Child Abuse and Neglect Practice Questions

Q: A young boy presents to the emergency department with a spiral fracture of the femur and multiple ecchymoses. What is the most likely cause of these injuries?

Child abuse. ### Explanation **Correct Answer: C. Child abuse** The combination of a **spiral fracture of the femur** in a young child and **multiple ecchymoses** (bruises) at various stages of healing is a classic "red flag" for Non-Accidental Injury (NAI) or child abuse. A spiral fracture occurs due to a forceful **torsional (twisting) motion**. While it can occur accidentally, in the absence of a clear, high-impact witnessed trauma, it suggests someone forcefully twisted the child's limb. Furthermore, the presence of multiple ecchymoses—especially if located on soft tissues (buttocks, thighs, trunk) rather than over bony prominences—strongly suggests repetitive physical abuse. **Why other options are incorrect:** * **A. Automobile hit-and-run:** This typically results in high-energy "crush" injuries, comminuted fractures, or internal organ trauma rather than isolated spiral fractures. * **B & D. Fall from a tree/bicycle:** Simple falls usually result in transverse or greenstick fractures. While a fall can cause a spiral fracture, it is unlikely to explain "multiple ecchymoses" across different body parts unless the trauma was catastrophic, which would present with more acute systemic distress. **Clinical Pearls for NEET-PG:** * **Most common fracture in child abuse:** Long bone fractures (femur is common in infants). * **Most specific fracture for child abuse:** **Metaphyseal Corner Fractures** (Bucket-handle fractures) caused by jarring/shaking. * **Other Red Flags:** Posterior rib fractures, cigarette burns, retinal hemorrhages (Shaken Baby Syndrome), and injuries inconsistent with the developmental age of the child. * **Legal Obligation:** In India, under the **POCSO Act**, healthcare professionals are legally mandated to report suspected child abuse.

Q: 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. ***Loop-shaped bruises on the back*** - **Loop-shaped bruises** are highly suspicious for **non-accidental trauma** as they are pathognomonic for impact with an object like a looped cord or belt - Bruises on the **back** of a young child are particularly concerning as the back is a non-bony prominence and less likely to be injured during normal play activities - Combined with the metaphyseal and posterior rib fractures already identified, patterned bruises strongly indicate inflicted trauma *Circular bruises on the knees* - Circular bruises on the knees are very common in toddlers and young children due to normal falls and play, which typically involve kneeling and crawling - This pattern is generally considered consistent with accidental injury and not indicative of abuse *Linear bruises on the shins* - Linear bruises on the shins can result from bumping into objects while playing or exploring, which is common in active children - The shins are bony prominences frequently injured during normal play activities *Irregular bruises on the forehead* - Irregular bruises on the forehead can result from accidental falls or bumps, which are common in young children learning to walk or play - While head injuries should always be carefully evaluated, irregular bruises on the forehead are common accidental injuries in ambulatory toddlers

Q: 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. ***Acceleration-deceleration forces*** - **Bilateral subdural hematomas of different ages** and **retinal hemorrhages** are classic findings in **abusive head trauma (shaken baby syndrome)**, caused by severe acceleration-deceleration forces. - These forces lead to the tearing of **bridging veins** and vitreoretinal traction, resulting in these distinct injuries. *Infectious meningitis* - While it can cause seizures, meningitis typically presents with **fever**, **lethargy**, and neck stiffness, and would not cause **subdural hematomas** or **retinal hemorrhages**. - Its effects on the brain are usually due to inflammation and increased intracranial pressure, not traumatic injury. *Birth trauma* - **Birth trauma** might cause subdural hematomas, but they would typically be **acute** and of a **single age**, directly related to the birthing process. - It is highly unlikely to cause hematomas of "different ages" in a 4-month-old infant, nor would it characteristically cause retinal hemorrhages without other signs of severe, acute trauma. *Genetic coagulopathy* - A **genetic coagulopathy** could predispose to bleeding, but it would typically result in more widespread or spontaneous internal bleeding, not specifically **bilateral subdural hematomas** accompanied by **retinal hemorrhages** without other trauma. - The "different ages" of the hematomas also strongly suggest recurrent episodes of trauma rather than an underlying bleeding disorder.

