Paediatrics · Hard
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 marked lethargy and poor feeding over the past 24 hours. The mother reports that he fell off a low sofa onto a carpeted floor two days ago. On examination, the infant is encephalopathic and irritable when moved. His anterior fontanelle is tense and bulging. Fundoscopy reveals bilateral multi-layered retinal haemorrhages. Physical examination shows faint, resolving linear bruising on the soft tissue of the left inner thigh and abdomen. A clotting screen and platelet count are within normal reference ranges.
Vital signs
- HR
- 162 bpm
- BP
- 82/48 mmHg
- RR
- 42/min
- Temp
- 36.7 °C
- SpO₂
- 97%
Examination findings
- Bulging anterior fontanelle
- Bilateral multi-layered retinal haemorrhages
- Bruising on inner thigh and abdomen
- Lethargy and irritability
Investigations
| Haemoglobin | 9.8 g/dL | reference: 10.5-13.5 |
| Platelets | 280 10^9/L | reference: 150-450 |
| PT | 11.5 seconds | reference: 10.0-13.0 |
| APTT | 29 seconds | reference: 25-35 |
Question 1 of 3
What is the single most appropriate immediate management step for this child?
The clinical picture strongly suggests abusive head trauma (non-accidental injury) with raised intracranial pressure (tense fontanelle, encephalopathy, retinal haemorrhages, soft-tissue bruises in non-ambulatory infant). The mandatory initial clinical steps are stabilizing the patient, securing emergency head CT, admitting to hospital, and referring immediately to local children's safeguarding services. Distractor A is unsafe as discharging a child with suspected severe safeguarding concerns puts them at critical risk. Distractor B (lumbar puncture) is contraindicated in the presence of signs of raised intracranial pressure (bulging fontanelle) due to the risk of brain herniation. Distractor C (steroids) is not indicated for traumatic brain injury/abusive head trauma cerebral oedema and fails to address safeguarding.
Teaching point: In infants with unexplained neurological impairment, retinal haemorrhages, or soft-tissue bruising, immediate hospital admission, urgent neuroimaging, and referral to child safeguarding services are paramount.
Question 2 of 3
Following emergency stabilization and neuroimaging confirming subdural haematomas, which initial investigation panel is most appropriate to evaluate for further occult physical injuries?
When child abuse is suspected in an infant (<2 years), a complete skeletal survey (radiographs of the entire skeleton) is essential to detect occult fractures (e.g., rib fractures, metaphyseal lesions) of varying ages. A formal ophthalmology consult (dilated fundoscopy) is mandatory to detail the extent of retinal haemorrhages. Distractor A (abdominal US/ECG) does not comprehensively evaluate the bony skeleton for occult trauma. Distractor C relies on unnecessary radiation and premature repeat imaging while missing occult skeletal injury. Distractor D (whole-body MRI and serum copper) is not the initial investigation protocol for suspected non-accidental injury in UK standard practice.
Teaching point: A full skeletal survey and formal ophthalmological assessment are mandatory secondary investigations in infants under 2 years old with suspected physical abuse or abusive head trauma.
Question 3 of 3
Which of the following clinical or radiological findings has the highest specificity for non-accidental physical injury in a non-ambulatory 4-month-old infant?
Posterior rib fractures (caused by force compressing the chest anterior-posteriorly during shaking) and classic metaphyseal lesions ('corner' or 'bucket-handle' fractures caused by shearing forces on limbs) are highly specific for child abuse in infants. Distractor D (isolated linear skull fracture) can occur from accidental low-height falls, although context matters. Distractor C (forehead bruise) can occasionally occur accidentally once mobile, though any bruise in a non-ambulatory child is concerning; however, posterior rib fractures carry significantly higher specificity. Distractor B (clavicle fracture) is a common birth injury or accidental fracture.
Teaching point: Posterior rib fractures and metaphyseal corner fractures in an infant are highly specific radiological markers of non-accidental injury.
Key learning points
- Any unexplained neurological symptom, retinal haemorrhage, or soft-tissue bruise in a non-ambulatory infant must raise immediate suspicion of abusive head trauma (safeguarding concern).
- Lumbar puncture is strictly contraindicated when clinical signs of raised intracranial pressure (such as a tense or bulging fontanelle) are present.
- Complete skeletal survey and dilated ophthalmological examination are essential standardized evaluations for infants with suspected non-accidental trauma.
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