Differential Diagnosis

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A. Child Abuse. Child abuse should always be considered, however briefly, in any child who presents with trauma. Significant injury, including fractures in an infant, has a higher risk of being inflicted.

B. Birth Trauma. Linear skull fractures (sometimes seen with cephalohematomas) and clavicle fractures can occur, and, less frequently, long bone fractures. Long bone fractures from birth trauma should be symptomatic within minutes to days of delivery.

C. Unintentional, Noninflicted Injury. Child abuse is most commonly confused with unintentional, noninflicted injury. Many inflicted injuries in children are indistinguishable from "accidental" trauma on clinical or radiologic grounds. The most important factor in deciding whether the injury is inflicted is a detailed description of the "accidental" event.

D. Metabolic, Genetic, and Infectious Bone Disorders. Abnormalities suggesting fractures or bone injury can be seen in several metabolic and genetic disorders that include abnormal or easily fractured bones. These disorders are often easily differentiated from abuse by presence of a family history, associated symptoms or physical findings, and specific abnormal-appearing bone configuration and density. Osteomyelitis may produce similar clinical signs in the extremities and radiologic changes in bone that mimic injury (eg, periosteal reaction), but fever, systemic symptoms, and elevated WBC counts, ESR, and C-reactive protein are typical of osteomyelitis.

E. Coagulation Disorders. Bruises are common in inflicted injury. Genetic diseases, including hemophilia and von Willebrand disease, and acquired disorders, including idiopathic thrombocytopenia and leukemia, may present with unusual bruising.

F. Dermatologic Conditions. Burns are a common form of inflicted injury. Impetigo, toxic epidermal necrolysis, pemphigus, and staphylococcal scalded skin syndrome can produce burnlike lesions.

G. Other Conditions. Henoch-Schonlein purpura can present with leg swelling and bruiselike lesions. Sickle cell crisis can present with extremity pain and swelling.

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