Bruising

Bruising is the extravasation of blood from the damaged vessels into the subcutaneous tissue (1).It can generally be divided into:

normal - caused by unintentional or accidental trauma (2) abnormal - those with an underlying haemostatic abnormality, such as an inherited bleeding disorder or those who have been subjected to non-accidental injury (NAI)

Bruising is more obvious in white skinned people than in people with darker skin tones. The incidence also increases with increasing family size and during the summer months (when children play outside in lightweight clothing) (1) Elderly people are also at increased risk of bruising due to poor skin and subcutaneous tissue turgor, decreased fatty tissue, ambulatory problems relating to cognitive impairment, neurological or physical disorders, effects of medications and nutritional factors (3). Reference: 1. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2141.2006.06016.x/full 2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1718790/pdf/v084p00488.pdf 3. http://journals.lww.com/smajournalonline/Fulltext/2006/04000/Easy_Bruisability. 15.aspx

normal bruising
Normal bruising or bleeding due to accidental injury is commonly seen around the age of 1 when most children become mobile or cruising (1) it is usually restricted to certain areas of the body o in crawling children bruises may be seen on the knees, shins and the forehead o in preschool and school age children, small bruises on bony prominences on the front of the body (2) o in young children (<6 years) if the head is involved - occurs predominantly in a T shape across the forehead, nose, upper lip and chin and more than a third of (37%) bruising is also present at the back of the head (3) is not associated with mucosal bleeding, petechiae, or purpura the family history is negative (1) In non mobile infants usually before the age of 9 months, occurrence of significant bruising is abnormal and is beyond the spectrum of normal bruising (2) A child with bruises in the typical distribution but seems to be over bruised may have a mild coagulation defect (4).

Reference: 1. 2. 3. 4. http://www.bmj.com/content/341/bmj.c4565.long http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2141.2006.06016.x/full http://ep.bmjjournals.com/content/95/6/170.full http://journals.lww.com/smajournalonline/Fulltext/2006/04000/Easy_Bruisability. 15.aspx

abnormal bruising
Patients who present with an abnormal pattern of bruising may have a haemostatic disorder or may have been subjected to non-accidental injury (NAI). physicians should remember that NAI and bleeding disorders are not mutually exclusive and any person with a haemostatic disorder may have experienced a nonaccidental injury if the bruising or bleeding is abnormal in site and severity relative to the history, suspect NAI (1) Reference: 1. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2141.2006.06016.x/full

aetiology of abnormal bruising

Numerous conditions may be responsible for abnormal bruising which includes haemostatic disorders, non accidental injury (NAI) and connective tissue disorders (affects the integrity of the blood vessel) (1,2).

abnormalities of platelets (deficiency and dysfunction) o autoimmune disorders (ITP, connective tissue disease, etc.) o systemic illness - liver disease, renal disease o lymphoid malignancy o myeloproliferative disorder (3) coagulation protein abnormalities o hemophilia - factor VIII, IX deficiency o Von Willebrand disease o vitamin K deficiency o plasmin or plasminogen deficiency or inhibitor o systemic illnesses - liver disease, amyloidosis (3) vascular or dermal abnormalities o Ehlers-Danlos syndrome o purpura simplex o senile purpura o vitamin C deficiency (scurvy) (1) medication o corticosteroids o anticoagulants - heparin, low-molecular-weight heparins, warfarin o antiplatelet drugs aspirin, clopidogrel o nonsteroidal anti-inflammatory drugs o antineoplastics cisplastin, doxorubicin o antibiotics cephalosporins, penicillins, quinine (3) non accidental injury (NAI)

Reference: 1. http://www.aafp.org/afp/2008/0415/p1117.html 2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1718790/pdf/v084p00488.pdf 3. http://journals.lww.com/smajournalonline/Fulltext/2006/04000/Easy_Bruisability. 15.aspx

