What is the most likely diagnosis for a child admitted to the Pediatric Intensive Care Unit (PICU) with a subdural hematoma, ecchymosis on the buttocks and back, and bilateral femoral fractures, after the father reported a fall from a bed?

Battered Child Syndrome (Non-Accidental Trauma)

The most likely diagnosis is C) Battered child syndrome (non-accidental trauma), given the constellation of subdural hematoma, bilateral femoral fractures, and ecchymosis in unusual locations (buttocks and back) that are inconsistent with the reported mechanism of a simple fall from bed.

Key Diagnostic Features Supporting Non-Accidental Trauma

Injury Pattern Analysis

The combination of injuries present is highly specific for abuse:

• Subdural hematoma is the most commonly seen intracranial injury in abusive head trauma and is one of the hallmark features of the battered child syndrome 1, 2

• Bilateral femoral fractures are strongly suspicious for abuse, particularly when the history provided (fall from bed) is inconsistent with the severity and pattern of injuries 1

• Multiple fractures in any location without overt trauma are strongly associated with abusive injury 1

Age and Developmental Considerations

• Femoral fractures in non-ambulatory children are more likely from abuse than falls 3

• Femoral fractures in a child who is not yet walking and unexplained fractures should be considered suspicious for abuse 1

• The child's motor developmental level is a key discriminator for abuse in certain fractures 1

Cutaneous Findings

• Ecchymosis on the buttocks and back represents bruising in uncommon locations, which is an important clinical sign of the battered child syndrome 2

• The presence of bruises in unusual locations combined with skeletal and intracranial injuries represents a combination of skeletal and nonskeletal injuries highly suggestive of abuse 1

Why Other Diagnoses Are Incorrect

Accidental Injury (Option D) - Ruled Out

• A simple fall from a bed cannot explain the constellation of bilateral femoral fractures, subdural hematoma, and bruising in multiple unusual locations 1

• Fractures that are inconsistent with the provided history or age of the child are highly suggestive of abuse 1

• The severity and multiplicity of injuries far exceed what would be expected from the reported mechanism 1

Pathological Fracture (Option B) - Unlikely

• While pathological fractures from conditions like osteogenesis imperfecta can occur with minimal trauma, they would not explain the subdural hematoma or the pattern of bruising on the buttocks and back 3

• No history of trauma in a child with fracture mandates investigation for metabolic bone disease, osteogenesis imperfecta, or abuse, but the presence of subdural hematoma and bruising makes abuse far more likely 3

Hematoma (Option A) - Incomplete Diagnosis

• While subdural hematoma is present, this option fails to address the bilateral femoral fractures and bruising pattern, making it an incomplete diagnosis 1

Critical Clinical Actions Required

Immediate Evaluation

• Complete skeletal survey is mandatory in this case given the age and multiple injuries, as 11% to 20% of infants undergoing evaluation for abuse have unsuspected fractures 1

• Funduscopic examination must be performed to check for retinal hemorrhages, which are characteristic findings in abusive head trauma 4, 5

• The presence of retinal hemorrhages and associated long bone fractures are significantly more common in the abuse group compared to accidental injuries 5

Documentation and Reporting

• Child protective services must be notified immediately as this represents suspected child abuse 1, 4

• Detailed documentation of all injuries, their locations, and the inconsistency between the reported history and injury pattern is essential 1, 2

Common Pitfalls to Avoid

• Do not accept a history that is inconsistent with the injury pattern - a fall from bed does not cause bilateral femoral fractures and subdural hematoma 1

• Do not overlook bruising in unusual locations (buttocks, back) as these are important indicators of abuse 2

• Do not fail to perform a complete evaluation including skeletal survey and ophthalmologic examination, as additional injuries are frequently found 1, 4, 5

• Nonaccidental injury is the commonest cause of subdural hematomas in children under 2 years of age, with a significantly higher incidence of retinal hemorrhages and associated long bone fractures in the abuse group 5