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Patterns and sites – abused

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.

 

Bruising in abused children

 

Gender

  • There is no difference in bruising patterns between boys and girls 3-5 

Trends in abusive bruising

  • Children who have been abused have on average more bruises than children who have not been abused, they may sustain anything from 0-44 bruises each 1,2,6
  • Abusive bruises were significantly bigger in abused children than in non-abused children 1,2,6

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References

  1. Atwal GS, Rutty GN, Carter N, Green MA. Bruising in non-accidental head injured children; a retrospective study of the prevalence, distribution and pathological associations in 24 cases. Forensic Science International. 1998;96(2):215-230 [Pubmed]
  2. Dunstan FD, Guildea ZE, Kontos K, Kemp AM, Sibert JR. A scoring system for bruise patterns: a tool for identifying abuse. Archives of Disease in Childhood. 2002;86(5):330-333 [Pubmed]
  3. Johnson CF, Showers J. Injury variables in child abuse. Child Abuse and Neglect. 1985;9(2):207-215 [Pubmed]
  4. Kemp AM, Dunstan F, Nuttall D, Hamilton M, Collins P, Maguire S. Patterns of bruising in preschool children - a longitudinal study. Archives of Disease in Childhood. 2015;100(5):426-31 [Pubmed]

  5. Nayak K, Spencer N, Shenoy M, Rubithon J, Coad N, Logan S. How useful is the presence of petechiae in distinguishing non-accidental from accidental injury? Child Abuse and Neglect. 2006;30(5):549-555 [Pubmed]
  6. Pierce M, Kaczor K, Aldridge S, O'Flynn J, Lorenz D. Bruising characteristics discriminating physical child abuse from accidental trauma [published erratum appears in Pediatrics 2010;125(4):861]. Pediatrics. 2010;125(1):67-74 [Pubmed]

The sites and characteristics of bruising in abused children

        • The head is by far the commonest site of bruising in child abuse 1,3,4,8,9,12,16,23,25
        • Three infants aged less than five months each presented with bruising to the face which was not investigated further. All three re-presented with abusive head trauma, reiterating that bruising to the face in a non-mobile infant may be a sentinel injury 21
        • Other commonly bruised sites in abuse include the ear, neck, trunk, buttocks, thighs, and arms 1,3,4,9,12,16,23,25
        • Although bruising is the commonest injury in physical abuse, fatal non-accidental head injury and non-accidental fractures can occur without bruising 1,3,4,9,16,23,25
        • Abusive bruises can occur amongst other types of soft tissue injuries. These may be recent and older injuries e.g. scars and healed abrasions 2,16,24
        • Any part of the body is vulnerable to bruising from abuse 2,16,24
        • Clusters of bruises are a common feature in abused children. These are often defensive injuries as the child tries to protect their head: on the upper arm, side of chest, outside of the thigh, or bruises on the trunk and adjacent limbs  2,12,13,15,16,24
        • The presence of areas of bruising interspersed with small abrasions is consistent with being hit with a rope 2,16,24
        • Abusive bruises often carry the imprint of the implement used. These include single or multiple linear bruising due to being struck with a rod-like instrument, banding where the hand has been tied and an imprint of the implement such as an electrical cord, studded belt or dog collar 2,5,7-11,13,15,16,18,19,24
        • A combination of digital photography and a plastic overlay outlining alleged perpetrator’s handprints may help to identify who caused the injury 19
        • In contrast to non-abused children, bruises in child abuse are commonly seen on soft parts of the body 6,12,17,22
        • Specific patterns of abusive bruising are described and include; vertical gluteal cleft bruising and bruising to the pinna of the ear where the shape of the bruise assumes the line of anatomical stress rather than the shape of the injuring object 7,8,14,16
        • Among a study of 519 children referred under child protection procedures, the 350 with abuse substantiated showed significantly more bruising than those with abuse excluded. The abused children had significant numbers of bruises on the cheeks, neck, head, trunk, front of thighs, upper arms, buttocks or genitalia 13

  • Patterned bruising may be accompanied by petechiae in abused children 2,9,13,18. The presence of petechiae with bruising occurs more commonly in abuse than accidental injuries, positive predictive value of 80.0 (95% CI 64.1 ,90.0). The absence of petechiae is not helpful in excluding abuse 18. 54/350 (15.4%) of the abused children in one study had petechiae 13
  • Abusive fractures were rarely accompanied by overlying bruises (58% of fractures had no bruises, 17% had bruises away from the fracture site) 20
  • This applied to diaphyseal and metaphyseal fractures 20
  • 23.3% of 137 infants aged less than 6 months investigated for an isolated bruise had occult fractures identified 8

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References

  1. Atwal GS, Rutty GN, Carter N, Green MA. Bruising in non-accidental head injured children; a retrospective study of the prevalence, distribution and pathological associations in 24 cases. Forensic Science International. 1998;96(2):215-230 [Pubmed]
  2. Brinkmann B, Püschel K, Mätzsch T. Forensic dermatological aspects of the battered child syndrome. Aktuelle Dermatologie. 1979;5(6):217-232
  3. de Silva S, Oates RK. Child homicide - the extreme of child abuse. Medical Journal of Australia. 1993;158(5):300-301 [Pubmed]
  4. Dunstan FD, Guildea ZE, Kontos K, Kemp AM, Sibert JR. A scoring system for bruise patterns: a tool for identifying abuse. Archives of Disease in Childhood. 2002;86(5):330-333 [Pubmed]
  5. Ellerstein NS. The cutaneous manifestations of child abuse and neglect. American Journal of Diseases of Children. 1979;133(9):906-909 [Pubmed]
  6. Feldman KW. The bruised premobile infant; should you evaluate further? Pediatric Emergency Care. 2009;25(1):37-39 [Pubmed]
  7. Feldman KW. Patterned abusive bruises of the buttocks and the pinnae. Pediatrics. 1992;90(4):633-636 [Pubmed citation only]
  8. 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]

