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ABP Child Abuse Pediatrics study materials
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ABP Child Abuse Pediatrics practice questions

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Question 1Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 3-year-old boy attends a well-child visit. Examination shows a 2-cm bruise on the right side of the neck and several small bruises over both shins. Which finding is most concerning for physical abuse?

  1. The bruise on the neck Correct answer.
  2. Both findings equally
  3. The bruises on the shins
  4. Neither finding is concerning

Explanation

The TEN-4 rule flags bruising to the torso, ears, or neck in children 4 years and younger, and any bruise in an infant 4 months or younger, as suspicious for abuse. Bruises over the shins are a common accidental finding in a child who walks and climbs, because they sit over bony prominences. A neck bruise is a protected-site injury and warrants further evaluation.

Question 2Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which rib fracture location in an infant is most specific for inflicted injury?

  1. Anterior arc
  2. Lateral arc
  3. Posterior arc Correct answer.
  4. Costochondral junction

Explanation

Posterior rib fractures near the costovertebral articulation result from anteroposterior squeezing of the chest, which levers the rib over the transverse process. This mechanism is strongly associated with inflicted injury in infants. Anterior and lateral rib fractures can follow cardiopulmonary resuscitation or direct impact and are therefore less specific.

Question 3Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which combination of findings in a 5-month-old is most typical of abusive head trauma?

  1. Epidural bleed after a short fall
  2. A few unilateral retinal hemorrhages
  3. Isolated subarachnoid blood
  4. Subdural and retinal hemorrhage Correct answer.

Explanation

Abusive head trauma classically produces subdural haemorrhage from tearing of bridging veins together with retinal haemorrhages from repeated acceleration-deceleration. A short household fall rarely generates this combination in an infant. Epidural haematoma accompanying a skull fracture is more typical of a direct accidental impact.

Question 4Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 4-month-old presents with seizures and a subdural haematoma. Which study best evaluates for retinal haemorrhages?

  1. CT of the orbits
  2. Bedside ocular ultrasound
  3. Bedside direct ophthalmoscopy by a resident
  4. Dilated fundoscopy by an ophthalmologist Correct answer.

Explanation

Dilated indirect ophthalmoscopy performed by an ophthalmologist is the standard method, because it visualises the retinal periphery where abusive haemorrhages often lie. Findings should be documented with fundus photographs. Direct ophthalmoscopy by a non-specialist frequently misses these peripheral lesions.

Question 5Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 7-month-old has a fracture through the metaphysis with a small corner fragment on skeletal survey. Which mechanism produces this lesion?

  1. Compression of the epiphysis
  2. Torsion applied at the midshaft
  3. Direct impact on the diaphysis
  4. Shearing across the physis Correct answer.

Explanation

A classical metaphyseal lesion follows forceful pulling or twisting of the limb, which shears the metaphysis at the level of the hypertrophic zone. Because periosteum is tightly adherent at the metaphysis, a small corner fragment is avulsed. The lesion is highly specific for inflicted injury in infants.

Question 6Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 10-month-old has a healing rib fracture but an otherwise normal initial skeletal survey. What is the most appropriate next step?

  1. Order a bone scan instead
  2. Repeat it immediately
  3. No further imaging
  4. Repeat it in 2 weeks Correct answer.

Explanation

A repeat skeletal survey about two weeks later detects fractures that were occult initially, because healing callus makes them visible. It also strengthens documentation for any legal process. The evaluation should also include assessment of siblings and contacts plus consideration of neuroimaging.

Question 7Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 5-month-old who cannot yet roll over has a spiral fracture of the femoral shaft. Which statement is most accurate?

  1. This is typical of a couch fall
  2. This raises concern for abuse Correct answer.
  3. This is diagnostic of osteogenesis imperfecta
  4. Infant femur fractures are usually accidental

Explanation

A femoral shaft fracture in a non-ambulatory infant, particularly a spiral pattern, is associated with inflicted injury and requires careful scrutiny of the history. The same fracture in a walking child with a plausible mechanism is more often accidental. The finding alone is concerning but not diagnostic.

Question 8Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A resident documents that a bruise is 'yellow-green, therefore 5 to 7 days old'. How should this be interpreted?

