This document discusses the assessment of physical abuse and injuries. It provides guidance on conducting a full physical examination from head to toe and documenting any injuries found. Various types of injuries are described that may indicate abuse, including bruises, burns, fractures, and ligature marks. Skeletal surveys are important to fully assess and document skeletal injuries in suspected abuse cases. Certain fractures like metaphyseal fractures are highly specific for abuse. The timing of injuries and dating fractures is important for legal purposes. Accidental injuries are distinguished from violent injuries. Signs and symptoms of non-accidental injuries are provided. Diseases that can mimic abuse and self-inflicted versus suicidal injuries are also discussed.

1. ASSESSMENT OF
PHYSICAL ABUSE
Dr.alhanouf
alsowayigh

2. ASSESSMENT OF PHYSICAL INJURIES IN
ABUSE
• Medical care for injuries is a priority.(evaluation,treatment)
• Documentation and collection of evidence(photography, clothes, samples)
• Physical examination( head to toe)

3. GENERAL EXAMINATION
• General appearance
• Upper arms,forearms,and hands
• Face,ears,lips
• Scalp
• Neck
• Chest
• Abdomen
• Thighs and legs
• Hips and buttock

4. TYPE OF INJURY
• Bruises and contusions.
• Lacerations.
• Ligature marks (wrist, neck,ankles)
• Sharp wound(knife, scissores,glass…etc)
• Burn(scalding ,flame burn)
• Pattern injuries (fingerprint contusions, scratch marks, bite marks, self inflicted, tram
line,patterened burn)
• Gun shot.

5. RADIOGRAPHY OF ABUSE(ADULT/CHILD)
• Radiologists maybe the first clinical staff to suspect non accidental injuries.
Clinical presentation:
• Injury and history inconsistent.
• Delay in seeking medical attention.
• Multiple fractures with no history of osteogenesis imperfecta.
• Retinal hemorrhage.
• Torn frenulum.
• Hisyory of household falls resulting in fracture ,despite falls being common, fractures
are uncommon.
• Specific injuriest like thoracic and abdominal injuries.

6. RADIOGRAPHIC FEATURES
Skeletal injuries:
A skeletal survey is performed in cases of suspected abuse to assess and document the
extent of skeletal injuries.
Specific fractures:
A number of fractures have been recognized as highly specific to non-accidental
injuries ,they include:
• Metaphyseal fracture (bucket handle fracture or corner fracture) ,present in up to
39%-50% of abused infants <18 months. Said to be virtually pathognomic of NAI.

7. RIB FRACTURES
• Posterior ribs especially.
• May have no overlying bruise.
• Although vigorous cardiopulmonary resuscitation can occasionaly cause anterior rib
fractures, posterior rib fractures do not occur.
• Costochondral junction injuries and/or fractures.

8. SKULL FRACTURES
• Non parietal skull fracture( a parietal fracture is more suggestive of accidental
injuries).
• Involve multiple bones.
• Diastatic sutures.
• Crosses sutures.
• Depressed fracture (fracture a la signature)

9. SPECIFIC FRACTURES
• Scapular fractures.
• Sternal fractures.
• Outer third clavicular fracture.

10. FRACTURES MODERATELY SPECIFIC FOR
NAI
• Bilateral fractures with fractures of differing ages.
• Digital fractures in non ambulant children.
• Vertebral fractures or vertebral subluxation.
• Spiral humeral fractures.
• Separation of epiphysis.
• Complex skull fractures.

11. FRACTURES WHICH HAVE LOW
SPECIFICITY FOR NAI
• Middle clavicular fractures.
• Linear simple fractures of parietal bone.
• Single fractures in diaphysis(spiral humeral fracture is an exception).
• Greenstick fractures.

12. DATING INJURIES
• The ability to date injuries is critical for medicolegal purposes and thus must be done
carefully.
• Traumatic periosteal injury can be seen up to 7 days post-injury.
• Traumatic periosteal injury can be seen on diaphyseal and rib injuries.
• Diaphyseal injuries start healing start healing after one week.healing should be complete
by 12 weeks..
• Rib fractures are often missed, hence current practice is to repeat chest films in tow weeks
to observe any healing fractures.
• Metaphyseal(and costochondral junction) injuries do not heal with periosteal reaction and
if visible are less than 4 weeks old.
• Skull fractures also do not heal with periosteal reaction and if seen are less than 2 weeks
old.

