11. Conditions Mistaken for Child Physical Abuse
Abstract Learning Objectives Confusing Cutaneous Conditions Folk Medicine Burns Intracranial Bleeding Ocular Hemorrhages Fractures Osteogenesis Imperfecta Diagnostic Considerations in Distinguishing Osteogenesis Imperfecta From Inflicted Injuries Temporary Brittle Bone Disease Infantile Cortical Hyperostosis (Caffey’s Disease) Other Miscellaneous Conditions Mistaken for Child Abuse References


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Numerous conditions exist that can suggest an etiology of inflicted injury. Strict adherence to evidence based on objective findings and consideration of all diagnostic possibilities help to avoid mistakes. An organ-system approach is outlined here. The medical conditions that may mimic child maltreatment are discussed with an eye toward distinguishing them from inflicted injury.

• Dermatitis herpetiformis • Diaper dermatitis • Chilblains • Drug eruption • Mechanical abrasion • Chemical burns • Staphylococcal scalded skin syndrome • Accidental burns

Learning Objectives
• To identify conditions, disorders, and syndromes that may be confused with child abuse • To differentiate inflicted injury from preexisting medical conditions • To identify cultural practices that may be confused with child abuse

Intracranial Bleeding
Accidental Trauma—There have been numerous articles detailing the kinds of falls that produce serious intracranial injuries in infants and children.9–32 The conclusion of these studies is that children do not suffer serious intracranial injuries from short (<4 feet) falls. The exception is epidural hematomas, which usually are easily distinguished on computed tomography (CT) scans of the head, appearing as lenticular-shaped densities. The impact caused by motor vehicle crashes and falls, usually from 2 to 3 stories, is necessary to produce subdural or subarachnoid hematomas. Extensive, multilayered retinal hemorrhages (RHs) are almost exclusively seen in shaken baby syndrome/shaken impact syndrome (SBS/SIS). Retinal folds are diagnostic of abusive head trauma. Coagulation Disorders—Although bleeding and clotting disorders can exacerbate intracranial bleeding when a traumatic event has occurred, the brain is not the usual site for such bleeding. In hemophilia, for example, bleeding is usually into joints or soft tissue. Appropriate laboratory tests for bleeding and clotting abnormalities will diagnose a coagulation disorder. Tumors—These are usually diagnosable by radiographic techniques such as CT scans or magnetic resonance imaging. Vascular Malformations—Rare in childhood, when intracranial bleeding is due to these it is usually in the brain tissue itself. Caida de Mollera (Fallen Fontanelle)33—In some cultures, a flat or sunken fontanelle is considered unhealthy, although it may be present for a variety of benign reasons. When caida de mollera is employed to “raise” the fallen fontanelle, the baby is held upside down, often shaken in that position, and the head is held over or dipped into boiling liquid. The shaking motion is sometimes extreme

Confusing Cutaneous Conditions
The process of diagnosing medical conditions is organized around gathering information about the onset, severity, and duration of the symptoms and signs; the objective findings on physical examination of the patient; and collection of additional data from the laboratory, special studies, or x-rays. When all of these are synthesized, a list of diagnostic possibilities is developed. This list—called the differential diagnosis—forms the basis for further thinking about the possible etiology of the patient’s disorder. It is no different when approaching a case of suspected abuse. There are a number of medical conditions that may mimic physical child abuse. These possibilities must be considered and ruled out in the diagnostic process.

Folk medicine
• Coin rubbing (cao gio)1,2 • Spooning (quat sha)3,4 • Moxibustion4,5 • Cupping4,6 • Maqua5