  1. Reliable only for the trunk
  2. Reliable if photographed first
  3. Unreliable, colour varies widely Correct answer.
  4. Reliable, since breakdown is fixed

Explanation

Studies show poor inter-observer agreement and no consistent relationship between bruise colour and elapsed time since injury. Attempting to date a bruise can mislead an investigation and imply a timeline that the examination cannot support. Bruises should be described by size, site and appearance and photographed instead.

Question 9Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which burn pattern in a toddler suggests forced immersion?

  1. Stocking-glove pattern sparing creases Correct answer.
  2. Soot around the mouth and nose
  3. Splash marks with irregular edges
  4. A circular blister on the palm

Explanation

Forced immersion produces burns of uniform depth with sharp demarcation in a glove or stocking distribution, and spares the flexural creases where skin surfaces are apposed. Splash marks with non-uniform depth favour an accidental spill. Soot around the mouth suggests inhalation injury from a fire.

Question 10Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which finding most strongly suggests osteogenesis imperfecta rather than abuse?

  1. Metaphyseal corner fractures
  2. Multiple healing rib fractures
  3. A torn labial frenulum
  4. Blue sclerae Correct answer.

Explanation

Blue sclerae, together with Wormian bones, dentinogenesis imperfecta, generalised osteopenia and a positive family history, point to osteogenesis imperfecta. Posterior rib fractures and classical metaphyseal lesions are instead characteristic of inflicted injury. A torn labial frenulum is a recognised abuse marker.

Question 11Physical abuse, including abusive head trauma, cutaneous and skeletal injury

An 18-month-old presents with many bruises of uncertain cause. Which initial laboratory testing is most appropriate?

  1. Bone marrow aspiration
  2. Serum calcium and vitamin D level
  3. Factor VIII level only
  4. CBC with platelet count and PT/PTT Correct answer.

Explanation

A complete blood count with platelet count and coagulation studies screens for thrombocytopenia and coagulopathy that could cause or contribute to bruising. Abnormal results prompt further factor or von Willebrand testing. In a child with unexplained bruising, hepatic transaminases and lipase are also useful to look for occult abdominal injury.

Question 12Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 2-year-old has symmetric, parallel linear marks on the back after coining (cao gio). Which statement is most accurate?

  1. It fits a cultural practice Correct answer.
  2. Coining usually causes burns
  3. Patterned marks confirm abuse
  4. It indicates a bleeding disorder

Explanation

Coining and cupping produce symmetric, geometric marks in characteristic sites that match the carer's account, and they leave no other injury. Recognising the practice prevents a false diagnosis of abuse. The child should still be examined fully for additional injuries that the practice would not explain.

Question 13Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which feature favours dermal melanocytosis over a bruise?

  1. Pigmentation present since birth Correct answer.
  2. A history of a fall
  3. Yellow-brown edges
  4. Tenderness when palpated

Explanation

Dermal melanocytosis (Mongolian spot) is congenital, slate-grey or blue, typically over the lumbosacral region and buttocks, non-tender and unchanged over time. It is important to document such lesions in the record so they are not mistaken for bruising on later review. Bruises are tender early and evolve in appearance.

Question 14Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which history feature most increases concern for inflicted injury?

  1. Mechanism fits the child's age
  2. Delay in seeking care Correct answer.
  3. Injury while a parent watched
  4. Prompt care after a witnessed fall

Explanation

A delay in seeking care without a reasonable explanation is a recognised red flag, as are an absent or changing account and a mechanism inconsistent with the child's developmental stage. A plausible mechanism observed by a carer, with prompt care, is reassuring. The history must always be compared with the injury pattern and the child's abilities.

Question 15Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 2-month-old who cannot roll over has a single bruise on the cheek. What is the best interpretation?

  1. A benign birthmark
  2. A normal infant self-injury
  3. A car seat strap mark
  4. A sentinel injury Correct answer.

Explanation

Bruising in a non-mobile infant under 4 months is rarely accidental and is regarded as a sentinel injury, one that may precede more severe abuse. It warrants a full evaluation, including a skeletal survey and consideration of neuroimaging, and a report to child protective services. The absence of other injuries does not make the bruise benign.

Question 16Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 2-month-old born by uncomplicated vaginal delivery is found unresponsive. CT shows a hyperdense posterior interhemispheric subdural haematoma with no skull fracture. Which statement is most accurate?

