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Inflicted Scald Burn. Partial thickness burn on the lower extremity with sharp demarcation is suspicious for intentional injury. (Photo contributor: Kathi Makoroff, MD.)

The authors acknowledge the special contributions of Robert A. Shapiro, Charles J. Schubert, and Megan L. McGraw for contributions to prior editions.


Clinical Summary

Bruises are the most common manifestation of child physical abuse. Children younger than 6 months and those that are not yet “mobile” rarely have any bruising from accidental injury. In older children, bruising to the abdomen, ear, neck, cheek, buttocks, or genitals is also less likely to be the result of accidental injury. Child abuse should also be strongly considered when a bruise takes the shape of an object (belt, cord, hand).

Certain clues may assist in differentiating abusive from accidental burns, but, often, doubt remains even after careful evaluation. With an immersion burn, the child is held into or under hot liquid and the burn margins are usually distinct. A “splash” pattern, conversely, will occur when a child attempts to get out of the way of the hot liquid; the burn margins are less distinct and there may be additional adjacent small burns. Contact burns usually have distinct and recognizable shapes but it is sometimes difficult to determine how the burn occurred. A child who has multiple contact burns or burns to areas that are unlikely to come in contact with the hot object accidentally should be evaluated for abuse.

While certain findings (bite marks, patterned bruises) are very specific for abuse, cutaneous findings are not sensitive for predicting other injuries such as fractures, brain injury, or abdominal injury. The absence of bruising should not preclude screening for other injuries.

Management and Disposition

With the exception of significant burns, abusive cutaneous injuries rarely require significant treatment. Rather, children with concerning cutaneous findings should be screened for other abusive injuries and medical mimics of abuse. Order neuroimaging (CT or MR) for children less than 6 months of age, skeletal survey for children less than 2 years old, and hepatic transaminases (alanine transferase [AST]/aspartate aminotransferase [ALT]) for children less than 5 years old. Order prothrombin time/partial thromboplastin time (PT/PTT) and complete blood count (CBC) for children with concerning bruises or other findings that could indicate a coagulopathy and consider hematology consultation for other coagulopathy testing.


Loop Marks. Subtle loop and linear marks are seen on the thigh and buttock of this child. (Photo contributor: Robert A. Shapiro, MD.)

If a human bite is suspected, photo document and swab for potential DNA analysis. Run a moistened swab followed by ...

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