Paediatrics · Easy
This case is fictional and exists for study. It describes no real patient.
0 years · male
A 4-month-old male infant is brought to the emergency department by his mother due to irritability and skin marks noticed over the past two days. The mother reports that the infant accidentally rolled off a low sofa onto a carpeted floor. The infant is not yet able to sit unsupported or roll over independently. On examination, the child is alert and crying consolably. There is a 2 cm area of ecchymosis behind the right pinna, petechiae on the right cheek, and a 3 cm linear bruise over the anterior chest wall. Examination of the abdomen is unremarkable, and the fontanelle is soft and flat. Baseline blood investigations including a full blood count and clotting screen are normal.
Vital signs
- HR
- 132 bpm
- BP
- 86/52 mmHg
- RR
- 34/min
- Temp
- 36.8 °C
- SpO₂
- 98%
Examination findings
- 2 cm ecchymosis behind right pinna
- Petechiae over right cheek
- 3 cm linear bruise over anterior chest wall
- Soft and flat anterior fontanelle
- Not yet developmental capable of rolling
Investigations
| Haemoglobin | 11.5 g/dL | reference: 10.0-14.0 |
| Platelets | 280 10^9/L | reference: 150-450 |
| Prothrombin Time (PT) | 11.8 seconds | reference: 10.0-13.0 |
| APTT | 31 seconds | reference: 26-36 |
Question 1 of 3
Which feature of the clinical presentation is most strongly suggestive of physical abuse (non-accidental injury)?
Bruising in an infant who is not yet independently mobile ('those who don't cruise, don't bruise') is extremely rare in accidental trauma and is a key indicator of non-accidental injury (NAI). Normal first-line results (Option B) make a bleeding disorder less likely but do not exclude one: von Willebrand disease often has a normal APTT, and platelet function disorders and factor XIII deficiency have a normal platelet count, PT and APTT. UK practice is therefore to send FBC and film, PT, APTT, fibrinogen, factor VIII, factor IX and von Willebrand studies, interpreted alongside a structured bleeding and family history. A normal screen also does not itself suggest abuse — and a bleeding disorder does not exclude abuse, as the two can coexist. The history of falling off a low sofa (Option D) does not typically explain bruises in protected sites like the ear or chest, making the developmental incompatibility of the injury the key red flag. Irritability (Option A) is non-specific.
Teaching point: Bruising in a non-mobile infant is a major red flag for physical abuse and always warrants a safeguarding assessment.
Question 2 of 3
Which of the following is the single most appropriate imaging investigation to assess for occult physical injuries in this child?
In any infant under 1 year of age where physical abuse is suspected, a full skeletal survey is indicated to screen for occult fractures (e.g., posterior rib fractures, metaphyseal corner fractures). A single-view chest X-ray (Option D) misses peripheral or appendicular fractures. Abdominal ultrasound (Option A) is reserved for suspected visceral injury based on clinical signs or raised transaminases. MRI of the spine (Option B) is not a first-line screening tool unless specific neurological deficits are present.
Teaching point: A skeletal survey is mandatory in all children under two years of age with suspected non-accidental injury to identify occult skeletal trauma; between two and five years, imaging is considered on a case-by-case basis.
Question 3 of 3
Which of the following is the single most appropriate immediate management step for this child?
When physical abuse is suspected, the immediate priority is ensuring the child's safety. The child must be admitted to a safe environment (the hospital paediatric ward) and a formal safeguarding referral made to child protection/social services. Discharging the child home under any arrangement (Options A, B, and D) puts the child at immediate risk of further harm.
Teaching point: When non-accidental injury is suspected, immediate hospital admission and referral to safeguarding services are required to protect the child.
Key learning points
- Remember the adage 'Those who don't cruise, don't bruise'—bruises in non-mobile infants require urgent safeguarding evaluation.
- A complete skeletal survey is the standard initial imaging modality to screen for occult fractures in infants under 1 year with suspected abuse.
- Immediate safety and hospital admission take priority over discharging a child with suspected non-accidental injury.
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