Well, yes, many of the events that bring pediatric patients to the Emergency Department could be due to child abuse or neglect. In fact, the American Academy of Pediatrics just recently published a new Clinical Report, The Evaluation of Suspected Child Physical Abuse. The main focus of this publication is that physical abuse is terrifyingly common across all socio-economic groups, under-diagnosed, and associated with significant long-term medical, psychological, and social harm.

Below are a set of images not meant to yield a binary response of abuse or not abuse, but to prime you to think about the possible mechanisms of injury and differential diagnoses that might explain the injury pattern.
What could have caused this oral injury in an 18-month old boy?

The concern for abuse is high with a frenulum injury as this is typically a protected structure, but accidental trauma in a mobile and accident-prone 18-month old boy (or in the case of this picture it is part of a planned operation :P).
This is why obtaining an unbiased history is so essential to assessment of suspected physical abuse: if the story changes, is widely different amongst care-givers, does not fit the extent or type of injuries, your suspicion for abuse should be higher.
Injury #1

Figure 3b. Immediate postoperative view by Pié-Sánchez J, España-Tost AJ, Arnabat-Domínguez J, and Gay-Escoda C, via OPENi.

Where's the non-traumatic dermatologic finding?

The Mongolian spot!

Does the pattern of injury in burns or bruising injuries help you differentiate accidental from non-accidental injuries?

While there are findings that point more towards non-accidental trauma in burns (well demarcated borders suggesting an immersion, wounds in various stages of healing) and bruising (on an immobile child, in protected areas), these physical examination findings are very nonspecific making any definitive claim about their origins challenging.

Fig1: Patient on admission by Bhatia VY, Mishra S, Menon PA, and Nanavati N via OPENi.

Classic Metaphyseal Lesion, anyone?

We thought that this one was a slam dunk for physical abuse, and it still might be, but the presence of Rickets (Vitamin D deficiency) led to the below radiographic findings of bilateral apparent bucket-handle fractures in an otherwise healthy, pain and tenderness-free child.

The long and short of all of this is to say, don’t anchor on abuse as the only possibility for the child’s presentation, but all too often a child’s presentation to the Emergency Department is a missed opportunity to identify abuse, physical or otherwise. As mandated reporters, we have an obligation to report suspected abuse, but for complex reasons we are unable to bring all of the resources at our disposable to potentially improve this patient’s life.
Christian, C. W., & Committee on Child Abuse and Neglect, A. A. O. P. The evaluation of suspected child physical abuse. Pediatrics [serial online]. 2015; 135: (5), e1337-54. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=25917988.
Kaplan, D. M. Chapter 290. Child Abuse: Physical, Sexual, and Neglect. In A. B. Wolfson, R. L. Cloutier, G. W. Hendey, L. J. Ling, C. L. Rosen, & J. Schaider (Eds.), Harwood-Nuss’ Clinical Practice of Emergency
Medicine (6th ed.). http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=booktext&D=books2&AN=01817268/6th_Edition/3&XPATH=/OVIDBOOK%5b1%5d/METADATA%5b1%5d/TBY%5b1%5d/EDITORS%5b1%5d.
Links to images above also provide links to open access publications.

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