Physical Abuse Recognition

Introduction & Red Flags - Spotting Trouble

• Physical Abuse: Non-accidental (inflicted) injury to a child.
• Key Principle: Injury clashes with developmental stage or given history.
• History Red Flags:
  • Vague, changing, or absent history.
  • Delay in seeking medical care.
  • Blaming siblings/self (if young).
  • History of "doctor shopping".
• Caregiver Behavior Red Flags:
  • Inappropriate concern (over/under-reactive).
  • Hostile, evasive, or uncooperative.
  • Focus on unrelated issues.
• Child Behavior Red Flags:
  • Excessive fear of caregiver/adults.
  • Apprehension when other children cry.
  • Extreme withdrawal or indiscriminate friendliness.

⭐ Multiple injuries in different stages of healing is highly suggestive of physical abuse.

Cutaneous Manifestations - Skin Deep Signs

• Bruises (Most Common):
  • Patterned: Belt, loop, handprints, ligature marks.
  • 📌 TEN-4 FACES-P mnemonic for suspicious bruising:
    • Torso, Ears, Neck in children < 4 years.
    • Frenulum, Auricle, Cheek, Eyelids, Sclera in any child.
    • Patterned bruising.
  • Multiple bruises in different stages of healing.
  • Bruises in non-ambulatory infants.

  ⭐ Sentinel injuries (e.g., a bruise in an infant < 4 months on Torso, Ears, or Neck) often precede severe abuse and require high suspicion.

• Burns:
  • Scald burns:
    • Immersion: Sharp demarcation ("glove/stocking"), sparing of flexed areas (doughnut sign on buttocks).
  • Contact burns:
    • Cigarette: Circular, punched-out, ~1 cm, uniform depth. Often multiple.
    • Dry burns: Patterned (e.g., iron, hot plate).
• Bites:
  • Human bite: Intercanine distance > 2.5-3 cm (adult). Ovoid, may show individual tooth marks.
• Lacerations/Abrasions:
  • Mouth (torn frenulum), lips. Ligature marks (neck, wrists, ankles).

Skeletal & Head Trauma - Bones Don't Lie

• Skeletal Survey: Indicated <2 yrs; consider 2-5 yrs if suspicious.

• High Specificity Fractures (HSF):

  • Metaphyseal lesions (CML): "corner" or "bucket-handle" fractures.
  • Rib fractures: esp. posterior (squeezing), multiple.
  • Scapular, sternal, spinous process fractures.
  • Multiple fractures, various healing stages (differential: Osteogenesis Imperfecta).

• Other Suspicious Fractures:

  • Long bone (femur, humerus) in non-ambulatory infants (<1 yr).
  • Skull fractures: complex, depressed, growing, occipital, bilateral.

• Abusive Head Trauma (AHT) / Shaken Baby Syndrome:

  • Subdural Hematoma (SDH): most common intracranial injury.
  • Retinal Hemorrhages (RH): bilateral, extensive, all layers, "too numerous to count".
  • Hypoxic-ischemic encephalopathy; cerebral edema.
  • Often NO external signs of injury (~50%).
  • Symptoms: apnea, seizures, irritability, lethargy, poor feeding.

⭐ Retinal hemorrhages are present in 75-80% of AHT cases and are a strong indicator of abusive head trauma when extensive and bilateral.

Differentials & Management - Ruling Out & Responding

• Key Differentials to Rule Out:

  • Accidental injuries (check history consistency)
  • Bleeding disorders (e.g., Hemophilia, ITP)
  • Osteogenesis Imperfecta (OI)
  • Mongolian spots (vs. bruises)
  • Cultural practices (e.g., coining, cupping - common in India)
  • Nutritional deficiencies (e.g., Rickets)

• Management Steps:

  • Prioritize child safety; hospitalize if needed.
  • Thorough documentation (detailed notes, photographs).
  • Report to Child Welfare Committee (CWC) and Police (under POCSO Act).
  • Involve a multidisciplinary team (MDT).

⭐ Skeletal survey is mandatory in suspected physical abuse for children < 2 years to identify occult fractures.

High‑Yield Points - ⚡ Biggest Takeaways

• Specific fractures: Metaphyseal (bucket-handle), posterior ribs, multiple fractures in varied healing stages.
• Bruising red flags: Any bruise in non-mobile infant, TEN-4 FACES-P areas, patterned marks.
• Characteristic burns: Immersion (stocking-glove, central sparing), cigarette burns (circular, uniform depth).
• Abusive Head Trauma: Subdural hematoma, bilateral retinal hemorrhages are highly indicative.
• Internal injuries: Unexplained duodenal hematoma, liver/spleen lacerations, or pancreatic injury.
• History mismatch: Inconsistent history with injury, or significant delay in seeking care.