1. Susan Lamb, MD Division of Child Abuse Pediatrics November 2015
When is a bruise NOT just a bruise: evaluating young children with bruising concerning for abuse
Susan Lamb, MD
Division of Child Abuse Pediatrics
November 2015

2. Dating of bruises depends on which of the following?
Color of the bruises
History of when bruises were observed by a caretaker
Size of the bruises
1 & 2
All of the above

3. Which of the following bruises are concerning for abuse?
Chest bruise in a 3 year old active boy
Anterior shin bruise in a 3 month old boy
Ear bruise in a 2 year old girl
2 & 3
All of the above

4. What is the indicated medical work-up for a 4 month old previously healthy infant boy with a bruise on his abdomen?
Skeletal Survey
Head CT
LFTs, amylase and lipase
1 & 2
All of the above

5. What is the indicated medical work-up for the 4 month old twin sister of the previous child with an abdominal bruise?
Skeletal Survey
Head CT
LFTs, amylase and lipase
1 & 2
All of the above

6. What percentage of children with serious physical abuse have a history of a prior suspicious injury?5%
15%
30%
40%
55%

7. I have no financial disclosures.

8. Participant will be able to identify the characteristics of abusive bruising and differentiate abusive from accidental bruising.
Participant will know the appropriate medical work-up for children with abusive bruises.
Objectives

9. Outline What is a bruise? Which bruises should concern me? Why?
What do I do next if I identify an abusive bruise?
What is the importance of the work-up?
An abusive bruise is missed; what is the potential harm?
Outline

10. Outline What is a bruise? Which bruises should concern me? Why?
What do I do next if I identify an abusive bruise?
What is the importance of the work-up?
An abusive bruise is missed; what is the potential harm?
Outline

11. Definitions Bruise/Contusion: Hematoma:
Bleeding beneath the intact skin at the site of blunt impact trauma
Hematoma:
Blood that has extravasated from the vascular system into the body
Hematomas may develop in the presence of natural disease process in the absence of trauma
Definitions

12. Definitions Ecchymosis: Petechiae:
Blood that has dissected through tissue planes to become visible externally
May be visible in an area never subjected to trauma
Petechiae:
Small (1-2mm) red or purple spot caused by a minor hemorrhage of capillary blood vessels
Definitions

13. Anatomy of the Skin
Epidermis- compact firm outer layer; not easily damaged
Dermis- capillaries and fibrous tissue; resistant to damage
Subcutaneous tissue- rich in capillaries and fat, easily deformed; majority of hemorrhage occurs here

14. Bruises are Injuries Blunt force impact to skin
External force exceeds vessel integrity  vessels are crushed and leak
Bruising is vascular damage, not skin damage
Site of discoloration is site of blunt impact
Presence of blood and its breakdown causes various colors associated with bruising
Bruises are Injuries

15. Dating Bruises Common knowledge:
Older bruises are green/yellow
Newer bruises are purple/red
Truth: Bruises cannot be dated by appearance
Dating Bruises

16. Can you age bruises accurately in children?
S. Maguire et al, Archives of Disease in Children 2005
Systematic review: 167 studies reviewed, 3 included
Conclusion: “A bruise cannot accurately be aged from clinical assessment in vivo or on a photograph.”
Can you age bruises accurately in children?

17. Bruising Appearance of bruise is influenced by Site of impact
Object used for impact
Amount + rate of force behind the impact
When a bruise appears depends on depth of injury
Superficial bruises appear early
Deep bruises may take days to appear
Healing time varies with location on body
Bruising

18. Dating Tools Biopsy History of a reliable caretaker
Presence of swelling
Dating Tools

19. Outline What is a bruise? Which bruises should concern me? Why?
What do I do next if I identify an abusive bruise?
What is the importance of the work-up?
An abusive bruise is missed; what is the potential harm?
Outline

20. “Those who don’t cruise rarely bruise”

