Inflicted Injury and the Child at Risk

Bruising patterns

These charts outline the typical bruising patterns of accidental and non-accidental injury in small children and are a useful adjunt to the information after the jump. I am indebted to Dr Nicola Cunningham FACEM from the Victorian Institute of Forensic Medicine and St Vincent's Emergency Department for sending me these slides from her talk at the St Vincent's and Bendigo Regional Teaching Day on Dec 14th 2011. They come originally from the following excellent article on the topic. 

Which injuries may indicate child abuse? S Maguire, Arch Dis Child Educ Pract Ed 2010 95: 170-177 originally published online October 6, 2010 doi: 10.1136/adc.2009.170431.


•Child abuse – harm cause to child by parent/carer
•Assault- harm caused by non-parent/carer
•Accidental – by chance
•Non-accidental – not by chance
•NAI – ? Useful. What is an accident? Term used in Vic. SA moving to 'inflicted injury'.
•Inflicted injury – injury caused by another person.

Inflicted Injury

•***Does the explanation provided adequately explain the injury?
•Consider developmental level of child.
•Consider past history, other presentations.
•** Think of the possibility**


Bruise – injury to the body by blunt instrument, causing discolouration but not laceration

Carpenter, 1999
  • 6-12 month old healthy children in clinic
  • 12% had bruises
  • All on front of body over bony prominences
  • Most on forehead. Some on shin in mobile children.


Sugar, 1999
  • About 1000 healthy children from 1 day old to 35 months 
  • 21% had bruises
  • 0.6% <6 months
  • 1.7% <9 months
  • 61% > 24 months
  • 93% over bony prominences


Bruising Areas

Common: shin, knee, forehead, scalp (cruisers and walkers)

Uncommon:back, chest, forearm, face (cheek or nose)

**Protected areas: ears, cheeks, lateral chest.

Other concerning sites: thigh, calf, abdominal wall, genitals.
Suspicious Bruising
•Age of child
•Site of bruise
•Developmental level- non-mobile, cruising, walking?

•Is there an adequate explanation?

Bony Injury

Inflicted injury more likely the younger the child, esp <18 months

No one fracture type specific to inflicted injury but esp be suspicious of:

•Long bone metaphyseal fracture
•Posterior rib fracture
•Undiagnosed healing fractures or different ages
•Vertebral fractures (very rare, need significant force)
•Hand or feet fractures in infants
•Occipital fractures
•No history of injury (esp if pre-mobile)
•Explanation does not account for type of fracture
•Explanation not congruous with developmental level
•Past history of multiple injuries

•Other injuries

Thermal Injury

•*think of the possibility – does the explanation provided adequately explain the injury?

•Case review 1999 SA of 245 patients with thermal injuries presenting to hospital

•Most had poor documentation, often brief history obtained
•In no cases was inflicted injury identified at time of presentation

•Retrospectively identified 20 cases where documented history did NOT provide adequate explanation for injury and the injury had concerning feature

•Immersion – fluid lines, well demarcated

•Site may suggest mechanism – eg spill or splash from above, water cools as runs down, less severe lower on body

Suspicious Thermal Injuries

•History does not adequately explain the injury
•Person who had care of child at time cannot be contacted to obtain history
•Child <1 year or developmentally unable to self-inflict
•If immersion injury- may need site visit to check water temperatures to assess explanation

•Bilateral injuries, full thickness, multiple contact burns.

Oro-nasal injury

•Epistaxis unusual <1 year. Common in older childhood
•Oronasal blood – is observed post suffocation
–but also medical causes - clotting problems, URTIs, congenital anomalies
•Pharyngeal lacerations – can present with stridor, bleeding, feeding probs – direct blunt trauma

•** consider trauma as a differential in infant with oro-nasal bleeding

Other Suspicions

•Ingestion in young child
•Poor growth not explained by illness
•Acute life threatening illness with no obvious cause (eg recurrent apnoea)
•Severe head injury in young child

•(near) drowning

Main Points

•Think of the possibility of inflicted injury
•Take a good history
•Discuss with a senior emergency doctor

•Answer the question: "Does the history taken provide an adequate explanation for the injury?"

Many thanks to Dr Deb Feldman, Paediatric Registrar, Bendigo Health Care Group, 2011 from whose talk this was adapted.