A Child With Multiple Bruises_child Abuse
Child abuse is the intentional infliction of physical, emotional, or sexual harm on a child by a caregiver, often presenting with multiple bruises in various stages of healing at unusual locations inconsistent with the child's developmental stage.
Lecture Map: The Big Idea
This lecture addresses one of the most clinically and ethically important topics in paediatrics: recognizing, diagnosing, and managing child abuse. The lecture is delivered by Dr. Maria NW Wong (Department of Paediatrics & Adolescent Medicine, HKU/QMH) and follows the Procedures for Handling Child Abuse (Revised 2015) published by the Social Welfare Department (SWD), HKSAR. [1]
The overarching message is deceptively simple but profound:
"If you don't think about it, you won't diagnose it." [1]
Child abuse is a diagnosis that requires suspicion first, followed by careful history, examination, and investigation. Unlike many other medical conditions, the history is often unreliable because the perpetrator is typically the historian. Therefore, the clinical findings must be interpreted in the context of consistency, developmental plausibility, and injury patterns.
- Recognize the different types of child abuse and their physical signs
- Differentiate between accidental and non-accidental injuries (NAI)
- Understand the long-term adverse effects of child abuse and the importance of child protection
- Understand the multidisciplinary approach to management
Child abuse is tested across multiple formats:
- MCQs: Pattern recognition (fracture types, burn patterns, bruise locations), differentials (ITP vs. NAI), forensic opinions on bruises
- SAQs/Mini-cases: Clinical scenarios with an infant presenting with bruises/fractures — you must list suspicious features, investigations, management steps, and the multidisciplinary pathway
- OSCEs: History-taking from a concerned teacher/nurse, counselling a parent, describing findings on images
"All children have the right to be protected against harm and exploitation. The safety, needs, welfare and rights of the children should always come first." [1]
These are not just ethical platitudes — they are legal and procedural cornerstones. In the Hong Kong context, the SWD's Procedural Guide for Handling Child Abuse Cases (Revised 2015) governs how all professionals (doctors, nurses, teachers, social workers, police) must act. [1]
Why this matters clinically: When you suspect child abuse, any concern regarding risk of harm to a child will always override a professional duty of confidentiality. [1] This means you can (and must) share information with child protection authorities even without parental consent.
Child abuse is defined as any act of commission or omission that endangers or impairs the physical/psychological health and development of an individual under the age of 18. [1]
Key conceptual breakdown:
- Commission = doing something harmful (hitting, burning, sexual contact)
- Omission = failing to do something necessary (not feeding, not providing medical care, not supervising)
- Judged on the basis of a combination of community standards and professional expertise — this means cultural context matters but does not excuse harm [1]
| Type | Key Features |
|---|---|
| Physical abuse | Non-accidental use of force, deliberate poisoning, suffocation, burning, Munchausen syndrome by proxy [1] |
| Sexual abuse | Involvement of child in sexual activities they cannot understand/consent to; includes contact and non-contact activities [1] |
| Neglect | Severe or repeated pattern of lacking attention to basic needs (physical, medical, educational, emotional) [1] |
| Psychological abuse | Acts that damage behavioural, cognitive, affective, or physical functioning: spurning, terrorizing, isolating, exploiting/corrupting, denying emotional responsiveness [1] |
| Mixed/Multiple abuses | Combination of the above [1] |
Exam Tip
The lecture emphasizes that physical abuse is the most commonly tested type, but neglect is the most common form of abuse in children under 2 years old in HK (75% of cases in this age group). [1] Know ALL types for MCQs.
The lecture categorizes risk factors into three domains [1]:
| Domain | Risk Factors |
|---|---|
| Family | Social isolation; crisis/tension (pregnancy, divorce, in-law conflict); cultural/superstitious beliefs; domestic violence (spouse battering) |
| Parents | History of childhood abuse; psychiatric disorder; alcoholism/drug abuse/gambling; rigid/unreasonable expectations; belief in corporal punishment; immature parents; poor impulse/anger control; poor parenting skills |
| Child | Unwanted child; illegitimate child; feeding/sleeping problems; early separation from parents; conflicting child-rearing practices; physical or mental disability; child associated with family misfortune |
Why understanding risk factors matters: These are not diagnostic of abuse, but they raise your index of suspicion. A child with Down syndrome whose single mother is a known drug addict (as in the tragic case of Yeung Chi-wai mentioned in the lecture) is at extremely high risk. [1]
5. Adverse Childhood Experiences (ACE) & Neurodevelopmental Impact
As the number of ACE increases, the risk for health problems increases.