Q: A baby was vigorously shaken by parents. What do you expect in the baby?

Sub-dural hematoma. ***Sub-dural hematoma*** - **Shaken baby syndrome** results from violent shaking, leading to rapid acceleration and deceleration that causes tearing of the **bridging veins** in the brain. - This tearing results in a **subdural hematoma**, which is a collection of blood between the dura mater and arachnoid mater. *Ruptured spleen* - While possible in severe trauma, a ruptured spleen is less common with shaking alone and more often associated with **direct abdominal impact**. - The mechanisms of injury for splenic rupture typically involve significant blunt force to the abdomen, which is not the primary injury in shaken baby syndrome. *Rib fractures* - Rib fractures are indicators of significant chest compression or **direct impact**, which can occur in child abuse but are not the primary, immediate effect of shaking a baby. - While rib fractures can be a component of child abuse, they typically result from a different type of forceful interaction than shaking. *Pelvic fracture* - Pelvic fractures in infants typically require **high-energy trauma**, such as a fall from a significant height or a motor vehicle accident. - They are highly unlikely to result from shaking alone, as the pelvis is not directly impacted during a typical shaking event.

Q: A 16-year-old girl comes to a doctor with fractured forearm. She said she tripped and fell but cigarette burns were observed on her forearm. What will be your next step?

To do a complete physical examination. ***To do a complete physical examination*** - A comprehensive **physical examination** is essential to assess the full extent of injuries and to identify any other signs of abuse that might not be immediately apparent. - This step ensures that all medical needs are addressed and that any potential harm is documented appropriately within the medical record. *To tell or discuss with colleagues that she is a case of abuse* - While suspicion of abuse is high, immediately labeling the patient as a "case of abuse" to colleagues without further assessment can be premature and may compromise patient confidentiality. - Discussing with colleagues should follow a thorough examination and be part of a structured approach to **interprofessional collaboration** once concerns are medically substantiated. *To inform higher authorities* - Reporting to higher authorities is a critical step in cases of suspected abuse, but it typically follows a **thorough medical evaluation** and documentation of findings. - Informing authorities prematurely without a complete medical assessment could lead to incomplete information and potentially delay necessary medical care for the patient. *To call local social worker for help* - Involving a social worker is an important component of managing suspected child abuse, as they can provide support and guidance for the patient and family. - However, the immediate priority is to address the patient's medical needs and gather medical evidence through a **complete physical examination** before initiating social services.

Q: 6 years old girl with vaginal spotting. Diagnosis is –

Foreign body. ***Foreign body*** - **Most common benign cause** of vaginal spotting in prepubertal girls - Typically presents with **foul-smelling discharge**, spotting, and irritation - Common objects include toilet paper, small toys, or other inserted items - Diagnosis confirmed by **gentle examination** ± vaginoscopy - **However:** Foreign body insertion itself may indicate curiosity, accident, OR behavioral concerns that warrant evaluation *Sexual abuse* - **MUST be considered and ruled out** in ANY prepubertal vaginal bleeding - Can present with spotting, discharge, lacerations, bruising, or behavioral changes - May have **NO obvious physical findings** in many cases - **Critical point:** Presence of foreign body does NOT exclude abuse - All cases require **careful history, examination, and consideration of child protection protocols** - If **PID or STI** is found in a prepubertal child, sexual abuse is highly likely *PID* - Pelvic inflammatory disease requires ascending infection, almost exclusively in **sexually active** females - In a 6-year-old, PID or STI should **immediately raise suspicion for sexual abuse** - Not a typical cause of isolated spotting in this age group *Ovarian cancer* - Extremely **rare** in prepubertal children - Ovarian tumors (especially granulosa cell tumors) can cause **precocious puberty** with breast development and menstrual-like bleeding - Would present with additional findings: abdominal mass, hormonal changes, not isolated spotting **Clinical Approach:** While foreign body is statistically most common, every case of prepubertal vaginal bleeding requires thorough evaluation including detailed history (with child alone if appropriate), complete examination (may need anesthesia), and maintaining high index of suspicion for abuse.