• Phytophotodermatitis7 • Impetigo • Varicella • Epidermolysis bullosa

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Mongolian spots

Distinguishing Features
• Slate gray and uniform in color from one side to the other • Seen at time of birth, become less visible slowly • Seen usually on buttocks, lower back, but can be seen anywhere on the body • Skin is velvety, hyperelastic, and fragile • Minor trauma can lead to bruises • Splotchy, covering various areas of body • Often itchy, may be raised (hives) • Recurrent, indolent • Exposure to psoralens in the juice of certain plants followed by exposure to sunlight (limes, lemons, figs, parsnip, celery, herbal preparations) • Mahogany-colored lesions from contact to skin • Rubber, face masks, surf boards, squash balls, elastic bands in clothing, plants, chemicals • Can inject anticoagulant under the skin causing deposit of hemosiderin • Mimics bruises or abrasions • Coagulation studies—PT, PTT, TT, fibrinogen, Factor VIII, platelets, special studies

Ehlers-Danlos syndrome (India rubber syndrome) Erythema multiforme Hypersensitivity vasculitis


Millipedes secretions8 Contact dermatitis and allergic reactions

Lice, “crabs” Ink or dye on skin (clothing) Coagulation defect (hemophilia, von Willebrand’s, leukemia, ITP, HSP, vitamin K deficiency, ingestion of anticoagulants

and can lead to tearing of the bridging veins and resultant subdural or subarachnoid hematomas. Obstetric Trauma—Cephalohematomas are common parturitional injuries, especially in births involving instrumentation. They occur in 3% to 10% of newborns.34 In 25% of cases they are associated with skull fractures, usually in the posterior parietal region.35 Subdural hemorrhage related to the tentorium is associated with vacuum extraction.36 Chronic subdural collections seen in the first months of life may be attributed to parturitional events, but examination of those events will usually clarify whether there were factors during the birth that may have given rise to the collections seen later. The CT imaging characteristics and the absence of associated injuries (other fractures, RHs, abusive bruises) and the social history often can help distinguish these conditions from parturitional injuries.37

Ocular Hemorrhages
Periorbital Ecchymoses—Bilateral black eyes are usually from abuse, but they can be caused by blunt trauma to the forehead with resultant seepage of the extravasated blood into the periorbital tissues. Subconjunctival Hemorrhage—Forceful coughing, sneezing, vomiting, or other Valsalva maneuvers can cause subconjunctival hemorrhages. Retinal Hemorrhages—Retinal hemorrhages must be described in terms of their characteristics, because not all RHs are alike.38 Retinal hemorrhages do not occur as the result of cardiopulmonary resuscitation,38–41 seizures,38–42 or thoracic compression in childhood (Purtscher’s retinopathy).38,43,44


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Other conditions in which RHs are seen include Vaginal Delivery—Occurring in 40% of children delivered vaginally, these fine petechial preretinal hemorrhages usually resolve within 10 to 14 days of delivery leaving no residual.38 Bleeding Disorders—Isolated RHs in coagulopathies have not been described. When they occur in patients with bleeding or clotting disorders, they are associated with other sites of bleeding. Arteriovenous Malformations—Arteriovenous malformations are extremely rare in infancy and, when present, are seldom associated with RHs. Increased Intracranial Pressure—This is present in most cases of SBS/SIS, but current thinking is that if this caused RHs, it would be present in all cases of increased intracranial pressure secondary to all causes. This is not supported by medical literature about accidental head trauma with increased intracranial pressure.24,45–49 Meningitis—Increasingly rare in pediatrics, it is not likely this diagnosis would be overlooked after clinical assessment, culturing, and examination of cerebrospinal fluid. Accidental Head Trauma—Recent literature on the incidence of RHs in accidental head trauma indicates they are seldom seen in cases of accidental origin. Thromboembolic Phenomena (eg, subacute bacterial endocarditis)—These conditions would be diagnosed based on numerous other findings.

Rib fractures resulting from birth trauma are almost unknown. Kleinman37 has found only 4 examples of rib fractures associated with birth injuries in otherwise normal infants.52–55 Forceful Manipulation—Overzealous passive exercise and chiropractic or other health care providers have been reported to cause fractures.56 Metabolic Disorders, Nutritional Deficiencies, and Infectious Conditions—Preterm or very low birth weight babies (neonatal osteopenia), Menke’s kinky hair syndrome, rickets, scurvy, and altered vitamin D metabolism due to drugs (phenobarbital, phenytoin) may cause fractures.