  1. This pattern suggests inflicted injury Correct answer.
  2. Posterior interhemispheric blood excludes abuse
  3. A normal birth explains blood at 2 months
  4. Vitamin K deficiency is the most likely cause

Explanation

Acute subdural blood in a posterior interhemispheric distribution without a skull fracture reflects shearing forces from violent acceleration-deceleration. Birth-related subdural collections are common but resolve within the first weeks of life and do not present acutely at 2 months. Infants routinely receive vitamin K at birth, and deficiency bleeding typically occurs earlier and elsewhere.

Question 17Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which additional injury should be specifically assessed in a 6-month-old with abusive head trauma?

  1. Sacroiliac joint widening
  2. Cervical spine ligamentous injury Correct answer.
  3. Lumbar disc herniation
  4. Bilateral carpal fractures

Explanation

Violent shaking imposes flexion-extension forces on the neck, so cervical cord and ligamentous injury is recognised in abusive head trauma and contributes to respiratory compromise and morbidity. Spine imaging with MRI is therefore recommended as part of the evaluation. Limb and rib fractures are also sought through the skeletal survey.

Question 18Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 3-month-old who received 20 minutes of cardiopulmonary resuscitation has bilateral anterior rib fractures. How should they be interpreted?

  1. CPR may explain these Correct answer.
  2. They indicate shaking
  3. They prove poor CPR technique
  4. They confirm abuse

Explanation

Chest compressions can produce anterior rib fractures in infants, so this pattern alone does not establish abuse. Posterior or lateral rib fractures, fractures of differing ages, and metaphyseal lesions are not explained by resuscitation. Each case requires correlation of the fracture pattern with the history and other findings.

Question 19Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 4-month-old with an unremarkable birth history presents with apnea and seizures. MRI shows hypoxic-ischemic injury together with an acute subdural haematoma. Which explanation fits best?

  1. An inborn metabolic disorder
  2. Birth asphyxia at four months old
  3. Inflicted trauma with hypoxia Correct answer.
  4. Apnea causing the hemorrhage

Explanation

Abusive head trauma frequently presents with apnea, lethargy or seizures, and the hypoxic-ischemic injury is a consequence of the trauma rather than its cause. Apnea does not produce subdural bleeding. A metabolic disorder or a birth event months earlier would not account for acute blood on imaging.

Question 20Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which humerus fracture pattern in a 6-month-old most suggests abuse?

  1. Greater tuberosity avulsion fracture
  2. Spiral midshaft fracture Correct answer.
  3. Supracondylar fracture with a fall
  4. Impacted surgical neck fracture

Explanation

A spiral or oblique midshaft humeral fracture in a non-ambulatory infant has a recognised association with inflicted injury, particularly when the history is absent or implausible. Supracondylar fractures are common accidental injuries in children who fall from height. The history must be matched to the child's developmental abilities.

Question 21Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which bruising pattern in a 3-year-old who runs and climbs is most consistent with accidental injury?

  1. Bruises on shins, knees and forehead Correct answer.
  2. Bruises on the neck and upper arms
  3. Bruises on the ears and left cheek
  4. Bruises on the abdomen and buttocks

Explanation

In mobile children, accidental bruises cluster over bony prominences on the front of the body, especially the shins, knees and forehead. Bruises over protected sites such as the torso, ears, neck, cheeks and buttocks are concerning for inflicted injury. The distribution matters more than the number of bruises.

Question 22Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which finding most suggests an inflicted striking injury?

  1. A forehead bruise after a fall
  2. A loop-shaped bruise Correct answer.
  3. A bruise on the chin
  4. A bruise over the shin

Explanation

A patterned bruise reproduces the shape of the object used, such as a looped cord, belt buckle or open hand. Such marks should be measured and photographed, and the suspected object documented. Forehead, shin and chin bruises over bony prominences fit ordinary falls.

Question 23Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A radiologist reports a femoral fracture with periosteal new bone but no callus in a young child. Approximately how old is the fracture?

  1. More than 8 weeks
  2. Less than 24 hours
  3. About 3 to 4 weeks
  4. About 1 to 2 weeks Correct answer.

Explanation

Periosteal new bone formation becomes radiographically visible roughly 7 to 14 days after injury, with callus and sclerosis following at about 2 to 3 weeks. Such estimates are approximate ranges rather than precise timing. Fracture dating cannot establish the exact moment of injury.

