Physical Abuse Clinical Pathway, Emergency Department, Outpatient Specialty Care and Primary Care – Injuries Suggestive of Abuse

Injuries Suggestive of Abuse

Exam	Injuries with Moderate or High Specificity for Abuse	Injuries with Low Specificity for Abuse
Skeleton	Fractures with high specificity for abuse, especially in infants: Metaphyseal Rib Scapular Spinous process Sternum Fractures with moderate specificity for abuse: Multiple, especially bilateral Different ages Epiphyseal separations Vertebral body fractures and subluxations Digital fractures Complex skull fractures Extremity fracture in infants < 12 mos, excluding exceptions to right	Long bone shaft fractures in children > 12 mos Specific long bone shaft fractures in ambulating infants > 9 mos Distal buckle fracture of radius/ulna Distal buckle fracture of tibia/fibula Toddler's fracture Clavicular fractures in Newborns Ambulatory Medicine Subperiosteal new bone formation
Head	Subdural hematoma with or without skull fracture Unexplained intracranial injury Subgaleal hematoma due to hair-pulling Linear skull fx in infants < 4 mos, although low specificity may benefit from more investigation Note: Infants with intracranial injury frequently have no or non-specific symptoms	Isolated linear skull fracture with plausible mechanism in well-appearing infant ≥ 4 mos
Eye	Retinal hemorrhage Subconjunctival hemorrhage in infants, not birth injury
Facial Injury	Unexplained Torn frenulum in non-ambulatory child Oral injury Ear injury Facial bruising in non-ambulatory child
Bruising	TEN-4 FACES P Bruising Clinical Decision Rule: If below criteria are met, have a clinical concern for abuse References Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics TEN-4-FACESp
Bite Marks	Semi-circular/oval patch May have associated bruising Adult bite: intercanine distance 3-4.5 cm Consider forensic evidence collection Concern for adult bite Sexual Abuse Pathway
Burns	Patterned contact burns with insufficient mechanism Cigarette burn Stocking, glove pattern Mirror image burns of the extremities Symmetric burns on buttocks Immersion burn Multiple burn sites ED Burn Pathway Inpatient Burn Pathway

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Physical Abuse Clinical Pathway, Emergency Department, Outpatient Specialty Care and Primary Care – Injuries Suggestive of Abuse

Injuries Suggestive of Abuse