Bruise of child abuse - Suspected Child Abuse
Alerts and Notices
Synopsis
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 abusive in nature.
After neglect, physical abuse is the most frequently reported form of child abuse, with skin being a commonly injured organ system. Abrasions and bruises are the most common signs of child abuse on the skin. Mechanisms of bruising include hitting with a hand or implement, 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.
Physical abuse can occur in children of any age but has a mean age of 6 years. Over 75% of fatalities occur in children younger than 3 years of age, with neonates and infants (children younger than 12 months) at the highest risk for serious injury or death.
Codes
ICD10CM:T76.12XA – Child physical abuse, suspected, initial encounter
SNOMEDCT:
371779005 – Physical child abuse
Look For
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
Differentiating features from abuse include critical elements of the history and physical examination, such as the characteristics of the lesion and associated symptoms.- Congenital dermal melanocytosis (formerly Mongolian spot)
- Capillary hemangioma (see infantile hemangioma)
- Lymphangiomas
- Ink, dye, or paint stains
- Blue nevi, especially facial
- Eczema
- Angioedema
- Phytophotodermatitis
- Coagulation disorders (factor VIII and IX deficiencies, von Willebrand's disease, idiopathic thrombocytopenic purpura [ITP], leukemia, acetylsalicylic acid toxicity, anticoagulation medication)
- Hypersensitivity vasculitis (immunoglobulin A vasculitis [formerly Henoch-Schönlein purpura])
- Hypersensitivity reactions (erythema multiforme, erythema marginatum, erythema nodosum)
- Purpura fulminans of meningococcemia
- Incontinentia pigmenti (rare)
- Disseminated intravascular coagulation (DIC)
- Impetigo
- Café au lait spots
- Chilblains
- Osteogenesis imperfecta
- Gardner-Diamond syndrome
- Ehlers-Danlos
- Bruising caused by cultural practices, such as cupping and coining; see Look For section for further details
- Dog-inflicted abrasions – This pattern can be mistaken for inflicted belt marks. With a scratch caused by a dog paw, the red lines are abraded; you should be able to feel the skin disruption. If the dog is large, the abrasions are often surrounded by bruising. In contrast, belt or cord marks are strips of bruising, typically without disruption of the skin surface and usually without a lot of surrounding bruising.
Best Tests
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Management Pearls
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Therapy
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References
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Last Reviewed:03/07/2023
Last Updated:03/28/2023
Last Updated:03/28/2023
Bruise of child abuse - Suspected Child Abuse