Red flag injuries suggesting physical child abuse in infants and young children

Injury	Patient age
Injury	<6 months	6 to 12 months	1 year old	2 to 3 years old
Soft tissue injury	Frenulum tears or unexplained oral injuries (teeth, lips, palate)	Frenulum tears or unexplained oral injuries (teeth, lips, palate)	Frenulum tears or unexplained oral injuries (teeth, lips, palate)	Frenulum tears or unexplained oral injuries (teeth, lips, palate)
	Isolated subconjunctival hemorrhage outside of the newborn period
	Any bruise	Unexplained bruises in non-cruising children
		Bruises of the trunk, ear, neck, jawline, or cheek	Bruises of the trunk, ear, neck, jawline, or cheek	Bruises of the trunk, ear, neck, jawline, or cheek
		Patterned bruising	Patterned bruising	Patterned bruising
Burns	Unexplained burns	Unexplained burns	Unexplained burns	Unexplained burns
	Burns in the shape of a heated object	Burns in the shape of a heated object	Burns in the shape of a heated object	Burns in the shape of a heated object
	Immersion burns	Immersion burns	Immersion burns	Immersion burns
	Burns of the perineum and lower extremities	Burns of the perineum and lower extremities	Burns of the perineum and lower extremities	Burns of the perineum and lower extremities
Fractures	Multiple fractures in different stages of healing	Multiple fractures in different stages of healing	Multiple fractures in different stages of healing	Multiple fractures in different stages of healing
Fractures	Any fracture other than skull or clavicle fractures in the newborn period	Any fracture other than skull fracture Skull fractures without history or other than simple linear parietal type	Any rib fracture Humerus fracture, other than supracondylar Fractures of other long bones Fracture without trauma history or presenting with evidence of healing	Fracture without trauma history or presenting with evidence of healing
Intracranial	Any subdural hemorrhage/hygroma	Any subdural hemorrhage/hygroma	Unexplained subdural hematoma without history of high-energy trauma (eg, motor vehicle collision, long-distance fall)
Visceral injury	Any visceral injury	Any visceral injury	Traumatic visceral injury unexplained by motor vehicle collision or verified history of accidental high-energy blow to the abdomen*

In the absence of significant, independently verified trauma mechanisms like motor vehicle collisions, the listed injuries by age should prompt further evaluation for physical child abuse. Other injuries not listed may also warrant further investigation. Refer to UpToDate content on recognition of physical child abuse.

* Proximal hollow-viscus and pancreatic injuries are more common in abuse than accidental trauma in young children and justify additional scrutiny of the given history.

Graphic 119441 Version 3.0

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Red flag injuries suggesting physical child abuse in infants and young children