Question 24Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which radiographic feature favours nutritional rickets over inflicted injury?

  1. Posterior rib fractures
  2. Metaphyseal cupping with osteopenia Correct answer.
  3. Fractures of different ages
  4. Corner fractures of the femur

Explanation

Rickets produces generalised osteopenia, widened physes, and metaphyseal cupping and fraying, with laboratory abnormalities of calcium, phosphate, alkaline phosphatase and vitamin D. Such changes are diffuse and symmetric rather than focal. Coexisting rickets does not exclude abuse, so the full picture still requires assessment.

Question 25Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which child with suspected physical abuse should undergo a full skeletal survey?

  1. A 4-year-old with a forearm fracture
  2. A 9-year-old with a clavicle fracture
  3. A 15-month-old with a sentinel bruise Correct answer.
  4. A 7-year-old with a shin bruise

Explanation

A skeletal survey is recommended for all children under 2 years when abuse is suspected, because occult fractures are common at this age. For children aged 2 to 5 years it is applied selectively based on findings and history. Older children with an isolated extremity fracture and a clear mechanism rarely need one.

Question 26Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 5-month-old infant's skeletal survey shows a corner fracture of the distal femoral metaphysis. Which statement about this finding is most accurate?

  1. It is a classic metaphyseal lesion caused by shearing forces and is highly specific for abuse. Correct answer.
  2. It is typical of birth trauma and generally resolves without any need for further concern or imaging.
  3. It results from a direct blow and is commonly seen after short falls in toddlers who are learning to walk.
  4. It is a normal variant of metaphyseal ossification that requires no further evaluation in a non-ambulatory infant.

Explanation

Classic metaphyseal lesions are planar fractures through the primary spongiosa produced by torsional and shearing forces applied to a limb while an infant is held, jerked, or shaken. They are among the most specific radiographic markers of inflicted injury in infants and are rarely explained by accidental trauma or by birth.

Question 27Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 4-month-old infant has a fracture of a posterior rib near the costovertebral articulation, with no history of significant trauma or resuscitation. Which statement best reflects its significance?

  1. It is most often caused by nutritional rickets and requires only vitamin D supplementation and repeat radiographs.
  2. It is an expected consequence of chest compressions and does not warrant any further evaluation or reporting.
  3. Posterior rib fractures in infants are highly specific for abuse, typically from forceful squeezing and shaking. Correct answer.
  4. It is consistent with a fall from a low height while the infant was learning to sit independently.

Explanation

Posterior and paravertebral rib fractures result from anteroposterior compression of the chest, which levers the rib head against the vertebra. Because an infant's chest is pliable, this requires substantial force not generated by routine handling or short falls, making the finding highly specific for inflicted injury.

Question 28Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 3-year-old has a circular, crater-like burn about 1 cm in diameter on the dorsum of the hand, with a raised margin and little surrounding inflammation. Several similar lesions are present at different stages of healing. What is the most likely explanation?

  1. Friction burn from a moving treadmill belt
  2. Inflicted cigarette burns Correct answer.
  3. Accidental contact with a hot stove burner during supervised cooking
  4. Impetigo lesions that have healed with post-inflammatory scarring

Explanation

Cigarette burns are small (roughly 8 to 10 mm), circular, crateriform lesions of uniform size and shape with a raised hyperkeratotic rim, often present in multiples at different stages of healing. Accidental contact burns are usually irregular or ovoid and vary in size and depth.

Question 29Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 6-year-old has a U-shaped, double-contoured linear bruise on the buttock that matches the loop of a folded electrical cord. Which interpretation is most appropriate?

  1. The bruise is likely a congenital vascular lesion that has become irritated by clothing.
  2. The shape is most consistent with a cultural healing practice performed by a caregiver.
  3. Inflicted injury from being struck with a looped cord. Correct answer.
  4. The pattern is typical of a fall onto the rounded edge of a piece of furniture.

Explanation

A bruise whose shape reproduces the contour of an object is a patterned injury, indicating that the object struck the skin. A double-contoured loop mark corresponds to a folded cord or similar implement and is a recognized form of inflicted injury.

Question 30Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which retinal hemorrhage pattern in a 3-month-old is most characteristic of abusive head trauma?

