Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, buttocks, ears, torso, neck if the child is not cruising yet
Bruises in clusters or patterned marks
Bruising of any child less than or equal to 6 months of age (or non-ambulatory) warrants a full child abuse work-up
Torn frenulum in premobile children is highly associated with physical abuse
Other reported oral injuries include laceration/bruising to the lips, mucosal lacerations, dental trauma, tongue injuries, and gingival lesions
Most commonly immersion injuries of the extremities, buttocks, or perineum
More likely symmetrical with clear upper margins
Many will also have occult fractures; children <24mo should undergo a skeletal survey
Fractures highly suspicious of abuse:
Rib fracture, especially posterior
Metaphyseal or Corner Fracture (Bucket Handle)
Scapula fracture
Spinous process fractures
Sternum fracture
Fracture not consistent with developmental stage (any fracture in non-ambulatory child)
Rib fracture, especially posterior
Metaphyseal or Corner Fracture (Bucket Handle)
Scapula fracture
Spinous process fractures
Sternum fracture
Fracture not consistent with developmental stage (any fracture in non-ambulatory child)
Fractures moderately suspicious of abuse:
Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
Multiple bilateral fractures
Different stages of healing with multiple fractures
Epiphyseal separations
Vertebral body separation
Complex skull fractures (i.e. depressed or cross suture lines)
Pelvic fractures
Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
Multiple bilateral fractures
Different stages of healing with multiple fractures
Epiphyseal separations
Vertebral body separation
Complex skull fractures (i.e. depressed or cross suture lines)
Pelvic fractures
Leading cause of death in abused children <2 years old
Shaken baby syndrome - Retinal hemorrhages
Present in up to 75% of cases and are virtually pathognomonic
Described as “dot and blot” hemorrhages or flame or splinter hemorrhages
Present in up to 75% of cases and are virtually pathognomonic
Described as “dot and blot” hemorrhages or flame or splinter hemorrhages
Most from a direct blow or from being thrown
Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
Consider abuse in preschool aged children with any hollow viscus or pancreatic injury
Even among children who report vaginal or anal penetration, the rate of abnormal physical examination findings is only 5 to 15%
Consult your local sexual assault response team or transfer to an appropriate facility as indicated.
Females
Preferred positioning for adequate examination: child lying supine with her hips externally rotated and knees flexed (frog-leg) or the prone knee-chest position.
Examine hymen for lacerations, transections, and bruising.
Prepubertal females do not require a speculum exam unless there is active bleeding.
Vaginal discharge in a prepubertal female should prompt testing for sexually transmitted infections.
The diameter of the hymenal orifice is not a marker for whether or not vaginal penetration occurred.
Males
Examine for lacerations, burns, bite marks, and bruises to the genital region. Penile and anal injuries are more common than scrotal injuries.
Swab any anal or penile discharge for sexually transmitted infections.
Preferred positioning for adequate examination: child lying supine with her hips externally rotated and knees flexed (frog-leg) or the prone knee-chest position.
Examine hymen for lacerations, transections, and bruising.
Prepubertal females do not require a speculum exam unless there is active bleeding.
Vaginal discharge in a prepubertal female should prompt testing for sexually transmitted infections.
The diameter of the hymenal orifice is not a marker for whether or not vaginal penetration occurred.
Examine for lacerations, burns, bite marks, and bruises to the genital region. Penile and anal injuries are more common than scrotal injuries.
Swab any anal or penile discharge for sexually transmitted infections.
Nonaccidental trauma
Bruising
Trauma 
Mongolian spots 
Abusive head trauma
Bleeding disorders
Submersion injury
Hemangiomas