Q: Which of the following findings is LEAST likely to be associated with battered child syndrome?

Failure to thrive. ***Failure to thrive*** - While **neglect** can lead to failure to thrive, it is **less directly indicative** of battered child syndrome compared to specific traumatic injuries - Failure to thrive reflects **chronic malnutrition and inadequate care** rather than acute physical abuse - Battered child syndrome primarily involves **physical trauma** (fractures, bruises, head injuries) rather than growth deficiencies - Of all the options, this finding is **LEAST characteristic** of direct physical battering *Subdural hematoma* - **Highly associated** with battered child syndrome, particularly in **abusive head trauma** (shaken baby syndrome) - Results from tearing of bridging veins due to violent shaking or impact - One of the most serious manifestations of physical abuse in children *Skin bruising* - The **most common visible sign** of physical abuse in children - Multiple bruises in **different stages of healing** and in unusual locations (face, neck, trunk, buttocks) are highly suspicious - Pattern bruising (hand prints, belt marks, loop marks) is pathognomonic of abuse *Multiple fractures in different stages of healing* - **Classic radiologic finding** in battered child syndrome - Metaphyseal corner fractures and posterior rib fractures are particularly specific for abuse - Different stages of healing indicate repeated episodes of trauma

Q: A child presents with multiple bruises of varying ages on the body, particularly in areas less likely to be injured accidentally. What is the most likely diagnosis?

Child abuse. ***Child abuse*** - **Multiple bruises of varying ages** in a child, especially in areas not typically prone to accidental injury (e.g., torso, ears, neck), are highly suspicious for **child physical abuse**. - **Inconsistent explanations** from caregivers or a delay in seeking medical attention can further support this diagnosis. *Accidental injury* - Accidental injuries typically present with **bruises of a similar age** and in locations consistent with typical childhood activities, such as shins, elbows, or forehead. - The pattern of injury in this scenario (varying ages, unusual locations) makes accidental injury less likely. *Hemophilia* - **Hemophilia** is a genetic bleeding disorder characterized by easy bruising and prolonged bleeding due to a deficiency in clotting factors. - While it causes bruising, the description of **bruises of varying ages** and in **unusual locations** strongly points away from a primary bleeding disorder as the sole cause. *Scurvy* - **Scurvy**, caused by **vitamin C deficiency**, can lead to easy bruising, petechiae, and bleeding gums. - However, it is usually accompanied by other symptoms like **fatigue, joint pain**, and poor wound healing, and does not typically manifest as multiple bruises of various ages in isolated unusual locations without other systemic signs.

Q: What is the MOST characteristic finding that distinguishes Battered Baby Syndrome from accidental trauma in a child?

Multiple bruises of different ages. ***Multiple bruises of different ages*** - The presence of **bruises in various stages of healing** suggests repeated injury over time, which is the **hallmark of non-accidental trauma**. - This pattern indicates a history of injury rather than a single accidental event, making it highly suspicious for **Battered Baby Syndrome**. - Different colored bruises (yellow-green vs purple-red) indicate different ages of injury, which is the **MOST characteristic finding** that distinguishes abuse from accidental trauma. *Incorrect: Single spiral fracture of femur* - A **spiral fracture** of the femur can occur from rotational forces, and while it should raise suspicion, a *single* injury may also result from a severe accident. - It does not inherently indicate a pattern of abuse as clearly as injuries of different ages do. *Incorrect: Single subdural hematoma* - A **subdural hematoma** can result from both accidental falls and non-accidental head trauma (e.g., shaken baby syndrome). - A *single* episode, without other accompanying injuries or a history of unexplained trauma, is not as definitive in distinguishing abuse from accident as multiple injuries of different ages. *Incorrect: Failure to thrive without other signs* - **Failure to thrive** can be multifactorial (e.g., medical conditions, nutritional deficiencies, neglect) and, by itself, doesn't distinguish physical abuse from other forms of neglect or medical causes. - While it can be *associated* with abuse, the absence of physical signs of trauma makes it less specific for **Battered Baby Syndrome** compared to active injury patterns.