ACE categories include:
- Childhood maltreatment (abuse & neglect)
- Household dysfunction (spouse abuse, substance abuse, mental illness, separation/divorce, incarceration)
Long-term health consequences of ACE [1]:
- Alcoholism, substance abuse, smoking
- Depression, suicide attempts
- Ischaemic heart disease, COPD, liver disease
- Multiple sexual partners, STDs, unintentional pregnancies
This section of the lecture draws from the Harvard Center on the Developing Child:
- Early experiences influence the developing brain
- Plasticity is greatest in the first years of life and decreases with age
- In the first few years of life, more than 1 million new neural connections are formed every second
- Normal brain development depends on "serve and return" interactions — responsive caregiving shapes brain circuitry
- Brains subjected to toxic stress have underdeveloped neural connections in areas most important for successful learning and behaviour
| Type | Description | Effect |
|---|---|---|
| Positive stress | Brief, mild stress responses (e.g. first day of school) | Normal, builds resilience |
| Tolerable stress | More severe but buffered by supportive adult relationships | Recoverable |
| Toxic stress | Strong, frequent, prolonged activation without buffering | Weakens developing brain architecture, lifelong problems in learning, behaviour, physical and mental health |
High Yield for Exam
The concept of toxic stress and its effect on brain architecture is a favourite exam topic. Know that the key protective factor is a stable, supportive adult relationship — this is the best way to prevent adverse effects of ACE. [1]
The Triad [1]
Suspicion → History → Investigation"If you don't think about it, you won't diagnose it." [1]
7. Physical Abuse — In Detail
A physical injury or physical suffering to a child, including non-accidental use of force, deliberate poisoning, suffocation, burning, and Medical Child Abuse (Munchausen Syndrome by Proxy).
- Severe life-threatening injuries
- Delay in seeking medical help in less severe injuries
- Bruises or minor injuries noticed by teachers or nursery staff
- Discovered on routine medical check-up
| Rank | Injury Type | Notes |
|---|---|---|
| 1 | Superficial injuries/bruises | Most common |
| 2 | Bone fractures | Second most common |
| 3 | Burn or scald | |
| 4 | Intracranial injuries | Most common cause of child abuse DEATH |
| 5 | Injuries to mouth | |
| 6 | Visceral injuries | Second most common cause of death (reported case fatality 40–50%) |
| 7 | Suffocation |
History is very important.
Features suggestive of abuse [1]:
| Feature | Why It's Suspicious |
|---|---|
| Injuries not consistent with history or developmental age of child | A 3-month-old cannot roll off a bed and fracture a femur |
| Unexplained or poorly explained injuries | Vague accounts like "I don't know what happened" |
| Inconsistent history between caregivers | Father says child fell; mother says child was hit by sibling |
| Changing history | Story changes each time you ask |
| Delay in seeking help | A parent who waits 2 days to bring a child with a fracture |
| Denial and defensiveness | Hostility when questioned |
8. Superficial Injuries / Bruises
- Suspicious sites: buttocks, abdomen, cheeks, genitalia, legs and arms — these are NOT typical sites for accidental injury
- Typical accidental bruises occur over bony prominences (forehead, shins, knees) in mobile children
- Absorption of bruises depends on vascularity of affected tissue and extent of injury
DO NOT try to age the bruise. [1]
This is a critical exam point. The colour of a bruise is not a reliable indicator of age because it depends on the depth, extent, location, and the child's skin colour. The lecture gives one exception:
A yellow bruise is 18–24 hours old. [1]
But this is the only colour that provides any reliability.
Infants who do not pull to standing seldom bruise. [1]
This is a landmark clinical pearl: pre-mobile infants (typically < 6–9 months) should essentially never have bruises. If they do, abuse must be considered. The classic teaching: "Those who don't cruise, rarely bruise."
