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Physical child abuse
Suspect abuse when the injury does not match the history or the child's developmental stage; a bruise in an infant who is not yet crawling, a posterior rib fracture or a classic metaphyseal "corner" fracture, and a subdural haemorrhage with retinal haemorrhages are signs that need a full work-up and a report.
Why it matters in the exam
The question describes a 4-month-old with a "fall from the sofa" and a femoral fracture, or a toddler with bruises on the ear, neck and abdomen, and asks for the next step. The answer: a full skeletal survey in every child under 2 years with suspected abuse, head imaging in a young infant, an eye examination, tests to exclude a bleeding disorder and bone disease — and a report as required by law.
The TEN-4-FACESp bruising rule helps: a bruise on the torso, ear or neck in a child under 4, any bruise in an infant under 4 months, bruises on the frenulum, angle of the jaw, cheek, eyelid or subconjunctiva, and a patterned bruise. "Those who don't cruise rarely bruise": an infant who does not crawl is almost never accidentally injured. A small "sentinel injury" in an infant, such as a minor bruise or bleeding in the mouth, sometimes precedes a severe injury.
Fractures of high specificity: classic metaphyseal lesions (corner or bucket-handle), posterior rib fractures (squeezing of the chest), scapula, spinous process and sternum fractures, and multiple fractures at different stages of healing. In abusive head trauma (AHT) there is subdural haemorrhage, extensive multilayered retinal haemorrhages and encephalopathy. Immersion burns have a "stocking and glove" pattern with a sharp border and no splash marks. Differential diagnosis: Mongolian spots, osteogenesis imperfecta (blue sclerae), bleeding disorders and practices such as cupping. In Israel there is a legal duty to report to a welfare officer or the police.
Key points
- Suspicion: an injury that does not match the history or developmental age.
- TEN-4-FACESp: bruises on the torso, ear or neck under age 4, and any bruise under 4 months.
- Metaphyseal and posterior rib fractures are specific for abuse.
- Skeletal survey in every child under 2 with suspected abuse.
- A legal duty to report in Israel.
Summary table
| Finding | What raises suspicion | Work-up | Note |
|---|---|---|---|
| Bruises | Torso, ear, neck under age 4; any bruise under 4 months; patterned | Blood count, PT/PTT, von Willebrand factor | Mongolian spots are not bruises |
| Fractures | Metaphyseal, posterior ribs, scapula, fractures at different healing stages, femoral fracture in a non-walking infant | Skeletal survey under 2 years, repeated after two weeks | Exclude osteogenesis imperfecta and bone disease |
| Abusive head trauma | Subdural haemorrhage, retinal haemorrhages, encephalopathy | Head CT or MRI, eye examination | No history of significant trauma |
| Burns | Stocking-glove immersion pattern, round cigarette burns | Documentation and photographs | Sharp border and no splash marks |
| Abdominal injury | Abdominal trauma without a history | Liver enzymes, lipase, urinalysis for blood | Sometimes without external signs |
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Sources
- AAP Clinical Report: Evaluating Children With Fractures for Child Physical Abuse, 2014 (reaffirmed) — Skeletal survey and fracture specificity
- AAP Clinical Report: The Evaluation of Suspected Child Physical Abuse, 2015 — Bruising patterns and sentinel injuries
- Israeli Penal Law, section 368D, current — Mandatory reporting of suspected abuse of a minor
- Nelson Textbook of Pediatrics, 22nd edition (2024) — Abused and Neglected Children
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.