When faced with a concerning cutaneous injury, it is important to consider not only child abuse but also other causes. Age and developmental ability of the patient, as well as the location and type of the lesion(s), help in determining the likelihood of an abusive or nonaccidental cause of cutaneous findings. Common cutaneous injuries seen in child physical abuse include bruises, pattern injuries, and burns. It is important to match the history (or mechanism) of how the findings appeared with the actual observed finding(s). Try to determine whether the mechanism is plausible, based on the child’s developmental ability. Photo-documentation can be important for the investigative process, for review by experts, and to document changes. For example, if a suspected bruise does not resolve with time, then it is not a bruise and could be a birthmark.

• Obtain a detailed history of the alleged cause of the cutaneous findings, if available.

• Sometimes no history is given, or only potential mechanisms are offered. For example, a caretaker may not have witnessed an actual event, but may believe that something specific happened to explain the findings.

• A vague history such as “fell from chair” is not adequate to match an injury to a mechanism; therefore, it is essential to gather details related to the fall.

• A changing or discrepant history is concerning for abuse.

• Height of the fall, specific details about the fall (i.e., Was it straight down or in an arc? Was there twisting or rotational motion? Were there multiple strikes with the child falling down stairs?), surface onto which the fall occurred, whether there were objects on the floor, and other such information can help evaluate whether the explanation fits the injury.

• Consider detailed questions about the environment, witnesses, and the child’s response to the event or injury.

• Delay in seeking care is potentially a concerning factor; an explanation for a delay in seeking care should be elicited and can be evaluated as being a reasonable explanation or not.

• For scald injuries, a temperature of the water should be obtained at the scene by investigators.

• Family history of bleeding disorders or other underlying conditions should be obtained.

• Medications, such as recent anticoagulant use, should be assessed.

• Previous accidents resulting in injuries such as fractures, burns, and head trauma can suggest a pattern of abuse and should raise suspicion for child physical abuse.

• Include in the medical record any explanation given by the child or adolescent for the injury, using their exact words, when possible.

• Corroborate the child’s developmental ability.

• Location is a key determinant of suspicion for abuse: buttocks, trunk, neck, ears, genitalia, and upper arms are concerning locations for bruises or other injuries.

• Examine the entire body. Subtle bruising or pattern marks can easily be missed.

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