Past Paper Alert
Past paper Q21 (Nov 2020 Fourth Summative MCQ): "Which of the following is a correct opinion regarding a bruise?" Correct answer: "Not all blunt force traumas result in a bruise." The colour of a bruise is NOT a good indicator of age. The shape of a bruise does NOT represent the shape of the weapon. The size is NOT a good indicator of force. [4][5]
| Condition | Key Differentiating Feature |
|---|---|
| Bleeding tendency (ITP, haemophilia) | Check CBC + coagulation screen; pattern of bleeding (petechiae in ITP, deep-seated bleeding in haemophilia) |
| Henoch-Schönlein purpura (HSP) | Palpable purpura over buttocks/lower extremities + arthralgia ± abdominal pain ± nephritis |
| Folk remedies: cupping (拔罐) and scraping (刮痧) | Characteristic circular marks (cupping) or linear marks (scraping) on back/limbs; cultural history |
9. Fractures
- 80% of inflicted fractures are found in infants under 18 months (only 2% of accidental fractures occur in this age group)
- 43% of fractures are unsuspected clinically — found only on skeletal survey
- Not moving/using the limb
- Pain
- Swelling
- > 1 fracture
- Fractures in multiple sites
- Fractures in different stages of healing
- Presence of other injuries
- History of injury not plausible
Classic metaphyseal lesion (CML) / "bucket-handle fracture" Posterior rib fracture Scapular fracture Spinous process fracture Sternal fracture
| Fracture Type | Why It Suggests Abuse |
|---|---|
| CML / Bucket-handle | Caused by shearing forces at the metaphysis when a limb is pulled/twisted violently; this mechanism does not occur in normal falls |
| Posterior rib fracture | Caused by antero-posterior compression of the chest (squeezing during shaking); virtually never occurs accidentally in infants |
| Scapular fracture | Requires significant direct force; extremely rare in accidental injury |
| Spinous process fracture | Requires hyperflexion/direct blow; unusual mechanism for accident |
| Sternal fracture | Requires severe direct force to anterior chest |
Spiral fractures of the lower extremities in non-ambulatory children are extremely suspicious. [1]
Why: A spiral fracture requires a twisting force. A pre-walking infant cannot generate this force on their own. In an ambulatory toddler, a "toddler's fracture" (spiral fracture of the tibia) is a recognized accidental injury — context matters.
| Radiographic Finding | Estimated Age |
|---|---|
| No early callus formation | < 7–10 days |
| Soft callus visible | After 1st week to 3–4 weeks |
Always perform skeletal survey in children < 2 years old in cases of suspected abuse. May repeat after 2 weeks. [1]
Why repeat? Early fractures may not be visible initially. By 2 weeks, periosteal reaction/callus formation becomes apparent, revealing fractures that were occult on initial imaging.
Bone scan helpful in early fractures [1] — a bone scan can detect fractures within 24–48 hours via increased uptake, even before radiographic changes are visible.
- Skull X-ray (SXR)
- Chest X-ray (CXR)
- X-ray of all 4 limbs
- X-ray of spine
Features of Non-Accidental Burns [1]
| Feature | Why It's Suspicious |
|---|---|
| Cigarette burns (7–8mm diameter) | Uniform circular burns; accidental cigarette contact is usually a glancing injury (elongated, not perfectly circular) |
| Scalds/immersion injury | 60°C for 4–6 seconds causes full-thickness burn |
| Burn of uniform thickness | Accidental splashes cause variable-depth burns |
| Clear demarcation line (glove or stocking pattern) | Indicates the child's hand or foot was held in hot water |
| Absence of splash marks | Accidental immersion produces splash marks; deliberate immersion does not |
| Doughnut pattern on buttocks | Central sparing where buttocks press against cooler bathtub base |
| Sparing of palms, soles, areas between toes, abdominal skin creases | These protected areas are spared in forced immersion because the child reflexively clenches/folds |
11. Intracranial Injury — Abusive Head Injury (AHI)
Abusive head injury is the most common cause of child abuse deaths. [1]
- Infants < 12 months old at greatest risk
- Injury inflicted by blunt force trauma, shaking, or a combination of forces
A constellation of clinical findings in infants:
- Retinal haemorrhages (65–95%)
- Subdural haemorrhages and/or subarachnoid haemorrhages
- Cerebral oedema
- Little evidence of external cranial trauma
- Head large in proportion to body size
- Weak neck muscles
- Fragile, underdeveloped brains
The infant head is about 25% of body length (vs. ~12% in adults). The neck muscles cannot resist the acceleration-deceleration forces. The unmyelinated brain has higher water content and is more susceptible to shearing injury. The bridging veins between the cortex and dural sinuses are easily torn.