  9. Jappie F. Non accidental injuries in children. Australian Family Physician 1994;23(6):1144-1150 [Pubmed citation only]
  10. Johnson CF, Kaufman KL, Callendar C. The hand as a target organ in child abuse. Clinical Pediatrics. 1990;29(2):66-72 [Pubmed]
  11. Johnson CF, Showers J. Injury variables in child abuse. Child Abuse and Neglect. 1985;9(2):207-215 [Pubmed]
  12. Kemp AM, Dunstan F, Nuttall D, Hamilton M, Collins P, Maguire S. Patterns of bruising in preschool children - a longitudinal study. Archives of Disease in Childhood. 2015;100(5):426-31 [Pubmed]

  13. Kemp AM, Maguire SA, Nuttall D, Collins P, Dunstan F. Bruising in children who are assessed for suspected physical abuse. Archives of Disease in Childhood. 2014;99(2):108-113 [Pubmed]

  14. Leavitt EB, Pincus RL, Bukachevsky R. Otolaryngologic manifestations of child abuse. Archives of Otolaryngology - Head & Neck Surgery. 1992;118(6):629-631 [Pubmed]
  15. Mosqueda Peña R, Ardura García C, Barrios López M, Casado Picón R, Palacios Cuesta A. Lesiones equimóticas en miembro superior [Spanish]. Ecchymotic injuries in upper extremity. Acta Pediátrica Española. 2008;66(4):198-200
  16. Murty OP, Ming CJ, Ezani MA, Yan PK, Yong TC. Physical injuries in fatal and non-fatal child abuse cases: A review of 16 years with hands on experience of 2 years in Malaysia. International Journal of Medical Toxicology and Legal Medicine. 2006;9(1):33-43
  17. Naidoo S. A profile of the oro-facial injuries in child physical abuse at a children's hospital. Child Abuse and Neglect. 2000;24(4):521-534 [Pubmed]
  18. Nayak K, Spencer N, Shenoy M, Rubithon J, Coad N, Logan S. How useful is the presence of petechiae in distinguishing non-accidental from accidental injury? Child Abuse and Neglect. 2006;30(5):549-555 [Pubmed]
  19. Patno K, Jenny C. Who slapped that child? Child Maltreatment. 2008;13(3):298-300 [Pubmed]
  20. Peters ML, Starling SP, Barnes-Eley ML, Heisler KW. The presence of bruising associated with fractures. Archives of Pediatrics & Adolescent Medicine. 2008;162(9):877-881 [Pubmed]
  21. Petska HW, Sheets LK, Knox BL. Facial bruising as a precursor to abusive head trauma. Clinical Pediatrics. 2013;52(1):86-8 [Pubmed citation only]

  22. Pierce M, Kaczor K, Aldridge S, O'Flynn J, Lorenz D. Bruising characteristics discriminating physical child abuse from accidental trauma [published erratum appears in Pediatrics 2010;125(4):861]. Pediatrics. 2010;125(1):67-74 [Pubmed]
  23. Smith SM, Hanson R. 134 battered children: a medical and psychological study. British Medical Journal. 1974;3(5932):666-670 [Pubmed]
  24. Sussman SJ. Skin manifestations of the battered-child syndrome. Journal of Pediatrics. 1968;72(1):99-101 [Pubmed citation only]
  25. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. British Medical Journal (Clinical Research Edition). 1986;293(6539):100-102 [Pubmed]

Scalping

  • One study found 5% of children had subgaleal haematomas (9/10 with associated skull fracture) 1
  • A boggy swelling to the forehead and periorbital oedema with no skull fracture, due to ‘scalping’ violently pulling the child’s hair leading to subgaleal haematoma 2,3

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References

  1. Peters ML, Starling SP, Barnes-Eley ML, Heisler KW. The presence of bruising associated with fractures. Archives of Pediatrics & Adolescent Medicine. 2008;162(9):877-881 [Pubmed]
  2. Schultes A, Lackner K, Rothschild MA. "Scalping": A possible indicator for child abuse [German]. Rechtsmedizin. 2007;17(5):318-320 [Abstract from Springer]
  3. Seifert D, Puschel K. Subgaleal hematoma in child abuse. Forensic Science International. 2006;157(2):131-133 [Pubmed]

Bruising in pre-mobile children

  • One study emphasised the need to investigate pre-mobile children with unexplained bruising (one haemophiliac and two abused infants) 1
  • Three infants noted to have bruising were not investigated for child protection concerns 2
  • All three re-presented with severe abuse (rank 1 – see ranking of abuse), two fatally 2

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References

  1. Feldman KW. The bruised premobile infant; should you evaluate further? Pediatric Emergency Care. 2009;25(1):37-39 [Pubmed]
  2. Pierce M, Smith S, Kaczor K. Bruising in infants: those with a bruise may be abused. Pediatric Emergency Care. 2009;25(12):845-847 [Pubmed]

 

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