22. Bruising and Mobility Bruises are uncommon in infants
<6 months of age
< 6 months: 2% had bruises
6-8 months: 5.6%
9-12 months- 17.8%
12-15 months- 51%
Study of 366 infants
Bruising and Mobility
Sugar NF et al. Bruises in infants and toddlers. Arch Pediatr Adolesc Med. 1999;153: 22 22

24. MC Pierce et al. Pediatrics 2010
Case control study of children 0 to 48 months of age admitted to PICU for trauma
42 case subjects, 53 control subjects (total 95)
Bruising characteristics (total number and body region) compared
Excluded children with bleeding disorders or indeterminate cases
Bruising Characteristics Discriminating Physical Child Abuse from Accidental Trauma

25. Cause of Injury n
MVC 29
Non–MVC 24
    Fall (ground based)a 1
    Fall from bed/couch/tablea 5
    Fall in car/bouncy seat from table/countera 4
    Fall out of bed of pick-up truck
    Fall with caregiver 2
    Fall from father's shoulders
    Fall from moving golf cart
    Pedestrian vs truck
    Jumped out of car
    All-terrain vehicle accident
    Dropped by caregiver
    Bouncy seat collapsed
    Stair fall (in walker)
    Stair fall (with caregiver)
    Caregiver fell on child
Total 53

27. Mary Clyde Pierce “Bruising Characteristics Discriminating Physical Child Abuse from Accidental Trauma” Pediatrics 2010

28. TEN 4 Bruising Model Torso: Ears: Neck: 4:
A lot of cushion to absorb injury forces
Direct abdominal blows can cause internal injury with minimal external bruising
Ears:
Difficult to bruise
Not very vascular
Neck:
Protected by the shoulders with short falls
Usually neck bruising is in the form of petechiae 4:
Bruising to T-E-N regions for children under 4 yrs of age
> 4 bruises
Any bruising on an infant < 4 months of age

29. Torso

30. Ears

31. Neck

32. Abuse
Accident
MVC
Non–MVC
All
Total no. of bruises (no. of patients)
226 (33)
49 (24)
19 (14)
68 (38)
No. of bruises in TEN aggregate region (no. of patients)
103 (25)
3 (3)
6 (6)
No. of bruises (all regions) on patients <4.0 mo of age (no. of patients)
74 (14)
9 (4)
4 (3)
13 (7)
No. of patients with >4 bruises 18

34. Stairway Injuries Significant injury is rare
Predominately reported in infants being carried down the stairs
Multiple injuries are rare
Most common injuries:
Minor soft tissue injury
Minor head or facial injury
Limb fractures
Stairway Injuries

35. M. Joffe and S. Ludwig “Stairway Injuries in Children” Pediatrics 1988

36. Patterned Injuries

40. •Relatively round marks that correspond with fingertips and/or thumb

41. Handprint (slap)

43. Buttock Bruising
Gluteal crease
Transverse blows to buttocks vertical bruising along the gluteal cleft
Vascular rupture at the junction between compressed vessels on the buttock and the protected vessels within the gluteal crease

46. Outline What is a bruise? Which bruises should concern me? Why?
What do I do next if I identify an abusive bruise?
What is the importance of the work-up?
An abusive bruise is missed; what is the potential harm?
Outline

47. Report to DSS
Work up is for ADDITIONAL injury

48. Work-Up Index Child Complete skin examination < 1 year: Head CT
< 2 years: Skeletal Survey
Follow up skeletal survey in 2 weeks
> 2 years: Targeted x-rays as indicated
Potential skeletal survey up to 4 years
Abdominal Injury suspected: LFTs, amylase, lipase
Work-Up Index Child

49. Bleeding Disorders Family history
Bleeding disorder clinically suspected
Isolated bruising without other injury
Screening with CBC, PT, PTT; consider adding Factor 8, Factor 9, testing for von Willebrand disease
Bleeding Disorders

50. N Harper et al Journal of Pediatrics 2014
Observational multicenter study
146 infants < 6 months had isolated bruising at presentation
No other injury clinically suspected
Additional Injuries in Young Infants with Concern for Abuse and Apparently Isolated Bruises