- History often unreliable
- Usually in < 3 years old (typically 1st year)
- Common symptoms: lethargy, irritability, impaired consciousness, vomiting, poor feeding, breathing difficulties, apnoea
- Seizures (40–70%)
- Retinal haemorrhages (65–95%)
- Bruises ± grip marks over upper arms/chest
- CT head: subdural haemorrhages (may be bilateral, different densities suggesting different ages), interhemispheric SDH
- MRI: superior for parenchymal injury, diffusion restriction
Mortality: 25% Up to 80% of survivors suffer lifelong disabilities
- Small head and brain atrophy (61–100%)
- Visual impairment (18–48%)
- Intractable epilepsy (11–32%)
- Those comatose on presentation: 60% died or had profound mental retardation, cerebral palsy
| Feature | Accidental | Suspicious of Abuse |
|---|---|---|
| Type | Single linear fracture | Multiple, complex, depressed, diastatic (width > 3mm), growing fracture |
| Location | Parietal bone most common | Non-parietal, involving > 1 cranial bone |
| Height of fall | Short falls < 4 feet | Greater force implied |
| Associated intracranial injury | Uncommon | Present |
- Broken teeth in older children
- Torn frenulum in infants — this is a classic sign; forced bottle feeding or direct blow
- Pharyngeal injuries
13. Abdominal (Visceral) Injuries [1]
Second most common cause of death from child abuse. Reported case fatalities: 40–50%.
- Direct blows → crushing of organs, hollow viscus perforation
- Indirect shearing forces
- Delay in presentation and diagnosis — the child may not present until shock develops
| Organ | Notes |
|---|---|
| Small intestine (especially jejunum) | Most common hollow viscus injury — compressed against vertebral column |
| Mesentery | Tears from shearing force |
| Liver | Most common solid organ injured (> kidney) |
| Pancreas | Not uncommon |
| Spleen | Rare in NAI (more common in accidental abdominal trauma) |
| Category | Tests |
|---|---|
| Blood tests | FBC, coagulation screen, LFT, RFT, amylase |
| Urine | Urine microscopy for RBC (to detect renal injury) |
| Radiology | Full skeletal survey (SXR, CXR, XR 4 limbs, XR spine) in < 2 years; repeat imaging at 10–14 days; bone scan |
| Neuroimaging | CT scan (acute); MRI scan (parenchymal detail) |
Why each test matters:
- FBC: Exclude thrombocytopenia (ITP) as cause of bruising; anaemia from chronic bleeding
- Coagulation screen: Exclude haemophilia or other coagulopathy
- LFT/RFT/Amylase: Detect occult liver, renal, or pancreatic injury from abdominal trauma (especially important as abdominal injuries may be clinically occult)
- Urine RBC: Renal contusion
- Skeletal survey: Detect occult fractures; repeat to find healing fractures not visible initially
15. Medical Child Abuse / Munchausen Syndrome by Proxy (MSBP)
Fabricated or Induced Illness [1]
- A parent or other caregiver fabricates an illness
- The child is presented persistently for medical assessment, often resulting in multiple procedures
- The perpetrator denies the cause of the child's illness
- Acute symptoms and signs stop when the child and perpetrator are separated
- Seen more commonly in younger children
- Mothers are the sole perpetrators in 94–99% of cases
- Many abusing mothers have friendly demeanours, some degree of medical training, and appear very involved in care during hospitalization
- Many have history of psychiatric illness
- Illness unexplained, prolonged
- Discrepancy between symptoms/signs and history
- Symptoms appear only when mother is attending
- Children alleged to be allergic to a large number of drugs or foods
- High index of clinical suspicion
- Objective verification of medical history
- Review of all medical records (often across multiple hospitals)
- Monitor social media
- Video surveillance (controversial but sometimes necessary)
16. Child Sexual Abuse
Involvement of children in sexual activities that they cannot understand, are not developmentally prepared for, cannot give informed consent for, and that violate societal taboos.