Osteogenesis Imperfecta
Osteogenesis imperfecta is a disorder of collagen synthesis.

Type I: 70% of all cases
• Normal stature • Little or no long bone involvement • Blue sclerae • Dentinogenesis imperfecta uncommon • Osteoporosis often found on plain radiograph • Autosomal dominant positive, family history usually positive

Type II: Severe bone disease evident prior to birth
• At birth, severe shortening and distortion of limbs ~ Large head ~ Striking blue sclerae ~ Severe generalized skeletal dysplasia ~ Poor mineralization of calvarium with wormian bones ~ Fractures and crumpling of long bones, beading of ribs, distortion of vertebral bodies ~ Early death in perinatal period or infancy ~ Autosomal dominant

Birth Injuries—Fracture of the clavicle is the most common obstetrical fracture with an incidence of up to 7 per 1,000 term deliveries.37 This fracture usually occurs in large babies. Callus formation is present by 11 days of age and if not present then, excludes the diagnosis of birth injury. Fracture of the humerus occurs in a small number of births (7/15,435).50 This fracture occurs in difficult deliveries and breech extractions. Fracture of the femur occurs even less frequently than humeral fractures (2/20,409).51 Subperisoteal new bone formation is present by 10 to 12 days of age and mature callus by 2 to 3 weeks.

Type III: Unlikely to be confused with inflicted injuries
• Large head • Severe bowing and shortening of extremities • Normal or slightly blue sclerae • Severe skeletal dysplasia • Presence of fractures at birth common • Severe deformities of extremities and spine • Autosomal recessive pattern of inheritance— family history often is negative

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Type IV
• Variable degree of short stature, some deformity • Fractures may begin prenatally, deformities at birth • Most affected infants are short in stature • Triangular heads, prominent foreheads • Normal sclerae • Osteoporosis, with variable deformity of long bones • Dentinogenesis imperfecta common • Autosomal dominant, family history typically positive
• Cerebral palsy • Osteopenia secondary to nutritional problems, Down syndrome, chronic pulmonary disease • Prostaglandin therapy for patent ductus arteriosus • Methotrexate therapy • Hypervitaminosis A • Congenital syphilis • Congenital indifference to pain

• Family history is positive in Types I and II. • Clinical features help distinguish. • If in doubt, cultured skin fibroblasts to detect collagen abnormalities yield a definitive diagnosis in 90% of cases tested.

colleagues suggest the underlying problem in TBBD is a “temporary deficiency of an enzyme, perhaps a metallo-enzyme, involved in the posttransitional processing of collagen.” Several investigators58 have challenged these assertions on the basis that there is no scientific evidence to support their theory.

Infantile Cortical Hyperostosis (Caffey’s Disease)
This rare idiopathic disease of young infants causes painful subperiosteal new bone formation and cortical thickening in multiple bones. It usually involves the mandible, clavicle, and ulna. Onset after 6 months of age is very rare. Complete healing is the rule in Caffey’s disease. Familial distribution is common.

Temporary Brittle Bone Disease (TBBD)
Paterson and colleagues57 described 39 patients older than 10 years who seemed to have “selflimiting osteogenesis imperfecta.” These patients had fractures in infancy, and the fractures occurred at home in 32 cases and in hospital in 7. This entity has stirred intense controversy in the medical community because of its citation in abuse cases by legal representatives of alleged perpetrators. Most of the features of temporary brittle bone disease (TBBD) are those seen in inflicted injury or normal variants in normal children. Paterson and

Other Miscellaneous Conditions Mistaken for Child Abuse
• Hair tourniquet syndrome • Alopecia areata • Hypogammaglobulinemia • Mental retardation in parent(s)


