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Medical: Shin on Back of Hands Bruise Easily. 70 Years of Age
Bruises
May Loo MD , in Integrative Medicine for Children, 2009
PEDIATRIC DIAGNOSIS AND TREATMENT
Bruises or ecchymoses are skin lesions caused by capillary bleeding. They are large lesions that are flat and usually not palpable, whereas hematomas are accumulations of blood in the skin or deeper tissues. Hematomas in the skin are raised and palpable and often tender, whereas bruises are usually painless.1,2
It is not uncommon for normal children older than 9 months to have 20 or more bruises, especially during the summer time, in a region with temperate climate, or during team sports season. The bruises are predominantly on the lower extremities, most frequently on the shins and knees.3
The color of a bruise reflects its age and the depth of injury. A fresh bruise generally appears blue or reddish purple. If a bruise is older, then yellow, green, or brown is present.2 A British review of 369 photographs of bruises from less than 6 hours to 21 days old concludes that a bruise with a yellow color was more than 18 hours old.4 A German study used spectrophotometry to distinguish superficial from deep bruises. The results indicate that superficial bruises have a more reddish appearance, whereas deeper bruises have a more bluish color. The optical characteristics of the skin may be explained by the fact that blue wavelengths of the light are scattered (and thus reflected) to a greater extent than the red wavelengths.5
The location and uniformity of color are important factors to consider in distinguishing accidental bruising from child abuse.6 Bruises that occur in nonmobile infants, those over soft tissue areas, and those that carry the imprint of the implement used or multiple bruises of uniform shape could be signs of physical abuse.7 Bruises to the buttocks, genitals, back,2 or numerous bruises in an infant younger than 9 months3 are less likely to be due to an accident. Patterns of bruising in infants and children that do not match the injury scenario offered by caretakers also should raise the suspicion of abuse.8
Bruises with different colors on the same body surface generally are not compatible with a single event. Dark skin may mask bruises.2 Wood lamp and digital photography can enhance visualization of faint bruises and bruises that are not readily visible.8
In the event of accidental bruising, it is important to make sure that there is no internal injury. Pain is usually associated with deeper trauma. Skin bruise corresponding to the site of the seat belt is known as the "seat belt mark" (SBM) sign and is associated with a high incidence of significant organ injuries, including thoracic trauma, myocardial contusion, and intraabdominal injuries, predominantly bowel and mesenteric lacerations that require laparotomy.9
The majority of bruises are self-limiting and do not require conventional treatment. However, the law requires that a child suspected of being abused or neglected should be reported immediately to Child Protective Services (CPS).2
Craig S. Kitchens MD, MACP , in Consultative Hemostasis and Thrombosis (Fourth Edition), 2019
Bruises and Hematomas
Bruises (including purpura simplex) are not palpable (i.e., not true hematomas) but are flat within the surface of the skin. Bruises result from trauma but of course can be exacerbated by platelet or coagulation defects to become larger bruises or even true hematomas. Simple bruises have been somewhat arbitrarily defined as smaller than 3 cm in diameter and not palpable; they usually number no more than four to six over the body. "Normal bruising" has been quantified in healthy infants, of whom 13% may have up to four bruises up to 10-mm maximum diameter. Such bruises tend to occur over bony prominences and increase in frequency as the child's mobility increases.77 Bruises not confined to bony prominences or in unusual places (soles or palms) may raise questions of abuse. If bruises are larger and more numerous, consideration may be given to a hemostatic defect, especially if the masses are palpable (i.e., true hematomas). Fig. 10.8 shows a large hematoma of the shin after an athletic incident that served as the diagnostic event for a teenager with heretofore undiagnosed mild hemophilia A with 7% of normal factor VIII activity. Large ecchymotic areas with hematoma formation (Fig. 10.9) provide the typical presentation of factor VIII inhibitors, as discussed in Chapter 5.
Adam J. Zolotor MD, MPH , Meghan Shanahan MPH , in Child Abuse and Neglect, 2011
Skin Injury
Bruises: Skin injury is one of the most common presentations for physical abuse, with bruises by far the most common injury. However, bruises are an extremely common injury in all children. A large prospective study of children seen for nontrauma reasons found that 76.6% had recent skin injuries, mostly bruises, and 17% had five or more injuries.53 Epidemiological studies have been invaluable in characterizing normal versus abnormal bruising. Large case series of abused children, nonabused children, and case-control studies have been used to characterize normal and potentially abusive bruising.33
Nonabused children rarely have bruises before starting to transition to independent mobility (<1%).54 The most common sites for nonabusive bruises are over the legs, bony prominences, and the head for infants and toddlers.53-55 Child abuse victims commonly have bruises (28%-98%).33 Bruises due to abuse tend to be greater in number, to be present with older injuries (i.e., scar or healing abrasion), and to be defensive in location (outer arm). Abusive bruises can carry the imprint of an implement such as a cord.33 Bruises that are high in number (studies suggest 10-15), unusual in location or pattern, or occurring in young children not yet walking should be considered for abuse or bleeding disorder.33,53,54
Burns: Most epidemiological studies of burns compare cases of inflicted pediatric burns with unintentional burns. In series of hospitalized pediatric burn patients, the rates of abuse and/or neglect range from 4% to 16%.56-60 These studies often combine abuse and neglect. A burn registry has recently allowed epidemiological study of nearly all serious pediatric burns in the United States.61 This study found that 6% of children aged 12 years or younger admitted to burn units were suspected victims of abuse. The use of registries comes at the cost of detail, and the assessment of abuse is less clear and perhaps less standardized than a single center's approach.
