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Slap Mark. (Photo contributor: Kathi L. Makoroff, MD.)


The authors acknowledge the special contribution of Robert A. Shapiro, MD; Charles J. Shubert, MD; Kathi L. Makoroff, MD; Megan L. McGraw, MD; and Marquerite M. Care, MD, for portions of this chapter written for the previous editions of this book.

Clinical Summary

Until we can prevent all physical abuse, the goal of the emergency clinician is early recognition. In most cases, this will rely on recognizing “sentinel injuries” (relatively minor injuries that should prompt an evaluation for abuse) since the history is frequently incomplete or incorrect. External cutaneous or facial injuries are the most common abusive injuries and can be easy to dismiss because they may seem minor or self-limiting.

Serious physical abuse is much more common in children < 3 years old, who are generally unable to give their own history. Rates are especially high in young infants < 6 months old, perhaps because this is the peak incidence of colic or because of the difficulties faced by new parents. In this age group, almost any injury should prompt consideration of abuse and at least a thorough physical examination, including ears, oropharynx, genitals, entire skin, fontanel, and growth chart.

While bruises are common in toddlers and older children, bruising in children who are not yet pulling to stand (cruising) and in those < 6 months old is highly concerning. In children up to 4 years old, bruises are most concerning when they occur on the torso, ears, neck, cheek, or eyelid, or when they are patterned in the shape of an object.

In a child with burns, abuse should be considered with patterned injury, when the history of injury is inconsistent with burn severity or the child’s developmental abilities, or when the burn pattern suggests immersion. Immersion burns can include the extremities (stocking or glove distribution) or the torso, with the latter commonly occurring with unrealistic toileting expectations.

Perhaps because the mouth and face are the site of so many stressful infant behaviors (crying, not eating), unexplained facial injuries (to the frenula, lips, palate, or sclera) should prompt thorough testing for abuse.


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


Loop Marks. Loop and linear marks signify use of a cord or other similar object. (Photo contributor: Alan B. Storrow, MD.)


Pinch Marks. Fusiform marks formed by pinching. (Photo contributor: Daniel M. Lindberg, MD.)


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