Cutaneous injuries are the most common presentation of child physical abuse. Identification of injuries concerning for physical abuse is a challenging but important responsibility of pediatric clinicians. It is important for pediatric clinicians to consider 3 key features including age/developmental abilities of child, location of injury, and pattern of injury when assessing injuries concerning for abuse. A thorough medical evaluation and consideration of a broad differential help ensure that a medical mimic is not mistaken for abuse. Early identification of concerning injuries and reporting to appropriate agencies may protect children from further harm.
Key points
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Cutaneous injuries are the most common form of physical abuse. When assessing likelihood of abuse consider: age/developmental abilities, location and pattern of injury.
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Early identification of concerning injuries and reporting to appropriate agencies may protect children from further harm.
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Consider a broad differential to ensure that an underlying medical condition that may mimic child physical abuse is not missed.
Introduction
Physical abuse is the second commonest type of maltreatment, behind neglect. In 2022, the national rate of child maltreatment victimization was 7.7 per 1000 US children. Physical abuse represented 17% of cases. Children younger than 1 year old have the highest rate of victimization and represent 44.7% of the estimated 1990 fatalities from abuse and neglect.
Definitions
Physical abuse is the intentional use of physical force against a child that results in, or has the potential to result in, physical injury. Physical abuse can result from physical discipline. Physical abuse ranges in severity from acts leaving no visible mark to acts causing permanent disability, disfigurement, or death. Physical acts may include hitting/striking, kicking, beating, stabbing, biting, throwing/dropping, shaking, strangling/smothering, burning, and others.
Cutaneous injuries are the most common injury from physical abuse. Minor injuries, including bruises, are common in childhood accidents. However, over half of children with child physical abuse present with bruises; cutaneous and oral injuries are the most common sentinel injuries (minor injuries that are the first outward manifestations of abuse and may be precursors to more severe abuse). ,
Background
Early identification of suspected abuse is a challenging but important responsibility of pediatric clinicians. Failure to recognize sentinel injuries leaves children vulnerable to serious harm. In children with severe abuse, 10% to 30% had visible sentinel injuries before the severe abusive event. , , , , Before recognition of their severe abuse, around 1/3 of children were seen in a health care setting with physical signs of trauma present, most commonly minor cutaneous injuries such as bruises, oral injuries, or burns. , , , As most visits occur in emergency or primary care settings, pediatric clinicians should be aware of injury features that raise concern for abuse. Early identification of concerning injuries and reporting to appropriate agencies may protect children from further harm.
Basics of skin
Skin is composed of 3 layers: epidermis, dermis, and subcutaneous tissue. The epidermis is the compact, firm outer layer. The dermis contains capillaries, fibrous tissue, nerves, hair follicles, sweat, and sebaceous glands. The innermost later of subcutaneous tissue is rich in capillaries and fat and is easily deformed. Injuries can affect any layers of skin. The mechanism of injury determines which layers are involved and the severity or depth of injury. Abrasions, lacerations, and burns involve the epidermis and may involve deeper layers or extend beyond the skin to tendons and muscle. Traumatic hemorrhage and bruising usually occur within the subcutaneous layer.
Bruising: appearance and healing
Bruising occurs when soft tissue is compressed between 2 hard surfaces and damaged blood vessels leak blood into tissue. Subcutaneous tissue contains abundant small blood vessels, which may be damaged by trauma, causing blood to leak out and visible bruising to form. Other forms of cutaneous injury may result from direct tissue disruption from traumatic, thermal, or chemical forces ( Table 1 ).
Bruises may take minutes to days to appear after trauma, and numerous factors affect the color, evolution, and resolution of bruises ( Fig. 1 ). As blood cells and hemoglobin break down, bruises change color. There is no predictable order or chronology through which bruises progress and many factors affect the rate of resolution. Bruises cannot be dated by visual assessment of their appearance. ,
Bruising: distinguishing abusive versus nonabusive bruising
A detailed injury history is of utmost importance in distinguishing accidental from abusive injuries. In cases of abusive injuries, caretakers may be unaware of the cause or may provide misleading histories. Pediatric clinicians should understand typical cutaneous injuries for a child’s age/development and understand features of injuries that are suspicious for abuse.
Three key features are important to consider when assessing the likelihood of abuse for a particular injury: age/developmental abilities of child, location of injury, and pattern of injury.
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Age/development : Nonambulatory infants and children not yet cruising/walking rarely bruise. They are unable to move about sufficiently or with enough force to injure their skin, and routine care and handling does not cause bruising. Bruising anywhere in children who are not yet ambulating should prompt consideration of abuse ( Fig. 2 ).
Fig. 2
An immobile infant with cheek and ear bruising.
( Courtesy of D. Horton, MD, Kansas City, MO.)