Inflicted burns are most often due to liquid scald (78% of inflicted burns versus 59% of unintentional burns).61 Abusive burns tend to be larger, involve younger children, have higher risk of mortality, and longer hospital stays.60,61 They tend to be deeper and more often require grafting.56,61 They more often involve both hands or both feet.58 Social stress is a prominent risk factor in these injuries. Victims of abusive burns are more often from unstable families,58,59 from single parent families,56,57,59 live in poverty,57,59 and have had prior involvement with protective services.56
Mark L. Bernstein , Franklin D. Wright , in Forensic Odontology, 2018
Results
1.
Bruises located within the first few millimeters of skin appear as dark areas. Of course, those bruises that reach the surface will also be seen visually but the patterns may differ as the topography of blood beneath the surface is visualized. Acute bruises that have not yet "developed" may first be seen with IR imaging.
2.
Blood in superficial veins is imaged by IR photography. Their branching anatomy will easily distinguish them from bruises. Blood within arteries is not seen as arteries are deeper, have a smaller diameter than corresponding veins, and are cloaked in a thicker vessel wall.
3.
Abrasions overlying bruises will be de-emphasized. They may not disappear completely, but bruises concealed by abrasions may become more distinct.
4.
Bruises concealed by all except darkly pigmented skin can be visualized with IR photography because the thin, homogeneous layer of melanin confined to the single-celled basal layer of epithelium is relatively transparent in IR imaging. Similarly, fine surface hairs containing melanin will disappear or lighten.
5.
The thin and homogeneous layer of blood in postmortem lividity is penetrated by IR light so that underlying bruises can be visualized.
Emmanuel Delay , in Aesthetic and Reconstructive Surgery of the Breast, 2010
At the graft site in the breast
Bruises on the breast resolve in approximately 15 days and swelling in 1 month. There is a progressive reduction of volume by 30%. However, because of initial swelling of the breast immediately after the procedure, the patient may feel that the loss is even greater (around 50%). The volume stabilizes in 3 or 4 months. A higher resorption rate (almost 50%) and a longer stabilization period (5 or 6 months) may be reported in patients with poor fat cell grafts (those for whom the volume of the oily supernatant in the harvested sample is high).
Steven W. Salyer PA‐C , ... Linda L. Lawrence , in Essential Emergency Medicine, 2007
Examination
Bruises and skin lesions are the most frequent indication of physical abuse, seen in 90% of abused children. Therefore, it is important for all children presenting to the ED to be undressed and placed in a gown so a quick skin examination can be performed, regardless of the presenting symptom.
An essential component of evaluating child abuse is knowledge of normal childhood developmental stages because they can provide important information about what injuries are real accidents versus abuse. The developmental milestones of rolling over, sitting up, standing, and walking are clearly important for consideration when evaluating the history and mechanism of injury. For example, children learning to walk will normally have numerous bruises on the anterior tibia, extensor surfaces, forearms, and even forehead. A disparity between injuries, possibly based on accidents during normal development and the physical findings, may alert the provider to abuse. Another important factor is the social situation. The caretaker who brought the child to the ED may or may not be the abuser, and he or she may not even be aware of the abuse.
Bruises that are linear or uniform raise suspicion because they may be caused by objects such as belts, buckles, light cords, or other instruments (Fig. 13‐5). The location of these bruises, especially on the back, buttocks, upper arm, chest, or face is also concerning. If bruising is found in multiple areas of the body in various stages of healing, physical abuse must be considered.
Other common injuries include the following: CNS injuries occur in 15% of abused children, 13% have burns, 10% have toxic ingestions, 8% have skeletal injuries, and 2% have abdominal injuries. CNS injuries are the most serious and lethal because children, especially those younger than 2 years old, can have intracranial hemorrhages from being shaken or beaten. Burns may have atypical/unusual patterns that will raise suspicion. Abdominal injuries may present as symptoms of recurrent or persistent vomiting, unexplained abdominal pain, bruising, or tenderness.
