A 3-year-old child is brought to the emergency department with multiple bruises in various stages of healing. X-rays reveal several metaphyseal fractures and posterior rib fractures. The parents claim the injuries resulted from normal play activities. Which of the following patterns would most strongly suggest non-accidental trauma?

Loop-shaped bruises on the back

Irregular bruises on the forehead

A 6-month-old male presents to the emergency department with his parents after his three-year-old brother hit him on the arm with a toy truck. His parents are concerned that the minor trauma caused an unusual amount of bruising. The patient has otherwise been developing well and meeting all his milestones. His parents report that he sleeps throughout the night and has just started to experiment with solid food. The patient’s older brother is in good health, but the patient’s mother reports that some members of her family have an unknown blood disorder. On physical exam, the patient is agitated and difficult to soothe. He has 2-3 inches of ecchymoses and swelling on the lateral aspect of the left forearm. The patient has a neurological exam within normal limits and pale skin with blue irises. An ophthalmologic evaluation is deferred. Which of the following is the best initial step?

Complete blood count and coagulation panel

Ensure the child's safety and alert the police

A 4-month-old infant is brought to the emergency department with seizures. CT scan reveals bilateral subdural hematomas of different ages and retinal hemorrhages. Which of the following mechanisms best explains these findings?

Acceleration-deceleration forces

A 7-year-old boy is brought to the emergency department by his mother 1 hour after falling off his bike and landing head-first on the pavement. His mother says that he did not lose consciousness but has been agitated and complaining about a headache since the event. He has no history of serious illness and takes no medications. His temperature is 37.1°C (98.7°F), pulse is 115/min, respirations are 20/min, and blood pressure is 100/65 mm Hg. There is a large bruise on the anterior scalp. Examination, including neurologic examination, shows no other abnormalities. A noncontrast CT scan of the head shows a non-depressed linear skull fracture with a 2-mm separation. Which of the following is the most appropriate next step in management?

Contact child protective services

A 3-month-old boy is brought to the emergency department by his mom for breathing difficulty after a recent fall. His parents say that he rolled off of the mattress and landed on the hard wood floor earlier today. After an extensive physical exam, he is found to have many purplish bruises and retinal hemorrhages. A non-contrast head CT scan shows a subdural hemorrhage. He was treated in the hospital with full recovery from his symptoms. Which of the following is the most important follow up plan?

Inform child protective services

Provide parents with anticipatory guidance

Referral to genetics for further testing

Reassurance that accidents are common

A 7-month-old boy is brought to the emergency department by his mother because of a 3-day history of vomiting and poor feeding. The vomit is non-bloody. He transitioned to pureed vegetables 10 days ago. Over the past 2 weeks, he has become increasingly irritable and within the past day has taken more daytime naps and appears much less responsive and interactive. His mother denies any history of fever or trauma at home. He has not received any vaccinations as his parents believe he is already healthy and does not need them. He spends most of the day with a babysitter while both parents are at work. He appears lethargic. His temperature is 37.8°C (100.1°F), pulse is 140/min, respirations are 18/min, and blood pressure is 90/55 mm Hg. The abdomen is soft and nontender. Auscultation of the heart and lungs shows no abnormalities. The anterior fontanelle is tense and bulging. Fundoscopic exam shows bilateral retinal hemorrhage. A complete blood count shows a leukocyte count of 10,000/mm3. An x-ray of the chest shows healing fractures of the 2nd and 3rd right ribs. Further evaluation of this patient is most likely to show which of the following findings?

Type I collagen synthesis defect

A 9-month-old male infant is brought to his pediatrician by his mother with lethargy and decreased oral intake for one day. His mother also mentions that he did not sleep well the previous night. A review of the medical record reveals several missed appointments and that the boy was born at 36 weeks gestation via spontaneous vaginal delivery. At the clinic, his temperature is 37.2ºC (99.0ºF), pulse rate is 140/minute, respirations are 44/minute, and blood pressure is 92/60 mm Hg. On physical exam the infant is awake but irritable and the rest of the physical is within normal limits for his age. On ophthalmologic examination, there are multiple retinal hemorrhages that extend to the periphery in both eyes. Which of the following investigations is most likely to be helpful in the management of the infant?

Noncontrast computed tomography of head

A 3-year-old girl is brought to the physician by her mother two days after the sudden onset of a rash. The mother says that the rash developed an hour after she bathed the child in hot water. Two weeks ago, the patient was diagnosed with a skin infection and was treated with penicillin V. She has been otherwise healthy but has missed several well-child examinations. She lives with her single mother, who recently lost her job and is now dependent on social assistance. The patient's mother has major depressive disorder and her maternal aunt has systemic lupus erythematosus. The girl's temperature is 36.8°C (98.2°F), pulse is 112/min, and blood pressure is 108/62 mm Hg. She has poor eye contact. Physical examination shows sharply delineated erythema on the lower extremities up to the umbilicus with sparing of the knees and flexor surfaces. Further evaluation is most likely to reveal which of the following?

