Child Abuse and Neglect

Bruises, Welts, and Scars

A bruise is an injury appearing as an area of discolored skin caused by an impact that ruptures underlying blood vessels. Blood leaks from the broken vessels into surrounding tissues, producing pain, swelling, and tenderness. The discoloration is a result of the blood seepage under the skin. On any day, nearly every ambulatory child has one or more bruises. Many bruises are the result of accidental play. However, it is possible to distinguish which bruises should raise concerns for physical abuse and which bruises are more consistent with accidental events. Bruises are the most common clinical finding in cases of physical abuse; they are seen in up to 75% of victims, and their presence should prompt a search for other, deeper injuries. Many factors can be informative.

The Location of Accidental Versus Abusive Bruising

Accidental bruises are most often over bony prominences. The most common sites of accidental bruises include shins, knees, and foreheads. Additionally, bruises directly over spinous processes or the iliac crest often have a clear accidental history.

In contrast, abusive bruises are found where common sites of bruising from accidental play are not found. Specifically, bruising over soft areas is concerning for abusive trauma. This includes the torso area, abdomen, genital areas, ears, angle of jaws, neck, buttocks, and soft areas of arms and legs ( Fig. 6.4 ).

Injuries to the Face and Neck

Bruises involving the head, face, mouth, neck, and ears are seen in a substantial percentage of physical abuse victims, approximately 50% of infants and 38% of toddlers (see Figs. 6.4 and 6.5 ). Subgaleal hematomas and contusions and petechiae involving the scalp may be the result of direct blows or impacts against a hard surface, or forceful hair pulling ( Fig. 6.6 ). Ear bruises are highly associated with abusive trauma. Bruising can be found in the inner folds of the ear, likely the result of a direct blow, and pinching the ears may result in bruises found on the outer edge and rear side of the helix (see Fig. 6.7 ).

Attempted smothering, choking, or severe and prolonged thoracic compression may produce showers of petechiae over the shoulders, neck, and face ( Fig. 6.8 ). The oral and conjunctival mucosa may be involved as well and should be carefully inspected (see Fig. 6.8E ). When strangulation is the mechanism, neck bruises may be visible (see Fig. 6.8B ). These petechiae may range from florid to faint and may be especially subtle when there has been a delay in seeking care. They can be mistaken for a rash if the examiner fails to check for blanching. Petechiae do not blanche.

Injuries to the Genital Area, Buttocks, and Lower Back

Bruising in the genital area may include direct trauma to the suprapubic area or genitalia. It may also include pinching of the penis and/or scrotum. These injuries are considered abusive until proven otherwise. This type of trauma can result in bruising and extraordinary swelling. Careful evaluation for scrotal hematomas, which can have serious sequelae if untreated, should be completed.

Bruises are often seen over the curvature of the buttocks and across the lower back after severe spankings, whether with a hand or an object ( Fig. 6.9 ). When linear marks from fingers, belt, or brush edges are seen, these tend to be horizontally or diagonally oriented (see Fig. 6.9B ). In some cases, a linear pattern of petechiae may be noted on either side of the gluteal crease (see Fig. 6.9C ). Despite their vertical orientation, these are also the result of forceful horizontal blows across tightly tensed glutei, as when the blows are delivered, the involved sites are closely apposed along the crease and thus are subject to maximal capillary distortion on impact.

Bruise Patterns, Shapes, or Sizes

Injuries inflicted with an object will often leave marks that reflect the outline of that object. Patterned injuries do not occur during normal play and should be considered abusive until proven otherwise. In many instances, the surface marks are recognizable imprints of the edge of an implement used, because the edge causes maximal capillary deformation on impact ( Fig. 6.10 ). Those most commonly seen are looped-cord marks, belt and belt-buckle marks, and switch marks, but almost any implement can be used.

