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 Head Trauma), including trauma through shaking and/or impact.

Useful resources and articles:

Pierce et al.’s article (2009) Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma offers a useful clinical screening tool for bruising.
The Canadian Paediatric Society’s Practice Point (Canada, 2017) The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective provides a good summary of key points in suspicious bruising
The American Academy of Pediatric’s Clinical Report (USA, 2013) Evaluation for Bleeding Disorder in Suspected Child Abuse provides a review of guidance for recommended investigations of underlying causes for bruising
The Royal College of Paediatrics and Child Health's review (UK, 2017) Child Protection Evidence on Bruising evaluates the literature on bruising and presents data on the following questions: Which patterns are suggestive of abuse? Can a bruise be accurately aged?
Wood et al.’s article (2015) Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Bruises presents the Children’s Hospital of Philadelphia’s approach to investigation for occult bony injury in patients with suspicious bruising
Collins et al.’s article Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study highlights the importance of considering physical abuse even in the context of underlying medical conditions

The Royal Children's Hospital Melbourne

Victorian Forensic Paediatric Medical Service