Multiple injuries in different stages of healing

Malar rash with sparing of the nasolabial folds

Child abuse evaluation for USMLE Step 3: High-Yield Pediatrics Lessons

Suspicion & Red Flags - Seeing the Unseen

History Discrepancies: Vague, changing, or inconsistent history; delay in seeking care; injury blamed on siblings or pets.
Pathognomonic Injuries: Injuries inconsistent with the child's developmental stage (e.g., fracture in a non-ambulatory infant).
- Bruises: Specific patterns are key. 📌 TEN-4 FACES: Torso, Ears, Neck in child >4 yrs; Frenulum, Auricular, Cheek, Eyelids, Sclera in any child.
- Fractures: Metaphyseal corner fractures, posterior rib fractures, sternal fractures.
- Burns: Stocking-glove distribution, cigarette burns, branding patterns.

TEN-4-FACESp Bruising Clinical Decision Rule

⭐ Metaphyseal corner fractures (bucket-handle fractures) are considered virtually pathognomonic of non-accidental trauma in infants.

Physical Abuse - Telltale Trauma Patterns

Bruising Patterns:
- 📌 TEN-4 FACES-P Mnemonic: Suspicious if on Torso, Ears, Neck in child ≥4 months; or Frenulum, Auricle, Cheeks, Eyes, Sclera, or Patterned in any child.
- Multiple bruises in different stages of healing.
- Patterned injuries: handprints, belt/loop marks.
High-Specificity Fractures:
- Metaphyseal corner/bucket-handle fractures.
- Posterior ribs (from squeezing).
- Scapula, sternum, spinous processes.
Characteristic Burns:
- Immersion burns: sharp "stocking-glove" demarcation.
- Cigarette burns: small, circular, deep.
Other Major Trauma:
- Abusive Head Trauma (AHT): subdural hematoma, retinal hemorrhages.
- Occult abdominal injury (e.g., duodenal hematoma).

⭐ Posterior rib fractures are considered pathognomonic for child abuse until proven otherwise, often caused by forceful squeezing of the chest.

AHT & Other Abuse - Shakes, Sex & Neglect

Abusive Head Trauma (AHT):
- Mechanism: Violent shaking → acceleration-deceleration injury.
- Key Findings:
  - Subdural hemorrhage (interhemispheric fissure).
  - Widespread, multi-layered retinal hemorrhages.
  - Metaphyseal corner fractures, posterior rib fractures.
  - Apnea, seizures, encephalopathy.

Radiographic findings in child abuse

Evaluation Flowchart:

⭐ Classic Triad of AHT: Encephalopathy, Subdural Hemorrhage, and Retinal Hemorrhages.

Sexual Abuse:
- Consider if STIs (e.g., Gonorrhea, Syphilis) in prepubertal child.
- Anogenital findings: acute trauma, scars, ↓ anal tone.
Neglect:
- Failure to thrive, poor hygiene, developmental delay.

The Workup - Proof & Protocol

Initial Steps: Stabilize (ABCDE), then mandatory reporting to Child Welfare Committee (CWC) / Child Protective Services (CPS).
Investigation Protocol:
- Skeletal Survey: All suspected victims <2 years. Repeat in 2 weeks to detect healing fractures.
- Neuroimaging (CT/MRI): All infants <1 year with suspected abuse, or any child with neurologic signs (seizures, ALTE).
- Ophthalmology Exam: Dilated fundoscopy for retinal hemorrhages.
- Bleeding Screen: Coagulation profile (PT/aPTT) & platelet count.

⭐ Retinal hemorrhages are highly specific for Abusive Head Trauma (AHT), but their absence does not rule it out.

Classic Metaphyseal Corner Fracture in Child Abuse

High-Yield Points - ⚡ Biggest Takeaways

Most common fracture is a skull fracture; most specific is a metaphyseal corner fracture.

Posterior rib, scapular, and sternal fractures are also highly specific for non-accidental trauma.

Shaken Baby Syndrome triad: subdural hemorrhage, retinal hemorrhages, and encephalopathy.

Multiple bruises in varying stages of healing are highly suspicious; dating individual bruises is unreliable.

A skeletal survey is mandatory for suspected physical abuse in children < 2 years old.

Suspected child abuse is a legally reportable offense for all healthcare providers.

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