Slap marks with an open hand can often leave a pattern consistent with the linear distribution of pressure from fingers (see Fig. 6.5 ). The hand leaves a negative imprint when the capillaries break under the slapping fingers, and the blood is pushed away from the point of contact. Slapping and direct hitting may produce diffuse bruising with petechiae (see Fig. 6.4 ).

Surface injuries involving more than one plane of the head or face are highly suspicious for abuse. An accidental event or “fall” does not typically involve multiple planes of the face and head. It is also important to recognize that contusions of the head, face, and ears are often associated with underlying intracranial injury, especially in infants.

Abrasions and Superficial Lacerations

Abrasions are also seen in abuse victims, although less commonly than bruises. In some cases, outline bruises of forcefully applied weapons have an overlying abraded or even lacerated surface ( Fig. 6.11 ). Abrasions also may result from friction on impact with a hard surface or from being dragged across a carpet or other rough surface. Fingernails can be dug into the skin, leaving small curvilinear marks.

Strangulation, Restraint, and Tourniquet Injuries

Strangulation and restraint marks result from attempts to hang, choke, or tie the child to a crib, bed, or chair. Abraded or blistered circumferential ligature marks can be seen in these cases ( Fig. 6.12 ).

Bite Marks

Bite marks can be another manifestation of physical abuse. Lesions tend to be oval or semicircular. The impressions of the incisal surfaces may be variably clear, depending on the force applied and the age of the bite. Suction petechiae may be noted centrally in some fresh lesions. If the injury is distinct, the size enables the examiner to clearly distinguish between the bite of another child (primary teeth) and an adult bite (secondary teeth). Adult bites with secondary teeth are greater than 3 cm in diameter ( Fig. 6.13 ). Each bite mark should be carefully photographed in its entirety, and then photos should be taken perpendicular to the plane of the imprint of each arch, with a measuring tool in each photo.

Burns

Similar to bruises or abrasions, some patterns of burns are highly associated with abusive injury.

Abusive burns are more commonly seen in children under the age of 5. Young children with immersion burns into hot water without any associated splash marks or dip burns in a stocking-glove distribution are very concerning for abusive injury. Burns to the back, buttocks, or genital burns in infants and toddlers are concerning for abusive injury while being bathed. Histories that include an unexpected toileting accident can alert a clinician to concerns for a frustrated caretaker. Deep contact burns with a clear imprint of the hot surface should raise concerns of a thoughtful clinician. When considering abusive injury for a burn, an inconsistent history, an unusual pattern of injury, or delay in seeking medical attention increase concerns. It is important to evaluate for other injuries when a burn is suspicious for abuse or neglect ( Fig. 6.14 ).

Immersion scalds or dip burns are among the most common forms of inflicted burns. Typical patterns include symmetrical burns of hands or feet in a stocking-glove distribution, with a sharp line of demarcation at the level of the water line ( Fig. 6.15A ). Circumferential burns of the feet and lower legs along with burns of the perineum and flexor surfaces of the thighs are seen in children who are dipped in scalding water (see Fig. 6.15B and C ). Sparing of apposed skin surfaces in flexor creases may also be noted in these cases. At the recommended hot water tank setting of 120°F maximum, scalding burns can be prevented ( Table 6.1 ).

There are some characteristics of burns that are commonly associated with accidental injuries. Accidental scalds typically occur when a hot liquid is spilled, producing a splash-and-droplet pattern in the case of a small spill ( Fig. 6.16A ) or an inverted arrowhead in cases of larger spills over the chest (see Fig. 6.16B ). The child usually presents with a history of having grabbed a cup of hot coffee, tea, or cocoa from the table while sitting on someone’s lap, or of having reached up and grabbed the projecting handle of a pot on the stove.