Q: Which of the following is not a differential diagnosis of non-accidental injury?

Osteopetrosis. ***Correct: Osteopetrosis*** - Osteopetrosis is a rare genetic disorder characterized by **increased bone density** due to defective osteoclast function - While it causes bones to be brittle and prone to fracture, it has **distinctive radiological features** including diffuse sclerosis and "bone-within-bone" appearance - The **increased bone density on X-ray** is pathognomonic and readily distinguishes it from NAI, making it **less likely to be confused** with non-accidental injury in clinical practice - Fractures occur but the radiological pattern is diagnostic of the underlying metabolic bone disease *Incorrect: Osteogenesis imperfecta* - This is a **classic differential** for NAI causing **multiple brittle bone fractures** that can be mistaken for abuse - Features include **blue sclera**, **dentinogenesis imperfecta**, **wormian bones**, and **family history** - Often presents with multiple fractures at different stages of healing, mimicking the pattern seen in NAI *Incorrect: Scurvy* - Caused by **vitamin C deficiency**, leads to defective collagen synthesis - Results in **subperiosteal hemorrhages**, **metaphyseal fractures**, and **periosteal elevation** that closely mimic NAI - Additional features include **gingival bleeding**, **petechiae**, **follicular hyperkeratosis**, and **poor wound healing** *Incorrect: Caffey's disease* - Also known as **infantile cortical hyperostosis**, presents in infants under 6 months - Causes **periosteal reactions**, **bone thickening**, and **soft tissue swelling** in long bones, ribs, and mandible - The periosteal new bone formation can be mistaken for healing fractures from NAI, making it an important differential

Question 1

A young boy presents to the emergency department with a spiral fracture of the femur and multiple ecchymoses. What is the most likely cause of these injuries?

Accepted Answer

Child abuse

Answer

Automobile hit-and-run accident

Answer

Fall from a tree

Answer

Fall from a bicycle

Question 2

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?

Accepted Answer

Loop-shaped bruises on the back

Answer

Circular bruises on the knees

Answer

Linear bruises on the shins

Answer

Irregular bruises on the forehead

Question 3

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?

Accepted Answer

Acceleration-deceleration forces

Answer

Infectious meningitis

Answer

Birth trauma

Answer

Genetic coagulopathy

Answer

Direct impact trauma

Question 4

A baby was vigorously shaken by parents. What do you expect in the baby?

Accepted Answer

Sub-dural hematoma

Answer

Ruptured spleen

Answer

Rib fractures

Answer

Pelvic fracture

Question 5

A 16-year-old girl comes to a doctor with fractured forearm. She said she tripped and fell but cigarette burns were observed on her forearm. What will be your next step?

Accepted Answer

To do a complete physical examination

Answer

To tell or discuss with colleagues that she is a case of abuse

Answer

To inform higher authorities

Answer

To call local social worker for help

Question 6

6 years old girl with vaginal spotting. Diagnosis is –

Accepted Answer

Foreign body

Answer

Ovarian cancer

Answer

PID

Answer

Sexual abuse

Question 7

Which of the following findings is LEAST likely to be associated with battered child syndrome?

Accepted Answer

Failure to thrive

Answer

Subdural hematoma

Answer

Skin bruising

Answer

Multiple fractures in different stages of healing

Question 8

A child presents with multiple bruises of varying ages on the body, particularly in areas less likely to be injured accidentally. What is the most likely diagnosis?

Accepted Answer

Child abuse

Answer

Accidental injury

Answer

Hemophilia

Answer

Scurvy

Question 9

What is the MOST characteristic finding that distinguishes Battered Baby Syndrome from accidental trauma in a child?

Accepted Answer

Multiple bruises of different ages

Answer

Single spiral fracture of femur

Answer

Single subdural hematoma

Answer

Failure to thrive without other signs

Question 10

Which of the following is not a differential diagnosis of non-accidental injury?

Accepted Answer

Osteopetrosis

Answer

Osteogenesis imperfecta

Answer

Scurvy

Answer

Caffey's disease

Child Abuse and Neglect — MCQs

Child Abuse and Neglect — MCQs

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