What is the appropriate evaluation and management for delayed bruising 6 weeks after an injury?

Delayed Bruising 6 Weeks After Injury

Bruising appearing 6 weeks after an injury is not physiologically consistent with normal trauma-related bruising and requires evaluation for alternative causes including underlying bleeding disorders, new trauma, or non-accidental injury.

Understanding the Timeline

The provided evidence focuses on acute trauma management rather than delayed bruising presentation. However, the fundamental principle is clear: bruising from traumatic injury appears within hours to days, not weeks later 1.

• Accidental bruises in older adults were documented to appear and resolve within a predictable timeframe, with no evidence supporting bruise appearance 6 weeks post-injury 1
• Yellow coloration can appear within the first 24 hours, contrary to common perception that it indicates an older bruise 1
• The color of a bruise cannot reliably predict its age 1

Evaluation Approach

History Assessment

Obtain specific details about:

• The original injury 6 weeks ago: mechanism, severity, immediate bruising at that time 2, 3
• Any new trauma or injury to the area, even minor 2, 3
• Medications affecting coagulation (anticoagulants, antiplatelet agents, NSAIDs, corticosteroids) 3, 1
• Personal or family history of bleeding disorders (easy bruising, prolonged bleeding from minor cuts, heavy menstrual bleeding, bleeding after dental procedures) 3, 4
• Other bleeding manifestations (epistaxis, gingival bleeding, petechiae) 3, 4

Physical Examination

Document the following:

• Bruise location, size, and color pattern 2, 1
• Distribution pattern: accidental bruises occur predominantly on extremities (nearly 90%), rarely on neck, ears, genitalia, buttocks, or soles of feet 1
• Multiple bruises in various stages of healing suggest ongoing process rather than single remote injury 1
• Signs of other bleeding (petechiae, mucosal bleeding) 3

Laboratory Investigation

Order baseline coagulation studies:

• Complete blood count with platelet count 3, 4
• PT/INR and aPTT 3, 4
• Consider von Willebrand factor studies and factor VIII/IX levels if history suggests inherited bleeding disorder 3
• Liver and kidney function tests if systemic disease suspected 4

Critical Considerations

This presentation warrants concern because:

• Normal bruising from trauma does not appear 6 weeks after injury—this represents either new trauma or an underlying pathologic process 1
• Patients with compromised coagulation function are more likely to have multiple bruises 1
• Transient acquired inhibitors of coagulation can cause spontaneous bleeding and must be excluded 5

Management Algorithm

1. If no new trauma identified and no bleeding disorder found: Consider non-accidental injury, particularly in vulnerable populations (children, elderly, dependent adults) 2, 3

2. If bleeding disorder identified: Refer to hematology for comprehensive evaluation and management 3, 4

3. If new minor trauma identified with normal coagulation studies: Reassure patient but counsel on fall prevention and medication review 4, 1

Common Pitfalls

• Do not assume delayed bruising is related to remote injury—this is physiologically implausible and delays diagnosis of the actual cause 1
• Do not rely on bruise color to date the injury—color changes are unreliable for timing 1
• Do not dismiss the possibility of non-accidental injury even when some coagulation abnormality is present, as the severity and pattern must still be compatible with the history 3