Any injury that is inconsistent with developmental capabilities is suggestive of nonaccidental trauma. Examples include a femur fracture in a nonambulatory child or a head injury in a 2-month-old infant who “rolled out” of the crib. Undue delays in seeking care for a significant injury are also concerning.

Soft Tissue Injuries: Bruises and Burns

Bruises may be the first, or only, visible sign of physical abuse. Careful inspection of the head, scalp, face, ears, and neck is crucial to detect nonaccidental bruising. With rare exceptions, nonambulatory infants should not have any bruising.

“Those who don’t cruise rarely bruise” is quoted in the 1999 landmark article by Dr. Sugar and colleagues. This cross-sectional study looked for bruises in nearly 1,000 children younger than 3 years of age. Their outcome measures were the “presence and location of bruises as related to age and developmental stage.” Bruises were rarely found in those younger than 6 months of age, and uncommonly seen in those younger than 9 months of age (1.7%).

The researchers concluded that bruises in this age group should be investigated further for nonaccidental trauma or medical illness.¹⁰

It is also important to know that estimation of the age of bruising by color has been shown to be highly inaccurate in multiple retrospective studies.¹¹

Suspicious history and patterns include but are not limited to (1) bruising in children who are not independently mobile; (2) clusters of bruises; (3) multiple bruises with a uniform imprint; and (4) bruises seen away from bony prominences, i.e., on the face, back, abdomen, arms, buttocks, ears, and hands.¹²

Pattern recognition for concerning burns is also essential. Patterns specific to abuse include glove and stocking distribution, localization to perineum and buttocks suggesting submersion, signs of forced immersion including absence of splash marks, and inflicted contact burns, such as from cigarettes, causing outlines of the contacted surface. The severity of the burns also tends to correlate with likelihood of abuse.¹³

Fractures

Fractures are common findings in abused children. A majority of abuse-related fractures occur in children under 1 year of age and should raise suspicion for abuse. Additional risk factors of concern for abuse are multiple fractures, bilateral long bone fractures, fractures that are in different stages of healing, and fractures in children with developmental disabilities.14,15 One study found that up to 20% of abuse-related fractures in children are missed on first presentation to a clinician.⁴

Fractures of the humerus, femur, and tibia are commonly seen in abused children. The younger the age, the more likely abuse is the etiology. The arms and legs serve as a “handle” so the infant can be easily thrown or shaken.