Contact burns show the imprint of the instruments used to inflict them and have a depth or degree of burn that is relatively even throughout. For example, one may see the imprint of a hot iron or of the grill of a space heater or radiator cover ( Fig. 6.17A–D ). No child with normal sensation would remain in contact with these objects long enough to incur such a burn. Burns caused by holding a hot hair dryer next to the skin leave an imprint of the screen that covers the heating element (see Fig. 6.17E ), and those inflicted with a curling iron produce cigar-shaped, deep partial- or full-thickness imprints (see Fig. 6.17F ). Most abusive contact burns are found in unusual locations for accidental burns, such as the extensor surfaces of the upper arms or legs, the back, chest, abdomen, or buttocks that are usually covered by clothing.

Inflicted cigarette burns usually leave sharply circumscribed, full-thickness imprints approximately 7 to 8 mm in diameter ( Fig. 6.18 ). These are surrounded by a deep, partial-thickness halo blister and then a rim of superficial erythema. A thick, black eschar soon forms over the central, full-thickness burn. Subacutely, these lesions fill in with granulation tissue, and on completion of healing, the child is left with a deep, punched-out scar. Other burning objects, such as a lighter, can create a distinctive pattern of inflicted burns as well. So-called “branding” injuries can also be seen on children ( Fig. 6.19 ).

Classic Metaphyseal Lesions or Corner Fractures

In infancy, the cartilage of the chondro-osseous junctions adjacent to the metaphyses of long bones is poorly mineralized, making these structures the weakest points in long bones. Classic metaphyseal lesions are planar fractures through these sites when the bones are subjected to shearing forces. The periosteum overlying the epiphyseal cartilage is firmly adherent and extends close to the diaphysis to cover the subperiosteal bony collar. Thus, when fractures occur, these peripheral segments are visibly thicker.

Metaphyseal fractures can be produced by the application of torsional or tractional forces delivered when an extremity is grabbed and yanked. They can also occur by rapid, repetitive acceleration and deceleration as the extremities flail back and forth in the process of violent shaking. Metaphyseal fractures can be found in any long bone but are most commonly seen in the distal femur, proximal and distal tibias, and proximal humerus. They may cover the entire metaphysis or only a portion of it. Clinically, they are not associated with any significant soft-tissue swelling.

Radiographic manifestations of metaphyseal fractures have led to the terms metaphyseal chip or corner fractures and bucket handle fractures. The first derives from the fact that in the anteroposterior view the central portion of the fracture is often invisible and only a chip of bone is seen on either the lateral or medial aspect of the metaphysis, or both ( Fig. 6.23 ). Chips may also be seen on lateral projections. In some cases, a thin central metaphyseal lucency can be detected. Special oblique views are necessary to reveal the true extent of the fracture, because in this projection the separation of the metaphyseal disk becomes readily evident, resembling a bucket handle. Healing of metaphyseal fractures is not usually accompanied by prominent callus or extensive subperiosteal new bone formation.

Rib Fractures

Rib fractures are also relatively unique to abused infants. Because of the plasticity and pliability of the thoracic cage in infancy, application of major forces is required to break ribs, and accidental rib fractures are exceptionally rare. A 2006 systematic review with 923 children (0 to 14 years) who received cardiopulmonary resuscitation (CPR) showed that three children sustained rib fractures, and all cases were anterior fractures. Abusive causative mechanisms include violent shaking or squeezing while holding the infant by the chest. The ribs are subjected to marked anteroposterior compression forces, and the posterior ribs are levered against the fulcrum of the vertebral bodies and their transverse processes. This often produces rows of multiple, posterior rib fractures, located near the costovertebral articulations ( Fig. 6.24 ). Extreme squeezing of the chest with or without shaking can produce fractures at multiple sites along the rib arcs. Most of these infants have no history of trauma and symptoms are nonspecific. Hence, the appropriate imaging is necessary.

Like metaphyseal fractures, rib fractures are not often associated with soft tissue swelling or bruising. When fractures involve the lower rib cage, associated abdominal injury should be considered ( Fig. 6.25 ).