13. PRACTICAL POINTS
• Skeletal dysplasias: one of the major-albeit uncommon –pitfalls in diagnosing
NAI.(e.g.Schmid type metaphyseal chondrodysplasia, osteogenesis imperfecta 1 and
4), which may lack the florid features of the full blown disease and can be easily
confused with NAI. Features to differentiate between them include: presense of
osteopenia, bowing or remodeling of bones, the presence of Wormian bones.
• Growth plates can also cause a degree of confusion , mostly at the hip, base of the
fifth metatarsal, elbow and the acromian.
• Birth injuries.
• Rickets.

14. ACCIDENTAL VS VIOLENT INJURIES
• Accidental injury : is an injury that could have been prevented.
Examples:
• Falls
• Poisoning
• Fires and burns
• Suffocation
• Drowning
• firearms

15. ACCIDENTAL VS VIOLENT INJURIES
• Violence: the intentional use of physical force or power, against oneself, another
person,or against a group or community, that either results in or has a high likelihood
of resulting in injury,death,psychological harm,maldevelopment,or deprivation.
Three subtypes
• Self directed violence where perpetrator and the victim are the same individual like
self abuse and suicide.
• Interpersonal violence which occur between individuals like family and intimate
partner violence and community violence including child maltreatment, elder abuse,
stranger assaults related to crime.
• Collective violence commited by large groups of individuals.

16. NON ACCIDENTAL INJURY
• Is any bodily injury that is deliberately inflicted on a vulnerable person that is
considered unacceptable .This may include hitting ,kicking, burning, biting or
choking.

17. SIGNS AND SYMPTOMS OF
NONACCIDENTAL INJURIES
The most common lesions are bruises and abrasions, followed by lacerations, strap
marks, haematomas, thermal burns and bites.
History of the presentation may raise the suspicion of non accidental injury .
• Delay in seeking medical attention.
• The details of the mechanism of injury are implausible , change overtime,inconsistent
with developemental stage of child.
• Lack of concern by the person accompanying the child.
• Abnormal behaviour by child e.g. withdrawn ,avoid eye contact.
• Direct disclosure that the injury was deliberately inflicted.

18. BRUISES
• Multiple and in different stages of healing.
• Suspicious location. Like thighs ,abdomen, buttock, neck, cheeks,
anogenital.(accidental usually over bony prominence)
• Particular pattern or shape including handprint bruise, six penny bruise as in
grabbing, imprint of object like belt or linear bruise from strucked by a stick or loop
mark caused by striking with a cable or cord.
• Accompanied by haematomas , hair loss, fracture of bone.

19. BURN
• Cigarette burns as rounded ulcers or erosions maybe accompanied bi singed hairs.
• Contact burn caused by heated object as spoons or forks which represent the shape
of the object.
• Immersion burns of buttocks and extrimities they tend to be sharpely demarcated
areas with sparing areas.

20. BITE MARKS
• Human bites tends to cause crush injuries rather than puncture wounds
• Arch like

21. BINDING INJURIES
• Where the wrist and ankles are tied.
• It may present with soft tissue swelling ,redness, or abrasions around the wrist and
ankles.

22. NEGLECT
• Maybe present with combination of poor hygiene,malnutrition, untreated
illness(dermatitis).
• Neglected child that has not recived immunisations.

23. DIESEASES MIMIC NON ACCIDENTAL
INJURIES
• Appearance of bruising and purpura caused by disorders of coagulations (vasculitis,
panniculitis, connective tissue disorder such as ehlers-danols
syndrome,perniosis,lichen sclerosis.
• Non delibrate mechanism of trauma that cause bruising like sport injuries, seatbelt
injuries.
• Dermal melanocytosis (mangolian blue spot)
• Blistering disease can mimic burns.
• Folk medicine remedies like Arabic therapeutic burns.
• Multiple fracture with family history of osteogenesis imperfecta.

