Child Abuse & Non-Accidental Trauma
A board-focused walkthrough of non-accidental trauma: red flags and high-specificity injuries (classic metaphyseal/posterior-rib fractures, abusive head trauma, immersion burns), the validated TEN-4-FACESp bruising rule, mimics to exclude, and the mandatory next step — report to CPS on reasonable suspicion. Emphasizes NEXT-BEST-STEP decisions the way Step 2 CK tests them.
The Big Picture
Non-accidental trauma (NAT) is physical child abuse and a leading cause of traumatic death in infants. On the boards, the diagnosis turns on pattern recognition and clinical suspicion, not proof. The single biggest red flag is an injury that does not fit the stated mechanism or the child's developmental stage — classically, "those who don't cruise rarely bruise" (bruising in a pre-ambulatory infant). Other alarm features: a history that changes or differs between caregivers, delayed presentation, injuries in multiple stages of healing, and patterned marks. Highest-risk victims are infants <1 year; risk rises with prematurity, disability, colic, unplanned pregnancy, young or single parents, poverty, caregiver substance abuse, and intimate-partner violence. Your job: recognize, work up, protect the child, and report — you need only reasonable suspicion, never certainty.
- Bruising — most common finding; suspicious when patterned (looped cord, slap/hand, bite, belt buckle) or seen in a non-mobile infant. Screen with the TEN-4-FACESp rule.
- Fractures with high specificity for abuse: classic metaphyseal lesions ("bucket-handle"/"corner" fractures), posterior rib fractures (anteroposterior chest compression), and scapular, sternal, or spinous-process fractures.
- Any fracture in a non-ambulatory infant (e.g., mid-shaft femur), or multiple fractures at different stages of healing.
- Abusive head trauma: subdural hematoma + retinal hemorrhages + encephalopathy, often with no external signs.
- Burns: immersion burns with a sharp waterline, stocking-glove distribution, and flexural/central buttock "doughnut" sparing; circular punched-out cigarette burns.
- Abdominal trauma: duodenal hematoma or pancreatic injury — the 2nd leading cause of abuse death after head trauma.
Vignette: A 4-month-old is brought in lethargic and vomiting after "falling off the couch." There is no external bruising, but the anterior fontanelle is full and the infant has a seizure. Non-contrast head CT shows a subdural hematoma; dilated fundoscopy reveals multiple, multilayered retinal hemorrhages extending to the periphery.
Diagnosis: Abusive head trauma — subdural from torn bridging veins; retinal hemorrhages + encephalopathy complete the triad. A short household fall does not explain subdural blood plus extensive, multilayered retinal hemorrhages.
Next best step: Stabilize (ABCs, treat seizures and raised ICP), then admit for safety, obtain a skeletal survey and formal ophthalmology exam (consider MRI — more sensitive than CT), and report to Child Protective Services.
Vignette: A 2-year-old has sharply demarcated burns of both feet and the buttocks in a stocking distribution with no splash or satellite marks; the popliteal creases are spared. The parents say the child "climbed into a hot bath." Exam also shows a healing wrist bruise.
Diagnosis: Immersion (dipping) burn. The sharp waterline, symmetry, flexural sparing, and absence of splash burns argue strongly against an accidental spill — a struggling child who fell in would have irregular, asymmetric splash injuries.
Next best step: Treat the burn, obtain a skeletal survey (child <2 yr), admit for protection, document and photograph injuries, and report to CPS. Do not delay the report to "prove" abuse first.
TEN-4-FACESp — a validated bruising clinical decision rule; any of these in a young child mandates an abuse work-up:
- T — Torso
- E — Ear
- N — Neck
…bruising in a child ≤4 years, or
- 4 — any bruising in an infant <4 months old
Refined additions (FACESp):
- F — Frenulum
- A — Angle of jaw
- C — Cheek (fleshy)
- E — Eyelid
- S — Subconjunctival hemorrhage
- p — patterned bruising
Corollary: "those who don't cruise rarely bruise" — bruising in a non-ambulatory infant is abuse until proven otherwise.
Mimics to Exclude Before Reporting
| Mimic | Key distinguishing feature |
|---|---|
| Congenital dermal melanocytosis (Mongolian spot) | Blue-gray, present from birth, over sacrum/buttocks, non-tender, does not evolve through bruise colors |
| Bleeding disorder (ITP, hemophilia, vWD, vitamin K deficiency) | Abnormal CBC/platelets or PT/PTT; mucosal bleeding; positive family history |
| Osteogenesis imperfecta | Blue sclerae, recurrent fractures, wormian bones, positive family history |
| Coining / cupping (cultural practice) | Linear or round marks in a stereotyped pattern; history is congruent |
| Accidental bruising | Over bony prominences (shins, forehead) in an ambulatory child |
- Skeletal survey — a series of ~20 dedicated, collimated radiographs (a single whole-body "babygram" is inadequate) — is mandatory in all children <2 yr with suspected physical abuse; repeat in ~2 weeks to reveal healing fractures.
- Neuroimaging (CT for the acute/unstable child; MRI is more sensitive) plus a dilated fundoscopic exam by ophthalmology when abusive head trauma is suspected.
- Screening labs to exclude mimics: CBC, PT/PTT (± vWF); add LFTs, lipase/amylase and abdominal imaging if occult abdominal trauma is suspected.
- Ensure safety first — admit if the home is unsafe or the work-up is incomplete.
- Mandatory reporting: clinicians must report to Child Protective Services on reasonable suspicion — you do not need proof, caregiver consent, or to identify the perpetrator. Failure to report carries legal liability.
- Document meticulously and photograph all injuries.
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