A 3 1/2-year-old girl, who is nonverbal because of an underlying neurological disorder, presented to day care with a pelvic bruise. The day-care attendant feared abuse and reported the findings to Child Protective Services (CPS).

The parents told CPS that the child had been alone with her father and fell getting out of the bathtub. The child was taken to a busy general hospital emergency department (ED) by the parents and the CPS worker. The parents gave the same explanation about the injury to the ED physician; they also noted that the child had a history of easy bruising. The ED physician determined that the injury was compatible with the history after conducting a physical examination and no laboratory tests.

The CPS worker was concerned that the ED visit had been too hasty and the situation inadequately evaluated. Therefore, the child was brought to an advocacy center for a second opinion a day after the ED visit. A thorough history was obtained and the family's account of the trauma remained unchanged. However, in the review of systems, the mother added that the child was having some difficulty with toilet training.

The second examination showed that there was no other bruising except on the pelvis. The pelvis appeared to have 3 individual bruises; however, no clear pattern could be identified. A complete genital examination was done. The hymen, posterior fourchette, and fossa navicularis were all normal and no acute injury could be identified. No laboratory tests were obtained at that time. Because of the slight additions to the history, a home visit was requested for scene evaluation.

Do you suspect abuse--or an underlying medical cause?

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