Bruises in Children: Normal or Child Abuse?

Tomika S. Harris, DNP, MSN, CPNP


J Pediatr Health Care. 2010;24(4):216-221. 

In This Article

The Bruising of Skin

Bruising of the skin occurs after blunt trauma, which disrupts underlying blood vessels and causes leaking and collection of blood in the dermal layers (Bariciak, Plint, Gaboury, & Bennett, 2003; Sibert, 2004). The breakdown of hemoglobin and blood cells results in a sequence of colors including red, purple, black, blue, yellow, green, and brown. Health care providers often are asked to date bruises to aid in the investigation of child abuse; however, it is not an exact science (Schwartz & Ricci, 1996). Langlois and Gresham (1991) studied the visual aging of bruises. The authors analyzed 369 photographs of bruises taken of 89 patients and staff in an emergency department to determine if the age of bruises could be estimated accurately. The age range of the patients and staff was 10 to 100 years. The authors concluded the following: (a) a bruise with any yellow is likely older than 18 hours; (b) the colors red, blue, purple, or black can occur any time from within 1 hour of bruising until resolution; (c) red can be present in a bruise regardless of the age; and (d) bruises of identical age and cause on the same person may not show the same color or change at the same rate.

Bariciak, Plint, Gaboury, and Bennett (2003) also studied the visual aging of bruising. Fifty children who presented to the emergency department with accidental bruises of known cause were observed by history-blinded pediatricians, physicians, and trainees. The bruised areas were independently examined and age estimation and characteristics were recorded. The authors concluded that physician accuracy within 24 hours of the actual age of the bruise was poor. The authors also reported high individual variability and poor interobserver reliability, suggesting that the age of bruises is difficult to estimate, even with direct examination of the bruised area.

The appearance and resolution of a bruise are affected by many factors, including the amount of force used, vascularity of underlying tissues, diseases, age, and skin color (Stephenson & Bialas, 1996). Bruises are more visible on lighter skin. The location of a bruise is also an important factor. In areas where the skin is loose or superficial, such as the periorbital area, bruises occur more easily. Considering these many factors, health care providers must be very cautious when attempting to date bruises based on color.


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