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When is a bruise NOT just a bruise: evaluating young children with bruising concerning for abuse

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. Dating of bruises depends on which of the following? Color of the bruises History of when bruises were observed by a caretaker

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When is a bruise NOT just a bruise: evaluating young children with bruising concerning for abuse

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  1. 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. Disclosure

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

  16. 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. 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. Biopsy • History of a reliable caretaker • Presence of swelling Dating Tools

  19. 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”

  21. 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% Bruising and Mobility Sugar NF et al. Bruises in infants and toddlers. Arch Pediatr Adolesc Med. 1999;153:399-403

  22. 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

  23. TEN 4 Bruising Model Torso: 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

  24. Torso

  25. Ears

  26. Neck

  27. 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

  28. M. Joffe and S. Ludwig “Stairway Injuries in Children” Pediatrics 1988.82;2:460

  29. Patterned Injuries

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

  31. Handprint (slap)

  32. Buttock Bruising 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 Gluteal crease

  33. 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

  34. Report to DSS Work up is for ADDITIONAL injury

  35. 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

  36. 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

  37. 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

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