evaluation of a patient with bruising

It is important to obtain a detailed personal and family history together with a physical examination in order to differentiate normal from abnormal bruising (1,2). past medical history (which should include comorbid conditions currently present) childhood illness -chemotherapy or radiation therapy for childhood malignancies may later lead to treatment related bleeding from bone marrow disorders (e.g. myelodysplasia or leukemia) autoimmune disorders which may affect the blood vessels renal disease - causing platelet dysfunction hepatic disorders - may affect the numbers of platelets, platelet function, quantity of coagulation proteins or the quality of the skin and connective tissue (2) thyroid dysfunction - skin and subcutaneous tissue may be affected pain or swelling in a joint or reluctance to move a limb may be due to haemarthroses (1) nutrition of the patient children on a limited diet is at a risk of developing nutritional deficiencies which in turn may cause coagulopathy, vascular fragility and/or bruising in thin teenage girls and in middle aged persons certain eating behaviours (e.g. - avoiding meat or fat due to an eating disorder or avoiding fruits and vegetables as a part of specific diet) may lead to nutritional deficiencies in elderly people especially those living alone or in a nursing home, due to poorly fitting dentures, lack of access to certain foods or a decreased appetite may also face nutritional deficiencies (2) symptoms which suggest an underlying platelet or coagulation disorder epistaxis gingival or mucocutaneous bleeding (1) excessive bleeding from childhood cuts or abrasions menorrhagia postpartum haemorrhage hematuria (2) excessive bleeding after tooth extractions or minor surgery (for example, tonsillectomy) (3) history of medication used including over-the-counter medications and herbal supplements which may cause bleeding abnormalities (2) family history of any known bleeding disorder in the family such as haemophilia, von Willebrand disease or platelet function defects new genetic mutation may be responsible for 30% of hamophilia cases hence there will be no family history in these patients (1) female family members with menorrhagia or members of both sexes with bleeding which may indicate a nonsex-linked disease e.g. - von Willebrand disease or factor XI deficiency

bleeding in males and with skipped generations may suggest sex-linked disorders such as haemophilia A and B (although rarely it may be seen in females in case of consanguinity and rare acquired antibody disorders) a history of consanguinity - suspect rare conditions such as autosomal recessively inherited (factor V, factor X and factor XIII) deficiencies a history of Ehlers-Danlos syndrome (2) if the patient is an infant or child, inquire specifically about whether the child is crawling since bruising is rare in infants before they crawl any history at birth of conditions suggestive of an undiagnosed bleeding disorder any bruising or bleeding at birth or from the umbilical stump haematoma after routine intramuscular vitamin K given at birth bleeding from the heel prick after the Guthrie test (1) During the physical examination, in children record the distribution, number, site, and size of bruising together with any petechiae, ecchymoses, and subcutaneous haematoma pictorial or photographic records (with parent consent) should be used also look for any additional signs such as abrasion of the skin or the outline of a hand or a belt (1) examine the pattern of bruising in dependent areas - can be due to thrombocytopaenia or stasis factor only on the arms or legs - suggests trauma or changes in the skin or subcutaneous tissue around the eyes - connective tissue disorder (2) in atypical areas such as back, buttocks, arms, and abdomen - suspect bleeding disorder, or non-accidental injury (1) typically over extensor surfaces of forearms - suspect senile purpura (4) examine the skin for pallor - suggests anemia purpura or petechiae - thrombocytopenia (2) thinning and dry skin - can be due to aging, thyroid disease, inherited disorders brittle hair and nails - due to nutritional factors, aging and thyroid diseases evidence of delayed healing (multiple scars or unresolved wounds) - may suggest steroids, thyroid disease, aging or factor XIII deficiency examine the joints: for any underlying rheumatological disorder (2) hypermobility - suggestive of Ehlers-Danlos syndrome (1) examine for hepatosplenomagaly (may be due to systemic disease) or for features of chronic liver disease (ascites, caput medusa or spider telangiectasias) (2) lymphadenopathy may suggest a viral illness or a lymphoid malignancy (2) Note: in clinical practice assessment of the age of a bruise according to the different colours (red, blue, yellow, green) is inaccurate. although some consider red/blue/purple is seen in recent bruising and yellow/brown and green with older resolving bruises, any of these colours can be present at any time before the bruise heals. Hence an accurate estimate of the age of a bruise cannot

be done by clinical assessment of the bruise (5)

Reference: http://www.bmj.com/content/341/bmj.c4565.long http://journals.lww.com/smajournalonline/Fulltext/2006/04000/Easy_Bruisability.15 .aspx http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1718790/pdf/v084p00488.pdf http://www.aafp.org/afp/2008/0415/p1117.html http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1720275/pdf/v090p00187.pdf

investigation in bruising
Appropriate baseline laboratory investigations include:

full blood count (FBC) with differential peripheral blood smear for platelet abnormalities coagulation screen o prothrombin time (PT) to assess the extrinsic and common clotting pathways o activated partial thromboplastin time (aPTT) - to assess the intrinsic pathway o Clauss fibrinogen - for fibrinogen function o thrombin time - for fibrinogen functional defects (1) hepatic and renal functions (2)

Reference: 1. http://www.bmj.com/content/341/bmj.c4565.long 2. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2141.2006.06016.x/full

bruising in physical abuse

Bruising is the commonest abusive injury seen in a suspected case of physical abuse (1). It is common in a normal active child. However, they tend to occur in specific places shins, elbows, foreheads. Bruising in other places is more suggestive of physical abuse.

be aware that a patient of any age may face an abusive situation leading to bruising (2) it is important not to misdiagnose mongolian blue spots as bruises bruises on the inner thighs or genitalia are suggestive of sexual abuse.

