Although child abuse continues to be a major concern for clinicians working in emergency departments, urgent care centers, and in primary care settings, it is important for pediatricians to recognize other medical conditions of the skin, bone, brain, and retina that may mimic the appearance of child abuse.

Bruises are the most common type of injury seen in abused children, but bruising can indicate a medical disorder. For instance, it may indicate a coagulopathy, such as hemophilia (factors VIII and IX deficiencies), or a clotting disorder, such as von Willebrand disease. Bruising can also be caused by low platelets, as in idiopathic thrombocytopenic purpura or thrombocytopenia, due to leukemia. Bruising may also be a sign of a vasculitis. Henoch-Schönlein purpura should be considered, especially if the “bruising” appears in dependent parts of the body (i.e., buttocks and legs in children and back and buttocks in infants). Salicylate ingestion can cause bruising, due to decreased platelet adhesion and increased capillary permeability, and should be considered in a child presenting with vomiting and metabolic acidosis. Mongolian spots are bluish-green areas of skin discoloration caused by a dense collection of melanocytes usually on the buttocks and lower back that are often differentiated from bruising by their indistinct borders.

Several medical conditions present with burnlike lesions that may mimic child abuse. Phytodermatitis can occur when sunlight interacts with photosensitizing compounds found in certain fruits, vegetables, and skin products. The lesions appear as erythematous lesions and bullae, often in a pattern resembling handprints or around the hands and mouth after a child handles or ingests lime or lemon juice. Staphylococci and streptococci impetigo may be mistaken for burns; however, they usually are superficial and heal cleanly, distinguishing them from cigarette burns, which usually are deeper (full-thickness), have raised margins, and heal with scarring. Other skin conditions that can mimic burns include herpes, eczema, contact dermatitis, and chronic bullous disease. In addition, cultural practices, such as cupping, coining, and spooning, may cause skin lesions that may be mistaken for child abuse.

Pediatricians should be able to recognize medical causes of radiologic abnormalities. The evaluation of suspected physical abuse in children younger than 2 years and in nonverbal children mandates a skeletal survey. The radiographic appearance of a fracture may be found in patients with normal variant changes in their bones, such as nutrient canals, cortical irregularities, metaphyseal beaks and spurs, distal ulnar cupping, normal symmetric peritoneal changes seen in infants, and ossification defects of the ribs. Neoplastic disease may also present with unexpected fractures. Metabolic bone disease that can lead to fractures includes rickets, a bone disease caused by vitamin D deficiency and resulting in osteopenia, metaphyseal cupping, physeal widening, and pseudofractures. Another source of multiple fractures is vitamin C deficiency (i.e., scurvy) in which children present with irritability; failure to thrive; coiled, fragmented hair; prominent hair follicles on the thighs and buttocks; and gingival hemorrhage. Other metabolic causes of pathologic fractures include McCune-Albright syndrome and Gaucher disease. Infectious etiologies of bone disease should be considered in a child who presents with a warm, swollen, and tender extremity. Proper diagnosis may require multiple radiographs, a pediatric radiologist, and, sometimes, a bone scan.