​Physical abuse

Orofacial trauma occurs in at least 50% of children diagnosed with physical abuse.14​,17

It is always important to remember that a child with one injury may have further injuries that are not visible. Where po​ssible, arrangements should be made for the child to have a comprehensive medical examination.

It is important to state that there are no injuries which are pathognomonic of (that is, only occur in or prove) child abuse although some injuries or patterns of injury will be highly suggestive of it.


The assessment of any physical injury involves three stages:

  • evaluating the injury itself, its extent, site and any particular patterns

  • taking a history to understand how and why the injury occurred and whether the findings match the story given

  • exploring the broader picture (e.g. the child’s behaviour, the parent-child interaction, underlying risk factors or markers of emotional abuse or neglect).


Further details on this page:

Typical features of accidental injuries

Typical features of non-accidental injuries

​​​​​
Types of injury:

  • bruising
  • bur​​ns
  • bite marks
  • eye injuries
  • bone fractures
  • abrasions and lacerations
  • intra-oral injuries

Differential diagnosis of physical abuse


Typical features of accidental injuries


Typical features of non-accidental injuries (injuries that should raise concerns)fig2_5.gif

fig2_6.jpg

​Burn on the side of the neck of a 6-year-old boy in the ‘triangle of safety’, an unusual site for an accidental injury. In this case there was a credible accidental explanation.


Reproduced with permission of Mrs JC Harris


Bruising

Accidental falls rarely cause bruises to the soft tissues of the cheek but instead tend to involve the skin overlying bony prominences such as the forehead or cheekbone. Inflicted bruises may occur at typical sites or fit recognizable patterns. Bruising in babies or children who are not independently mobile are a cause for concern. Multiple bruises in clusters or of uniform shape are suggestive of physical abuse and may occur with older injuries.18 However, the clinical dating of bruises according to colour is inaccurate.19

Bruises on the ear may result from being pinched or pulled by the ear and there may be a matching bruise on its posterior surface. Bruises or cuts on the neck may result from choking or strangling by a human hand, cord or collar. Accidents to this site are rare and should be looked upon with suspicion. Bruising on the wrists or ankles that look like ligature marks may be a sign of self-harm or inflicted abuse.

Particular patterns of bruises may be caused by pinching (paired, oval or round bruises - see artists impression below). Bizarre-shaped bruises with sharp borders are nearly always deliberately inflicted. If there is a pattern on the inflicting implement, this may be duplicated in the bruise — so-called tattoo bruising.

fig2_7.jpg ​Pinch mark on the leg of a 7-year-old boy at a site where accidental bruising is unlikely. Note the two small bruises separated by a clear space.




Reproduced with permission of Mrs JC Harris


Artist’s impression of grip marks such as may be present when a young child has been gripped and force fed. Note the round thumb imprint on one cheek with 3 or 4 finger-tip bruises on the other. You should also examine for intra-oral injuries.

fig2_8.gif

Artist’s impression of a slap mark. Note the parallel lines of petechial bruising at finger-width spacing, the marks appearing in the gaps between the fingers

fig2_9.gif

Abrasions and lacerations

Abrasions and lacerations on the face in abused children may be caused by a variety of objects but are most commonly due to rings or fingernails on the inflicting hand. Such injuries are rarely confined to the orofacial structures. Accidental facial abrasions and lacerations are usually explained by a consistent history, such as falling off a bicycle, and are often associated with injuries at other sites, such as knees and elbows.

Burns

Approximately 10% of physical abuse cases involve burns. Burns to the oral mucosa can be the result of forced ingestion of hot or caustic fluids in young children. Burns from hot solid objects applied to the face are usually without blister formation and the shape of the burn often resembles the implement used. Cigarette burns result in circular, punched out lesions of uniform size.

Cigarette burn, showing the typical appearance 0.8-1.0 cm diameter with a smooth, well-defined edge

fig2_10.jpg

Bite marks (clinical presentation)

Human bite marks are identified by their shape and size. They may appear only as bruising, or as a pattern of abrasions and lacerations. They may be caused by other children, or by adults in assault or as an inappropriate form of punishment. Sexually orientated bite marks occur more frequently in adolescents and adults.

The duration of a bite mark is dependent on the force applied and the extent of tissue damage. Teeth marks that do not break the skin can disappear within 24 hours but may persist for longer. In those cases where the skin is broken, the borders or edges will be apparent for several days depending on the thickness of the tissue. Thinner tissues retain the marks longer. A bite mark presents a unique opportunity to identify the perpetrator20 (see discussion of the forensic aspects of bite mark interpretation).

Human bite mark - note use of a rigid, right-angled measuring scale 

fig2_11.jpg
Reproduced with permission of Professor GT Craig​ 


Eye injuries

Periorbital bruising in children is uncommon and should raise suspicions, particularly if bilateral. Ocular damage in child physical abuse includes acute hyphema (bleeding in the anterior chamber of the eye), dislocated lens, traumatic cataract and detached retina. More than half of these injuries result in permanent impairment of vision affecting one or both eyes.

Bone fractures

Fractures resulting from abuse may occur in almost any bone including the facial skeleton. They may be single or multiple, clinically obvious or detectable only by radiography. Most fractures in physically abused children occur under the age of three. In contrast, accidental fractures occur more commonly in children of school age. Facial fractures are relatively uncommon in children.

When abuse is suspected, the presence of any fracture is an indication for a full skeletal radiographic survey. A child who has suffered sustained physical abuse may have multiple fractures at different stages of healing.

Intra-oral injuries

Damage to the primary or permanent teeth can be due to blunt trauma. Such injuries are often accompanied by local soft tissue lacerations and bruising. The age of the child and the history of the incident are crucial factors in determining whether the injury was caused by abusive behaviour.

Penetrating injuries to the palate, vestibule and floor of the mouth can occur during forceful feeding of young infants and are usually caused by the feeding utensil.

Bruising and laceration of the upper labial frenum is not uncommon in a young child who falls while learning to walk (generally between 8–18 months) or in older children due to other accidental trauma. However, a frenum tear in a very young non-ambulatory patient (less than 1 year) should arouse suspicion.47,48​​ It may be produced by a direct blow to the mouth. This injury may remain hidden unless the lip is carefully everted. Any accompanying facial bruising or abrasions should also be meticulously noted.

fig2_12a.jpg

(Above) Torn and bruised frenum in association with other accidental dental and oral injuries and (Right) Facial abrasions in a 7-year-old child (consistent with the history given of a fall from a skateboard)

Reproduced with permission of Mrs JC Harris


fig2_12b.jpg

fig2_13.jpg ​Torn frenum in a 3-month-old baby. Further investigation showed fractured ribs





Reproduced with permission of Elsevier


Differential diagnosis

Various diseases can be mistaken for physical abuse:

  • impetigo may look similar to cigarette burns

  • birthmarks (e.g. haemangiomas, mongolian blue spots) can be mistaken for bruising

  • conjunctivitis can be mistaken for trauma

All children who are said to bruise easily and extensively should be screened for bleeding disorders. Unexplained, multiple or frequent fractures may rarely be due to osteogenesis imperfecta (look for a family history, blue sclerae and the signs of dentinogenesis imperfecta).