Tests
1st tests to order
CBC
Test
Excludes some platelet abnormalities as a cause of bruising, identifies other hematologic abnormalities (e.g., leukemia), and highlights presence of anemia or blood loss.
Result
variable
clotting profile/coagulation studies
Test
Excludes many clotting abnormalities as a cause of bleeding and bruising.[76]
Result
normal; mild abnormalities may be present in head trauma
dilated funduscopy
Test
It is vital that an ophthalmologist conducts a detailed dilated examination of the fundi, using indirect funduscopy/RetCam (wide-field digital retinal imaging) in any child <3 years of age where abusive head trauma (AHT) is suspected. The presence of extensive, multilayered retinal hemorrhage in a child <3 years of age with an intracranial injury is highly specific for AHT, and it is seen in approximately 85% of cases.[22][23][24][74]
Retinal hemorrhages are also recorded following accidental trauma, where high-impact trauma has occurred. Other medical causes include birth, coagulation disorders, and carbon monoxide poisoning, although the pattern and character of hemorrhage differs from that seen in AHT. Infants <6 weeks old may have minor retinal hemorrhages following birth, particularly after a ventouse or other instrumental delivery.[77] However, retinal hemorrhages associated with these medical causes have distinctly different characteristics than those seen in inflicted and significant trauma.[78]
Result
retinal hemorrhages that are many in number, in multiple quadrants, and outside the posterior pole
photo-documentation of injuries
Test
It is useful to photo-document the extent and site of bruising. In cases of suspected bite, the dental pattern may be reconstructed from photographs. Although the accuracy of forensic dentistry for identifying the “biter” from a bite mark is uncertain, helpful information may be obtained from a review of bite images. The photographs should be taken with a right-angled measuring device and in at least 2 planes, if the injury is on a curved surface.[36]
Result
record of bruises, burns, or bites
skeletal survey
Test
Up to one third of children <2 years of age who have experienced physical abuse sustain fractures.[90][91][92] They are frequently occult and not suspected clinically.
A 22-film skeletal survey is indicated if the child is <2 years of age if maltreatment is suspected.[147][161]
A repeat skeletal survey should be performed 11 to 14 days later. Repeat skeletal surveys can add information to the evaluation and management of the patient.
Rib fractures are a strong predictor of child abuse in infants in the absence of major trauma or pathologic causes, and are due to either the squeezing of the chest or a direct blow.[29] They are characteristically multiple and can occur at any point on the ribs.[29][94][95][96]
Fractures of long bones and classic metaphyseal lesions (also called metaphyseal fractures, corner fractures, or bucket handle fractures) in premobile, healthy children are highly specific for abuse.[30][31][97]
Result
identification of occult fractures (e.g., rib fractures, classic metaphyseal lesions, digit fractures); normal bone mineralization; no evidence of bone disease; possible soft tissue swelling
CT brain
Test
Testing should be done in all children <1 year of age who are suspected abuse victims, in children with neurologic symptoms or signs, and in all children with significant head injury.[155]
A CT brain should also be considered if abusive abdominal injury is found.
Research suggests non-contrast head CT aids in identifying occult head injury in children and is the standard of care for first-line evaluation of possible inflicted head trauma.[155][156][157]
The signs found to be significantly associated with abusive head trauma include: multiple or bilateral subdural hemorrhage over the convexity; interhemispheric hemorrhages; hypoxic-ischemic injury; and cerebral edema.[61][62][158]
If abnormalities are seen, an MRI of the head should be performed in 3 to 5 days.[159]
Result
subdural hemorrhage, subarachnoid hemorrhage, complex skull fractures, parenchymal injury, cerebral edema
LFTs/amylase/lipase
serum calcium
Test
Can assist in the evaluation of possible bone disease associated with increased risk of bone fracture.
Result
normal
serum phosphate
Test
Can assist in the evaluation of possible bone disease associated with increased risk of bone fracture.
Result
normal
serum alkaline phosphatase
Test
Can assist in the evaluation of possible bone disease associated with increased risk of bone fracture.
Result
may be elevated as a result of fracture
serum parathyroid hormone
Test
Can assist in the evaluation of possible bone disease associated with increased risk of bone fracture.
Result
normal
serum 25-hydroxyvitamin D
Test
Can assist in the evaluation of possible bone disease associated with increased risk of bone fracture.
Result
normal >20 ng/mL (or >50 nmol/L) represents adequate levels for bone health
urinalysis
Test
May identify trauma to the urinary tract and kidneys.[10]
Result
hematuria
Tests to consider
radionuclide bone scan
Test
Performed as an alternative to a repeat skeletal survey in children with suspected fractures when the initial skeletal survey is negative or equivocal. A bone scan becomes positive within 4 hours of a fracture occurring, but remains positive for many months, so does not contribute to the dating of fractures. It is of no value in detecting skull fractures and is less sensitive in identifying metaphyseal lesions. Plain films should also be obtained and the tests may confirm fractures seen as hotspots.
Result
fracture identified as a hotspot; presence of soft-tissue injuries
MRI brain/spine
Test
Should be performed within 3 to 5 days or soon after the child is stable if any abnormalities are found on CT brain.[155][159] The scan should include diffusion-weighted imaging (DWI), T1- and T2- weighted sequences, and fluid-attenuated inversion recovery (FLAIR). DWI sequences may also help with prognosis.
Spinal MRI detects fractures or listhesis, enables full delineation of the extent of the injury, and should be considered in young infants with suspected abuse, particularly if abusive head trauma is found.
Result
subdural hemorrhage, subarachnoid hemorrhage, parenchymal injury, cerebral edema, hypoxic-ischemic injury/cytotoxic edema, diffuse axonal injury, and spinal injuries
ultrasound abdomen
Test
Has a limited role screening for traumatic abdominal injuries. Not recommended for the evaluation of inflicted abdominal trauma.
Result
free fluid or blood in the abdominal space
CT abdomen
Test
Definitive test for abdominal injuries, contrast studies may be required.
Result
hollow organ rupture, subcapsular hematomas, ruptures of liver or spleen, renal injury
platelet function studies and von Willebrand factor assays
x-ray mouth
Test
Distinguishing accidental from nonaccidental oral injuries may be difficult. If dental injury is suspected, it is advisable to seek the opinion of a pediatric dentist. Up to 50% of children with dental injuries sustain them accidentally, commonly from falls or sports injuries.[107]
Result
dental or mandibular fracture
forensic dental referral
Test
It is essential that children with suspected adult bites are referred in a timely way to a forensic dentist (via the American Board of Forensic Odontology or British Association of Forensic Odontologists) for further evaluation.[122] Forensic dentists can perform CT scanning, dental reconstructions, DNA retrieval, or UV digital imaging to potentially identify a perpetrator.[160]
Result
may identify perpetrator
forensic swabs for DNA
Test
In cases of bites.
Result
may identify perpetrator
toxicology testing
Test
The most common agents of intentional poisoning include drugs prescribed for family members (e.g., anticonvulsants, antidepressants, iron, laxatives, insulin) as well as salt, emetics, and recreational drugs of abuse.
Frequent presentations with purported "accidental" ingestion should raise the suspicion of child neglect due to poor supervision or lack of safety provision in the home.
Result
positive for specific agent(s) used
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