Case 20

Bruises to the pinna of the ear are an unusual accidental finding. Bilateral bruising is even less likely to be accidental. A history of a fall to a carpeted floor does not explain the injuries. Certain areas of a child’s body are more likely to bruise accidentally, such as the extremities or forehead. The head may be the first area to strike in a downward fall of a child, but not typically the ear and not both ears.

Answer A, checking the platelet count, may be helpful in the legal arena to provide absolute proof that there is not thrombocytopenia. However, the clinical finding of no other bruises is enough proof that the platelets are normal. An active toddler at this age might be likely to have signs of accidental bruising to his shins (toddler bruises), and a toddler with thrombocytopenia would likely have extremity bruises. Therefore, checking platelets is not the most appropriate next step. Answer D includes beginning the medical work up for child abuse, which usually includes some blood work, such as checking platelets.

Observation alone, as in answer B, is not a good option. Abuse should be immediately suspected in this child. Sending the child home to the place where the injuries most likely occurred can be life threatening.

Performing computed tomography (CT) of the brain of an otherwise healthy child is not recommended. Although he may have had a head injury associated with the ear bruises, his physical examination reveals that he is acting appropriately and that there are no neurologic changes. If there is concern that a small subdural hemorrhage may be present, magnetic resonance imaging could be obtained. If his fontanel is still open, an ultrasound may be helpful. However, the long-term risks of a CT scan in this scenario likely outweigh the benefits. On the other hand, if the scenario were slightly different, such as a history of a fall from a greater height or other bruises to his head, or if other significant injuries were identified, a CT scan might be indicated.

The medical work up for suspected physical abuse should include a complete skeletal survey. Skeletal surveys should be performed on children younger than 2 years of age when there is an unexplained injury, multiple injuries, an inconsistent history of injuries, an injury that does not match with the given mechanism of trauma or other situations where child abuse is suspected. For more information regarding skeletal surveys, click on "CHAMP Practice Recommendations: Skeletal Survey" in the Resources list below.

A medical work up should also include checking coagulation factors, a CBC with platelet count, liver function tests, a stool guaiac and urinalysis as clinically appropriate. With children who have multiple injuries and a suspicion of physical abuse, checking the urine for exposure to common drugs of abuse may assist in determining further risks to the child. For further suggestions regarding the work up for physical abuse, click on Evaluation Guidelines for Suspected Child Physical Abuse in the Further Reading list below.

Further Reading

• CHAMP Practice Recommendations: Skeletal Survey
• Evaluation Guidelines for Suspected Child Physical Abuse