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Objectives
• Create differential diagnosis for bruising
• Review red flags concerning for inflicted injury
• Work up required for a child presenting with bruising suspicious for inflicted injury
• Understand implications of bruising as sentinel injuries
Bruising
• Caused by trauma or impact to the skin
• Blood vessel injury and leakage of blood into subcutaneous tissues
• When there is underlying bone close to skin, bruising occurs more easily
• When there is soft tissue close to skin, it acts as a cushion and bruising occurs less easily
Background
• Bruises are common in children
• Cannot be dated based on their colour
• Accidental bruising: Usually due to minor trauma - Bump, fall, routine active play
• Inflicted bruising: child maltreatment • Do not use “intentional” or “unintentional”
- Intentionality cannot be determined objectively - Unintended meaning in Justice system
The Case
• Oliver Twist • 3 month old baby boy
• Mother brings him to hospital due to runny nose, coughing, and crying
• While performing the physical examination, you notice something on his abdomen
The Case
• Describe what you see – are you concerned?
Image: Livingston, N., Bruising in Infancy; Annals of Pediatrics; 2010
History
• How did the bruise get there?
• Does the child have bleeding elsewhere (epistaxis, hematuria, blood in stools?)
• Medications, nutritional history, temperament of child
• Family history: bleeding or collagen vascular disease
• Detailed social history of home situation, stressors, supports, previous involvement of CAS with family
History
• Bruise got there because Oliver was sleeping on a toy
• He has never had bleeding or bruising before
• No medications; Formula feeding well with good growth
• No family history of bleeding or collagen vascular disease
• Mother is 30 year old accountant, lives in Burlington with husband who is a lawyer. No previous CAS involvement, having Oliver at home has been little stressful because he cries often. Rest of family lives in England.
Physical Exam
• HR 162, RR 40, BP 72/45, Temp 37°C, O2 sat 99% on RA
• Flat fontanelle, crying, but consolable • Normal cardiac exam • Normal respiratory exam
• Small purple bruises on right abdomen otherwise normal abdominal exam
• Normal male genitalia, testes descended bilaterally • Normal hips and spine • Moving all four limbs, good suck and tone
Physical Exam • On examination of Oliver’s legs, you notice
something. Describe what you see – are you concerned?
Image: Livingston, N., Bruising in Infancy; Annals of Pediatrics; 2010
Suspected Child Maltreatment • Red flags for inflicted injury in child with bruising
1. Bruises in babies who are not yet cruising 2. Bruises on ears, neck, feet, buttocks, or torso
(torso = chest, back, abdomen, genitalia) 3. Bruises not on front of body and/or overlying bone 4. Unusually large or numerous 5. Clustered or pattered (pattern may include, handprints, loop or belt marks) 6. Bruise does not fit with mechanism described
CPS Practice Point, Medical Assessment of Bruising in Suspected Child Maltreatment cases; 2013
Differential Diagnosis
Not all Bruising is Abuse! Slate Grey Nevus of Childhood (Mongolian blue spots)
Connec?ve Tissue Disorders Ehlers-‐Danlos Osteogenesis Imperfecta Infec?ons (ex. Meningococcemia)
Bleeding disorders Immune thrombocytopenic purpura Von Willebrand Disease Hemophillia A (Factor 8 deficiency) Hemophillia B (Factor 9 deficiency)
Malignancy (ex. Leukemia, neuroblastoma)
Severe systemic illness (ex. DIC)
Vasculi?s (ex. Henonch-‐Schonlein Purpura)
Nutri?onal Deficiencies (ex. Vitamin K or C)
Hemangioma Striae
Phytophotoderma??s Erythema Mul?forme
Cupping or Coining Skin staining from dyes
Eczema Incon?en?a Pigmen?, Nevi of Ito
CPS Practice Point, Medical Assessment of Bruising in Suspected Child Maltreatment cases; 2013
Workup
• Admit Oliver to hospital • Call Child Protection Services (Children’s Aid
Society) • Involve Child Maltreatment Pediatricians (at McMaster, CAAP team – Child Advocacy & Protection)
• CBC and differential • INR and PTT • Liver enzymes, lipase
• Skeletal Survey • Head CT and Abdominal CT • Opthalmology exam
Workup
• CBC and differential – NORMAL • INR and PTT – NORMAL • Liver enzymes, lipase – NORMAL
• Skeletal Survey – PENDING • Head CT and Abdominal CT – NORMAL • Opthalmology exam – NORMAL
Workup
• Describe finding on skeletal survey – are you concerned?
Image: Pressel, D., Evaluation of Physical Abuse in Children; American Family Physician; 2000
Workup
• Describe finding on skeletal survey – are you concerned?
Image: Pressel, D., Evaluation of Physical Abuse in Children; American Family Physician; 2000
Test Your Knowledge
• Which bruise is the oldest?
Bruise #1 Bruise #2
A. Bruise #1 B. Bruise #2 C. They are the same age D. No idea
Test Your Knowledge
• Concerning or not concerning for abuse?
Image: Pressel, D., Evaluation of Physical Abuse in Children; American Family Physician; 2000
Test Your Knowledge
• Concerning or not concerning for abuse?
Image: Pressel, D., Evaluation of Physical Abuse in Children; American Family Physician; 2000
The Answer
• Answer D: Concerning
Repeated patterned bruises on the back (in this case, loop marks from a cord)
?
Test Your Knowledge
• Concerning or not concerning for abuse?
Image: Harris, T, Bruises in Children; JPEDHC; 2010
Summary
• Bruising is common and not all bruising is child abuse
• Always consider medical and accidental explanations
• Always consider child abuse on the differential
• Red flag bruising can be a sentinel finding for more significant injuries associated with child abuse