Lesson 1 - Skin Injuries - Bruising

Again, when considering whether bruises are accidental or inflicted, there are several questions to be considered. Click below to display information.

1) Is the patient an infant?
While bruising in toddlers and children is quite common, bruising in young infants is uncommon. In one large study, bruising in non-ambulatory infants presenting for well-child care was found to be present in only 0.6% of infants under the age of 6 months. (Sugar NF, et al. Bruises in infants and toddlers, those who don’t cruise rarely bruise. 1999, Archives of pediatric and adolescent medicine). As infants are completely dependent on their caregivers, they are typically not able to sustain injuries on their own. A bruise in an infant should prompt a full evaluation for other injuries and should be reported to a child protective agency. Exceptions to this may include forehead and shin bruises in ambulatory or mobile infants.

As the majority of toddlers and older children will have bruises, the actual appearance of the bruise is more important.
2) Is the bruise patterned?
Some bruises will have a clear shape such as a cord, belt, hand, or grab mark. Spanking or disciplining that leave marks or injuries constitutes physical abuse. These bruises are often on areas covered by clothing, such as the buttocks, in an attempt to conceal the injury. Therefore, they are only revealed through a thorough skin evaluation including undressing the child. Bruises such as these should be reported in any age group.
3) Is the bruise well-demarcated?
This refers to bruises that may not have an obvious identifiable pattern but have a clear outline or edge. This type of bruising is uncommon in accidental mechanisms and suggests being struck with an object.
4) Is the bruising in an area of the body that is not commonly injured during accidental play?
Common areas that are injured in accidental play include the bony prominences, especially the forehead, chin, knees, shins, elbows, etc. Areas that are not commonly bruised accidentally, and are therefore concerning for inflicted injury, include the ears, neck, abdomen, soft tissues of the cheeks, buttocks, and genitalia.
5) Is the bruising excessive or extensive?
Excessive or extensive bruising may suggest severe abuse, or it may be a sign of an underlying medical condition such as ITP (idiopathic thrombocytopenic purpura) or leukemia. While labs are not necessary in most children with bruising, children with excessive or extensive bruising should have routine screening labs rule out an underlying medical disorder.
6) Does the history provided make sense?
Even with extensive medical training, professionals also often rely on common sense. For example, if a child presents with a patterned bruise or multiple bruises after “rolling off the couch”, the injury is not consistent with the history provided.
7) Do the bruises appear to be of the same age?
This is a trick question. In years past it was believed that bruises could be aged or dated based on their color. However, we now know that this is not an accurate practice at all. Many factors affect the color of a bruise including location of the body, pigment of the skin, vascularity of the tissue, depth of the bruise, and mechanism of injury. It has also been shown that bruises on the same person from the same accident will change color at various rates. (Langlois NE, et al. The ageing of bruises: a review and study of the colour changes with time. 1991, Forensic Sci Int)

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