Evaluation and Management of Leg Bruising in a 6-Year-Old Female
Bruising on the legs in a 6-year-old girl is generally benign and does not require skeletal survey or extensive workup if the bruises are located on bony prominences (shins, knees) with a consistent accidental history, but you must systematically evaluate for concerning features that would change management. 1
Initial Risk Stratification
Low-Risk Features (No Further Workup Needed)
- Single or few bruises on the shins, knees, or other bony prominences of the lower extremities 2
- Consistent history of accidental trauma (playground fall, sports injury) 2
- Child is developmentally mobile and active 1
- No additional concerning injuries on examination 2
High-Risk Features (Require Immediate Action)
You must obtain a skeletal survey if any of the following are present:
- Bruising on the feet, upper legs (thighs), or buttocks without clear accidental history 1
- Patterned bruising (belt marks, hand prints, loop marks) 2, 1
- Multiple bruises in various stages of healing 3
- Any witnessed or confessed abuse, or history of domestic violence 2, 1
- Additional injuries such as burns, whip marks, or frenulum tears 2, 1
Bleeding Disorder Evaluation
Obtain CBC, PT, aPTT, and peripheral blood smear if: 1, 4
- Bruising is disproportionate to the reported trauma 1, 4
- Multiple bruises in unusual locations (not just bony prominences) 1, 4
- Personal or family history of easy bruising, prolonged bleeding after dental procedures, heavy menstrual bleeding in family members, or known bleeding disorders 5, 4
- Bruises appear spontaneously without any trauma history 6, 4
Documentation Requirements
If there is ANY concern for non-accidental trauma: 1, 7
- Photograph all bruises with a ruler for scale 1, 7
- Document exact location, size, color, and pattern 7
- Record the child's developmental stage and mobility 2
- Document the caregiver's explanation verbatim 2
Critical Pitfalls to Avoid
- Do not dismiss bruising in unusual locations (feet, hands, torso, ears, neck) even with a plausible history, as these locations have high specificity for abuse in young children 1
- Do not assume all leg bruising is benign without assessing the specific location—upper leg/thigh bruising requires different consideration than shin bruising 2, 1
- Do not delay bleeding disorder workup if bruising is disproportionate to trauma, as waiting for "more serious" bleeding increases morbidity risk 8, 1
- Assess for deeper injuries, as surface bruising may indicate underlying fractures or organ damage requiring imaging 1
Special Considerations
For children receiving chemotherapy: 8, 1
- Obtain immediate platelet count 8, 1
- Hold all anticoagulation including prophylactic LMWH 8
- Transfuse platelets to maintain >20 × 10⁹/L prophylactically or >50 × 10⁹/L if active bleeding 8
Age-specific context: At 6 years old, this child is well beyond the age where any bruising triggers automatic skeletal survey (which applies to children <24 months), making location and pattern the key determinants of concern 2, 1