Physical Abuse (Nonaccidental Trauma)

Author(s): Maurice Sholas, MD, PhD

Originally published:11/10/2011

Last updated:08/16/2016



Physical abuse is non self-inflicted trauma that causes damage to a person and is not the result of an accidental incident.


Parents who have substance abuse problems or were abused have a higher chance of being abusers. Children thought to be more at risk include: first-born children, children with disabilities, step-children, and premature infants.

Epidemiology including risk factors and primary prevention

There is a 25% risk of serious injury and 5% risk of death in all cases of physical abuse. It is the second leading cause of mortality in infants and children. This affects 1% to 1.5% of all children in the United States, which is estimated to be around 700,000 to 2,000,000 children. The greatest incidence of nonaccidental trauma is in the first 6 months of life.


  1. Retinal hemorrhages, secondary to rapid acceleration and deceleration effects.
  2. Mental status changes from brain injury
  3. Vomiting because of increased intracranial pressure.
  4. Poor parent-child interaction.
  5. Bite marks
  6. Burns that are in a stocking/glove distribution sparing creases, palms, or soles because this shows an immersion into scalding water.
  7. Burns in the shape of an object.
  8. Seizures because of brain injury or cortical irritability after concussion or hemorrhage.
  9. Spiral fractures of the arm/leg, secondary to a child being dragged or pulled forcefully.
  10. Posterior rib fractures from being held by the chest and shaken by a larger individual.
  11. Humerus fracture in children under 3 years old; they do not generate enough force to fracture this bone in normative life activities.
  12. Metapheseal corner (bucket-handle) fractures because of traction of ligaments on bone attachment points.
  13. Femur fracture in children less than one year old, because they do not generate enough force to fracture this bone in normative life activities.
  14. Sternal fractures from being struck in the chest with force.
  15. Fractures at multiple stages of healing, indicating multiple episodes of trauma.



Inconsistencies, or changes in the presenting history should raise suspicions of nonaccidental trauma. Look for incompatibility of the severity of the injury and the explanation of how it occurred. If the explanation is reluctantly provided, contradictory, or vague, there should be suspicion. Finally, if there have been several presentations of trauma, the usage of multiple emergency departments, or several failed routine appointments, the provider should be suspicious. A history of failure to thrive or factitious infirmities is also important to elicit the history.

Physical examination

Start with the standard primary survey. Check for bruises in unusual locations, and/or bruises of varying ages. An imprint of an object, such as a hand, belt buckle, or cord, is also suggestive. A thorough examination of the skin, a neurologic exam, and an examination of the abdomen are important steps. Retinal hemorrhages, spiral fractures in a child who is preambulatory, and unexplained visceral injuries are important for notation.

Functional assessment

Observe the child’s behavior and how they interact with the parent, the providers, and other members of the family. Assess if there is an overly accommodating nature, a significant change in the patient’s abilities relative to baseline, or if there are elements of the child that are developmentally regressed from what would be expected for their chronologic age.

Laboratory studies

Complete blood count, protime (PT), prothrombin time (PTT), and international normalized ratio (INR) are important to rule out bleeding dyscrasias that would confuse the clinical picture. For repeat fractures, genetic testing for osteogenesis imperfecta is indicated as well.


A computed tomography scan of the head is preferred as the initial evaluation tool because of the speed of the results and their sensitivity toward hemorrhage.  A similar scan of the spine is indicated at times based on clinical correlation of findings driving suspicion. Magnetic resonance imaging scans are typically not initially requested, but they may show chronic lesions in the acute setting suggesting prior injury. Imaging of the axial and peripheral skeleton is important, and a skeletal survey is standard fare.  Patients that have metabolic or other causes of osteopenia typically have bones that are not just fractured, but appear very demineralized. There are also clinical correlations of imaging studies that rule in or out competing diagnoses to help distinguish fractures associated with nonaccidental trauma and those from profound osteopenia from conditions such as osteogenesis imperfecta. An abdominal ultrasound is performed when there are clinical indices that lead to suspicion of visceral damage.

Supplemental assessment tools

A dilated pupil examination by ophthalmology is a good supplemental assessment.

Early predictions of outcomes

More severe lesions, as indicated by Glasgow Coma Scale or and injury severity scale, especially those affecting the central nervous system, lead to worse outcomes. The best physical outcomes are for isolated musculoskeletal or limited dermatologic findings. However, emotional outcomes are not solely related to the severity of presentation. Children who are relatively physically intact can still have lasting deficits from abuse that negatively impacts emotional, social, and cognitive development.


