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A 1-month-old child was seen in the emergency room for bruising. Physical examination revealed bruises to the buttocks, chest, and eye. The parents reported that the child received the buttock bruise (Figure 9-1) after being dropped by the father, that the chest bruise was from the child's seat belt, and the eye bruise was from accidentally hitting the child with an elbow while cosleeping. The social worker was consulted in the emergency room, and found no concerning "red flags" in the family. The emergency room physician felt the findings were because of inexperienced parents. The child was sent home with the parents, and the emergency room later reported the case to Child Protective Services (CPS) in hopes of providing the family with support services. A child abuse pediatrician (CAP) was consulted by CPS to review the case the next day. The CAP requested that the child be brought back to the hospital emergently for further evaluation. A skeletal survey, including oblique views of the ribs, at that time showed a healing fracture of the eighth posterior rib (Figure 9-2). A head CT and liver function tests were performed to screen for occult trauma, and laboratory tests were done to evaluate for a bleeding diathesis. All results were negative. Law enforcement was contacted and coinvestigated with CPS. The child was placed in the home of a relative. Two weeks later, a repeat skeletal survey showed new bone formation over the right femur, indicating a healing fracture.


Bruising to the left buttock noted in a 1-month-old child. Any bruising on an immobile child is highly concerning for child physical abuse. Bleeding disorders must be considered in the differential diagnosis. (Reproduced with permission from James Anderst, MD, MS.)


Healing eighth posterior rib fracture in the same child from Figure 9-1. A skeletal survey is indicated in any child younger than 2 years of age where suspicions of physical abuse exist. (Reproduced with permission from James Anderst, MD, MS.)


A 15-month-old child is brought to the emergency department by the police after a relative called 911. The child and his mother attended a family gathering where concerned relatives viewed the mother's story that the child "falls a lot" with suspicion. On examination there were many signs of physical abuse (Figures 9-3, 9-4, 9-5). His face was covered with bruises, especially around the right eye and cheek (see Figure 9-3). His axilla showed signs of being gouged with fingernails (see Figure 9-4). In the emergency department, the child was evaluated by a forensic nurse examiner trained in child-abuse photo documentation. The child was ...

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