24. SUICIDAL INJURIES
• Stabbing and cutting.
• Firearms .
• Fall from a height.
• Burning.
• Hanging.

25. SUICIDAL WOUNDS
• Typically multiple with preliminary tral cuts, called tentative incisions, mostly seen on
throat and wrists , where the person makes a series of shallow incisions, hesitating
while gaining courage to make final decisive cut.
• A suicidal cut throat usually has these trial incisions, there maybe only one or tow or
scores of trial cuts, the classical description of incisions strating high on the left side
of the neck below the angle of the jaw, passes oblique across the front of the neck to
end at a lower level on the right(assuming victim is right handed). Deep at the
origin,shallower as they cross the throat, tailing off into surface cuts at extremity.
• Delibrate cutting of the wrist is rarely effective, and may have scars from previous
unsuccessful attempts, the usual site is on flexor surface, with shallow tentative
incisions,more common on left wrist if right handed.

26. SUICIDAL WOUNDS
• Suicidal injuries of the chest are almost always stab with linear cuts are made over
the front of the chest, which maybe multiple ,parallel, sometimes crisscrossing, which
rarely do serious damage. Usually made over the left side of the chest where the
heart places,butmaybe alongside sternum.
• Suicidal knife wounds are not often made on abdomen but they do occur.

27. SUICIDAL FIREARM WOUND
• women rarely shoot themselves.
• Weapon must always be present.
• The location on head(temple), neck,mouth, chest.
• Entry wound close contact.
• Shooting in unaccessible site cannot be suicide.

28. SELF INFLICTED WOUNDS
Fabricated wounds are produced by a person on his own body or by another with his
own consent.
Reasons: to support a fasle charge with ulterior motive.
• Charge an enemy with assault.
• Convert simple injury to grevious one.
• Women to bring a charge of rape.

29. SELF INFLICTED WOUNDS
• Usually superficial,multiple,and often parallel, rarely cause danger to life.
• Not in sensitive areas like mouth, nose,eyas, and ears.
• Regular incisions with equal depth at origin and termination.
• Uniform injuries.
• With right handed persons mostly on the left side.
• If clothing presents the relevant clothing mayshow no cuts or cuts do not match the
injuries in position or direction.

30. MUNCHAUSAN SYNDROME
• Refers to adults who injure themselves or feign sign of illness in order to gain
medical attention and often admission to hospital.
• Munchausan syndrome by proxy: where apparent repetitively injure their child ,
occasionally fatal to gain the same attention.

31. Neglect and Starvation
• It is the lack of provision of proper care and nutrition.
• Though, starvation one of the most widespread scourges of our planet , in our
practice we are concerned with individual neglect with which starvation is often
associated, either as potentially criminal act or as a manifestation of self- neglect.
• The extremes of life are most affected , rather than the middle years.
• This is because infants and children are at the mercy of their parents for care , while
the old are prey to senile dementias and other disorders, as well as often being
devoid by caring relatives or lack of financial support

32. GENERAL FEATURES OF NEGLECT AND
STARVATION
• The obvious and outstanding appearance is of emaciation caused by inadequate
intake of food.
• The words cachexia, emaciation, marasmus are all synonymous as used today ,
though marasmus is confined to the description of infant victims
• Two main types of starvation were seen:
• Dry type in which there was emaciation ,with a body weight up to half the normal.
• Wet type had marked edema of face , trunk and limbs, with ascitis and pleural
effusions

34. • The edema of hypoproteinaemia is caused by protein being diverted to produce
energy when carbohydrate and fat are grossly deficient in the diet.
• In some victims , the skeleton accounted for 50% of the total body weight , instead of
the usual 15%.
• Other features are secondary to this nutritional deficiency, such as intercurrent
infections, avitaminosis, skin disorders and nutritional edema.
• Dehydration, hypothermia and actual necrosis of the extremities are the most severe
manifestations that contribute to death

35. MEDICO-LEGAL-PROBLEMS
• In infants there may sometimes be physical abuse associated with neglect.
• the relevance of the diseases, chronic infections and neoplasms must be evaluated.
• particularly important in children are familial metabolic diseases that maybe
associated with failure to thrive and frank emaciation

36. CONSENT
INFORMED
• General and local examination.
• Photographic documentation.
• Biological samples.
• Name of victim and caregiver if under 18 years and their signuture.
• Finger prints.
• ID card.
• Name of police officer and number.
• Time and date.
• Examiner name and nurse .

37. INFORMED CONSENT
• Patients rights to refuse any of the above mentioned with declairments , explanation
of the importance of documentations and collection of samples.
• Confidentiality.