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We greatly appreciate the authors of the third edition chapter Matthew Cox, MD, and Sara L. Beers, MD. This fourth edition chapter is an update of their previous chapter.

High-Yield Facts

  • A key aspect in making a diagnosis of physical abuse is identifying the incompatibility of the history of trauma with the injuries identified.

  • Skeletal injuries, such as metaphyseal corner fractures and posterior rib fractures, have a high specificity for inflicted injury and child abuse.

  • Abusive head trauma encompasses a spectrum of abnormalities including subdural hematomas, skull fracture, and retinal hemorrhages.

  • Neglect is the most common type of maltreatment reported. Neglect encompasses medical, physical, environmental, emotional educational, nutritional neglect, and inadequate supervision.


Child maltreatment is a serious cause of morbidity and mortality affecting young children in the United States and around the world. Child physical abuse is physical harm to a child at the hands of a caregiver that may encompass a single incident or repeated incidents.1 Examples of physical abuse include abusive head trauma (the “shaken baby syndrome”), immersion burns, skeletal injuries, and inflicted, patterned bruises. According to recent data in Child Maltreatment 2010, there were 3.3 million referrals to child welfare agencies in the United States in 2010. Investigation into these referrals revealed abuse nearly 1 million children (30%). It is estimated that in 2010, there were more than 1700 deaths in the United States related to abuse and neglect.2 The United States has the worst record in the industrialized nations with five children dying each day. The youngest children are most at risk for being abused. It is important to note that more than one-third of child abuse fatalities were involved with child welfare agencies prior to the child's death. This fact highlights the critical nature of a complete medical evaluation, thorough documentation, and communication with the child welfare system investigators. Children commonly present initially to an ED with injuries or medical problems caused by abuse and neglect.

The spectrum of child abuse and neglect is broad and includes physical abuse (17%), sexual abuse (9%), emotional abuse (8%), and neglect (78%). There are many manifestations of neglect including medical, supervisional, physical, nutritional, and emotional forms. The broad spectrum of child abuse and neglect can range from clearly inflicted injuries pathognomonic for abuse to suspicious scenarios and injuries that warrant further investigation by the local child protection agency. The diagnosis of child abuse depends on information obtained from the medical history, physical examination, and injuries identified by ancillary studies. It is critical that a detailed medical record is kept in cases of suspected abuse since this information would be frequently used by investigating agencies such as the police and child protection services. This chapter delineates the types of abuse most commonly seen in the ED. It is vital that emergency medical care providers recognize, evaluate, and report suspected child abuse and neglect ...

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