Differential Diagnosis for Non-Accidental Injury

When considering the differential diagnosis for a case where non-accidental injury (NAI) is a concern, it's crucial to approach the situation with a broad perspective to ensure that all potential causes are evaluated. The differential can be organized into the following categories:

• Single Most Likely Diagnosis
  • Accidental injury: This is often the most common explanation for injuries in children and adults alike. A thorough history and examination can usually distinguish accidental from non-accidental injuries, but it remains a critical consideration to rule out NAI.
• Other Likely Diagnoses
  • Physical abuse: This is a primary concern when NAI is suspected. It involves intentional harm or injury inflicted by a caregiver or other person.
  • Neglect: While not an injury per se, neglect can lead to harm or injury due to lack of proper care or supervision.
  • Munchausen syndrome by proxy (Factitious Disorder Imposed on Another): A form of child abuse in which a caregiver fabricates or induces illnesses in a child to gain attention and sympathy for themselves.
• Do Not Miss Diagnoses
  • Osteogenesis imperfecta: A genetic disorder characterized by fragile bones, which can be mistaken for NAI due to the presence of multiple fractures.
  • Bleeding disorders (e.g., hemophilia): Conditions that affect the blood's ability to clot, leading to easy bruising or bleeding, which might be misinterpreted as signs of abuse.
  • Congenital syphilis: Can cause bone abnormalities and skin lesions that might be confused with signs of physical abuse.
• Rare Diagnoses
  • Menkes disease: A rare genetic disorder affecting copper levels in the body, leading to fragile bones and hair, which could potentially be mistaken for signs of NAI.
  • Caffey disease (Infantile cortical hyperostosis): A rare condition characterized by inflammation of the bone and its surrounding tissues, which can cause symptoms that might be mistaken for physical abuse.

Each of these diagnoses requires careful consideration and a thorough evaluation to ensure that non-accidental injury is accurately identified or ruled out. A multidisciplinary approach, including medical professionals, social workers, and law enforcement, is often necessary to determine the cause of injuries and to ensure the safety and well-being of the individual.