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1. Yeatman GW, Shaw C, Barlow MJ, Bartlett G. Pseudobattering in Vietnamese children. Pediatrics. 1976;58: 616–618 2. Bryan C. Vietnamese coin rubbing. Ann Emerg Med 1987; 16:602 3. Leung A. Ecchymoses from spoon scratching simulating child abuse. Clin Pediatr. 1986;25:98 4. Look K, Look R. Skin scraping, cupping and moxibustion that may mimic physical abuse. J Forensic Sci. 1997;42: 103–105 5. Feldman KW. Pseudoabusive burns in Asian refugees [letter]. Child Abuse Negl. 1995;19(5):657–658 6. Asnes RS, Wisotsky DH. Cupping lesions simulating child abuse. J Pediatr. 1981;99:267–268 7. Coffman K, Boyce WT, Hansen RC. Phytodermatitis simulating child abuse. Am J Dis Child. 1985;139:239–240 8. Shpall S, Frieden I. Mohagany discoloration of the skin due to the defensive secretion of a millipede. Pediatr Dermatol. 1991;8:25–27 9. Barlow B. Accidents in childhood. Nurs Mirror Midwives J. 1977;144(8):39–40 10. Billmire ME, Myers PA. Serious head injury in infants: accident or abuse? Pediatrics. 1985;75:340–342 11. Chadwick DL, Chin S, Salerno C, Landsverk J, Kitchen L. Deaths from falls in children: how far is fatal? J Trauma. 1991;31(10):1353–1355 12. Chiaviello CT, Cristoph RA, Bond GR. Infant walker-related injuries: a prospective study of severity and incidence. Pediatrics. 1994;93:974–976 13. Chiaviello C, Christoph RA, Bond GR. Stairway-related injuries in children. Pediatrics. 1994;94:679–681 14. dos Santos AL, Plese JP, Ciquini Junior O, Shu EB, Manreza LA, Marino Junior R. Extradural hematomas in children. Pediatr Neurosurg. 1994;21:50–54 15. Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics. 1977;60:533–535 16. Joffe M, Ludwig S. Stairway injuries in children. Pediatrics. 1988;82:457–461 17. Lehman D, Schonfeld N. Falls from heights: a problem not just in the Northeast. Pediatrics. 1993;92:121–124 18. Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics. 1993; 92:125–127 19. Mayr J, Gaisl M, Purtscher K, et al. Baby walkers—an underestimated hazard for our children? Eur J Pediatr. 1994;153:531–533 20. Mayr JM, Seebacher U, Shimpl G, Fiala F. Highchair accidents. Acta Pediatr. 1999;88:319–322

21. Mayr JM, Seebacher U, Lawrenz K, et al. Bunk beds—a still underestimated risk for accidents in childhood? Eur J Pediatr. 2000;159:440–443 22. Musemeche CA, Barthel M, Cosentino C, Reynolds M. Pediatric falls from heights. J Trauma. 1991;31(10): 1347–1349 23. Nimityongskul P, Anderson L. The likelihood of injuries when children fall out of bed. J Pediatr Orthop. 1987;7: 184–186 24. Reece RM, Sege R. Childhood head injuries: accidental or inflicted? [see comments]. Arch Pediatr Adolesc Med. 2000;154(1):11–15 25. Reiber GD. Fatal falls in childhood. How far must children fall to sustain fatal head injury? Report of cases and review of the literature. Am J Forensic Med Pathol. 1993;14(3): 201–207 26. Reider MJ, Schwartz C, Newman J. Patterns of walker use and walker injury. Pediatrics. 1986;78:488–493 27. Selbst SM, Baker MD, Shames M. Bunk bed injuries. Am J Dis Child. 1990;144(6):721–723 28. Smith GA, Dietrich AM, Garcia CT, Shields BJ. Injuries to children related to shopping carts. Pediatrics. 1996;97(2): 161–165 29. Smith GA, Bowman MJ, Luria JW, Shields BJ. Babywalkerrelated injuries continue despite warning labels and public education. Pediatrics. 1997;100(2):e1 30. Smith MD, Burrington JD, Woolf AD. Injuries in children sustained in free falls: an analysis of 66 cases. J Trauma. 1975;15(11):987–991 31. Williams RA. Injuries in infants and small children resulting from witnessed and corroborated free falls. J Trauma. 1991;31(10):1350–1352 32. Williams AF. Children killed in falls from motor vehicles. Pediatrics. 1981;68(4):576–578 33. Hansen KK. Folk remedies and child abuse: a review with emphasis on caida de mollera and its relationship to shaken baby syndrome. Child Abuse Negl. 1997;22(2): 117–127 34. Gresham EL. Birth trauma. Pediatr Clin North Am. 1975; 22:317–328 35. Kendall N, Woloshin H. Cephalohematoma associated with fracture of the skull. J Pediatr. 1952;41:125 36. Hanigan WC, Morgan AM, Stahlberg LK, Hiller JL. Tentorial hemorrhage associated with vacuum extraction. Pediatrics. 1990;85:534–539 37. Kleinman PK, ed. Diagnostic Imaging of Child Abuse. 2nd ed. St Louis, MO: Mosby; 1998 38. Levin A. Ocular manifestations of child abuse. In: Reece R, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management. Baltimore, MD: Lippincott, Williams and Wilkins; 2001