  1. Bilateral, multilayered hemorrhages extending out to the ora serrata Correct answer.
  2. A few scattered dot hemorrhages confined to the posterior pole
  3. A single preretinal hemorrhage at the optic disc margin only
  4. Diffuse hemorrhages arising during a prolonged coughing paroxysm

Explanation

Hemorrhages in abusive head trauma are characteristically numerous, bilateral, involve multiple retinal layers, and extend to the periphery near the ora serrata. They arise from repeated vitreoretinal traction and abrupt intracranial pressure shifts during shaking.

Question 31Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 2-year-old with a bruise on the abdominal wall is vomiting. CT shows a duodenal intramural hematoma. Which mechanism best explains this injury?

  1. A twisting injury of the mesentery during a tumble down a carpeted staircase
  2. A coagulation disorder causing spontaneous intramural bleeding
  3. Low-flow bowel ischemia during a long car journey
  4. A direct blow that compresses the duodenum against the spine Correct answer.

Explanation

The duodenum lies close to the vertebral column, so a direct blunt blow can crush it against the spine and produce an intramural hematoma or perforation. This is a classic inflicted abdominal injury in young children and is rarely explained by ordinary falls.

Question 32Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A human bite mark on a child's arm has an intercanine distance of 4.5 cm. What does this measurement most suggest?

  1. The measurement is too small to permit any conclusion about the biter.
  2. The bite was made by a young child's primary dentition.
  3. The mark is a birthmark rather than a true bite.
  4. The bite came from an adult or older adolescent dentition. Correct answer.

Explanation

Intercanine distance in adults and older adolescents generally exceeds 3 cm, whereas bites from young children are smaller. A distance greater than about 3 cm therefore suggests an adult or older adolescent biter. Bite marks should be photographed with a scale and swabbed for DNA.

Question 33Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 5-month-old has a skull fracture that is multiple, diastatic, and crosses suture lines after reportedly rolling off a sofa onto carpet. How should this be interpreted?

  1. The pattern suggests an underlying metabolic bone disease of infancy.
  2. The complexity is inconsistent with a short fall and suggests abuse. Correct answer.
  3. The pattern is expected for a fall from sofa height and is not concerning.
  4. The pattern is typical of a normal variant suture line and needs no follow-up.

Explanation

Simple, linear skull fractures can follow short falls, but multiple fractures, wide diastasis, crossing of suture lines, and growing fractures indicate higher-energy blunt impact. Such a pattern is not explained by rolling off low furniture and should prompt evaluation for inflicted injury.

Question 34Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which set of injuries is most consistent with a genuine short fall of under 1.5 m in a young child?

  1. Bilateral subdural hematomas with extensive retinal hemorrhages and no marks of impact
  2. A single simple linear skull fracture with a brief loss of consciousness Correct answer.
  3. Multiple posterior rib fractures of differing ages with no chest wall bruising
  4. A metaphyseal corner fracture of the distal tibia in a child who is not yet walking

Explanation

Short falls typically produce minor injury, most often a single simple linear skull fracture, a brief loss of consciousness, or a solitary limb fracture. Severe intracranial injury, extensive retinal hemorrhage, rib fractures, and classic metaphyseal lesions are not explained by such a mechanism.

Question 35Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 7-month-old who cannot yet pull to stand has a torn maxillary labial frenulum with no other injury. Which statement is most accurate?

  1. It is concerning for inflicted injury, since accidental tears are unusual before walking. Correct answer.
  2. It is most often caused by a fall from standing height in this age group.
  3. It is a common consequence of intramuscular immunizations given in the thigh.
  4. This injury is a normal finding in infants who are teething and needs no evaluation.

Explanation

Labial or lingual frenulum tears in a pre-mobile infant have low accidental plausibility and may follow a blow to the mouth or forced feeding. Once children walk and fall frequently, accidental frenulum tears become more plausible.

Question 36Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 3-year-old has a bruise over the epigastrium and mild abdominal tenderness but stable vital signs. Which initial laboratory panel best screens for occult abdominal injury?