51. Total 73 children of 146 had an additional serious injury identified (50%)
Skeletal survey identified new injury in 34 (23%)
Neuroimaging identified new injury in 40 (27%)
Abdominal injury identified in 4 (3 %)
103 had coagulation studies performed and no bleeding disorders were identified
Results

52. Siblings All siblings should have a complete skin examination Twins
Don’t forget household contacts
Twins
Skeletal surveys < 2 years EVEN IF there are no visible injuries
Strongly consider Head CT < 1 year
Siblings

53. Outline What is a bruise? Which bruises should concern me? Why?
What do I do next if I identify an abusive bruise?
What is the importance of the work-up?
An abusive bruise is missed; what is the potential harm?
Outline

54. Sentinel Injuries in Infants Evaluated for Child Physical Abuse
L. Sheets et al. Pediatrics 2013
Retrospective case-control study
401 infants <12 months of age evaluated for abuse by the hospital based child abuse team
Sentinel injury defined as previous injury suspicious for abuse
Child was non-mobile
Explanation implausible
Sentinel Injuries in Infants Evaluated for Child Physical Abuse

55. Results Of 200 definitely abused infants, 27.5% had sentinel injuries
30 in AHT cohort
25 in the non-AHT cohort
Of 100 infants with intermediate concern for abuse, 8% had sentinel injuries
Of 101 nonabused infants, none had sentinel injuries
Odds Ratio: 4.4 (CI 2-9.6) p<.001
Results

56. Sentinel Injuries:
80% bruises, 11% intraoral injury, 7% fracture
In 23 of 55 (42%) abuse cases parents reported a medical provider was aware of the sentinel injury
10/23 cases provider suspected abuse
Some reported abuse and child was not protected by authorities
Some providers concluded there was no abuse due to no additional injuries
13/53 cases provider did NOT suspect abuse
Diagnosed as accident, self-inflicted or medical condition

57. In 27% of cases of definite physical abuse there may be escalating and repeated violence
Finding of a sentinel injury or the history of a sentinel injury is an opportunity to intervene and prevent further abuse
Conclusion

58. Practice Recommendations
Do a thorough skin examination
Always consider injuries in light of child’s mobility
Utilize the TEN-4 rule when evaluating young children and infants with bruising
Complete the medical work-up indicated by a suspicious bruise
Report all suspicious bruising to DSS EVEN IF no additional injuries are found during the work-up
Practice Recommendations

59. Dating of bruises depends on which of the following?
Color of the bruises
History of when bruises were observed by a caretaker
Size of the bruises
1 & 2
All of the above

60. Which of the following bruises are concerning for abuse?
Chest bruise in a 3 year old active boy
Anterior shin bruise in a 3 month old boy
Ear bruise in a 2 year old girl
2 & 3
All of the above

61. What is the indicated medical work-up for a 4 month old previously healthy infant boy with a bruise on his abdomen?
Skeletal Survey
Head CT
LFTs, amylase and lipase
1 & 2
All of the above

62. What is the indicated medical work-up for the 4 month old twin sister of the previous child with an abdominal bruise?
Skeletal Survey
Head CT
LFTs, amylase and lipase
1 & 2
All of the above

63. What percentage of children with serious physical abuse have a history of a prior suspicious injury?5%
15%
30%
40%
55%

64. S. Maguire et al. “Can you age bruises accurately in children
S. Maguire et al. “Can you age bruises accurately in children? A systemic review.” Archives of Diseases in Children 2005;90:
MC. Pierce et al. “Bruising Characteristics Discriminating Physical Child Abuse from Accidental Trauma.” Pediatrics 2010;125:67-74.
American Academy of Pediatrics. “The Evaluation of Suspected Child Physical Abuse” Pediatrics 2015.
M. Joffe and S. Ludwig “Stairway Injuries in Children” Pediatrics ;2:
N. Harper et al. “Additional Injuries in Young Infants with Concern for Abuse and Apparently Isolated Bruises.” Journal of Pediatrics 2014;165:
L. Sheets et al. “Sentinel Injuries in Infants Evaluated for Child Physical Abuse.” Pediatrics 2013;131:
References

65. Thank you