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39. Fackler J, Berkowitz I, Green R. Retinal hemorrhages in newborn piglets following cardiopulmonary resuscitation. Am J Dis Child. 1992;146:1294–1296 40. Gilliland MGF, Luckenbach MW. Are retinal hemorrhages found after resuscitation attempts? A study of the eyes of 169 children. Am J Forensic Med Pathol. 1993;14:187–192 41. Kanter R. Retinal hemorrhage after cardiopulmonary resuscitation or child abuse? J Pediatr. 1986;108:430–432 42. Sandramouli S, Robinson R, Tsaloumas M, Willshaw H. Retinal hemorrhages and convulsions. Arch Dis Child. 1997;76:449–451 43. Morgan O. A case of crush injury to the chest associated with ocular complication. Trans Ophthalmol Soc UK. 1945;65:366–369 44. Tomsai L, Rosman N. Purtscher retinopathy in the battered child syndrome. Am J Dis Child. 1975;129:1335–1337 45. Johnson D, Braun D, Friendly D. Accidental head trauma and retinal hemorrhage. Neurosurgery. 1993;33:231–235 46. Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics. 1992;90:179–185 47. Duhaime AC. Head trauma. Thousand Oaks, CA: Sage Publications, Inc; 1997 48. Betz P, Puschel K, Miltner E, Lignitz E, Eisenmenger W. Morphometric analysis of retinal hemorrhages in the shaken baby syndrome. Forensic Sci Int. 1996;78:71–80 49. Elder JE, Taylor RG, Klug GL. Retinal haemorrhages in accidental head trauma in childhood. J Paediatr Child Health. 1991;27:286–289

50. Rubin A. Birth injuries: incidence, mechanisms and end results. J Obstet Gynecol. 1964;23:218–221 51. Camus M, Lefebvre G, Veron P, Darbois Y. Traumatismes obstetricaux du nouveau-ne. Enquete retrospective a propos de 20,409 naissances. J Gynecol Obstet Biol Reprod. 1985;14:1033–1044 52. Barry P, Hocking M. Infant rib fracture-birth trauma or nonaccidental injury [letter]. Arch Dis Child. 1993;68:250 53. Hartmann R. Radiological case of the month. Rib fractures produced by birth trauma. Arch Pediatr Adolesc Med. 1997;151:947–948 54. Rizzolo P, Coleman P. Neonatal rib fracture: birth trauma or child abuse? J Fam Pract. 1989;29:561–563 55. Thomas P. Rib fractures in infancy. Ann Radiol. 1977;20: 115–122 56. Helfer R, Scheurer S, Alexander R, Reed J, Slovis T. Trauma to the bones of small infants from passive exercise: a factor in the etiology of child abuse. J Pediatr. 1984;104:47–50 57. Paterson CR, Burns J, McAllion SJ. Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form [see comments]. Am J Med Genet. 1993;45(2):187–192 58. Ablin D, Sane S. Non-accidental injury: confusion with temporary brittle bone disease and mild osteogenesis imperfecta. Pediatr Radiol. 1997;27:111–113


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