Bruise of Child Abuse

Information has been excerpted from VisualDx clinical decision support system as a public health service. Additional information, including symptoms, diagnostic pearls, differential diagnosis, best tests, and management pearls, is available in VisualDx.


Accidental bruising is common in healthy and active children. However, bruises can also be a sign of child abuse and are the most common type of physical injury in abused children. An injury can be considered physical abuse if it is defined as nonaccidental and lasts beyond temporary reddening of the skin. Differentiating inflicted bruises from those sustained accidentally can be challenging. However, a careful evaluation including the distribution, pattern, and history of the skin lesion in the context of the developmental capabilities of the child can help assess whether the injury was intentional.

Physical abuse is the most frequently reported form of child abuse, with skin being the most commonly injured organ system. Abrasions and bruises are the most common signs of child abuse on the skin. Scratches and bites are less common. Burns, hematomas, edema, and marks from physical implements are also less common but should not be missed. Physical abuse can occur in children of any age and has a mean age of 6. Mechanisms of bruising include hitting, whipping, biting, and kicking.

It is important to note that cultural practices such as cupping and coining lead to ecchymosis formation in distinctive patterns. Proper evaluation is necessary because the use of cultural practices does not exclude the potential for child abuse. In these cases, significant attention should also be focused on educating the parents to explain the adverse outcomes, discourage future harmful behavior, and suggest alternative forms of treatment.

Childhood physical abuse is a problem of epidemic proportions affecting children of all ages and economic and cultural backgrounds. It is estimated that each year over 3 million children are victims of abuse, with close to 2,000 fatalities secondary to maltreatment. Although awareness is increasing, it is often challenging to differentiate findings attributable to child abuse from those of other benign skin conditions.

Look For

In general, when abuse is considered, look for hyperpigmented or red-purple patches with minimal or no explanation or unlikely mechanism. There may be associated scars, hyperpigmentation, and bruises in different stages of development. Bruises age in characteristic color, initially red-blue, then purple at 3–5 days, then green at about a week, and finally yellow at 8–12 days. Bruises or physical marks caused by abuse can occur anywhere, although the buttocks, arms, head, and neck are the most common.

Accidental bruising:
Noninflicted bruising tends to occur in independently mobile children on anterior bony prominences, such as the forehead and shins, and is more common during the summer months. Look for hyperpigmented or purpuric patches in these areas. Ambulatory children acquiring bruises through normal play typically have fewer than 3 bruises, each measuring less than 10 mm in size.

Bruises suggestive of abuse:
Bruises in a defined pattern or those that carry the imprint of an implement are suggestive of abuse. Patterns include geometric patterns, such as from belt buckles, loops from electric cords, hand or knuckle imprints, ropes, or linear marks from sticks or rods. For example, slapping produces a negative imprint when capillaries break between the fingers, causing petechial bruising as blood is pushed away from the point of impact, leaving an outline of the hand.

Look for ecchymoses in areas that are typically protected, such as the buttocks, back, trunk, genitalia, inner thighs, cheeks, ears, neck, or philtrum. These are difficult to incur through normal childhood activities and are, therefore, suggestive of abuse. For example, a blow to the ear can result in “cauliflower ear” secondary to a subperichondrial hematoma, which may be associated with retinal hemorrhage and even cerebral edema.

Cultural practices:
In cupping, a heated cup is inverted on the skin, typically on a child’s back, creating a suction force from the cooling and contracting air thought to “draw out” the ailment. Look for circular erythema or bullae from the heat and central ecchymosis and petechiae from the suction effect.

In coining or spooning, oiled skin is firmly rubbed with the edge of a coin, producing linear erythematous patches, petechiae, or purpura, usually on the back.

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