Paeds · child-safety-and-social-paediatrics
Inflicted abdominal and thoracic injury
Also known as Non-accidental abdominal trauma · Abusive visceral injury · Inflicted truncal injury · Child abuse abdominal injury · Non-accidental thoracic trauma · Hollow viscus injury from abuse · Abusive liver laceration
Fellowship-level coverage of inflicted abdominal and thoracic injury: the hidden high-specificity patterns (posterior rib fractures, duodenal and pancreatic injury), why delay and an inconsistent story matter, the AST/ALT and lipase occult-injury screen, trauma-team care running in parallel with safeguarding, and ANZ/UK/US practice differences.
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Red flags
- Pancreatic, duodenal or jejunal injury in a pre-verbal child — high specificity for inflicted trauma
- Posterior or multiple rib fractures in an infant without a credible major mechanism
- Injury pattern or severity that does not fit the history or the child's developmental stage
- Delayed presentation with evolving peritonitis, sepsis or shock attributed to a sudden illness
- Multiple injuries of different ages, or occult injuries found on screening
- Changing history between caregivers or over time
- Hepatic transaminases > 80–100 U/L after any concerning injury — screen for occult liver injury
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Board mappings
- General and Community Paediatrics
- Accident and Emergency Medicine
- Paediatric Surgery
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 20: Child safety and maltreatment
- Renewed curriculum for first-year trainees from 2027 — Learning goal 21: The acutely ill or injured child
- Clinical Applications
- Emergency Paediatrics
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 9. Safeguarding vulnerable children
- 10. Critical appraisal and evidence-based practice
- General Paediatrics: Manages acutely ill and injured children and escalates safeguarding concerns
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- History
- Communication
- Child with suspected physical abuse
- General Pediatrics Content Outline — Domain 6: Emergency Medicine/Trauma
- General Pediatrics Content Outline — Domain 8: Child Abuse and Neglect
- General Pediatrics Content Outline — Universal Task 2: Epidemiology and Risk Assessment
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- Patient Care 3: Trauma and acute injury management
- Patient Care 6: Recognition and management of child maltreatment
- Systems-Based Practice 2: Coordination of care and interprofessional teams
- Professionalism 3: Ethical and legal obligations in child protection
- Medical Expert
- Collaborator
- Health Advocate
- Pediatrics: Core EPA #8 — Recognizing and managing suspected child maltreatment and/or neglect
- Pediatrics: Core EPA #10 — Managing the pediatric trauma patient
Overview & Definition
A toddler arrives drowsy with a tender, rigid abdomen and a story of a short fall. The injury is real. The story is not. Inflicted abdominal and thoracic injury is blunt or, rarely, penetrating trunk trauma caused by a caregiver's assault — a kick, a punch, a squeeze, a throw, or a slam into a hard surface. The injury sits inside the body, the child often cannot speak, and the offered mechanism usually under-explains the damage. [1] [2]
Abdominal injury is the second leading cause of death from physical abuse after head injury, and it kills children because we miss it. The viscera that bear the force — liver, duodenum, pancreas, jejunum, mesentery — sit deep and quiet. Perforation may take twenty-four to forty-eight hours to declare itself as peritonitis and sepsis, by which point the child has deteriorated and the history has drifted. The thorax adds its own warning signs: rib fractures, pulmonary contusion, pneumothorax and, rarely, cardiac contusion or great-vessel injury. [1] [5] [6]
This leaf covers inflicted solid-organ, hollow-viscus, pancreatic and thoracic injury as one connected problem. Bruising, sentinel injuries, abusive head trauma and inflicted fractures live in sibling leaves — cross-link them. This page deals with the trunk cavity, the occult-injury screen, and the safeguarding interface that decides whether a child goes home. [1] [9]
References20ShowHide
- [1]Maguire SA A systematic review of abusive visceral injuries in childhood--their range and recognition Child Abuse Negl, 2013.PMID 23306146
- [2]Wood J Distinguishing inflicted versus accidental abdominal injuries in young children J Trauma, 2005.PMID 16385300
- [3]Lindberg DM Utility of hepatic transaminases in children with concern for abuse Pediatrics, 2013.PMID 23319537
- [4]Lindberg D Utility of hepatic transaminases to recognize abuse in children Pediatrics, 2009.PMID 19620197
- [5]Trokel M Patient and injury characteristics in abusive abdominal injuries Pediatr Emerg Care, 2006.PMID 17047468
- [6]Trokel M Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes Child Maltreat, 2004.PMID 14871002
- [7]Sowrey L Duodenal injuries in the very young: child abuse? J Trauma Acute Care Surg, 2013.PMID 23271088
- [8]Baxter AL Hepatic enzyme decline after pediatric blunt trauma: a tool for timing child abuse? Child Abuse Negl, 2008.PMID 18945486
- [9]Barsness KA The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children J Trauma, 2003.PMID 12813330
- [10]Maguire S Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review Child Abuse Negl, 2006.PMID 16857258
- [11]Kemp AM Patterns of skeletal fractures in child abuse: systematic review BMJ, 2008.PMID 18832412
- [12]Bennett BL Serum Cardiac Troponin I in the Evaluation of Nonaccidental Trauma J Pediatr, 2015.PMID 26141552
- [13]Otjen JP Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children Semin Ultrasound CT MR, 2022.PMID 35164910
- [14]Rosenfeld EH Understanding non-accidental trauma in the United States: A national trauma databank study J Pediatr Surg, 2020.PMID 31103270
- [15]Carter KW Pediatric abdominal injury patterns caused by falls: A comparison between nonaccidental and accidental trauma J Pediatr Surg, 2016.PMID 26850907
- [16]Callahan K The Pancreas in Child Abuse Acad Forensic Pathol, 2018.PMID 31240040
- [17]Ledbetter DJ Diagnostic and surgical implications of child abuse Arch Surg, 1988.PMID 3415461
- [18]Beckmann KR Small bowel perforation: an unusual presentation for child abuse J Am Osteopath Assoc, 2000.PMID 10979255
- [19]Wootton-Gorges SL ACR Appropriateness Criteria(®) Suspected Physical Abuse-Child J Am Coll Radiol, 2017.PMID 28473090
- [20]Karmazyn B Comparison of clinical and abdominal CT imaging findings in children evaluated for abusive and accidental abdominal trauma Emerg Radiol, 2025.PMID 39708206