  1. Coagulation studies with hemoglobin electrophoresis
  2. Aspartate aminotransferase, alanine aminotransferase, lipase, and urinalysis Correct answer.
  3. Complete blood count with erythrocyte sedimentation rate and C-reactive protein
  4. Urinalysis and stool occult blood testing only

Explanation

Hepatic transaminases, pancreatic enzymes, and urinalysis screen for occult liver, pancreatic, and renal injury in children with abdominal trauma. Abnormal AST, ALT, lipase, or hematuria warrants cross-sectional imaging.

Question 37Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A 2-year-old has a fracture of the body of the scapula after reportedly falling while running. Which statement is most accurate?

  1. Scapular body fractures are among the most common accidental injuries seen in ambulatory toddlers and preschoolers.
  2. Scapular fractures in children are uncommon and should raise concern for abuse. Correct answer.
  3. The fracture is most likely a normal variant of scapular ossification and requires no follow-up.
  4. Scapular fractures at this age are usually the result of birth trauma during delivery.

Explanation

The scapula is protected by thick muscle and requires substantial direct force to fracture. In young children these fractures are uncommon, and in the absence of a major mechanism such as a motor vehicle crash they should prompt evaluation for inflicted injury.

Question 38Physical abuse, including abusive head trauma, cutaneous and skeletal injury

Which clinical picture most suggests glutaric aciduria type 1 rather than abusive head trauma?

  1. Bilateral retinal hemorrhages with metaphyseal corner fractures and posterior rib fractures
  2. A spiral femoral shaft fracture in a non-ambulatory 4-month-old infant
  3. Bruising in the TEN-4 regions of an infant who is not yet rolling over
  4. Macrocephaly with an encephalopathic crisis, basal ganglia injury, and subdural collections Correct answer.

Explanation

Glutaric aciduria type 1 causes macrocephaly with frontotemporal atrophy and a sudden encephalopathic crisis with striatal injury, and subdural collections may develop after minor stress or illness. The combination of macrocephaly, acute encephalopathy, and basal ganglia involvement is not typical of inflicted head injury.

Question 39Physical abuse, including abusive head trauma, cutaneous and skeletal injury

In a shaking injury without impact, which mechanism best explains the combination of subdural hemorrhage and retinal hemorrhage?

  1. Traction on bridging veins and vitreoretinal attachments during acceleration-deceleration Correct answer.
  2. Hypoxic-ischemic injury from a prolonged seizure occurring hours afterward
  3. Direct contusion of the cortex against the inner table of the skull vault
  4. Rupture of cortical arteries from a sudden rise in systemic blood pressure

Explanation

Repetitive acceleration-deceleration tears bridging veins as the brain moves within the skull, producing subdural blood. The same forces create vitreoretinal traction, generating retinal hemorrhages, so impact is not required to explain either finding.

Question 40Physical abuse, including abusive head trauma, cutaneous and skeletal injury

A head CT obtained 6 hours after presentation shows a subdural collection that is hyperdense compared with cortex. What is the best interpretation of this finding?

  1. The hemorrhage is at least two weeks old and beginning to organize with membrane formation.
  2. Hyperdensity indicates acute hemorrhage; dating must rely on the history and other findings. Correct answer.
  3. Hyperdensity is an artifact of the CT scanner and should be disregarded.
  4. The density reflects a chronic subdural effusion of infancy rather than blood.

Explanation

Acute subdural blood appears hyperdense on CT and becomes isodense and then hypodense over days to weeks, and MRI is superior for dating. Imaging can establish broad acuity but cannot pinpoint an exact time, so the history and pattern of other injuries must be integrated.

Question 41Sexual abuse, sexual exploitation, and anogenital findings

Which finding on a prepubertal girl's genital examination is considered a normal variant?

  1. A perianal scar
  2. A small hymenal tag Correct answer.
  3. Genital bruising
  4. A healed hymenal transection

Explanation

Hymenal tags, mounds, and shallow notches can be normal variants in prepubertal girls. Transections, scars, and unexplained bruising raise concern for trauma or abuse.

Question 42Sexual abuse, sexual exploitation, and anogenital findings

Which statement best describes the typical pattern of child sexual abuse perpetrators?

  1. They are almost always strangers.
  2. They usually know the child. Correct answer.
  3. They are most often female caregivers.
  4. They rarely contact the family.

Explanation

Most children know the person who abuses them; perpetrators may be relatives, acquaintances, or juveniles. Stranger abuse occurs but is a minority.