Skeletal injuries may present as unexplained or asymmetrical swelling or refusal to bear weight or walk. Long bone fractures are most common in abuse, and metaphyseal fractures are most specific for physical abuse. Spiral fractures are caused by a twisting motion. The provider should suspect physical abuse if the stated history is not consistent with a twisting motion when a spiral fracture is found.
If abuse is suspected, a complete physical examination is warranted to document any findings of bruises, burns, scars, or other abnormalities. Burns should be evaluated for size and shape, paying close attention to margins (Fig. 13‐6). Burns with a "glove and stocking" pattern with sharp demarcation of the burn margin can indicate immersion in hot water. Real accidents involving liquid burns are likely to have irregular borders and with areas of "splash." Cigarette burns will give a characteristic circumferential shape and size. It is important to examine the skin for old scars or marks as well as acute injuries.
Oral lacerations, including lacerations of the frenulum or other areas of the oral mucosa, may be present in infants who have been force‐fed. If head injury or "shaken‐baby" syndrome is suspected, a good funduscopic examination is warranted, looking for signs of retinal hemorrhages (associated with subdural hematomas), hyphema, lens dislocation, or retinal detachment.
Physical examination of a sexually abused child can be difficult. These patients should undergo a genital examination that includes careful inspection of the genitalia and perianal region. The "frog‐leg" position is normally best for this examination in children. Speculum examinations are not necessary unless the patient is an older adolescent or if vaginal trauma is suspected. The examination should look for acute injuries such as bruises, abrasions, and lacerations, as well as for evidence of forensic material such as semen. Any findings indicative or sexually transmitted infections should be documented.
Knowledge of the normal anatomy for age group of the female patient is very important because the female genitalia changes with age. In the prepubescent group, girls will have a thin, small labia minora and a full labia majora. The hymen is reddish‐orange and will cover the vagina. In infancy, the hymen is thick. From infancy to puberty, it is thin with smooth edges and is annular or crescent shaped. The hymen should be examined for trauma. An indentation at the 6‐o'clock position suggests penetration trauma. White areas or areas of swirling vascularity are signs of scarring. It is important to note that redness is a sign of inflammation or irritation and does not necessarily indicate abuse. Genital examinations in males should consist of inspection of the penis and testicles. In rare cases, there may be bite marks on the genitalia. Bruising, abrasions, scars, and any urethral discharge should be documented.
The perianal examination in males and females may show fissures, abrasions, or hematomas. Anal penetration is easier than vaginal penetration in the young female, and therefore this portion of the examination must not be overlooked. Anal tone should be evaluated because it is often decreased when there has been repetitive prior anal penetration. The clinician should look for thickening or thinning in the anal rugae.
The healthcare provider should consider orogenital contact in cases of suspected sexual abuse. The mouth and throat should be examined for trauma, including lacerations and bruising. If sexually transmitted infections are suspected, cultures should be taken of the oropharynx, anus, and penis or cervix/vagina.
Tara L. Harris MD , Emalee G. Flaherty MD , in Child Abuse and Neglect, 2011
Documentation
Bruises should be documented as descriptively as possible, including the color, shape, size, site, whether they are palpable or flat, and any other notable characteristics. Whenever possible, photodocumentation is recommended (see Chapter 27).
Unfortunately, it does not appear that clinical practice meets current recommendations. In a study of all children aged 9 months and younger that were admitted to the general pediatrics service or pediatric intensive care unit at Carolinas Medical Center over 1 year, only 70% had a documented skin examination.38 For children admitted with "nonaccidental trauma relevant diagnoses such as convulsions," presence or absence of bruising was noted in only 27%. Only 20% of admission notes included assessment of developmental ability (by parental report or direct observation). Clearly, if this is standard practice, many skin injuries in infants are being missed, and those that are being detected are likely not being adequately evaluated or their significance appreciated. Research by Pierce at al39 also would support this. They found that among 18 victims of fatal or near-fatal child abuse, 7 (39%) had prior unexplained bruising that was specifically noted by medical providers but no further action had been taken.
Paula Mazur , ... Lynn J. Hernan , in Pediatric Critical Care (Third Edition), 2006
Bruising
Inflicted bruises are often bilateral, widely distributed, and located on soft tissue areas of the body that are unlikely to make surface contact during a fall. They may take the shape of the inflicting object (e.g., fingers, a hand print, linear whip marks from a belt, loop marks from a folded belt or cord). They are frequently found on the posterior trunk, buttocks, and the posterior side of the extremities because the victim would naturally be trying to run away from the perpetrator.
