patterns of bruising in non-accidental injury of children
The Welsh Child Protection Systematic Review Group (http://www.core-info.cardiff.ac.uk/about%20wcpsrg.html) conducted an all language literature review in order to answer the question 'Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse?'.
Maquire et al (2005) reviewed 167 papers, of which 23 met their inclusion criteria.
Bruising in non-abused children
Bruising is the commonest injury in children who have been physically abused, but they also sustain bruises from every day activities.
Patterns of bruising do not differ by socio-economic group in non-abused children, and there is no difference bewteen girls and boys. An increase in accidental bruising has been noted in the summer months and with a larger family size (Carpenter 1999; Labbe and Caouette 2001).
Bruising is strongly associated with increased mobility, (Carpenter 1999; Wedgwood 1990) and children sustain more bruises as they become older. Bruising in a baby who is not crawling (with no independent mobility) is very uncommon (in less than 1%) (Sugar et al 1999).
17% of infants who are cruising have bruises (range 1-5), whilst 52% of those who are walking have bruises (mean 5.6, range 1-27 bruises).
In mobile children, the commonest site of bruising is the shins and knees, and most accidental bruises are noted over bony prominences, on the front of the body.
Bruising to the head may be seen in children who are pulling to stand, and who often bump their heads, especially their foreheads (Sugar et al 1999; Tush 1982; Wedgwood 1990; Carpenter 1999).
Bruising is uncommon on the following areas; back, buttocks, forearm, face, ears, abdomen or hip, upper arm, posterior leg, foot or hands (Sugar et al 1999; Tush 1982; Wedgwood 1990; Carpenter 1999; Dunstan et al 2002).
The following conditions have been confused with bruising in cases of possible Non Accidental Injury (NAI) in children;
- Platelet aggregation disorders
- Disseminated intravascular coagulation
- Vitamin K deficiency
- Henoch-Schonlein purpura
In addition, ‘Mongolian blue spots’ (McKee et al 2005) are a ‘classic’ mimic for bruising. These are particularly common amongst African or Asian children, and are merely congenital marks on the back, shoulders, shins or ankles etc, and which are often dark blue or violet in colour.
Bruising in abused children
There is no difference between patterns of bruising in boys or girls (Johnson and Showers 1985). Bruises are larger in abused children, and they have more bruises (0-44) (Atwal et al 1998; Dunstan et al 2002).
Bruising is most common on the head, but any part of the body is vulnerable - in particular other sites commonly found to be bruised include the ear, face, neck, trunk, buttocks and arms.
Bruising is the most common injury in physical abuse, but fatal head injuries and fractures can occur without bruising (71% of fatal cases reviewed by Atwal et al (1998) had evidence of new bruising (63% had old bruises, whilst 54% had a combination of fresh and old bruises indicating abuse over an extended time frame) (de Silva and Oates 1993; Dunstan et al 2002; Jappie 1994; Smith and Hanson 1974, Worlock et al 1986).
Where bruising is absent, Atwal et al (1998) speculated that this was due to an insufficient degree of force being applied, gripping being cushioned by clothing, or the disappearance of the bruising by the time of autopsy. Bruising found on those with fatal head injuries is primarily found on the head and face, with lesser amounts on the lower limbs and the buttocks.
Clusters of bruises are common - often defensive injuries on the upper arm, outside of the thigh or bruises on the trunk and adjacent limb. They are often seen on soft parts of the body (in contrast to those in non-abused children) and can be accompanied by scars and/ or abrasions (Brinkmann et al 1979; Sussman 1968; Naidoo 2000).
Abusive bruises are often patterned or 'tramline', including those caused by hands ('slaps'), electric cords or ropes etc (Brinkman et al 1979; Ellerstein 1979; Jappie 1985; Johnson 1985; Johnson et al 1990; Sussman 1968).
Bruising to the cheeks and ears was found to be typical of punches and slaps, whilst when they were present, bruises around the ankles were thought to be ‘diagnostic’ of gripping (Atwal et al 1998).
Specific patterns of bruising have been described in abuse cases; vertical gluteal cleft bruising and bruising to the pinna of the ear where the shape assumes the line of anatomical stress, rather than the shape of the injuring object (Feldman 1992; Jappie 1994; Leavitt et al 1992).
Derm Atlas image - 'tramline bruise' from lamp cord
When deciding whether bruising was caused as the result of an accident or abuse, the history of the injury may indicate which is the most likely explanation (having regard of the site of the injury, any pattern present, the stage of development of the child and the presence of other (older) injuries etc).
Where the child is mobile, areas overlying bony parts of the body, such as the shins and the forehead are particularly prone to getting knocked accidentally (as any parent will know!), and so judgement must be based on common sense as much as anything else.
