Differential Diagnosis

A parent can be labelled a perpetrator of harm when in fact the child may have a medical condition which has resulted injury like symptoms.

There are many medical conditions that can imitate some of the findings observed in physical abuse. It is important to look at differential diagnoses in cases of suspected non accidental injury so that parents or carers are not accused inappropriately.

It is essential that there is careful assessment of an injury to a child to determine whether its nature is accidental or not so that medical explanations for an injury are not overlooked.

Types of injuries and differential diagnosis

Bruises

This type of injury is very common and typically will involve social services where the child concerned is not mobile or where there is a history of bruising, for example a four-week-old baby with facial bruising could not have been injured whilst falling over because they are unable to sit up in the first place, or alternatively, a child with bruises of different ages could not have sustained them all in a single incident.

Bruising can take place on all parts of the body and the pattern of bruising could indicate a specific cause or lack of it: slap marks, fingertip bruises and the imprint of items could be seen where an object has been used as a point of impact.

Accidental bruises commonly occur over bony areas whereas bruising on other sites is more doubtful.

There are various medical conditions and diseases, which cause easy bruising, and should be investigated before reaching a conclusion on non-accidental injury.

These include such conditions as ldiopathic Thrombocytopenic Purpura (ITP), and Haemophilia, which should be considered if a child has extensive unexplained bruising.  Other differential diagnoses can include Mongolian spots (collection of melanocytes producing a bluish colour present at birth) Hemangiomas (overgrowth of capillaries), Eczema, Ehlers-Danlos syndrome

Fractures

Fractures involve a partial or complete break in the bone.

The common types of fractures that may happen in children are:

  • Metaphyseal Fractures – involves an injury to the metaphysis which is the growing plate at each end of a long bone. These types of fractures can present on their own or alongside other injuries and are also often seen as part of the triad of Shaken Baby Syndrome.
  • Greenstick – Incomplete fracture. A portion of the bone is broken, causing the other side to bend, this occurs most often in children
  • Transverse –The break is in a straight line across the bone.
  • Oblique –Diagonal break across the bone
  • Comminuted –a fracture in which the bone fragments into several pieces

A major diagnostic challenge for clinicians is the identification of non-accidental nature of fractures in children.

Metaphyseal fractures most often present in children, require careful examination as they are often misdiagnosed as an injury resulting from abuse by a carer whereas this type of fracture could have arisen due to structural abnormalities, disease or infection.

For skeletal fractures, the differential diagnoses include:

  • Rickets
  • Other mineralisation deficits
  • Osteoporosis – a disorder in which the bones thin and lose strength as they age, causes more than 300,000 fractures each year in the UK, especially in the hip, wrist and spine.
  • Bone cancer – which is another disease that may lead to pathological fractures.
  • Osteogenesis imperfecta (OI) – is frequently raised as a possibility in cases of an unexplained fracture and possible physical abuse, there are different types of OI each with different diagnostic findings such as mild, moderate or severe bone fragility, fractures at birth and easy bruising.

Burns and scalds

 Accidental burns may come about due to neglect or reckless care whereas deliberate burns are the result of direct abuse by the carer.

Such injuries are normally caused by hot liquids and can result in blistering. The injuries present would show characteristic drip, pour and splash patterns.

Cigarette burns may be common and those that a deliberately inflicted are likely to form a circular lesion with a crater, however skin infections can leave almost identical marks.

The differential diagnoses the physician should look at over a diagnosis of suspected physical abuse for burns include:

  • Allergy or hypersensitivity reaction with blistering
  • Friction blisters
  • Impetigo (may appear circular and be confused with cigarette burns), Phytophotodermatitis (reddened areas and erosions that result from sun exposure of skin that has psoralen residue)
  • Dermatitis herpetiformis (immunobullous skin condition characterized by blisters that may erode)
  • Folk-healing practices such as cupping (application of heated cup over skin with resultant vacuum action as it cools), and moxibustion (application of heated incense to skin), coining (rubbing of coin or spoon repetitively over the skin),

Shaken Baby Syndrome / Abusive head trauma (AHT)

This is a controversial and complex injury which has been explored in a separate article. The differential diagnosis in subdural haematoma (bleeds inside the brain) and retinal haemorrhages (bleeds behind the eyes) would need to be considered.

For subdural haematoma, the differential diagnoses include

  • accidental trauma,
  • coagulation disorders,
  • vascular malformations,
  • the rare amino acid inborn error of metabolism glutaric aciduria type I (associated with acute encephalopathy and chronic subdural hematoma),
  • the folk-healing practicecaida di mollera, in which a child with a sunken fontanel is inverted, held upside down by the ankles, and shaken.

For retinal haemorrhages, the differential diagnoses include:

  • vasculitis,
  • vascular obstruction,
  • toxic febrile states associated with serious infection.

Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is a rare inherited condition that affects collagen proteins in the body. Collagen is found in tendons, ligaments, cartilage, skin, bone, blood vessels, the gut and the spine and is a component that strengthens and supports various body tissues. EDS leads to the weakening of collagen which happens due to alterations in certain genes. These “faulty” genes can be passed from parents to their children.  As there are over 30 types of collagen in the body, EDS can be very difficult to diagnose.

EDS is usually ascertained due to abnormal skin texture, scarring complications, vascular fragility, or chronic symptoms, such as fatigue and musculoskeletal pain.

Children with EDS may appear healthy but have many bruises and their joints could easily get dislocated. They would have skin which gets grazed and cut easily with wounds heal slower than expected.

The misdiagnosis of EDS with child abuse remains a contentious area. There has been possible association of EDS and bone fragility and a strong association of EDS with generalized joint hypermobility and reduced bone mass density in older children and adults.

In a case of suspected child abuse, EDS can be a differential diagnosis for bruising, especially in EDS types with marked cutaneous and capillary involvement. Some infants and small children suffer spiral and other fractures and joint dislocations which at first glance may appear to be caused by rough handling, but on more detailed consideration of context and symptoms may indicate EDS.

Conclusion

In child protection matters the impact of an incorrect judgement would be detrimental on the child and the family unit.  Parents involved in cases where there is an allegation of non-accidental injury, need to be alerted to the numerous medical possibilities that may have played a part, a detailed medical expert assessment of the child’s injuries is crucial.

Parent Not Perpetrator, June 2017