Nonaccidental trauma can happen to persons of any race, religion, or ethnicity and in all socioeconomic levels. The bias the examiner may have of the presenting victim and their family may increase or decrease the likelihood that nonaccidental trauma is recognized.

Social role and social support system

The involvement of child life, social work, and physician specialists equipped to further evaluate and support victims is critical. These personnel or the initial reporter should involve law enforcement authorities when information supporting the suspicion of nonaccidental trauma is accrued.

Professional Issues

Mandatory reporting of possible abuse is required of nearly all medical providers in U.S. jurisdictions, but state law should be consulted for clarity. Thus, if a physician, mid-level provider, nurse, therapist, or para-medical professional suspects abuse, they must report it to the appropriate governmental authorities for investigation.


Available or current treatment guidelines

Children with central nervous system deficits are stratified as having mild, moderate, or severe impairments. Based on those deficits, they qualify for inpatient or outpatient therapy services. Children with musculoskeletal deficits are also classified based on relevant fracture classification systems. The more mildly affected children will just have symptomatic treatment. The more severely affected children may also qualify for inpatient or outpatient therapy services. All children who are victims of abuse and have any insight into their injuries, the mechanism of injury, or their deficits should receive ongoing psychiatric and psychosocial support.

Coordination of care

  1. Parallel practice: Individual practitioners should involve a team of professionals to address the medical, social, legal, and emotional issues related to nonaccidental trauma. It is contrary to best practice to do all aspects of care in isolation.
  2. Coordinated: Efforts between the medical staff, the psychosocial support team, and the law enforcement and government agencies is essential for treating the child and maintaining them in a safe environment.
  3. Integrated: Documentation is critical to the process. When directly quoting information from the victim and/or the perpetrator, quotation marks should be used. Legible and careful notation is important. Drawings, sketches, and descriptions of the physical findings are encouraged. Police and governmental agencies use medical records to follow up on the incident of abuse.

Patient & family education

The involvement of the family in the treatment and education process is ultimately determined by the circumstances around the abuse. Many advocacy groups have organized campaigns to promote awareness. However, most are geared towards the lay public as opposed to medical professionals.

Emerging / unique Interventions


Notation of the Glasgow Coma Scale or use of a trauma scoring index to assess severity of presentation is useful for future prognosis.

Translation into practice: practice “pearls” / performance improvement in practice (PIPs) / changes in clinical practice behaviors and skills

There are some medical conditions that may be confused with nonaccidental trauma. Children with bleeding disorders, such as hemophilia and von Willibrand disease, frequently present to emergency departments with significant bruising that is out of proportion with the amount of trauma. They also have bruises of different ages. These children can be identified via coagulation studies and genetic testing. Another class of patients that can be confused with those suffering from nonaccidental trauma are those with bone disorders. Osteogenisis imperfecta patients and those with metabolic bone disease can repeatedly present to the emergency room and have fractures of varying ages that are out of proportion to the reported trauma. These patients can be diagnosed via genetic testing.


Cutting edge concepts and practice

Not applicable at this time.


Gaps in the evidence-based knowledge

Not applicable at this time.


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Kellogg ND, and Committee on Child Abuse and Neglect, American Academy of Pediatrics. Evaluation of suspected child physical abuse. Peds,2007;119(6):1232-1241.

Christian CW, Block R and Committee on Child Abuse and Neglect, American Academy of Pediatrics. Abusive head trauma in infants and children. Peds,2009:123j(5):1409-1411.

Keenan, HT, Hooper SR, Wetherington CE, et al. Neurodevelopmental consequences of early traumatic brain injury in 3-year-old children. Peds,2007:119(3):e616-e623.

Vinchon M, Defoort-Dehllemmes S, Desurmont M, Dhellemmes P. Accidental and nonaccidental head injuries in infants: A prospective study. J Neurosurg:Pediatrics, 2005;102:380-384.

Kemp AM, Dunstan F, Harrison, S, et al. Patterns of skeletal fractures in child abuse: Systematic review. BMJ, 2008;337:a1518.

Chadwick DL, Bertocci G, Castillo E, et al. Annual risk of death resulting from short falls among young children: Less than 1 in 1 million. Peds, 2008;121(6): 1213-1224.

Original Version of the Topic:

Maurice Sholas, MD, PhD. Physical Abuse (Nonaccidental Trauma). Publication Date: 2011/11/10.

Author Disclosure

Maurice Sholas, MD, PhD
Nothing to Disclose

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