- Perpetrators are usually known to the child and intend to maintain secrecy [1]
- Direct disclosure of inappropriate sexual contact
- Behavioural concerns
- Physical injury to genitals
- Genitourinary symptoms
- STIs
| Level | Features |
|---|---|
| High | Genital injuries inconsistent with accident; severe psychiatric disturbance (mutism, eating disorder, suicide, self-mutilation); repeated sexualized behaviour; marked frozen behaviour; worrying info from adults |
| Medium | Combination of recurrent medical symptoms (unexplained vaginal soreness/bleeding, UTIs, sleep disturbances, anorexia) |
| Low | Isolated sexualized behaviour; single physical symptom without behavioural/emotional problems (e.g. recurrent UTI, vaginal/penile discharge) |
- Child's safety — safe to go home? Will the child be punished for disclosing?
- Reporting to child protection authorities — inform social worker ± police
- Child's mental health — screen for depression, PTSD; trauma symptoms are highly associated with degree of self-blame
- Need for physical examination — by experienced doctor; colposcope; photographic documentation
- Need for forensic evidence collection — refer to forensic pathologist; best collected within 72 hours
- Obtain consent
- Prepare the child — avoid repetitive genital examination
- Use colposcope
- Photographic documentation
NORMAL exams are the NORM — for both girls and boys. [1]
This is counterintuitive but critical: abuse may not have injured the genitals, may not have involved the genitals, or injuries may have healed. Positive clinical findings were more likely when children were examined within 72 hours after the abuse. [1]
| STI | Implication for Sexual Abuse | Action |
|---|---|---|
| Gonorrhoea | Diagnostic | Report |
| Syphilis | Diagnostic | Report |
| HIV | Diagnostic | Report |
| Chlamydia trachomatis | Diagnostic | Report |
| Trichomonas vaginalis | Highly suspicious | Report |
| Condylomata acuminata (anogenital warts) | Suspicious | Report |
| Herpes simplex (genital) | Suspicious | Report |
| Bacterial vaginosis | Inconclusive | Medical follow-up |
*Important caveat: all "diagnostic" STIs must exclude perinatal acquisition and rare non-sexual vertical transmission. [1]
17. Neglect
A severe or repeated pattern of lacking attention to a child's basic needs that endangers or impairs the child's health or development.
| Type | Examples |
|---|---|
| Physical | Failure to provide necessary food/clothing/shelter; failure to prevent injury; lack of supervision; left unattended |
| Medical | Not seeking medical care for sick child |
| Educational | Not enrolling child in school |
| Emotional | Ignoring, withholding affection |
- Chronic neglect can alter biological stress response systems, compromising children's ability to cope with adversity
- More likely to have cognitive problems, academic delays, deficits in executive function, and difficulties with attention regulation
- Negative consequences can be reduced or reversed through appropriate and timely interventions — this is a key exam point that emphasizes the plasticity argument
Acts that damage a child's behavioural, cognitive, affective, or physical functioning:
| Subtype | Description |
|---|---|
| Spurning | Hostile rejecting/degrading — verbal and non-verbal |
| Terrorizing | Threatening to hurt, kill, abandon, or place the child in danger |
| Isolating | Restricting social contact |
| Exploiting/corrupting | Encouraging inappropriate behaviour (criminal, self-destructive) |
| Denying emotional responsiveness (ignoring) | Persistent emotional unavailability |
19. Management of Child Abuse
Multidisciplinary approach. Safety and welfare of the child. Good paediatric care: treat injuries, obtain help for psychological problems, assist in protecting the child from further abuse.