Bruise color is not a reliable indicator of the time an injury occurred. Bruises resolve and therefore change color at different rates depending on their location and the force with which they were inflicted.3 Nevertheless, documenting bruise colors is important, particularly with the presence of bruises of markedly different colors at the same time, suggesting that the child may have been abused on more than one occasion. A simple gingerbread-man drawing of the child's body, marked with the locations of all the child's injuries, is a concise descriptive tool, which will quickly jar a physician's memory before any legal proceeding.
Photographic documentation of the child's injuries is essential. Every effort should be made to obtain the best photographs; 35mm photographs taken by a medical or law enforcement photographer are the ideal. If a professional photographer is unavailable or if the attempt to obtain a professional will delay documentation of rapidly resolving bruises (e.g., petechiae), any staff person familiar with the use of a 35mm camera should take photographs for the medical record. Polaroid photographs have been used in court, but they are inferior to 35mm photographs in both clarity and durability. Digital photographs are not used in court proceedings because they can be altered.
S. Pollak , P. Saukko , in Encyclopedia of Forensic Sciences (Second Edition), 2013
Contusions
Contusions or bruises are extravasations of blood within the soft tissues originating from ruptured vessels as a result of blunt trauma. In this context, only the contusions that are visible externally are considered. Textbooks usually differentiate between intradermal and subcutaneous bruises. In the first-mentioned category, the hemorrhage is located directly under the epidermis, that is, in the corium. This kind of superficial hematoma is usually sharply defined and red, whereas the more common bruises of the deeper subcutaneous layer have blurred edges and, at least initially, a bluish-purple color.
Intradermal bruises may reflect the surface configuration of the impacting object (Figure 2). The skin that is squeezed into grooves will show intradermal bleeding, whereas the areas exposed to the elevated parts remain pale. Especially in falls from a height, the texture of the clothing may produce a pattern of intradermal bruises corresponding to the weaving structure. Patterned extravasations of this type are also seen in tire tread marks when an individual is run over by a wheel, and in bruises from vertical stamping with ribbed soles.
Figure 2. (a) Intradermal bruising corresponding to the ribbed sole pattern of the perpetrator's training shoes (b). The imprint was caused by stamping actions against the face and neck of the victim lying on the ground.
Subcutaneous bruises are usually nonpatterned. Nevertheless, there may be bruising of special significance. If the body is struck by a stick, a broom handle, a pool cue, a rod, or any other elongated instrument, every blow leaves a double 'tramline' bruise consisting of two parallel linear hematomas with an undamaged zone in between. Victims of blunt force violence often sustain contusions from self-defense, typically located on the ulnar aspects of the forearms and on the back of the hands. The upper arms may show groups of roundish bruises from fingertip pressure in cases of vigorous gripping. A periorbital hematoma ('black eye') is induced either by direct impact (e.g., a punch or a kick) or indirectly (due to seepage of blood from a fractured orbital roof, a fractured nasal bone, or from a neighboring scalp injury of the forehead; Figure 3).
Figure 3. Periorbital hematoma of a live victim from a blow to the left frontal region. As a result of gravitational movement, the blood from the injured forehead spread to the eyelids within 1 day.
In general, bruises are regarded as a sign of vitality indicating that the contusion was inflicted prior to death. During life, the blood from ruptured vessels is forced into the soft tissue by active extravasation. Nevertheless, to a limited extent, postmortem formation of contusions is possible due to passive ooze of blood. In surviving victims, a deep bruise may not become apparent on the skin until several hours or even days later because of the slow percolation of free blood from the original site to superficial tissue layers.
In a living person, the contusion undergoes a temporal series of color changes. Initially, most subcutaneous bruises appear purple-blue. As the hematoma resolves during the healing process, the hemoglobin released from the red blood cells is chemically degraded into other pigments such as hemosiderin, biliverdin, and bilirubin. The color changes – usually over the course of several days – to green and yellow before it finally disappears (Figure 4). However, the rate of change is quite variable and depends on numerous factors, above all, the extent of the bruise.
Figure 4. 'Black eyes' inflicted by a single fist blow to the root of the nose (6 days before the photograph was taken). Note the yellow color on the periphery of the bruises.
The size of an intradermal or subcutaneous hematoma is not always indicative of the intensity of the force applied to the affected area. Elderly people or patients suffering from bleeding diathesis may get bruises from slight knocks or for other minor reasons. On the other hand, the absence of an externally visible injury does not necessarily mean that there was no relevant trauma. Subcutaneous bruises of surviving victims are often followed by gravity shifting of the hemorrhage leading to a secondary downward movement of the hematoma.
A special type of blunt injury to the soft tissues is frequently seen in pedestrians who have been struck or run over by motor vehicles. Both the skin and the subcutaneous layer may be avulsed from the underlying fascia or bones by shearing forces so that a blood-filled pocket is formed, typically in combination with a crush damage to the adjoining fatty tissue.
