Friday, September 11, 2015

A Child with Bruises of Different Ages

A Child with Bruises of Different Ages

Case presentation: The 3 - year - old male pictured here has been brought in by his parents because of altered mental status following a fall. His parents report that about an hour ago he tripped on some of his own toys and fell down the stairs at home. He did not lose consciousness but he has been “very sleepy” since. On examination, he is lethargic but arousable and obeys commands.

He also has gross deformity, point tenderness, and erythema at the middle anterior aspect of his right humerus.

In addition, he has facial contusions and back contusions as illustrated that appear to be of varying ages.

Question: Which of the following bruising patterns is least concerning for child abuse?

A. Bruising on the right knee of a 2-month-old infant

B. Multiple bruises on the knees and shins of a 3-year old female

C. A 5-year-old male with multiple bruises on his cheeks and forehead

D. A 2-year-old female with bruising along the arms that appears to have a consistent loop pattern

E. Multiple bruises along the buttocks of a 2-year-old male

Answer: BDiagnosis: Child abuse

Discussion: Much effort has been directed toward collecting and interpreting information about patterns of bruising in children in order to allay or corroborate the suspicion of child abuse, and this remains an area of active research. Any concern based on bruising alone should always be interpreted in the context of the developmental status of the child, the clinical scenario, and the explanation given by caregivers (as well as the consistency of that explanation). While each child should be evaluated in such context, a review of the recent medical literature does support the finding that some patterns of bruising are more suggestive of abuse and should therefore alert the physician to consider that possibility.

Some patterns of bruising are found more often with accidental mechanisms and may be more reassuring. For example, bruising of the shins and knees in a child old enough to ambulate independently can be expected as developmentally appropriate. Bruises over bony prominences
(e.g., the forehead) may also be less suspicious in appropriately mobile children.

In contrast, bruising in a child or infant that is not independently mobile is worthy of some suspicion, especially if the proposed mechanism is not plausible. Bruising in infants less than 6 months of age has been found to be extremely uncommon. Even as a child reaches 9 months, bruises remain relatively scarce. There are certain areas of the body where the discovery of bruises should be  considered suspicious for abuse.

These include areas away from bony prominences, and parts of the body that are heavily padded with underlying fat. Some of the concerning areas include the following: the buttocks, face (especially the philtrum and upper lip), neck, trunk, arms, and hands. Multiple bruising in clusters or with pathognomonic patterns also should be investigated. Examples of the latter might include bruises in a pediatric patient with distinctive imprints (such as from implements like an electrical cord or leather belt) or uniformity of size and shape.

When suspicious bruising is present, most experts agree that laboratory evaluation should be done to check for evidence of a bleeding disorder. Most experts recommend at least a platelet count and basic coagulation studies such as a prothrombin time and activated partial thromboplastin time. Some argue for a more extensive evaluation, and this may be especially relevant if indicated by elements of a patient’s personal clinical and family history.

Further evaluation is needed when suspicion of abuse exists. Most experts recommend a skeletal survey when this concern exists, especially in children under 2 years old, or if fractures suggestive of abuse (e.g., posterior rib fractures) are discovered.

Computed tomography (CT) of the head is also recommended – keeping in mind that traumatic brain injury may still exist in infants with a normal-appearing physical examination. Altered mental status (as in this case) is even more suggestive of central nervous system involvement. If brain injury is
identified, a formal retinal examination by an ophthalmologist is needed.

The discovery of retinal hemorrhages is also a strong indicator of abusive head injury. Evaluation of possible abdominal trauma should be considered. Some experts advocate laboratory screening testing such as liver function tests and serum amylase levels to search for signs of abdominal injury. If such screening is positive, bruising of the trunk or abdomen is found, or bilious emesis is present, one should consider an abdominal CT.


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