Clinical Pearls & Morning Reports

Published April 26, 2017


What types of fractures are suspicious for inflicted trauma?

Assessments of child abuse involve the interaction of multiple disciplines, including medicine, social work, law enforcement, and the judicial system. This interdisciplinary approach, which is facilitated by Child Advocacy Centers or similar multidisciplinary models, can be challenging because of differing definitions of child abuse, expectations regarding information that can be determined during the medical evaluation, or interpretations of findings. Read the new Clinical Practice review on this topic.

Clinical Pearls

Q. What are some of the findings associated with abusive head trauma in infants and children?

A. Affected infants may have nonspecific symptoms or signs, such as a brief unexplained event that has resolved, apnea, altered mental status, loss of consciousness, limpness, vomiting, seizure, poor feeding, or swelling of the scalp. In the absence of another reasonable explanation, these clinical features should prompt consideration of abusive head trauma. Retinal hemorrhages are reported in approximately 85% of children with abusive head trauma.

Q. Is abdominal trauma more common than head trauma in some age groups?

A. Isolated inflicted abdominal trauma, although less common than head trauma across all age groups, affects older toddlers (median age, 2.6 years) more often than younger infants and carries a high risk of death because medical care may be delayed or symptoms misdiagnosed. The most common injuries include laceration or hematoma of the liver, splenic injury, hollow viscus injury or pancreatic injury, and hematoma of the duodenum. Studies have shown that 3 to 4% of children who are evaluated for child abuse for any reason have elevated hepatic or pancreatic enzyme levels.

Morning Report Quesitons

Q: When should the presence of bruises arouse suspicion for inflicted trauma?

A: Bruises are common in young, mobile children and do not necessarily indicate inflicted injury. Medical conditions, such as coagulopathies or certain genetic disorders, can confer a predisposition to “easy bruisability,” and screening for these disorders is recommended in a child who has extensive or atypical bruising. Falls often cause bruises over bony prominences (shins and forehead) but are less likely to cause bruising over areas such as the buttocks, hands, and trunk. A pediatric adage, “Those who don’t cruise rarely bruise,” denotes that bruises, especially on the face or trunk, rarely occur in nonambulatory infants. Bruises in these, as well as intraoral lesions, should be considered to be sentinel findings that arouse suspicion of inflicted trauma.

Q: What types of fractures are suspicious for inflicted trauma?

A: In contrast to fractures in normally active children, fractures in children who are nonambulatory arouse concern for inflicted trauma, as do certain types of fractures. Both rib fractures and classic metaphyseal lesions (“chip” fractures or “bucket handle” fractures) are considered to be fairly specific for inflicted injuries. Among infants with abusive head trauma, associated rib fractures from forceful thoracic compression as the infant is held and shaken or fractures of the metaphyseal areas of the legs as the legs jerk back and forth during the shaking episode may be present. Fractures involving the scapula, sternum, or acromion are less common but are of similar concern. Skeletal surveys are recommended in all children 2 years of age or younger in whom abuse is suspected (whether a fracture is specifically suspected or not) as well as in children older than 2 years of age in whom a fracture is present and an inflicted injury is suspected.


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