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Differential diagnosis of suspected child physical abuse

Stephen C Boos, MD, FAAP
Section Editors
Daniel M Lindberg, MD
Jan E Drutz, MD
Deputy Editor
James F Wiley, II, MD, MPH


The differential diagnosis of the common clinical manifestations of child abuse is presented here.

The clinical manifestations of child abuse, the diagnostic evaluation for suspected child abuse, and the differential diagnosis of abusive head trauma are discussed separately. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Differential diagnosis'.)


When evaluating the child who is suspected of being physically abused, it is important to remember that findings that appear to be abusive may result from other causes.

The differential diagnosis of child abuse varies depending upon the clinical manifestations. Familiarity with the medical conditions or cultural practices that mimic child abuse can facilitate arrival at the correct diagnosis, initiation of appropriate therapy, and avoidance of the consequences of an unnecessary evaluation of and/or report of suspected child abuse. One helpful distinguishing feature is that many abused children present with multiple types of injuries (eg, bruising and fractures). Identifying multiple types of injuries decreases the likelihood that a single medical entity has produced all of the findings although certain conditions (eg, osteogenesis imperfecta [OI]) provide exception to this rule. It is most appropriately a consideration in children with fractures. Though data is weak, easy bruising is often cited in children with OI. Rare cases of subdural collections and retinal hemorrhage in children with OI have also been reported. (See "Differential diagnosis of the orthopedic manifestations of child abuse", section on 'Osteogenesis imperfecta'.)

The medical literature contains many assertions of medical conditions being confused for abuse that are incompletely documented or speculative. Sometimes these assertions are challenged, and other times not [1-3]. Ultimately, a clinician must consider the relative likelihoods of all potential conditions alongside the possibility that a child with a medical condition may, in addition, be abused [4]. One study found that just under 5 percent of almost 3000 children evaluated for physical abuse had a cutaneous mimic (eg, Mongolian spot, impetigo, and bruising due to a bleeding disorder) [5]. Six percent of children with cutaneous mimics still had "high concern" for child abuse when the full picture was considered. Another study found that 3 percent of these same children had non-cutaneous mimics, with or without a cutaneous finding; 7 percent of children with non-cutaneous mimics still had "high concern" for child abuse when the full picture was considered and another 21 percent had an "intermediate level of concern" [6].

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Literature review current through: Nov 2017. | This topic last updated: Aug 11, 2016.
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