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Location : Inflicted injury can occur anywhere on the body. However, certain body locations are more commonly injured by accidents in mobile children, whereas other areas are frequently injured by abusive trauma. The most common sites of bruising in abused children are the head and face, whereas the most common sites of accidental bruising in mobile children are over bony prominences, including the forehead, knees, shins, and elbows ( Fig. 3 ). Injury to soft or protected areas has higher specificity for abuse: eyelids ( Fig. 4 ), cheek (buccal, soft tissue), angle of the jaw, ear, neck, abdomen/torso ( Fig. 5 ), buttocks, and genitals. , ,
Fig. 3
Bruising over bony prominences (shins) in a mobile child.
( Courtesy of D. Horton, MD, Kansas City, MO.)
Fig. 4
Bruising to the eyelid and subconjunctival hemorrhage.
( Courtesy of D. Horton, MD, Kansas City, MO.)
Fig. 5
Bruising to chest and abdomen of a child.
( Courtesy of D. Horton, MD, Kansas City, MO.)
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Pattern : Certain patterns of cutaneous injury are more common in physical abuse than in accidental injury. Patterned injuries are frequently described as negative imprints or positive imprints. Negative imprint bruising shows the outline of the object that caused the injury, typically occurring in high velocity impacts, such as hitting with an open hand or flexible implement like a belt or cord. The high velocity impact forces blood away from the point of impact, stretching capillaries at the margins of the object, resulting in petechial bruising that outlines the edges. Positive imprint bruising occurs at the site of impact when force is applied more slowly, crushing the blood vessels directly underneath the impact. Some injuries involve both positive and negative imprints when directly impacted blood vessels rupture, and the velocity of the impact exceeds the elastic limit of the capillaries at the edges of the object. ,
Sometimes the pattern of injury is due to anatomic stress on the affected tissue rather than the object impacting the skin. Examples of some of the most frequently seen patterned cutaneous injuries are described below. ,
Patterned bruising associated with common abusive mechanisms of injury
Slap Mark
A blow to the face with an open hand (hand slap), typically a high velocity impact, results in a negative imprint of the hand on the side of the face ( Fig. 6 ). Blood is pushed away from the point of impact under the fingers and the capillaries break between the fingers resulting in the appearance of multiple parallel linear or curvilinear bruises extending across the face. ,
Loop Marks
Hitting a child with a flexible implement such as a belt or a cord frequently results in loop marks, or U -shaped injuries. Loop marks are negative imprint bruises with parallel lines that outline the width of the belt or cord ( Fig. 7 ). The end of the implement is typically moving at the highest speed and causes more severe injury, sometimes tearing/breaking the skin. ,
Tram Track and Other Object Patterned Injury
Children may be hit with other household items, which leave injuries that reflect the negative imprint of those objects. Thin linear or curvilinear objects like curtain rods or hangers result in parallel linear bruises with central clearing, commonly referred to as tram track bruising ( Fig. 8 ). Objects with holes or slats may result in negative imprints that outline both the external edges and openings ( Fig. 9 ). ,
Gluteal Cleft Bruising
In 1992, Feldman published a series of cases with gluteal cleft bruising and proposed a mechanism of injury to explain this pattern. All cases involved transverse forces applied to the buttock from whipping, spanking or paddling, with resultant vertical bruising extending along the gluteal cleft ( Fig. 10 ). This pattern of injury is thought to result from anatomic stress on the tissue of the buttock, rather than an imprint of the object used to inflict the forces. Feldman postulated that the vessels along the cleft experience shearing and/or compressive forces leading to this pattern of injury.
Pinna Bruising
Bruising to the pinna of the ear also results from anatomic stress ( Fig. 11 ). Linear petechial bruising to the rim of the pinna is postulated to occur when a force impacts the ear causing the pinna to crimp or fold on itself.
Abusive Squeezing
In 2019, Petska published a case series of bruising from abusive squeezing. Violent squeezing of an extremity compresses the underlying capillaries, and blood is forced away from the greatest area of tissue deformation resulting in negative imprint bruising along the lines of flexural creases of the fingers and hand. This bruising is typically described as a honeycomb or branching pattern and is most seen in young infants ( Fig. 12 ).
Grab Marks
Grab marks are caused by forceful grabbing, usually of an extremity, and are commonly a positive imprint injury ( Fig. 13 ). There is oblong or round bruising that underlies the fingers of the perpetrator. ,
Bite Marks
Human bite marks commonly appear as 2 opposing elliptical bruises with central clearing ( Fig. 14 ). There may be central bruising or abrasion from crushing, or suction-related injury, or small bruises or abrasions from individual teeth ( Fig. 15 ). Clinicians should be cautious to estimate age of a perpetrator based on size of a bite mark and/or intercanine distance; adult dentition is present as early as 12 years of age and significant variability in intercanine distance exists. ,
Strangulation
Direct trauma to the neck from strangulation may result in bruising, abrasion, and/or lacerations depending on the forces applied and/or implement used to inflict the injury ( Fig. 16 ). Additionally, compression of the veins in the neck from strangulation causes increased vascular pressure above the level of compression and may result in venous capillary rupture and petechiae to the scalp, face, behind the ears, conjunctivae, and oral mucosa ( Figs. 17 and 18 ). However, many children who report nonfatal strangulation have no external signs of trauma, and radiologic evidence of injury is rare. ,
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