What are the causes of bruising to the neck?

Causes of Bruising to the Neck

Neck bruising in children and adults has distinct etiologies, with trauma (both accidental and non-accidental), vascular injury, and bleeding disorders being the primary causes, though the clinical significance and evaluation approach differs dramatically by age.

Pediatric Population

Non-Accidental Injury (Physical Abuse)

• Neck bruising in young children is a critical red flag for physical abuse and warrants immediate comprehensive evaluation. 1
• Bruising on the neck is the most common injury in young victims of physical abuse and may be the only visible sign of serious underlying injuries such as fractures or traumatic brain injury 1
• In infants <6 months old, ANY bruising (including neck) necessitates skeletal survey regardless of history, as accidental bruising is extremely rare in pre-mobile infants 1
• For children 6-12 months old, neck bruising requires skeletal survey even with a history of accidental trauma 1
• Abusive neck bruising frequently precedes more severe forms of physical abuse, including fatal head trauma 1

Accidental Trauma

• Accidental neck bruising becomes more common in mobile older infants and toddlers (>12 months), though it remains less common than bruising to bony prominences 1
• Minor injuries from falls or collisions can cause superficial neck bruising, particularly in active toddlers 2

Bleeding Disorders

• Underlying hemostatic abnormalities (inherited bleeding disorders, thrombocytopenia, coagulopathies) can present with excessive or unexplained bruising, including the neck region 3
• These children require hematologic evaluation when bruising severity is disproportionate to reported trauma 3

Adult Population

Penetrating Trauma

• Penetrating neck injuries from stabbings, gunshot wounds, or impalement cause immediate vascular and soft tissue damage with visible bruising and hematoma formation. 4, 5
• Hard signs (expanding hematoma, active hemorrhage, pulsatile hematoma, hemodynamic instability) indicate major vascular injury requiring immediate surgical exploration without imaging 4
• Soft signs (nonpulsatile hematoma, dysphonia, subcutaneous emphysema) allow time for CT angiography before determining surgical need 4, 6

Blunt Trauma

• High-energy blunt neck trauma from motor vehicle collisions, falls, or assault can cause blunt cerebrovascular injury (BCVI) with associated bruising 7, 8
• Patients meeting expanded Denver criteria (cervical spine fractures, basilar skull fractures, neurologic deficits, high-energy mechanisms) require CT angiography screening 7
• Blunt injuries can present with delayed stroke symptoms, making early detection critical 8

Strangulation/Ligature Injuries

• Manual strangulation or ligature application causes characteristic patterned bruising on the neck 1
• These injuries may indicate intimate partner violence or assault and require thorough vascular and airway evaluation 1

Iatrogenic Causes

• Central line placement, surgical procedures, or endoscopic interventions can cause localized neck bruising 8

Critical Clinical Pitfalls

Age-Specific Evaluation Errors

• The single most dangerous pitfall is dismissing neck bruising in infants <12 months as accidental—this age group has the highest risk of occult abusive injuries. 1
• Failing to obtain skeletal survey in young children with neck bruising when indicated can miss life-threatening fractures 1

Delayed Recognition of Vascular Injury

• Blunt cerebrovascular injuries can present with delayed neurologic symptoms; early CTA screening in high-risk patients prevents stroke 7, 8
• Penetrating injuries with soft signs still require imaging—approximately 15.6% have arterial lesions despite stable presentation 5

Inadequate Bleeding Disorder Workup

• When bruising severity is incompatible with reported trauma history, hemostatic evaluation must be performed even when abuse is suspected 3
• Both abuse AND bleeding disorders can coexist; one diagnosis does not exclude the other 3

Diagnostic Approach by Clinical Context

Stable Patient with Neck Bruising

• CT angiography has 90-100% sensitivity and 98.6-100% specificity for detecting vascular injuries and should be first-line imaging 4, 6, 5
• In children <24 months with neck bruising, skeletal survey is necessary unless the child is >12 months with clear accidental mechanism and single bruise 1

Unstable Patient with Neck Bruising

• Immediate surgical exploration is indicated for hard signs without delay for imaging, as mortality increases significantly with delayed intervention 4
• Airway management and hemorrhage control with direct pressure take priority over diagnostic workup 8