| Stakeholder | Roles |
|---|---|
| Doctor/Nurse/HCP | Emergency Medicine, Paediatrics, Orthopaedics, Psychiatry, Surgery, Neurosurgery, Ophthalmology, O&G, Clinical Psychology, Forensic Pathology |
| Social Worker | SWD Family & Child Protective Services Unit (FCPSU), Integrated Family Services Centre (IFSC), NGO, Medical Social Workers |
| Police | Child Abuse Investigation Unit (CAIU), CID |
| School | Teachers, school guidance teachers, school social workers |
- Case identification and initial assessment
- Crisis intervention and investigations
- Welfare plan and support services
- Medical assessment and treatment
- Explain to parents/guardians the management plan
- Strategic planning meeting — preliminary plan
- Report to police (some cases require video-recorded interview)
- Safety issues: other siblings must be assessed
- Home or placement decision
- Multi-disciplinary Case Conference (MDCC)
- Communicate with all stakeholders before MDCC
- Share information
- Determine case nature: abuse, not abuse, or high risk
- If abuse/high risk → register on Child Protection Registry
- Consider Care or Protection Order
- Welfare plan: placement options (home, relatives, emergency foster homes, foster homes, small group homes, children's home, residential schools)
- Support services: psychological, family & school support, drug services
- Follow-up: review meeting, progress report, family participation
- Protecting a child from abuse is the joint responsibility of different professionals
- Priority should be given to ensuring immediate safety of the child
- The safety and welfare of the child should be the paramount concern
- Information sharing on a need-to-know basis
- The child should not be required to repeat the abuse incident(s) except when necessary
1. Be familiar with common manifestations of child abuse 2. Be motivated to report findings 3. Keep a good medical record 4. Be prepared to testify 5. Prevention
| Level | Strategy | Examples |
|---|---|---|
| Primary/Universal | Educate entire community; create social change intolerant of child maltreatment | Mass media, MCHC family & child health services, family life education |
| Secondary/Selected | Focus on those at risk for abuse/neglect | Intervention programs for transition to parenthood; high-risk family assessments |
| Tertiary/Indicated | Treatment for families already affected; prevent recurrence | Family support programs, family group conferencing, parenting skill classes |
Key statistics from the Child Protection Registry (SWD):
- ~65% of abusers are parents
- Abuse in under-2-year-olds is rising — 75% of these are neglect
- Most abuse occurs at home
From the Introduction to Forensic Path lecture [5]:
- Multiple injuries of different types and different ages → think child abuse
- Skeletal injuries, scald/burn injuries
- Account of incident does not match injuries found, or frequently changing account
- ENSURE SAFETY OF CHILD — ERR on the side of CAUTION
Regarding bruises specifically [5]:
- A bruise is caused by blunt force trauma → damage to blood vessels under the skin → bleeding into soft tissues
- Not all blunt force traumas result in a bruise (this was tested in the Nov 2020 MCQ) [4]
- Generally, bruises give no clues as to the nature of weapon or force used
- The colour of a bruise is not a reliable indicator of age
- The size of a bruise is not a reliable indicator of the amount of force
Likely Exam Questions
-
An 8-month-old non-ambulatory infant presents with multiple bruises over the buttocks, abdomen, and cheeks. Which of the following features is MOST suspicious for non-accidental injury?
- A. A single bruise over the forehead
- B. Bruises in various stages of healing over the buttocks
- C. A linear bruise over the shin
- D. A yellow bruise over the knee
Answer: B. Multiple bruises in different stages of healing in suspicious locations (buttocks) in a pre-mobile infant is highly suspicious for NAI. [1]
-
Which fracture type is MOST highly suggestive of child abuse?
- A. Transverse fracture of the clavicle
- B. Greenstick fracture of the distal radius
- C. Classic metaphyseal lesion (bucket-handle fracture)
- D. Spiral fracture of the tibia in a 3-year-old toddler
Answer: C. CML is virtually pathognomonic of NAI. A spiral tibial fracture in a walking toddler can be a "toddler's fracture." [1]
-
A 4-month-old infant presents with seizures, bilateral subdural haemorrhages, and retinal haemorrhages. The most likely diagnosis is:
- A. Birth trauma
- B. Abusive head injury (shaken baby syndrome)
- C. Bacterial meningitis
- D. Coagulopathy
Answer: B. The triad of SDH + retinal haemorrhages + encephalopathy (seizures) in a young infant = AHI until proven otherwise. [1]
-
In Munchausen syndrome by proxy, which of the following is TRUE?