Post mortem evaluation of bruising articles:
- In the infant/ child - James and Leadbeatter (2002);
- Examination of the back - Hiss and Kahana (1996)
- Atwal G.S., Rutty G.N., Carter N., Green M.A. (1998), ‘Bruising in non-accidental head injured children: a retrospective study of the prevalence, distribution and pathological associations in 24 cases’, Forensic Science International 96(2-3):215-230
- Brinkman B , Puschel K, Matzsch T. (1979) 'Forensic dermatological aspects of the battered child syndrome. Akt Dermatolol 5:217–32.
- Carpenter RF. (1999) 'The prevalence and distribution of bruising in babies'. Arch Dis Child 80:363–6
- de Silva S , Oates K. (1993) 'Child homicide—the extreme of child abuse'. Med J Aust 158:300–1
- Dunstan FD, Guildea ZE, Kontos K, et al. (2002) 'A scoring system for bruise patterns: a tool for identifying abuse'. Arch Dis Child 86:330–3.
- Ellerstein NS. (1979) 'The cutaneous manifestations of child abuse'. Am J Dis Child 133:906–9
- Feldman KW. (1992) 'Patterned abusive bruises of the buttocks and the pinna'. Pediatrics 90:633–6.
- Hiss J, Kahana T (1996), 'Medicolegal investigation of death in custody: a postmortem procedure for detection of blunt force injuries', Am J Forensic Med Pathol 17(4):312-314
- James R, Leadbeatter S (2002), 'The forensic examination of the infant and young child', Current Diagnostic Pathology 8:384-394
- Johnson CF, Showers J. (1985) 'Injury variables in child abuse. Child Abuse Negl 9:207–15
- Johnson CF, Kaufman KL, Callendar C. (1990) 'The hand as a target organ in child abuse'. Clin Pediatr (Phila) 29 (2) :66–72.
- Labbe J , Caouette G. (2001) 'Recent skin injuries in normal children'. Pediatrics 108:271–6
- Leavitt EB, Pincus RL, Bukachevsky YR. (1992) 'Otolaryngoloesgic manifestations of child abuse'. Arch Otolaryngol Head Neck Surg 118:629–31.
- Maquire S, Mann MK, Sibert J, Kemp A (2005), 'Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review', Arch Dis Child 90:182-186
- McKee PH, Calonje E, Grantner SR (2005), 'Pathology of the skin - with clinical correlations', 3rd Edition, Elsevier Mosby, Philadelphia, USA
- Naidoo S . (2000) 'A profile of the oro-facial injuries in child physical abuse at a children’s hospital'. Child Abuse Negl 24:521–34
- Nathanson M. (2003), ‘The physically and emotionally abused child’, Chapter 11 in Mason J.A. and Purdue B.N. (Ed), ‘The Pathology of Trauma’, 3rd Ed Arnold Publishing
- Smith SM, Hanson R. (1974) '134 battered children: a medical and psychological study'. BMJ 3:666–70
- Sugar NF, Taylor JA, Feldman KW. (1999) 'Bruises in infants and toddlers: those who don’t cruise rarely bruise'. Puget Sound Pediatric Network. Arch Pediatr Adolesc Med 153:399–403
- Sussman SJ. (1968) 'Skin manifestations in the battered child syndrome'. J Pediatr 1968;72:99–100
- Tush BAR. (1982) 'Bruising in healthy 3-year-old children'. Matern Child Nurs J 11 (23) :165–79
- Wedgwood J . (1990) 'Childhood bruises'. Practitioner 234:598–601.[Medline]
- Worlock P , Stower M, Barbor P. (1986) 'Patterns of fractures in accidental and non-accidental injury in children: a comparative study'. BMJ 293:100–2.[Medline]
Additional references from Maquire et al (2005)
- Lynch A . (1975) 'Child abuse in the school-age population'. Journal of School Health 45:141–8.
- Centre for Reviews and Dissemination (CRD). Undertaking systematic reviews of research on effectiveness. CRD’s guidance for those carrying out or commissioning reviews. CRD report number 4, 2nd edn. University of York 2001.
- Mortimer PE, Freeman M. (1983) 'Are facial bruises in babies ever accidental?' Arch Dis Child 58:75–6.
- Lyons TJ, Oates K, (1993) 'Falling out of bed: a relatively benign occurrence'. Pediatrics 92:125–7 McMahon P , Grossman W, Gaffney M, et al.(1995) 'Soft tissue injury as an indication of child abuse'. J Bone Joint Surg 77A:1179–83.
- Galleno H , Oppenheim WL. (1982) 'The battered child syndrome revisited'. Clin Orthop 162:11–19 Keen JH. (1981) 'Normal bruises in pre-school children'. Arch Dis Child 56:75.
- Roberton DM, Barbor P, Hull D. (1982) 'Unusual injury? Recent injury in normal children and children with suspected non accidental injury'. BMJ 285:1399–401 del Ciampo LA, Ricco RG, De Almeida CA, et al (2001) 'Incidence of childhood accidents determined in a study based on home surveys'. Ann Trop Paediatr 21:239–43