Pediatric Annals

Accidental or Inflicted?

Sara Thompson, MD, MPH


Evaluating cutaneous, skeletal, and abdominal trauma in children.


Evaluating cutaneous, skeletal, and abdominal trauma in children.

Pediatric primary care providers frequently encounter the sequelae of childhood injury as their patients acquire new developmental capabilities and increasing levels of independence. While many traumatic physical findings are the result of unintentional trauma, child physical abuse continues to be a significant part of the differential diagnosis of traumatic injury in children.

In 2002, child physical abuse affected 166,920 children and killed 276 children in the United States. Infants and toddlers represent a disproportionate percentage of child abuse victims, are at greatest risk of suffering severe trauma, and are at greatest risk of being victims of recurrent abuse. National rates of child physical abuse have dropped recently, from 2.9 per 1,000 children in 1998 to 2.3 per 1,000 children in 2002.1

Figure 1. "Stocking-glove" burn on distal extremity. (Courtesy Joseph Zenel, MD)

Figure 1. "Stocking-glove" burn on distal extremity. (Courtesy Joseph Zenel, MD)

Figure 2. Cigarette burns with characteristic deep, "punched out" appearance. (Courtesy Zitelli & Davis, Mosby)36

Figure 2. Cigarette burns with characteristic deep, "punched out" appearance. (Courtesy Zitelli & Davis, Mosby)36

Identifying victims of abuse continues to be a challenge for health care providers since they often present with few external signs of trauma. Since "battered child syndrome" was described by Kempe et al.,2 the medical profession has continued to better define patterns of inflicted injury, improving the ability of physicians to approach the identification of inflicted head, skin, skeletal, abdominal, and genital trauma systematically.


Cutaneous findings such as bruises, lacerations, abrasions, bites, burns, and soft tissue swelling are the most common sequelae of inflicted trauma. Abusive skin findings may be difficult to recognize, however, particularly in a nonverbal or preverbal child. Age and mobility of the child are historical factors that contribute to a healthcare provider's degree of suspicion that an injury is inflicted. Study of general populations of children has shown that preambulatory children younger than 6 months rarely have evidence of accidental skin trauma.3 The presence of skin trauma in this age group should prompt questioning as to the etiology of the mark or marks. Physical factors such as the location of the skin finding and the presence of a patterned injury also should contribute to a provider's concern for abuse.

When suspicious skin trauma is noted, a thorough physical examination should be performed to document any associated injuries while noting the child's developmental capabilities, particularly motor development. Documentation of skin trauma should include the reported mechanism of injury for each lesion, obtained in a nonjudgmental manner (eg, "How did this happen?"). The size, color, and location of each skin lesion should be photographed or labeled on a preprinted body diagram.

In children younger than 2 with suspicious skin findings, a supplementary radiographic skeletal survey should be obtained to look for occult or healing fractures. Central nervous system imaging or ophthalmologic examination should be considered when the suspicious marks occur on the head or face in children of this same age group. In assessing whether the child's physical findings seem consistent with the reported mechanism of injury, the provider must determine if the mechanism seems biomechanically plausible and if the child's developmental capabilities fit the proposed mechanism of injury.


Studies of age-related patterns of bruising have shown that the incidence of bruising increases significantly as infants are developmentally able to cruise, and that those pre-ambulatory infants who do have accidental bruises have few in number.3'4 Ninety-three percent of accidental bruises occur over bony prominences, and among children not yet able to walk, the most common locations include the extensor surfaces of the lower leg, the forehead and the scalp. Older, walking children most commonly have bruises on the extensor surfaces of the lower leg, the anterior thigh, and the forehead.

Uncommon locations for bruising at all ages include the chest, abdomen, back, buttocks, soft tissue of the face, ears, and "protected areas" such as the neck, genital area, and inner thighs.3 The presence of a bruise in any of these uncommon locations may be a marker for more serious underlying pathology such as intracranial injury, a rib fracture, or intraabdominal trauma, particularly in a child younger than 2.

In the past, estimations of the ages of bruises were made according to a presumed predictable timetable of color change, but further study has shown that this is not a reliable practice. Bruises are likely to appear more rapidly in loose or superficial tissue, and color change depends on the location and depth of the bruise, the vascularity of the tissue, and the complexion of the child. Yellow coloration of the bruise has been noted as early as 18 hours after injury, and a red or purple color may be present throughout the lifetime of the bruise.5

At times, it can be difficult to distinguish a bruise from other skin markings. In these situations, it often is helpful to have the child return for re-examination 48 to 72 hours after the initial examination, allowing the examiner to evaluate whether the lesion has changed as expected of a bruise.

