PEM Pearls 02: Non-Accidental Trauma pt. 1

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Welcome back to PEM Pearls: the CanadiEM Infographic Series focused on providing approaches and high-yield pearls for important pediatric EM topics! This is part 1 of our 2 part Non-Accidental Trauma posts. Today we will be discussing the history, physical exam, and differential diagnosis considerations for potential non-accidental trauma cases.​1​

Physical child abuse is a frequently missed emergency department presentation. It is most common in children aged 6 months or younger, although it can occur at any age. Regardless of ethnicity and socioeconomic status, non-accidental trauma can occur in all families, and should always be on your differential when assessing children with physical injuries.


When gathering history from the child or caregiver use open ended questions. Specifically, physicians need to determine if the pattern of injury is consistent with the proposed mechanism, and if there is an unexplained delay in seeking medical care. Serious injuries from seemingly benign mechanisms, or delays in presenting to the hospital may be concerning features for child abuse.

Infants do not localize their injuries as well as older children and adults. Additionally, injuries may only have mild symptoms, such as irritability, decreased appetite, or mild lethargy. Here are a few symptoms to watch for that may indicate a serious underlying pathology:

  • Closed head injuries: present with irritability, somnolence, seizures, or prolonged vomiting
  • Fractures: present with fussiness, local tenderness, decreased limb use, or refusal to weight bear

Physical Exam

Non-accidental traumas commonly have missed injuries. Therefore, head-to-toe physical exams are required to identify potential underlying injuries. Patterns of injuries can present in many ways, so here’s a few tips on bruises, burns and mouth injuries:

  • Bruises: While bruising is common on healthy children, it’s important to know the signs of a pathologic bruise. Potential child abuse bruises can present as the shape of an object, or a negative outline of the object. Furthermore, inflicted bruises may also be linear, symmetrical, or located on non-bony prominences. Above all, remember that those who don’t cruise, don’t bruise!
    • The TEN-4 Rule stands for bruising on the Torso, Ear, Neck, or anywhere in an infant <4 months. Bruising noted in these areas has a 97% sensitivity and 84% specificity for child abuse.​2​
  • Burns: Immersion burns are from the submerging the child in a scalding fluid. They are found in the anogenital and extremity regions, and the burns may have a sharp demarcated line, or skin folds sparing. Cigarette burns are 8-10mm and have a circular blistered appearance. However, children may also accidentally scald themselves: these injuries have a drip appearance, and are more severe proximally.
  • Mouth Injuries: look for oropharyngeal injuries in all suspected non-accidental trauma presentations. Specifically, frenula tears and unexplained injuries to the lips, teeth, and soft palate are suggestive of abuse.

Differential Diagnosis

In short, there are a variety of conditions that can mimic the bruises, burns, fractures, and head injuries found in non-accidental trauma. Furthermore, Remember to keep your differential diagnosis broad, and consider other possible etiologies. Lastly, check out the infographic for a brief overview of alternative diagnoses!

Stay tuned for part 2 of our Non-Accidental Trauma mini-series coming soon!


  1. 1.
    Lindberg D. Child Abuse. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2017:2225-2236.
  2. 2.
    Pierce M, Kaczor K, Aldridge S, O’Flynn J, Lorenz D. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125(1):67-74. doi:10.1542/peds.2008-3632

Expert Review

This infographic contains vital information with the background considerations for non-accidental trauma/injury in children seen in the ED. It is part 1 of 2 (the other infographic featuring more on treatment and investigative approaches) of a series on the topic. The infographic succinctly highlight important points for diagnostic consideration, particularly with consideration of differential diagnosis, advocacy for reporting SUSPECTED (not confirmed) child abuse, and major mortality causes (head injury). Also helpful are the listed clinical examination findings and red flags with clinical assessment to prompt consideration of NAT.

Dr. James S Leung
MD, FRCPC (Pediatrics, Pediatric Emergency Medicine)

Andrew Tolmie

Andrew is a PGY-1 at the University of Saskatchewan Emergency Medicine Program. He is also a Graphic Design Lead for the CanadiEM Infographics team. Outside of medicine, Andrew enjoys pour-over coffee, downhill skiing, and mountain biking.
Alvin is currently a PGY5 in the FRCP EM program at McMaster University. He serves as Director of Design for CanadiEM and has interests in knowledge translation and health innovation.