Child Abuse

  • An estimated 2,815,600 children are harmed or endangered by their caretakers annually
  • Bruises and Fractures are the most common injuries seen with abuse, but also occur frequently from accidents (I’ve certainly seen more accidental bruises and broken bones than abusive… is there any clear clues that can help distinguish the two?)
  • As with everything in Pediatrics, the history and the age of the child are important factors to consider.
    • Developmental abilities certainly play a role regarding what is and isn’t possible.
    • The youngest (<3yrs) are most likely to be physically abused, with children <1yr having the highest rate of abuse in the US.


  • The pattern of bruising is important (see attached diagram from Macguire)
  • The presence of petechiae associated with the bruise is a strong predictor of abusive injury (their absence does not rule it out). So look closely!


  • No fracture is pathognomonic of abuse (again, what I was taught is wrong… spiral fractures can happen from accidents)
    • Some are suggestive:
      • Spinal fx
      • Digital fx
      • Complex skull fx
      • Spiral Long Bone fx
      • Scapular fx
      • Sternal fx
      • Metaphyseal fx
      • Periosteal separation
    • Some are more specific
      • Rib fx (anterior, lateral, or posterior)
      • Acromioclavicular Fx
      • Multiple fxs of different ages

Make sure you document specifics to assist other practitioners later: fall height, weight of child, surface composition, and how the child was oriented upon impact (pretend that you are a forensic officer on CSI).

Maguire, S. Which Injuries may indicate child abuse? Arch Dis Child Educ Pract Ed 2010;95:170–177.

C Y Skellern, D O Wood, A Murphy, M Crawford (2000). Non-accidental fractures in infants: Risk of further abuse. Journal of Paediatrics and Child Health 36 (6), 590–592.

K. Nimkin, P. Kleinman. IMAGING OF CHILD ABUSE. Radiologic Clinics of North America, Volume 39, Issue 4, Pages 843-864

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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