Interpreting physical signs of child maltreatment: ‘grey cases’ and what is ‘reasonably possible’

There is a growing evidence-base for physical signs of child maltreatment. However, health professionals sometimes find themselves in situations that are not clear cut, particularly when there is one suspicious injury in an otherwise normal child in a family where there are no risk factors for maltreatment present. This paper highlights such situations and guides the clinician through uncertainty to a consideration of whether or not the explanation for an injury is reasonably possible. This will be done by discussing the location, configuration and patterns of injury arising from low level falls, stairway falls, climbing into the bathtub, pacifiers or bottles, and being bitten by another child; explanations often proffered for an injury.The location of bruising in disabled children and young people will also be discussed.If uncertainty surrounding the causation of an injury remains following advice and peer review, this must be acknowledged and stated unequivocally.