Symptoms:

An adult may bring an injured child to an emergency room with a strange explanation of the cause of the injury. The child's injury may not be recent.

Symptoms include:

• Black eyes
• Broken bones that are unusual and unexplained
• Bruise marks shaped like hands, fingers, or objects (such as a belt)
• Bruises in areas where normal childhood activities would not usually result in bruising
• Bulging fontanelle (soft spot) or separated sutures in an infant's skull
• Burn (scalding) marks, usually seen on the child's hands, arms, or buttocks
• Choke marks around the neck
• Cigarette burns on exposed areas or on the genitals
• Circular marks around the wrists or ankles (signs of twisting or tying up)
• Human bite marks
• Lash marks
• Unexplained unconsciousness in an infant

Signs and tests:

Typical injuries in abused children include:

• Any fracture in an infant too young to walk or crawl
• Bleeding in the back of the eye, seen with shaken baby syndrome or a direct blow to the head
• Collection of blood in the brain (subdural hematoma) without good explanation
• Evidence of fractures at the tip of long bones or spiral-type fractures that result from twisting
• Evidence of skull fracture
• Fractured ribs, especially in the back
• Internal damage, such as bleeding or rupture of an organ from blunt trauma
• Multiple bruises that occurred at different times -- especially in unusual areas of the body or in patterns that suggest choking, twisting, or severe beating with objects or hands
• Other unusual skin damage, including burns or burn scars

The following tests can reveal physical injuries:

• Bone x-ray. All of the child's bones, including the skull, are x-rayed to look for unseen fractures or old, healing fractures.
• MRI or CT scan of the head or abdomen are done if there is a skull fracture; bleeding in the eye; unexplained vomiting; severe bruising of the face, skull, or abdomen; unexplained nervous system (neurological) symptoms; headaches; or loss of consciousness.

The following medical conditions have symptoms similar to those of physical abuse:

• Osteogenesis imperfecta - almost all children with this condition have an abnormal (blue) coloring of the whites of the eyes. These children may have spontaneous fractures or break bones after accidents that would not harm the bones of a normal child.
• Undetected bleeding disorders such as hemophilia, Von Willebrand's disease, or liver disease can lead to abnormal bruising patterns. The doctor can test for these disorders.
• Unusual bruising and scarring patterns can also be caused by folk medicine or Oriental medicine practices such as coin rubbing, cupping, and burning herbs on the skin over acupuncture points (called moxibustion). The doctor should always ask about alternative healing practices.