatarsals and metacarpals are suspicious for abuse. These fractures can be caused by forced extension of the fingers and toes.¹⁷

Nonextremity fractures also should raise significant concerns. Rib, sternal, and scapular fractures suggest a high degree of force not usually seen in accidental trauma.¹⁵ Acute rib fractures are often missed and are more easily identified after callus formation, which may take up to 14 days to become apparent.¹⁸ Skull fractures with questionable history also require further evaluation.

It is important to note that no specific fracture can be considered definitive for nonaccidental trauma, as similar fractures can be caused by abuse or accidental injury.^14,17 Therefore, if suspicion of abuse is present, a skeletal survey must be done. This is the preferred screening study to evaluate for other fractures of abuse.¹⁹ The survey is most useful for children under 2 years of age with concerning extremity, abdominal, and head trauma. For situations with high suspicion, the full skeletal survey should be repeated 14 days later.^4,19

Abusive Head Trauma

Abusive head trauma (AHT) is the most common cause of pediatric deaths related to child abuse.²⁰ The true incidence is unknown because many cases go unreported, and unfortunately, even patients who are seen by clinicians may not have their presentation recognized as AHT. Children under 1 year of age, especially those in the 2- to 6-month age group, are at increased risk for AHT.²⁰

Children with AHT will present in various ways to the ED. Some presentations, such as seizures, lethargy, respiratory distress, or apnea, are obvious. The more dramatic the presentation, the more likely the diagnosis will be made.

Previous studies have shown that up to 1%-3% of acute life-threatening events are caused by abuse.^21,22 Other young infants may present with nonspecific complaints such as vomiting, crying, not eating, or respiratory symptoms. These nonspecific symptoms are also commonly seen in nonabused infants, making the diagnosis of AHT challenging.

A landmark article from 1999, “Analysis of Missed Cases of Abusive Head Trauma,” revealed how difficult this diagnosis can be.²³ The authors looked at children younger than

3 years of age who were diagnosed with AHT and then retrospectively reviewed their charts to see how frequently the child presented to a clinician before the diagnosis was made. Their results were startling. Nearly one-third of all children diagnosed with AHT were previously seen by a clinician and given a different diagnosis. Erroneous diagnoses included gastroenteritis, influenza, rule out sepsis, increasing head size, otitis media, seizure disorder, reflux, apnea, upper respiratory infection, urinary tract infection, and bruising. Given the subtlety of the presenting complaints, it is easy to see how AHT can be confused with other common pediatric conditions.

The physical exam for an infant suspected of having suffered an AHT must be detailed and thorough. Close inspection of the head, scalp, face, ears, and oropharynx is important. Is there scalp swelling or evidence of a small hematoma? Is there facial bruising? Bruising to the ear? Is there dried blood around the nose or mouth? Is there oropharyngeal trauma, such as a torn frenulum? Scalp swelling, facial or neck bruising, and oropharyngeal trauma in nonambulatory infants are all potential indicators of abuse.

Retinal hemorrhages and the neurologic exam in infants deserve special mention when considering AHT. Retinal hemorrhages are a key physical finding for AHT.24 Many, although not all, children with AHT will have retinal hemorrhages. Because the finding of retinal hemorrhage may be subtle, this exam finding should be sought by an ophthalmologist. Additionally, while a normal neurologic examination in a well-appearing infant does not exclude the diagnosis of AHT, a positive finding clearly requires further investigation.

Mimickers

It is important to note that children may have findings that appear to be from an abusive etiology but are due to genetic, nutritional, metabolic, or cultural reasons. In some of these cases, significant injury may occur with a trivial mechanism. Examples include metabolic bone diseases such as rickets, nutritional deficits such as vitamin C deficiency causing scurvy, skeletal dysplasia such as osteogenesis imperfecta, infections such as osteomyelitis, and malignancies such as leukemia.²⁵

Bleeding disorders, photodermatitis, salicylate ingestion, Henoch-Schonlein purpura, vasculitides, and Mongolian spots are commonly mistaken for nonaccidental bruising. Additionally, cultural treatments such as cupping, coining, and spooning are often mistaken for abusive injury.²⁶

Summary

Emergency physicians have an important responsibility to help to combat the “silent epidemic” of child abuse. We are often the last or only providers who can prevent a child from suffering severe injury or death from abuse. Careful matching of history, physical examination, radiographic findings, and developmental capabilities is imperative when evaluating a child for nonaccidental trauma. A high index of suspicion is needed for detecting the more subtle presentations.

References

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2. Green M, Haggerty RJ. Physically abused children. In: Ambulatory Pediatrics, WB Saunders, Philadelphia, 1968, p. 285.
3. Oral R, et al. Fractures in young children: Are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse? Pediatr. Emerg. Care 2003; 19:148-53.
4. Ravichandiran N, et al. Delayed identification of pediatric abuse-related injuries. Pediatrics 2010;125:60.
5. Lung CT, Daro D. Current trends in child abuse reporting and fatalities: The results of the 1995 annual 50 state survey. National Committee to Prevent Child Abuse, Chicago, 1996.
6. National Child Abuse and Neglect Data System Summary of Key Findings from Calendar Year 2000. Children’s Bureau Administration on Children, Youth and Families, Washington, D.C., 2002.
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