- A. Fathers are the most common perpetrators
- B. Symptoms resolve when the child is separated from the perpetrator
- C. The perpetrator readily admits to fabricating illness
- D. It typically affects adolescents
Answer: B. Mothers are perpetrators in 94–99%, symptoms stop on separation, perpetrators deny, and it is more common in younger children. [1]
-
A 6-month-old infant is brought to the emergency department with a swollen right thigh. X-ray shows a spiral fracture of the right femur. The father says the baby "rolled off the sofa." List 4 features that would make you suspect non-accidental injury. (4 marks)
Markscheme:
- Injury not consistent with developmental age (6-month-old cannot roll off sofa and sustain spiral fracture)
- Spiral fracture in non-ambulatory child is highly suspicious
- Single caregiver history without corroboration
- Delay in seeking medical attention (if present)
- (Any 4 from lecture list) [1]
-
List the investigations you would perform in a suspected case of physical child abuse in a 10-month-old. (5 marks)
Markscheme: FBC (1), coagulation screen (1), LFT/RFT/amylase (1), urine microscopy for RBC (1), full skeletal survey ± repeat at 10–14 days (1), CT/MRI brain if indicated (bonus). [1]
| Paper | Question Theme | Key Point |
|---|---|---|
| Nov 2020 MCQ Q21 [4] | Correct opinion about bruises | Not all blunt force traumas result in bruise — colour ≠ age, shape ≠ weapon, size ≠ force |
| June 2021 MCQ Q94 [6] | 12-year-old with pallor, bruises, bone pain | DDx between ALL, aplastic anaemia, ITP, JIA — Answer: ALL (pallor + bruises + bone pain + low-grade fever) |
| 2019 MCQ Q1–2 [7] | Dermatological DDx including HSP | Know HSP as a mimic of child abuse (palpable purpura on buttocks/legs) |
High Yield Summary
Child abuse = any act of commission or omission that endangers a child under 18. Types: physical, sexual, neglect, psychological, mixed. Physical abuse is most tested; neglect is most common in infants. Key to recognition: suspicion → careful history (inconsistencies, delay, implausibility) → examination (suspicious locations: buttocks, cheeks, genitalia; pre-mobile infants should not bruise) → investigations (FBC, coag screen, LFT/RFT/amylase, urine RBC, skeletal survey in < 2 yrs). Do NOT age bruises by colour (except yellow = 18–24 hrs). Fractures highly suggestive: CML (bucket-handle), posterior rib, scapula, spinous process, sternum. AHI/Shaken baby syndrome: SDH + retinal haemorrhages + cerebral oedema ± seizures; 25% mortality, 80% survivors disabled. MSBP: mother fabricates illness; symptoms stop on separation. Sexual abuse: normal exam is the norm; forensic evidence best within 72 hours; STIs (gonorrhoea, syphilis, HIV, chlamydia) are diagnostic. Management: multidisciplinary (doctor, social worker, police, school); prioritize child safety; MDCC; Child Protection Registry. Prevention: primary (universal education), secondary (at-risk families), tertiary (prevent recurrence). ACE/toxic stress: lifelong health consequences; protective factor = stable supportive adult relationship.
Active Recall - Child Abuse
[1] Lecture slides: GC 143. A child with multiple bruises_child abuse.pdf (all pages) [2] Paediatrics block notes: Block C - A child with multiple bruises_ child abuse.pdf [3] Senior notes: Adrian Lui Pediatrics Notes.pdf (pp. 492–493) [4] Past papers: November 2020 Fourth Summative Assessment MCQ paper.pdf (Q21) [5] Lecture slides: Intro to Forensic Path 2023.pdf (pp. 19, 109, 126) [6] Past papers: June 2021 Fourth Summative Assessment MCQ.pdf (Q94) [7] Past papers: 2019 Fourth Summative MCQ.pdf (Q1–2)
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