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.
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.
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.
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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