X-Ray Imaging for an 18-Month-Old with Bruising After Object Falls
Yes, obtain x-ray imaging of the affected area in this 18-month-old child with bruising from a falling object, as children under 2 years of age with bruising from trauma require a low threshold for imaging to exclude occult fractures and, critically, to evaluate for possible non-accidental injury.
Primary Imaging Recommendation
X-ray the specific area of bruising and clinical concern as the initial imaging study. 1 In children under 2 years of age, the presence of bruising after trauma warrants careful evaluation, as apparently isolated bruises can be associated with underlying fractures or more serious injuries. 1
Critical Age-Related Considerations
At 18 months of age, this child falls into a high-risk category that demands heightened clinical vigilance:
- Children under 2 years are at highest risk for occult injuries, including fractures that may not be immediately apparent on clinical examination alone 1
- Bruising in infants and young children requires consideration of both accidental and non-accidental injury, as well as potential bleeding disorders 2
- Femoral fractures in children who are not yet walking independently and unexplained humeral fractures in children under 15 months should raise suspicion for abuse 1
When to Expand Imaging Beyond the Bruised Area
Consider Full Skeletal Survey If:
- Multiple areas of bruising are present 1
- The mechanism of injury is unclear or inconsistent with the injury pattern 1
- There are any other concerning features suggesting possible non-accidental injury 1
Consider Head CT or MRI If:
Maintain a low threshold for neuroimaging in this age group, as 27-37% of children under 2 years with high-risk criteria (including age under 6 months, multiple fractures, or facial injury) have occult head injuries even without overt neurological signs. 1 The presence of apparently isolated bruises in infants under 6 months correlated with new injury on neuroimaging in 27% of cases. 1
Specific Clinical Indicators for Imaging
Obtain X-rays if ANY of the following are present:
- Focal bony tenderness on palpation 3
- Inability or refusal to bear weight or use the affected limb 3
- Significant mechanism (heavy object, fall from height) 4
- Extensive bruising or swelling 4
Documentation Requirements
Document meticulously with diagrams and photographs when possible, as medical records will likely be reviewed for legal proceedings. 5 Use the child's own words (or parent's exact description) when documenting the history. 5
Mandatory Reporting Obligation
Child protective services must be notified as required by law, regardless of whether the injury appears accidental, as bruising in young children requires evaluation to distinguish between accidental and non-accidental trauma. 5 This is a legal requirement in all jurisdictions and should not delay medical evaluation. 5
Common Pitfalls to Avoid
- Failing to image based solely on "minor" external appearance - occult fractures are common in this age group and may not be apparent on physical examination alone 1
- Missing the opportunity to detect non-accidental injury early - bruising patterns and underlying fractures may be the only initial indicators 1, 2
- Inadequate documentation that may be needed for legal proceedings 5
- Assuming bruising alone excludes fracture - soft tissue injury and bony injury frequently coexist 4, 6
Alternative Imaging Modalities
If x-rays are negative but clinical suspicion remains high, ultrasound can be considered as a complementary study (sensitivity 92.9%, specificity 99.5% for fracture detection in children), particularly for clavicle injuries. 6 However, x-ray remains the standard initial imaging modality. 1