The differential diagnosis of bruising includes Mongolian spots, phytophotodermatitis, coagulopathy, Henoch-Schonlein purpura, Ehlers-Danlos syndrome, erythema multiforme, and cultural practices such as "coining" (cao gio) or "cupping." Cao gio is the Southeast Asian practice of rubbing the head and torso with a coin, typically in a linear pattern, to relieve common symptoms of illness. "Cupping" is the practice of placing a heated cup on the skin. The trapped air cools, creating a vacuum and resulting in skin erythema, petechiae, and ecchymosis in the round shape of the cup. Most of these diagnoses can be distinguished based on the history and physical, along with laboratory testing that may include hematocrit, platelet count, prothrombin time, and partial thromboplastin time.


TABLE.Common Patterned Injuries


Common Patterned Injuries


Children younger than 4 are represented disproportionately among burn victims; studies have found that up to one-quarter of all pediatric burns are abusive in origin.6 Several characteristics can be used to help differentiate intentional from unintentional burns. These include the configuration of the burn, the location on the body, and the compatibility of the burn characteristics with the mechanism of injury.

Inflicted burns typically are deeper and more symmetrical than accidental burns and are more likely to be patterned or circumferential around a digit or extremity. Burns that occur in protected areas such as the genitals, inner thighs, buttocks, and back are also less likely to be accidental.

As with other traumatic findings in infants, toddlers and older children, the mechanism of burning must be consistent with the developmental capabilities of the child. Any burn of unknown etiology should be highly concerning for abuse, particularly in a child younger than 4. Other diagnoses that may be confused with a burn include streptococcal and staphylococcal infections such as impetigo and scalded skin syndrome, herpes, varicella, severe dermatitis, epidermolysis bullosa, phytophotodermatiUs, and herbal remedies such as the application of garlic to the skin.

Thermal burns are the most common type of burn in children and typically result from either a scald from hot liquid or prolonged contact with a hot object. Scald burns are the most common type of inflicted burns and are categorized as either splash or immersion burns. Splash burns often have associated drip marks and are irregular in shape, with a tapering distribution that reflects the path of the hot liquid running down the body. This configuration may be altered, however, if the child is wearing clothing. It may be difficult to distinguish intentional from accidental splash burns, but one useful clue in this assessment is the location of the burn. Accidental splash burns typically are located on the face, neck, upper extremities, and trunk.

It can be easier to distinguish between intentional and accidental immersion burns. Accidental immersion bums have irregular lines of demarcation and may have associated splash marks due to the child's ability to move and withdraw the affected body part from the liquid. Inflicted immersions have sharp lines of demarcation, are uniform in depth, and have no splash marks, reflecting a child's inability to move the affected body part from the liquid, due to enforced restraint.

One example of an immersion bum is the "stocking-glove" distribution of a bum on a distal extremity. This bum is circumferential and sharply demarcated from forced immersion of the extremity (Figure 1, see page 374). Another pattern is the "doughnut sign," which reflects forced immersion of the buttocks, often as a result of a toileting accident. In this instance, the buttocks, upper thighs, and genital area are burned, with sparing of the central-most portion of the buttocks. This central area remains unburned as a result of being held against the bottom of the bathtub or sink during the forced immersion.

Two key variables in the assessment of whether a scald bum is consistent with the reported mechanism of injury are the water temperature and the reported duration of immersion. Inspection of the home water heater by a child protection agency can help to determine the water temperature. Calculations derived from adult data estimate that at 130 degrees F, a child will sustain a full-thickness bum with 10 seconds of exposure, and at 140 degrees F, a full-thickness bum results from 1 second of contact.7

Contact bums are the second most common type of inflicted bum, and often the pattern of the burn reflects the shape of the offending object. Common objects include heating grates, curling irons, cigarettes, cigarette lighters, and irons. Cigarette burns, in particular, often are seen on the hands and feet and appear as "punched out," deep lesions that are 7.5 to 10 mm in diameter (Figure 2, see page 374). 8 They can be confused with impetigo; however, cigarette bums are very regular in shape, are deeper, and lack the golden crust of impetigo.

Chemical bums occur after contact with either acidic or alkaline substances, and in children they most commonly result from contact with household cleaning products. While chemical burns typically are unintentional, there may be neglectful circumstances surrounding the incident that mandate a report to a child protection agency.

Cutaneous Patterns

Bruises, lacerations, abrasions, and burns all may appear as patterned lesions. In comparison to an unintentional act, an intentional one often results in contact of a greater portion of the hand or object with the skin. This often results in a more regularly shaped, geometric skin lesion that reflects the shape of the object.

