Diagnosis : Physical Abuse

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.

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 Specificity of Radiological Findings and Abuse table in RADIOLOGY: Extremity Fractures and Skeletal Survey.

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 AP, Krugman RD. Physical abuse of children: an update. Pediatrics in Review. 1994; 15 (10) : 394-9. (DOI)

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 [] NEED LINK, and the Differential Diagnosis Table, Appendix [ ] NEED LINK.

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 harmful.

A parent has discretion to use home remedies and culture-based practices to the extent that they are providing a minimum degree of care. For more information on these practices, see Test Your Knowledge Question 22: https://champprogram.com/abuse-cases-resource.php?case=22 and World Health Organization - Traditional medicine has a long history of contributing to conventional medicine and continues to hold promise .

In New York State, 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. See below for information on female genital mutilation.

Female Circumcision or Female Genital Mutilation

Female circumcision (FC) or female genital mutilation (FGM) is the name for several different practices that involve excision, circumcision or infibulation of female genitals. The timing of the procedure varies among countries and cultural and ethnic groups. It has been performed as early as a few days after birth and as late as the seventh month of the first pregnancy.

In 2008, the World Health Assembly passed resolution WHA61.16 on the elimination of female genital mutilation. FGM is a crime under federal law except in circumstances where it is deemed necessary to the health of the person on whom it is performed and when performed by a medical practitioner (18 USC §116: Female genital mutilation) In New York State, female genital mutilation is a felony Class E offense. According to New York Penal Code §130.85, it is the excision, circumcision or infibulation of any part of the clitoris or labia of a girl who is younger than eighteen years of age.

The World Health Organization (WHO) has grouped the types of FC/FGM into four broad categories:

Type I

clitoridectomy 
The excision of the prepuce with or without excision of the clitoris 

Type II

excision 
The excision of the prepuce and clitoris together with partial or total excision of the labia minora 

Type III

infibulation 
The excision of part or all of the external genitalia and stitching or narrowing of the vaginal opening

Type IV

all other procedures 
The partial or total removal of the female external genitalia for cultural or any other non-therapeutic reasons

For more information regarding FC/FGM, see: World Health Organization - Female genital mutilation .

FC/FGM has serious health consequences. The immediate complications include severe pain, infection, bleeding that can lead to hemorrhaging, and shock. Long-term complications include keloid formation, labial adherences, clitoral cysts, chronic urinary or pelvic infection, pain during sexual intercourse, infertility, and problems during pregnancy. The prevalence of FC/FGM in the United States is not known.

The National Women’s Health Information Center answers frequently asked questions about FC/FGM. For more information, see: US HHS - Office on Women's Health - Female Genital Cutting and World Health Organization - Female genital mutilation .

Bruises

As with all medical diagnoses, diagnosing a coagulopathy (bleeding disorder) starts with a good history and physical examination. When child abuse is suspected and bruises are present, determining whether the findings are the result of trauma versus a possible medical explanation, or both, can be critical. Note that mimics of abuse include congenital nevi, as well as patterned marks from cultural practices such as cupping or coining, see: Test Your Knowledge Q22.

A detailed history, including family and patient history of unusual or excessive bruising or bleeding, is important. Even when there is pattern bruising, but particularly in the setting of non-patterned bruising, a good history may suggest that further work-up for a bleeding disorder is necessary. Screening laboratory tests will help with the decision to refer to a pediatric hematologist for further evaluation. Note that the presence of a bleeding disorder does not rule out the possibility of abuse. In some cases, bruises may be small and seemingly insignificant. However, any bruise on a non-ambulatory infant, particularly on the face, should be considered suspicious for non-accidental trauma and may represent a sentinel injury. Sentinel injuries are described in the Curbside Consult Sentinel Injuries.

Decision rules for suspicion of abuse may also be helpful, see: Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Network Open. 2021; 4 (4) : 1-12. (DOI) . The bruising clinical decision rule is a useful screening tool to assist with distinguishing bruises caused by physical child abuse from those caused by non-abuse. Bruising to the torso, ear, or neck or any bruising on an infant are considered suspicious for abuse. See: TEN-4-FACESp. Appendix [ ] NEED LINK