NICE have suggested guidance concerning bruises in a child where child maltreatment should be suspected or considered (3):

child maltreatment should be suspected if a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement child maltreatment be suspected if there is bruising or petechiae that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable. Examples where a clinician would suspect child maltreatment include: o bruising in a child who is not independently mobile o multiple bruises or bruises in clusters o bruises of a similar shape and size o bruises on any non-bony part of the body or face including the eyes, ears and buttocks o bruises on the neck that look like attempted strangulation o bruises on the ankles and wrists that look like ligature marks

Notes:

suspect
o

for the purposes of this guidance, to suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it (1)

Reference: 1. http://ep.bmjjournals.com/content/95/6/170.full 2. http://journals.lww.com/smajournalonline/Fulltext/2006/04000/Easy_Bruisability. 15.aspx 3. NICE (July 2009). When to suspect child maltreatment.

abusive bruises in children

It is important to differentiate accidental from abusive bruises.

accidental bruising in young children o depends on their level of independent mobility. The prevalence of experiencing accidental bruises is,

<1% in non-mobile infants 17% in crawling, cruising infants >50% in walking infants (1) o is seen in specific locations occurs on the front of the body and over bony prominences <6% of accidental bruises to the face are found on the cheeks or periorbital area abusive bruises o although any part of the body may be involved, abusive bruises should be suspected if seen predominantly on the cheeks, neck, genitals, buttocks, and back (1,2) o involvement of the forearms, upper limb and adjoining area of trunk, or outside thigh may indicate defensive bruising (when the child has tried to protect themselves from the blows) (1) o if associated with petechiae is a strong predictor of abusive injury (but the absence of petechiae is of no diagnostic value) o occasionally the imprint of the weapon (e.g. - studded dog collar, belt buckle) might be visible (1)

Reference: 1. http://ep.bmjjournals.com/content/95/6/170.full 2. word doc

abusive bruises in the elderly population

Bruises are common in the general geriatric population. In spite of them being the most frequent visitors to the doctors office, clinicians rarely suspect bruising associated with physical elder abuse (1). a 2005 study of accidental geriatric bruising revealed that

o o o o

around 90% accidental bruising in the geriatric population were on extremities around 50% of bruises resolved in less than 6 days (bruise was visible for 4 to 41) colour cannot be used to estimate the age of the bruise multiple bruises were more common in elders who were on anticoagulation medications (1)

The following factors should prompt the clinicians to suspect an abusive aetiology for the bruises: an elder who seems to be more withdrawn than usual a concerned caretaker who refuses to leave the patient alone bruising patterns which cannot be connected to daily activities or routine daily care (2) Bruises which occur due to physical abuse of the elders are often large (>5 cm) and are present on the face, lateral right arm and posterior torso (1). Elders with suspected abusive bruises should be inquired about the cause and if the patient fails to mention abuse as the cause question the patient in a more reassuring manner so that the patient feels safe and may reveal a previously unrecognized abusive situation (1). Reference: 1. http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02330.x/pdf 2. http://journals.lww.com/smajournalonline/Fulltext/2006/04000/Easy_Bruisability. 15.aspx

evaluating a bruise of possible abusive aetiology

A careful investigation of a child with an unexplained or inadequately explained bruise is important since in some cases the bruises may not be associated with abuse e.g. underlying coagulopathies (1).

During assessment:

document the following o location, number, size (two maximum diameters) o petechiae if present o history of cause (if any given) photograph relevant bruises, including a right angled measuring device and colour scale in the photo FBC, coagulation studies, von Willebrand Factor obtain a family/personal history of bleeding disorder if age is <2 years consider other occult injury e.g. - fractures, retinal haemorrhage, intracranial abnormality (1)

Reference: 1. http://ep.bmjjournals.com/content/95/6/170.full#F2

incidence of physical abuse

In literature, the younger children (predominantly <3 years) are considered to be the most likely age group to be physically abused. it is not restricted to this age group since children up to late teens are also at risk of being abused

the highest rate of abuse is seen in children aged <1 (21.9 per 1000 children) (1)

Sociodemographic characteristics seem to vary from country to country. Increased prevalence of physical abuse was associated with: lower socioeconomic status immigrant children - in Sweden, these children are eight times more likely to be reported as abused asylum seekers internationally adopted children (1) Disabled children and children with behavioural or learning difficulties may become more vulnerable to abuse (1). In addition to children, elderly people are also at a risk of being abused (2). according to a summary of international elder abuse prevalence, as many as 4.3% of older adults are reported to be physically abused annually the reported rates are higher for dependant older adults with caregivers (2) Reference: 1. http://ep.bmjjournals.com/content/95/6/170.full 2. http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02330.x/pdf