Most impacts result in a positive image (ecchymosis) in the shape of the object, but a high-velocity impact such as a handslap may result in a negative image, such as an unbruised area surrounded by a petechial outline of the object. Common patterned injuries include pinch marks, cigarette burns, human bites, hand slaps, ligature marks around the neck or extremities, and marks from blows with electrical cords, belts, brushes, shoes, and kitchen utensils (Table, see page 375).


Skeletal trauma is the second most common manifestation of child physical abuse, and 80% of inflicted fractures occur in children younger than 18 months.9 Forty-three percent of all inflicted skeletal fractures are unsuspected clinically at the time of the child's evaluation, and approximately 50% of children diagnosed with an inflicted fracture have more than one fracture at the time of diagnosis.10 Often, these fractures are in different stages of healing. As a result, the radiographic skeletal survey is considered to be a standard part of the evaluation of an alleged victim of physical abuse who is younger than 2.

Once a fracture is detected in an infant or older child, the medical provider must determine whether the fracture was inflicted. Factors that contribute to this assessment include the age and developmental status of the child, whether there is a history of trauma, the consistency of the injury with the mechanism described, and whether there has been a delay in seeking medical care for the child. The fracture pattern also can help the clinician determine whether reasonable suspicion for an inflicted injury exists, as fracture patterns and characteristics have been classified into groups with high, moderate, and low specificity for abuse (Sidebar 1, see page 376).

Rib fractures and metaphysealepiphyseal fractures can be particularly difficult to detect, yet they are significant markers for severe physical abuse. Kleinman et al.1 * found that metaphyseal fractures and rib fractures accounted for 90% of fractures in their cohort of fatal child abuse victims.

In making the diagnosis of inflicted skeletal trauma, the clinician must be mindful of several rare congenital, acquired/nutritional, infectious, and druginduced conditions that may mimic the metaphyseal or diaphyseal changes seen with occult fractures, or that may cause alterations in the integrity of a child's bones so that they are predisposed to fracture (Sidebar 2). While many of these disorders can be ruled out on the basis of the history and physical alone, consultation with a geneticist or other appropriate subspecialist is indicated if there is concern for the presence of one of these disorders.

Rib Fractures

Rib fractures are seen uncommonly as a result of accidental trauma in children because of the high plasticity of the ribs compared with those of older children and adults. When rib fractures occur in the setting of accidental blunt trauma, it is from major traumatic events such as a motor vehicle crash or a complicated fall, not from simple short falls from furniture to the floor.12,13

Inflicted rib fractures are caused by unique forces applied to the ribcage by adult hands during the abusive episode.14 When an adult hand encircles the ribcage of an infant or toddler and squeezes, anteroposterior compression of the ribcage causes hyperextension of the posterior rib over the transverse process of the spine, which acts as a stress point. The fracture occurs in the posterior rib, adjacent to the spine. The compression also causes inward bending of the anterior rib and outward bending of the lateral rib, resulting in rib fractures.

Figure 3. Classic metaphyseal lesions (CML) of the medial distal femurs and medial proximal tibias. (Courtesy Carol Berkowitz, MD)

Figure 3. Classic metaphyseal lesions (CML) of the medial distal femurs and medial proximal tibias. (Courtesy Carol Berkowitz, MD)

Posterior rib fractures have a particularly high specificity for inflicted trauma because it is difficult to cause levering of the rib over the transverse process with accidental mechanisms of injury.11 An adult hand covers a broad area of a child's chest, so rib fractures frequently are multiple or bilateral.

Rib fractures account for 27% of all skeletal injuries in abused children and may be difficult to detect by x-ray examination until callus formation 1 to 2 weeks after the time of injury.15 For this reason, skeletal scintigraphy may be used as an adjunct to the skeletal survey in diagnosing acute rib fractures at the time of initial presentation. A repeat skeletal survey also may be obtained 2 weeks later to detect healing rib fractures that were not apparent on the initial skeletal survey.

Classic Metaphyseal Lesions

Previous terms for the classic metaphyseal lesion (CML) have included "metaphyseal-epiphyseal lesion of the long bones" and "bucket-handle fracture." These fractures are highly specific for abuse, are typically found in children younger than 2, and occur most commonly in the distal femur, proximal and distal tibia, and humerus. Skin or soft tissue changes rarely are associated with this type of fracture.

