Nonaccidental trauma


  • Newer term that encompasses child abuse
  • Infant and children with disabilities are at higher risk
  • In >80% of cases, the parent or primary guardian is the abuser
  • Report suspicion
    • Transparent, frank discussion with caregivers
    • Social work or child protection agency involvement
      • Protect the child first, admit if suspicious
      • Social work may follow-up as outpatient for very low risk cases

Risk Factors

Red flags

  • History given is inconsistent with the mechanism of injury
  • Changes in caregivers report
  • Significant delays in care
  • Any injury to a young, pre-ambulatory infant
  • Injuries to multiple organ systems
  • Injuries in different stages of healing;
  • Patterned injuries
  • Injuries to non-bony or other unusual locations, (torso, ears, face, neck, or upper arms)
  • Significant injuries that are unexplained
  • Other evidence of child neglect.

Clinical Features


  • Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, buttocks, ears, torso, neck if the child is not cruising yet
  • Bruises in clusters or patterned marks
  • Bruising of any child less than or equal to 6 months of age (or non-ambulatory) warrants a full child abuse work-up

Oral injuries

  • Torn frenulum in premobile children is highly associated with physical abuse
  • Other reported oral injuries include laceration/bruising to the lips, mucosal lacerations, dental trauma, tongue injuries, and gingival lesions


  • Most commonly immersion injuries of the extremities, buttocks, or perineum
  • More likely symmetrical with clear upper margins
  • Many will also have occult fractures; children <24mo should undergo a skeletal survey


Bucket Handle Fracture (Courtesy of Michael Mojica[1])
Metaphyseal Chip Fracture (Courtesy of Michael Mojica)
  • Fractures moderately suspicious of abuse:
    • Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
    • Multiple bilateral fractures
    • Different stages of healing with multiple fractures
    • Epiphyseal separations
    • Vertebral body separation
    • Complex skull fractures (i.e. depressed or cross suture lines)
    • Pelvic fractures

Head Trauma

  • Leading cause of death in abused children <2 years old
  • Shaken baby syndrome - Retinal hemorrhages
    • Present in up to 75% of cases and are virtually pathognomonic
    • Described as “dot and blot” hemorrhages or flame or splinter hemorrhages

Abdominal Trauma

  • Most from a direct blow or from being thrown
  • Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
  • Consider abuse in preschool aged children with any hollow viscus or pancreatic injury

Sexual Trauma

  • Even among children who report vaginal or anal penetration, the rate of abnormal physical examination findings is only 5 to 15%
  • Consult your local sexual assault response team or transfer to an appropriate facility as indicated.
  • Females
    • Preferred positioning for adequate examination: child lying supine with her hips externally rotated and knees flexed (frog-leg) or the prone knee-chest position.
    • Examine hymen for lacerations, transections, and bruising.
    • Prepubertal females do not require a speculum exam unless there is active bleeding.
    • Vaginal discharge in a prepubertal female should prompt testing for sexually transmitted infections.
    • The diameter of the hymenal orifice is not a marker for whether or not vaginal penetration occurred.
  • Males
    • Examine for lacerations, burns, bite marks, and bruises to the genital region. Penile and anal injuries are more common than scrotal injuries.
    • Swab any anal or penile discharge for sexually transmitted infections.

Differential Diagnosis

Crying Infant


Multiple rib fractures in an infant secondary to child abuse.
  • Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
    • Skull AP and lateral view (left and right)
    • Chest AP and lateral view
    • Right and left oblique of the chest
    • AP of the abdomen to include pelvis and hips
    • AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
    • AP bilateral humerus
    • AP bilateral forearms
    • AP bilateral femurs
    • AP bilateral tibia and fibula
    • Posterior view of the hands
    • Dorsoplantar view of the feet
  • Head CT without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
  • Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
    • Consider CPK and platelet function studies if extensive bruising is present
    • If trauma labs are abnormal (AST or ALT > 80, lipase > 100), obtain a CT of abdomen/pelvis with IV contrast
  • Consider a dilated fundoscopic exam if under 2 years
  • Photograph injuries
  • Obtain a social work consult

Inpatient Workup[2]

  • Ophtho consult for retinal hemorrhages
  • CBC
  • CMP, Mg, phos
  • PT/INR/aPTT, fibrinogen
  • PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
  • vW panel (vW AT, ristocetin cofactors, factor VIII)


  • Treat injuries as indicated
  • Keep alleged perpetrator separate from the patient if possible and/or keep patient supervised at all times
  • Report abuse to the appropriate state child protection authority


  • Admit for medical treatment or if any question of child's safety

See Also

External Links


  1. Mojica, Michael. 2015. PEM Guides. NYU Langone Health.
  2. Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.