What is the appropriate management for bruising?

Management of Bruising

The appropriate management of bruising depends on the patient's age, bruise location, and clinical context, with special consideration needed for children under 24 months where skeletal surveys are necessary when abuse is suspected or in specific high-risk presentations. 1

Assessment of Bruising in Children

Age-Specific Considerations

• In children under 6 months with any bruising, a skeletal survey (SS) is necessary regardless of the history of trauma or bruise location 1
• For children 6-9 months old, SS is necessary if there is no history of trauma explaining the bruising 1
• For children 9-12 months old, SS is necessary if bruising is located in the cheek/eye area 1
• For children 12-24 months old, SS is necessary for bruises on the ear, neck, torso, hand, or foot without an adequate explanation 1

High-Risk Indicators Requiring Skeletal Survey

• Witnessed or confessed history of abuse causing bruise 1
• History of domestic violence causing bruise 1
• Additional injuries on examination (e.g., whip marks, burns, frenulum tears) 1
• Patterned bruises (having the imprint of an object), regardless of trauma history 1

Evaluation for Medical Causes of Bruising

Initial Assessment

• Detailed history should include: onset of bruising, pattern of bruising, family history of bleeding disorders, medication use (especially anticoagulants), and correlation between trauma and bruising severity 2, 3
• Physical examination should focus on: number, size, shape, and distribution of bruises, presence of other bleeding manifestations (petechiae, mucosal bleeding) 4, 5

Laboratory Evaluation

• Screening tests for patients with concerning bruising include: platelet count, prothrombin time, partial thromboplastin time, and bleeding time 4, 5
• More extensive testing may be required at specialized hemostasis centers if screening tests are abnormal or if there is a strong family/personal history of abnormal bleeding 3, 6

Distinguishing Between Medical Causes and Non-Accidental Trauma

• Leg bruises are more common among patients with hematologic disorders (62.5%) compared to those with abuse (27.8%) 6
• Bruising in TEN locations (torso, ears, neck) is present in 96.9% of abused children versus 50% of children with hematologic disorders 6
• Both hematologic disorders and abuse can coexist - a confirmed bleeding disorder does not rule out the possibility of non-accidental injury 5, 6

Common Pitfalls and Caveats

• Failing to consider both medical and non-accidental causes simultaneously 2, 6
• Inadequate follow-up for abnormal hematologic testing (only 71% of children with abnormal results received appropriate follow-up) 6
• Dismissing the possibility of abuse in children with confirmed bleeding disorders when the severity of injury is incompatible with the history 5
• Not recognizing that certain bruise locations (ear, neck, torso, hand, foot) are highly suspicious for abuse in young children 1
• Overlooking the need for age-specific evaluation protocols, especially in non-mobile infants where any bruising is concerning 1