Bruises –the external impact of a hard object that compresses the skin and subcutaneous tissues against another hard object (usually bone) causing the rupture of blood vessels and allowing the escape of blood into the dermis or subcutaneous tissues.
*Remember “If you don’t cruise you don’t bruise!” Remember* Bruises anywhere on the body are extremely uncommon in infants younger than 6 months but become more commonly acquired as the child becomes increasingly mobile.
Visual aging of bruises is not an exact science and should not be relied on to ascertain that a particular bruise is consistent with a specific age.
Distinguishing between inflicted and accidental bruises: Location Accidental BruisesInflicted Bruises
>Shins >Upper arms
>Lower arms >Upper anterior thighs
>Elbows >Buttocks >Ankles >Face
Pinch marks appear as small double bruises.
An open-handed slap produces clear skin mark where fingers hit with fingers outlined.
Belts, ropes, strings, cords, shoes, hairbrushes, coat hangers, extension cords, kitchen utensils, and many other instruments can leave identifiable prints.
Bilateral black eyes in a child are almost always of inflicted origin.
Points to consider when evaluating a bruise:
1. Take a good history (look for discrepancies between story and presenting injury)
2. Perform a complete skin examination (photographs are extremely helpful)
3. Have a complete physical examination done
4. Obtain a developmental history
5. Observe parent/child interaction
6. When indicated, obtain appropriate laboratory examinations
>Inflicted burns occur more often than accidental burns in younger children
Types of Burns
Thermal Burns-caused by tissue coagulation
Scald Burns-account for approximately 85% of burns in children. Forced immersion scald burns are uniform in depth with sharply demarcated borders, and flexion creases are spared.
Stocking/glove appearance occurs when the child’s hands or feet are held forcibly in hot water, usually bilateral
Buttocks, lower back, and perineum burns occur when a child’s middle body is forcibly held under hot water. “Donut burns” occur when areas of the skin are in contact with a cooler surface (eg, if a child is held in water with a small area of the buttocks contacting the bottom of the tub)
All these signs suggest restricted motion and significant exposure time.
Essential in the evaluation of scalding burns is an understanding of the time and temperature relationships of water.
TIME-TEMPERATURE SCALES-EXPOSURE TIME TO CAUSE 2ND DEGREE BURNS^
Temperature (F) Adults Children
127 60 seconds ----
130 30 seconds 10 seconds
140 5 seconds 1 second
150 2 seconds <1 second
158 1 second ----
^Adapted from Katcher ML. Scald burns from hot tap water. JAMA 1;246;1219
Dry contact burns-occur when a hot object is brought in contact with the skin.
Objects of all kinds, especially household appliances, are used in this type
burning. The most frequent appliances are irons, hair dryers, hair curlers,
cigarette lighters, light bulbs, grills from stoves or heaters, and cigarettes.
Radiation burns-are mostly caused by ultraviolet exposure resulting in sunburn.
Chemical burns-are commonly caused by acids (sulfuric) and alkalis (lye, calcium chloride)
Electrical burns-are caused by a combination of heat and direct action of electricity.
Note: >Human adult bite marks are 2.5 to 3.5 cm. in width from cuspid to cuspid
>Teeth may mark clearly or may seem to be scratches or bruises.
>Photographing the bite marks is recommended. Some sources recommend repeated
daily photographs of the lesions. Pictures should be taken both close up and from a distance for reference purposes.
>Animal bites cause a tearing of the skin and tissues.
Source: Visual Diagnosis of Child Abuse, 2nd Edition. American Academy of Pediatrics