1. General features. Child abuse can present with a single injury, but presence of multiple injuries, particularly involving multiple body surfaces or planes, in different stages of healing, caused by different mechanisms or agents, showing inflicted patterns, or found "by surprise" on examination are hallmarks of inflicted injury.
2. Measurements. Below-average weight, length (height) and head circumference, particularly infants and toddlers with measurements below the fifth percentile, suggest growth delay or failure to thrive (see Appendix G, Growth Charts, p. 766). Psychosocial factors or neglect are responsible for many cases of failure to thrive. It is important to compare current measurements with prior measurements.
3. Vital signs. Fever is typically absent, except in some cases of inflicted abdominal injury. Hypotension can occur with significant bleeding into an extremity, but shock or unusual respiratory patterns raise concerns about intracranial, thoracic, or intra-abdominal injury.
4. Skin. Inflicted bone, head, and abdominal trauma can occur without any cutaneous findings; however, skin findings are the most common manifestation of inflicted injury. All body surfaces should be inspected.
a. Bruises. Normally occurring bruises are found over bony prominences (knees, shins, elbow, forehead, and chin); they are typically oval or rounded with indistinct borders. Inflicted bruises are often found over soft tissue areas and show patterns and shapes with distinct borders suggestive of the striking implement. Bruises in noncruising and nonambula-tory infants are unusual.
b. Burns. Noninflicted scald burns show a pattern of cooling liquids, following gravity down a surface, and splash marks. Inflicted scald burns are often circumferential on extremities or involve buttocks and show clear lines of demarcation between normal and burned skin with no splash marks.
Noninflicted contact burns typically involve palmar surface of the hand and show no distinct shapes. Inflicted contact burns often show distinct shapes with distinct margins.
5. HEENT. Scalp bruises and swelling are associated with impact injury. Large head circumference and full or bulging fontanel may be evidence of intracranial injury. Bilateral retinal hemorrhages are suggestive of, but not specific for, inflicted head injury. Oral lacerations or injury to the frenulum may result from forced feeding or forcing objects into the mouth to stop crying. Blood in the ear canal or behind the tympanic membrane may be associated with head trauma.
6. Extremities. Inspect, palpate, and test range of motion of all joints of all extremities for signs of tenderness, pain, or deformity.
7. Abdomen. Abdominal distention and tenderness should raise concerns about intra-abdominal injury. Bruising over abdomen is unusual, but should raise concerns about blunt injury to abdominal organs when present.
8. Neurologic exam. An infant with an isolated cutaneous injury or fracture should have normal findings on neurologic exam. Lethargy, decreased responses, increased or decreased tone, cranial nerve signs, or focal neurologic findings suggest intracranial injury.
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