The McMaster at night

Pediatric Curriculum

BRUISING

Objectives

•  Create differential diagnosis for bruising

•  Review red flags concerning for inflicted injury

•  Work up required for a child presenting with bruising suspicious for inflicted injury

•  Understand implications of bruising as sentinel injuries

Bruising

•  Caused by trauma or impact to the skin

•  Blood vessel injury and leakage of blood into subcutaneous tissues

•  When there is underlying bone close to skin, bruising occurs more easily

•  When there is soft tissue close to skin, it acts as a cushion and bruising occurs less easily

Background

•  Bruises are common in children

•  Cannot be dated based on their colour

•  Accidental bruising: Usually due to minor trauma -  Bump, fall, routine active play

•  Inflicted bruising: child maltreatment •  Do not use “intentional” or “unintentional”

-  Intentionality cannot be determined objectively -  Unintended meaning in Justice system

The Case

•  Oliver Twist •  3 month old baby boy

•  Mother brings him to hospital due to runny nose, coughing, and crying

•  While performing the physical examination, you notice something on his abdomen

The Case

•  Describe what you see – are you concerned?

Image: Livingston, N., Bruising in Infancy; Annals of Pediatrics; 2010

History

What would you ask?

History

•  How did the bruise get there?

•  Does the child have bleeding elsewhere (epistaxis, hematuria, blood in stools?)

•  Medications, nutritional history, temperament of child

•  Family history: bleeding or collagen vascular disease

•  Detailed social history of home situation, stressors, supports, previous involvement of CAS with family

History

•  Bruise got there because Oliver was sleeping on a toy

•  He has never had bleeding or bruising before

•  No medications; Formula feeding well with good growth

•  No family history of bleeding or collagen vascular disease

•  Mother is 30 year old accountant, lives in Burlington with husband who is a lawyer. No previous CAS involvement, having Oliver at home has been little stressful because he cries often. Rest of family lives in England.

Physical Exam

What else would you look for?

Physical Exam

•  HR 162, RR 40, BP 72/45, Temp 37°C, O2 sat 99% on RA

•  Flat fontanelle, crying, but consolable •  Normal cardiac exam •  Normal respiratory exam

•  Small purple bruises on right abdomen otherwise normal abdominal exam

•  Normal male genitalia, testes descended bilaterally •  Normal hips and spine •  Moving all four limbs, good suck and tone

Physical Exam •  On examination of Oliver’s legs, you notice

something. Describe what you see – are you concerned?

Image: Livingston, N., Bruising in Infancy; Annals of Pediatrics; 2010

Suspected Child Maltreatment

List Red Flags of Inflicted Injury in a Child with Bruising

Suspected Child Maltreatment •  Red flags for inflicted injury in child with bruising

1. Bruises in babies who are not yet cruising 2. Bruises on ears, neck, feet, buttocks, or torso

(torso = chest, back, abdomen, genitalia) 3. Bruises not on front of body and/or overlying bone 4. Unusually large or numerous 5. Clustered or pattered (pattern may include, handprints, loop or belt marks) 6. Bruise does not fit with mechanism described

CPS Practice Point, Medical Assessment of Bruising in Suspected Child Maltreatment cases; 2013

Differential Diagnosis

Not  all  Bruising  is  Abuse!  Slate  Grey  Nevus  of  Childhood              (Mongolian  blue  spots)  

Connec?ve  Tissue  Disorders            Ehlers-­‐Danlos            Osteogenesis  Imperfecta  Infec?ons  (ex.  Meningococcemia)  

Bleeding  disorders            Immune  thrombocytopenic  purpura            Von  Willebrand  Disease            Hemophillia  A  (Factor  8  deficiency)            Hemophillia  B  (Factor  9  deficiency)  

Malignancy  (ex.  Leukemia,  neuroblastoma)  

Severe  systemic  illness  (ex.  DIC)  

Vasculi?s  (ex.  Henonch-­‐Schonlein  Purpura)  

Nutri?onal  Deficiencies  (ex.  Vitamin  K  or  C)  

Hemangioma   Striae  

Phytophotoderma??s   Erythema  Mul?forme  

Cupping  or  Coining   Skin  staining  from  dyes  

Eczema   Incon?en?a  Pigmen?,  Nevi  of  Ito  

CPS Practice Point, Medical Assessment of Bruising in Suspected Child Maltreatment cases; 2013

Workup

What would you order and who else would you involve?

Workup

•  Admit Oliver to hospital •  Call Child Protection Services (Children’s Aid

Society) •  Involve Child Maltreatment Pediatricians (at McMaster, CAAP team – Child Advocacy & Protection)

•  CBC and differential •  INR and PTT •  Liver enzymes, lipase

•  Skeletal Survey •  Head CT and Abdominal CT •  Opthalmology exam

Workup

•  CBC and differential – NORMAL •  INR and PTT – NORMAL •  Liver enzymes, lipase – NORMAL

•  Skeletal Survey – PENDING •  Head CT and Abdominal CT – NORMAL •  Opthalmology exam – NORMAL

Workup

•  Describe finding on skeletal survey – are you concerned?

Image: Pressel, D., Evaluation of Physical Abuse in Children; American Family Physician; 2000

Workup

•  Posterior rib fractures – concerning!

Workup

•  Describe finding on skeletal survey – are you concerned?

Image: Pressel, D., Evaluation of Physical Abuse in Children; American Family Physician; 2000

Workup

•  Metaphyseal or “bucket handle” fracture of tibia – Concerning!

Test Your Knowledge

•  Which bruise is the oldest?

Bruise #1 Bruise #2

A.  Bruise #1 B.  Bruise #2 C.  They are the same age D.  No idea

The Answer

•  Answer D: No idea

We cannot date bruises based on their colour or appearance

?

Test Your Knowledge

•  Concerning or not concerning for abuse?

Image: Pressel, D., Evaluation of Physical Abuse in Children; American Family Physician; 2000

The Answer

•  Answer D: Non-Concerning

Mongolian Spots (Slate Grey Nevi of Childhood)

?

Test Your Knowledge

•  Concerning or not concerning for abuse?

Image: Pressel, D., Evaluation of Physical Abuse in Children; American Family Physician; 2000

The Answer

•  Answer D: Concerning

Repeated patterned bruises on the back (in this case, loop marks from a cord)

?

Test Your Knowledge

•  Concerning or not concerning for abuse?

Image: Harris, T, Bruises in Children; JPEDHC; 2010

The Answer

•  Answer D: Non-Concerning

Capillary Hemangioma

?

Summary

•  Bruising is common and not all bruising is child abuse

•  Always consider medical and accidental explanations

•  Always consider child abuse on the differential

•  Red flag bruising can be a sentinel finding for more significant injuries associated with child abuse

Fin