Question 43Sexual abuse, sexual exploitation, and anogenital findings

A clinician suspects child sexual abuse after evaluating a 6-year-old. What is the clinician's immediate legal obligation?

  1. Confirm the diagnosis with a forensic interview before reporting.
  2. Obtain parental consent before contacting authorities.
  3. Wait for laboratory results to support the suspicion.
  4. Report the suspicion to child protective services. Correct answer.

Explanation

Mandated reporters must report reasonable suspicion, not a confirmed diagnosis, and do not need parental consent. Waiting for interviews or laboratory results can delay protection.

Question 44Sexual abuse, sexual exploitation, and anogenital findings

Which statement about disclosure of child sexual abuse is most accurate?

  1. Disclosure is often delayed or gradual. Correct answer.
  2. A delayed disclosure makes abuse unlikely.
  3. Recantation proves that abuse did not occur.
  4. Children usually disclose promptly and in full detail.

Explanation

Delay, partial disclosure, and recantation are common and do not exclude abuse. Prompt full disclosure is not typical for many children.

Question 45Sexual abuse, sexual exploitation, and anogenital findings

A 14-year-old reports a penile-vaginal assault 6 hours ago. When should forensic evidence collection be performed?

  1. As soon as possible after the assault Correct answer.
  2. After a 72-hour observation period
  3. Only if the patient agrees to press charges first
  4. Only after the patient showers and changes clothes

Explanation

Forensic evidence should be collected as soon as possible because early collection improves DNA recovery. Waiting, washing, or requiring prosecution first can reduce evidence and delay care.

Question 46Sexual abuse, sexual exploitation, and anogenital findings

Which test is appropriate for baseline gonorrhea and chlamydia screening in a sexually abused prepubertal girl?

  1. Vaginal bacterial vaginosis culture
  2. NAAT of a vaginal swab Correct answer.
  3. Cervical HPV DNA testing
  4. Serum HSV-2 antibody testing

Explanation

Nucleic acid amplification testing of exposed sites is recommended, and a vaginal swab is acceptable in prepubertal girls. HSV serology, HPV DNA testing, and bacterial vaginosis culture are not routine baseline abuse screening tests.

Question 47Sexual abuse, sexual exploitation, and anogenital findings

Which situation best fits the definition of child sexual exploitation?

  1. A child exchanges sexual acts for money, drugs, or shelter. Correct answer.
  2. A child is neglected by a caregiver who leaves them home alone.
  3. A child receives a gift from a relative after a birthday party.
  4. A child is bullied at school for wearing glasses.

Explanation

Exploitation involves exchanging sexual acts for something of value, such as money, drugs, or shelter. Gifts, bullying, and neglect are not sexual exploitation by definition.

Question 48Sexual abuse, sexual exploitation, and anogenital findings

During an initial assessment of a child who may have been sexually abused, which interviewing approach is best?

  1. Show the child detailed crime-scene photographs first.
  2. Ask repeated closed yes-or-no questions until a disclosure is obtained.
  3. Promise the child that the abuser will not be punished.
  4. Use open-ended prompts and let the child describe what happened. Correct answer.

Explanation

Open-ended, nonleading questions help preserve the accuracy of a child's account. Repeated closed questions, graphic images, and false promises can contaminate memory or undermine trust.

Question 49Sexual abuse, sexual exploitation, and anogenital findings

A 5-year-old girl has a healed hymenal transection extending through the hymenal edge. What does this finding most strongly suggest?

  1. A common hymenal notch
  2. Healed penetrating trauma Correct answer.
  3. Normal estrogen effect
  4. Labial adhesion

Explanation

A complete transection through the hymenal edge is a concerning finding for penetrating trauma. Estrogen effect, notches, and labial adhesions do not cause a transection.

Question 50Sexual abuse, sexual exploitation, and anogenital findings

A 7-year-old falls onto a bicycle crossbar and has a unilateral anterior vulvar bruise. Which feature best supports an accidental straddle injury?

  1. Injury matching the reported mechanism Correct answer.
  2. Multiple healed anal scars
  3. A hymenal transection with no external bruising
  4. Bilateral posterior fourchette lacerations

Explanation

Accidental straddle injuries usually match the reported mechanism and are often anterior and unilateral. Hymenal transection, anal scars, and posterior lacerations raise more concern for abuse.