The mechanism of injury is a sudden yank or pull/twist of the extremity, resulting in a shearing force on the metaphysis of the bone. This shearing force causes a complete or partial fracture through the primary spongiosum of the metaphysis, where ossification of cartilage occurs. The fracture fragment seen on x-ray is a piece of this ossified metaphysis, and depending upon the angle at which the fracture line is viewed on x-ray, the ossified fracture fragment may appear as a triangular "comer fracture" or a curved "bucket handle fracture" (Figure 3).14

Long Bone Fractures

The most common location for an inflicted fracture is in one of the long bones; the configuration frequently is transverse, spiral, or oblique.16 A transverse fracture is the result of a tensile or bending load that is applied directly to the bone in the form of a direct blow, or that is indirectly transmitted to the diaphysis, such as when a child falls and lands on an elbow or knee. A spiral fracture results from a torsional load, or twisting, of the diaphysis along its axis, and oblique fractures result from a combination of forces that may include twisting, compression, or bending.17

In children younger than 1, 60% to 70% of femur fractures are due to physical abuse, and inflicted trauma should remain high on the differential diagnosis of a femur fracture in any child younger than 2.18'19 One predictor of the likelihood of abuse is the child's ability to ambulate freely; after age 2, the incidence of inflicted femur fractures decreases to 20%. 18'20

Radiographic skeletal surveys are performed on any chind younger than 2 with a femur fracture, but in older children, histories can be obtained more easily, and skeletal surveys are obtained at the discretion of the medical examiner. Historically, medical providers were taught that spiral femur fractures are highly suspicious for abuse. However, more recent data have shown that the fracture configuration alone (eg, spiral, transverse, oblique) is not predictive of an inflicted femur fracture.21 Instead, the child's age and developmental level should be used in conjunction with the history and physical findings to determine the level of concern for an abuse-related femur fracture.

While studies of inflicted fractures have identified the humerus as a commonly affected bone, studies of general populations of children indicate that most humerus fractures are accidental in nature. Strait et al.22 found that in children younger than 15 months with humerus fractures, 36% were due to abuse, whereas only 1% were due to abuse in children older than 15 months. Therefore, in determining the likelihood of abuse as the cause of a humerus fracture, the age of the child (older or younger than 15 months) appears to be an important factor. The location of the fracture and the fracture configuration have not been shown to be significant factors in differentiating accidental from inflicted, abuse-related humerus fractures.

The tibias commonly are affected bones in inflicted trauma, but the clinician may also encounter the "toddler's fracture," or childhood accidental spiral tibial (CAST) fracture, in children ages 9 months to 4 years.23'24 These ambulatory children often present with no known history of trauma or a history of minor trauma and a refusal to bear weight. X-ray evaluation reveals a nondisplaced spiral fracture of the distal two-thirds of the tibial diaphysis.

There are no radiographic criteria to differentiate between accidental and nonaccidental spiral tibial fractures in an ambulatory child. If reasonable suspicion persists in the clinician's mind, the case must be reported to child protection authorities for further investigation.


Abdominal trauma accounts for 6% to 8% of all cases of physical abuse and is the second-leading cause of death from abusive injury, with a mortality rate of up to 50%. These victims are typically infants and toddlers, while victims of accidental trauma are more likely to be school-aged.

Children with abdominal trauma resulting from abuse are more likely to have vague histories of trauma compared with those who have suffered accidental trauma; they also have a higher mortality rate (odds ratio = 6.45).25 A significant contributor to this higher mortality is the fact that abuse victims are more likely to have a delayed presentation for medical care when compared with accident victims.26'27 This delay in seeking care for a child is thought to be due to several factors. Parents or caretakers may be unaware that a child has been hurt by another person or may be in denial of the effects of their own actions.

The physiologic mechanisms that typically lead to death may not develop immediately. Symptoms of peritonitis may take time to develop, and since children are able to compensate hemodynamically for active hemorrhage for a longer period of time than adults, it may take time for a child to become noticeably symptomatic from hypovolemic shock.

Both solid organs and hollow viscous organs can be affected by compression between the spine and the external blunt force of a punch or kick. Injuries may involve the liver, intestinal tract, spleen, pancreas, kidney, bladder, vascular supply, or lymphatic drainage system, with superficial organs and fixed organs more easily damaged than deeper structures or mobile structures. In infants and young children, the force of the impact from an adult hand or foot covers a large percentage of body surface area and is likely to cause damage to multiple structures.

Establishing the diagnosis of abdominal injury can be difficult in cases of physical abuse, because there typically is no clear history of trauma, many of the patients are preverbal, and symptoms often are nonspecific. Most often, there is no bruising or other cutaneous sign of abdominal trauma because the smaller subcutaneous fat pads and more pliable abdominal musculature in children fail to absorb the blow. Instead, the force is transmitted to the internal organs.28 The high mortality of these injuries is due to the resulting hemorrhage, shock, and peritonitis.

