Bruising

  • VFPMS Guideline: Forensic investigation of bruising

    Bruising is caused by bleeding under intact skin due to trauma. Bruises are common childhood injuries. Bruising is also the most common injury sustained by children who have been abused. Differentiating between bruising from accidental and inflicted mechanisms can be challenging.

    Key points:

    The following findings are concerning:

    • Bruising in children who are not cruising or independently mobile.
    • Bruising on torso (including chest, abdomen, back, buttocks and genitalia), ears and neck (use TEN 4 FACES Clinical Decision Rule). Under certain circumstances, bruising on upper arms or anterior thighs might also raise suspicion for abuse.
    • Bruising that is not on the front of the body or over a bony prominence.
    • Bruising that is abnormally large or multiple bruises.
    • Bruising that is clustered or patterned.
    • Bruising with petechiae.
    • Bruising that does not fit with the mechanism described.

    The age of a bruise cannot be determined on the basis of its colour. Multiple bruises that appear different may have been sustained at the same time.

    The possibility that the child has a bleeding disorder should be considered although it should be remembered that children who have bleeding disorders can also sustain inflicted injuries.

     TEN 4 FACES Clinical Decision Rule (adapted from Pierce et al, 2009)
     

    If these criteria are met, have clinical concern for abuse:

    • Bruising in TEN location (Torso, Ear, Neck) in child <4years-old
    • Any bruising in child <4-6months-old
    • Injury to FACES (Frenulum, Angle of jaw, Cheek, Eyelid, Sclera) in child of any age

    Investigations:

    Laboratory investigations for underlying causes of bruising

     First line investigations
    • FBE
    • APTT
    • PT/INR
    • Fibrinogen
     

    Second line investigations

    (to be performed whenever Abusive Head Trauma is suspected and in selected situations when disorders of coagulation are suspected)

    • VWD screen and blood group
    • Factor VIII and IX levels (girls as well as boys)
    • Calcium
    • LFT (proteins) – for secondary platelet dysfunction
    • U&E, Creatinine – for secondary platelet dysfunction 
     

    Additional investigations may be indicated

     

    In young children who have intracranial bleeding (known or suspected) then consider ordering additional tests of blood coagulation known as “extended clotting studies”. These are second line investigations to be performed in carefully selected cases.

    • Factor XIII (and consider factor XI)
    • Platelet function tests
    • +/- Inflammatory markers (if vasculitis suspected)
    • Consider consulting with paediatric haematologist


    Investigations for associated (possibly occult) injuries

    • In children <2years-old (and rarely in older children) consideration should be given to radiological investigation of occult fractures.
    • In the presence of abdominal bruising, consideration should be given for screening of abdominal injury.
    • In selected cases (including any young infant with bruising) consideration should be given to possible head injury (Abusive Heat Trauma), including trauma through shaking and/or impact.


    Useful resources and articles: