From bruises to brain injury: The physician's role in the assessment of inflicted traumatic head injury.

A four-month-old boy, born at term without complications, presents for his well-baby appointment with his mother. He is developmentally normal and has a negative review of systems, except that he is described as ‘colicky’. His height, weight and head circumference are slightly above the 50th percentile. On examination, two small brown-yellow bruises on the right arm superior to the antecubital fossa are noted. The mother reports that she hadn’t noticed the bruises before, but she believes they may correspond to the location where the baby is typically held during his bath. The physician requests that the mother return if more bruises develop. Two weeks later, the mother presents with the baby to the emergency department because of vomiting with each feed for 24 h without diarrhea. The baby is afebrile, well hydrated and has a normal examination. A diagnosis of viral gastroenteritis is made, and the physician recommends monitoring the baby’s hydration status. One week later, the baby returns to the emergency department accompanied by paramedics. The parents report that following a feed, he turned blue and went limp. On examination, the baby is irritable and has two small bruises over the left knee. On further history, there is no known trauma and no personal or family history of bleeding disorders. A computed tomography (CT) scan of the head is requested because of the apneic episode, previous vomiting and concerns for possible trauma. The CT scan shows subdural and subarachnoid hemorrhages. The baby is admitted to hospital for further evaluation. The complete blood count, international normalized ratio, partial thromboplastin time and screening blood work are normal. An ophthalmologist’s examination shows multiple hemorrhages bilaterally in different layers of the retina. A skeletal survey is positive for metaphyseal fractures at both distal femora and the left proximal tibia. In a nonmobile infant without a history of trauma, the latter is considered to be a possible cause for these injuries. Child welfare authorities are notified of these results as being highly concerning for inflicted injury, and a joint investigation with the police is initiated.