Diagnostic Tests That May Be Used in the Medical Assessment of Suspected Physical Abuse and Differential Diagnosesa

Type of Injury or ConditionLaboratory TestingRadiologic TestingComments
Fractures108• Bone health laboratory testing, including calcium, phosphorus, alkaline phosphatase
• Consider 25-hydroxyvitamin D and PTH level
• Consider serum copper, Vitamin C, and ceruloplasmin levels if child is at risk for scurvy or copper deficiency
• Consider skin biopsy for fibroblast culture and/or venous blood for DNA analysis for osteogenesis imperfectaSkeletal survey• Repeat skeletal survey in 2 wk for high-risk cases
• Single whole-body films are unacceptable
• Bone scintigraphy may be used to complement the skeletal survey
Bruises85,86Tests for hematologic disorders: CBC, platelets, PT, INR, aPTT, VWF antigen, VWF activity (ristocetin cofactor), factor VIII level, factor IX level• Skeletal survey for nonambulatory infants with bruises and for infants and toddlers with suspicious bruising
• Brain imaging for infants with suspicious bruising.• Useful when bleeding disorder is a concern because of clinical presentation or family history
• Consultation with pediatric hematologist for any abnormal screen or other concern
Abdominal trauma• Liver enzyme tests: aspartate aminotransferase, alanine aminotransferase
• Pancreatic enzymes: amylase, lipase; urinalysis• CT of abdomen with contrast
• Skeletal survey in children <2 y• Screening abdominal laboratory tests are helpful in diagnosing occult abdominal injury in young abuse victims
• IV contrast should be used for CT scan and is preferable to PO135
Head trauma• CBC with platelets, PT/INR/aPTT; factor VIII level, factor IX level, fibrinogen, d-dimer
• Review newborn screen
• Consider urine organic acids to screen for GA1• CT scan: headb
• MRI of head and spine
• Skeletal survey• MRI may provide better dating of intracranial injuries than CT
• MRI more sensitive than CT for subtle intracranial injuries in patients with normal CT and abnormal neurologic examinations
• Diffusion-weighted imaging may show extent of parenchymal injury early in course
• MRI more sensitive than plain radiographs and CT for detecting cervical spine fractures/injury
• CT, and three-dimensional spiral CT enhance detection of skull fractures
Cardiac injuryCardiac enzymes: troponin, creatine kinase with muscle and brain subunits (CK-MB); troponin
  • aPTT, activated partial thromboplastin time; CBC, complete blood cell count; CK-MB, creatine kinase MB band; GA1, glutaric aciduria type I; INR, international normalized ratio; IV, intravenous; PO, oral; PT, prothrombin time; PTH, parathyroid hormone; VWF, von Willebrand factor.

  • a Tests can be ordered judiciously and in consultation with the appropriate genetics, hematology, radiology, and child abuse specialists. Careful consideration of the patient’s history, age, and clinical findings guide selection of the appropriate tests.

  • b CT scan may provide clinically relevant information more expeditiously than MRI in some facilities.