Radiographically, rib fractures may not be visible before the appearance of callus and/or subperiosteal new bone. It is the standard of care that a repeat skeletal survey is completed 10 to 14 days after the initial x-rays. These follow-up films can reveal fractures not visible on the first study. An early sign of healing, seen 5 to 10 days post injury on standard radiographs, consists of a vertical lucency at the site of the fracture surrounded by soft callus with indistinct margins. Subsequently (at 14 to 21 days), callus takes on a more nodular appearance with sharper margins and is then termed hard callus . Reinjury can result in florid callus formation. Complete remodeling and radiographic disappearance occur within a few months in the absence of reinjury.

Additional Fractures With High Specificity for Physical Abuse

Vertebral fractures, scapula fractures, and sternal fractures are rare. However, each of these fractures is highly specific for physical abuse. Scapular fractures of the acromion probably result from shearing forces during shaking or traction to the upper extremities. Fractures to the body of the scapula or the sternum are the result of very high force blunt trauma. Each of these fractures is unusual but highly associated with inflicted trauma ( Fig. 6.26 ).

Abusive fractures have been described in virtually every bone in the body, and any single fracture can be the result of accident or abuse, particularly when considering the age of the child and the history provided. Below are some fractures in the context of a lack of history or a history that does not fit with the developmental age of the child, which should be very concerning.

Long Bone Fractures

Long bones may fracture through the diaphysis in a variety of patterns. Transverse, oblique, spiral, or compression fractures may all be seen. These fractures take a substantial amount of force. Although not specific for inflicted injury, diaphyseal fractures are highly suspect when found in infants who are not yet crawling or walking, especially when seen in the absence of a history of significant trauma. An understanding of the direction and magnitude of force required to produce a given type of diaphyseal fracture compared to the provided history is important to try to distinguish between accidental and inflicted injury ( Figs. 6.27 and 6.28 ).

Although more commonly accidental in origin, torus or buckle fractures can be the result of abuse, especially in very young children. When mild with only slight cortical buckling, they are the result of mild-to-moderate compression forces delivered in a direction parallel or nearly parallel to the axis of a long bone. When higher energy forces are delivered, whether accidental or inflicted, there is usually some degree of angulation; in such cases, it may be more accurate to classify them as a form of compression injury ( Fig. 6.29 ). More severe forms involving the femur or tibia can be caused by throwing or slamming a child feet first or onto the knees on a hard surface.

Transverse fractures are high-energy injuries that are much more likely to be accompanied by acute soft tissue swelling and deformity. Transverse fractures are often the result of a rapidly delivered direct blow perpendicular to the long axis of a bone, such as “karate chop” or “night stick” injury ( Fig. 6.30 ). They can also occur when a child is thrown or swung and, in the process, hits an extremity against a hard edge such as that of a table, as a result of falls of greater than 6 feet, and when half of an extremity is held with both hands and snapped. Violently yanking a child up from his crib while holding an extremity or grabbing an arm and yanking it upward or sideways when the child is fixed in position by the belt of a highchair or infant seat are possible etiologies for these fractures. Inflicted supracondylar humerus fractures of the compression/distraction type are the result of grabbing an arm and yanking it into hyperextension ( Fig. 6.31 ).

Other Fractures That Warrant Evaluation for Abuse

Vertebral body fractures, metacarpal and metatarsal fractures, distal or proximal clavicular fractures, and complex skull fractures are concerning for physical abuse ( Fig. 6.32 ). Vertebral body fractures are due to compression, typically associated with a child being slammed down violently and axial loading transmitting through the vertebral canal ( Fig. 6.26B ). Cervical fractures are usually the result of violent hyperflexion or hyperextension. Below the cervical spine, most fractures occur near the thoracolumbar junction. Fractures of the hands and feet are relatively uncommon but important findings to consider physical abuse. These tend to be clinically occult when first seen. Grabbing and yanking, twisting, or bending the hand or foot tend to produce metacarpal/metatarsal fractures. Subtle subperiosteal new bone formation and/or medullary sclerosis are common radiographic findings. Forced hyperextension of the phalanges can cause buckle fractures at their bases (see Fig. 6.33 ).