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Other useful references

The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.


  • Tourniquet syndrome has been described in infants as both an abusive and non-abusive injury 1,2,3,4
    • One comparative study (57 children) noted 67% were experiencing extreme poverty or neglect 3
  • Surgeons and paediatricians both need to be aware of a possible abusive aetiology 1,2

  • Petechiae in the absence of bruising may occur as a consequence of suffocation 5

  • Mongolian blue spots are recorded on feet, scalp, knee and back as well as lumbosacral and gluteal area 6

  • Acute haemorrhagic oedema of infancy may present with multiple purpuric lesions which may mimic bruising 7
  • Subgaleal haematoma has been described in a toddler following hair braiding 8

  • Extended coagulation screen was not performed 8

  • Soft tissue injury, evidenced by elevated CPK 9 or renal failure as a consequence of haemoglobinuria has been sustained when children were severely beaten 10

  • Absence of abdominal bruising does not preclude a significant abdominal injury 11 just as the absence of bruising does not preclude AHT 12
  • Amongst a group of infants aged less than one year with confirmed abuse, the most frequent “sentinel injury” identified prior to this was a bruise 13
  • A study of 77 infants with abusive fractures of whom 32% had missed opportunities for the diagnosis of child abuse and the most common sign on examination prior to the diagnosis of abuse was bruising or swelling 14
  • An analysis of children with suspected abuse and an apparently isolated bruise underwent investigation. 23.3% of whom had positive skeletal survey, and 27.4% positive neuroimaging 15


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  1. Biehler JL, Sieck C, Bonner B, Steumky JH. A survey of health care and child protective services provider knowledge regarding the Toe Tourniquet syndrome. Child Abuse and Neglect. 1994;18(11):987-993 [Pubmed]
  2. Klusmann A, Lenard H-G. Tourniquet syndrome: accident or abuse? European Journal of Pediatrics. 2004;163(8):495-498 [Pubmed]
  3. Claudet I, Pasian N, Maréchal C, Salanne S, Debuisson C, Grouteau E. [Hair-thread tourniquet syndrome] [French]. Archives de Pédiatrie. 2010;17(5):474-479 [Pubmed]
  4. Cutrone M., Magagnato L. Hair thread tourniquet syndrome. Three cases in ten years. European Journal of Pediatric Dermatology. 2009;19(1):23-26 [Abstract provided by European Journal of Pediatric Dermatology]
  5. Oehmichen M, Gerling I, Meißner C. Petechiae of the baby's skin as differentiation symptom of infanticide versus SIDS. Journal of Forensic Sciences. 2000;45(3):602-607 [Pubmed]
  6. Egemen A, Ikizoglu T, Ergör S, Asar GM, Yilmaz O. Frequency and characteristics of mongolian spots among Turkish children in Aegean region. Turkish Journal of Pediatrics. 2006;48(3):232-236 [Pubmed]
  7. Robl R, Robl M, Marinoni LP, Abagge KT, Carvalho VO. Target-shaped edematous purple lesions: is it child abuse? Archives of Disease in Childhood. 2014;99(1):44-5 [Pubmed citation only]

  8. Onyeama CO, Lotke M, Edelstein B. Subgaleal hematoma secondary to hair braiding in a 31-month-old child. Pediatric Emergency Care. 2009;25(1):40-41 [Pubmed]
  9. Sussman S, Squires J, Stitt R, Zuckerbraun N, Berger RP. Increased serum creatine phosphokinase in a child with bruising due to physical abuse. Pediatric Emergency Care. 2012;28(12)1366:1368.[Pubmed]

  10. Rimer RL, Roy S, 3rd. Child Abuse and Hemoglobinuria. Journal of the American Medical Association. 1977;238(19):2034-2035 [Pubmed]
  11. Barnes PM, Norton CM, Dunstan FD, Kemp AM, Yates DW, Sibert JR. Abdominal injury due to child abuse. Lancet. 2005;366(9481):234-235 [Pubmed]
  12. Maguire SA, Kemp AM, Lumb RC, Farewell DM. Estimating the probability of abusive head trauma: A pooled analysis. Pediatrics. 2011;128(3):e550-e564 [Pubmed]
  13. Sheets LK, Leach ME, Koszewski IJ, Lessmeier BS, Nugent M, Simpson P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707. [Pubmed]

  14. Thorpe EL, Zuckerbraun NS, Wolford JE, Berger RP. Missed opportunities to diagnose child physical abuse. Pediatric Emergency Care. 2014;30(11):771-776 [Pubmed]

  15. Harper NS, Feldman KW, Sugar NF, Anderst JD, Lindberg DM. Additional injuries in young infants with concern for abuse and apparently isolated bruises.The Journal of Pediatrics. 2014;165(2):383-388 [Pubmed]


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