Clinically, these children present with hemodynamic instability, altered mental status, abdominal pain, abdominal distention, fever, or emesis. There are frequently associated injuries. Cooper et al.25 found that in victims of abuserelated abdominal trauma, 95% had soft tissue injury, 45% had evidence of head trauma, and 45% had a skeletal fracture.


Just as in cases of accidental abdominal trauma, injury to the liver, pancreas, kidneys, and spleen can be seen after inflicted, intentional trauma. The liver is the most commonly injured solid organ, and common symptoms of hepatic injury include abdominal pain and right shoulder pain (Kehr's sign). The trauma can be difficult to detect, however, in those who are asymptomatic or in those who are preverbal and cannot provide an accurate history.

Major hepatic trauma is best visualized with an abdominal computed tomography (CT) scan. Minor liver trauma is associated with elevated hepatic transaminases (Figure 4, see page 380). Positive radiographic findings such as lacerations and hematomas have been correlated with an aspartate aminotransferase (AST) level greater than 450 U/L and an alanine aminotransferase (ALT) level greater than 250 U/L.29,30

Figure 4. Abdominal CT of inflicted liver lacerations. (Courtesy Joseph Zenel, MD)

Figure 4. Abdominal CT of inflicted liver lacerations. (Courtesy Joseph Zenel, MD)

Pancreatic injury may present as major damage such as a transection but more commonly presents as a laceration or contusion or as posttraumatic pancreatitis. Although the pancreas is a deep abdominal organ, it is susceptible to abuse-related injury because of its fixed location and its susceptibility to compression against the spine.31 Abdominal CT and measurement of pancreatic enzymes remain the best methods of diagnosing pancreatic injury (Figure 5).

Figure 5. Abdominal CT of inflicted pancreatic laceration. (Courtesy Joseph Zenel, MD)

Figure 5. Abdominal CT of inflicted pancreatic laceration. (Courtesy Joseph Zenel, MD)

An amylase level of greater than 200 IU/L and a lipase level of greater than 1,800 IU/L have been correlated with the presence of major pancreatic injury.32 However, normal amylase and lipase levels do not rule out the possibility of pancreatic trauma, and an abdominal CT should be obtained if abdominal trauma is suspected. Among children younger than 3 with elevated pancreatic enzymes but no radiographic visible damage, physical abuse should remain high on the differential diagnosis of posttraumatic pancreatitis.

Renal and splenic injuries are seen less frequently with inflicted abdominal trauma. Splenic laceration or rupture may be associated with injury to the lower ribs, and renal damage may include not only the kidney but also its vascular supply. Both of these injuries are best diagnosed with abdominal CT scan.


While the most common cause of small bowel trauma is a motor vehicle accident, it also has been well documented as a result of bicycle accidents and child abuse.33 Perforation of the small bowel can occur at any level and may be a direct result of compression between the blunt traumatic force and the spine or the delayed result of bowel wall necrosis. In motor vehicle accidents, this external blunt force typically is generated by sudden deceleration, causing the seat belt or lap belt to compress the abdomen. In child abuse, this force is commonly the result of a punch or kick.

A diagnosis of intestinal perforation can be difficult to make, but clinical signs include abdominal tenderness, cutaneous findings of abdominal trauma, and free peritoneal air on x-ray or CT scan. Untreated, a patient with intestinal perforation will progress to frank peritonitis or shock.

The duodenum is an intestinal segment that is particularly vulnerable to blunt abdominal trauma, and child physical abuse is the leading cause of injury to this area in children younger than 4.34 The duodenum is fixed in its retroperitoneal location and crosses the spine; therefore, it is less likely than other portions of bowel to become displaced and protected from blunt force trauma. It is also more susceptible to compression against the spine.35 Intramural duodenal hematomas are also sequelae of blunt trauma to the epigastrium and may present with symptoms of obstruction or with symptoms similar to a perforation. An abdominal CT scan and radiographic upper gastrointestinal series are useful in making this diagnosis.


The visible evidence of child physical abuse most often is minimal or nonexistent, and the children at greatest risk of becoming victims are those too young to verbalize the history. As pediatric clinicians, we must be able to recognize potential sequelae of abuse and the high-risk situations that lead to physical abuse; we also must acknowledge that victims of child physical abuse often have injuries at multiple locations and in multiple organ systems.

As a routine part of pediatric practice, healthcare providers, through anticipatory guidance, try to maximize the child's safety in the home environment. With this goal in mind, healthcare providers must consider the possibility of physical abuse when faced with a child with a traumatic injury. While it is important to identify these inflicted injuries, our ultimate goal is to prevent their occurrence in the first place.


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Common Patterned Injuries


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