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

Characteristics of Abusive Bruising

When evaluating children with bruises, the location, shape, and pattern of the bruising should be noted (Hornor, 2005). Bruises that are most likely accidental are commonly seen over bony areas such as the knees, elbow, and forehead (Herendeen, 2002). Areas that are uncommon for accidental bruising include the cheeks, neck, genitals, buttocks, and back (Herendeen; Sugar et al., 1999) (Figure 1). Bruises in these areas should be considered suspicious for inflicted injury and may indicate a more serious underlying condition such as fractures, intracranial injury, and intra-abdominal injuries, especially in children younger than 2 years of age (Thompson, 2005).

Figure 1.

Inflicted bruises to the back of a child struck with a belt. This figure is available in color at

The pattern and shape of a bruise are also important when distinguishing accidental versus inflicted bruising. Inflicted bruises often are shaped like the object that caused it (Jenny, 2001). The hand commonly is used to injure children and can leave a negative imprint when capillaries break between the fingers as blood is pushed away from the point of impact (Figure 2). Additional objects commonly used to inflict injury on children include belts, cords, shoes, and kitchen utensils (Figure 3, Figure 4). Generally, patterned injuries do not occur during normal play and should be considered inflicted until proven otherwise.

Figure 2.

Slap mark to the face. This figure is available in color at

Figure 3.

Looped marks on the legs of a child struck with a cord. This figure is available in color at

Figure 4.

Patterned mark on the buttock of a child struck with a belt. This figure is available in color at

Bite marks also can be an abusive injury that leaves a patterned bruise. They typically appear as ovoid or elliptical bruises or abrasions that may have central clearing or bruising (AAP, 1999). When evaluating a child with a bruise that may be a bite mark, it is important to determine if the bruise is from a human or animal. If the bite is human in origin, it must be determined whether an adult or a child caused it. Bites from dogs or other animals tend to tear flesh and cause puncture wounds; human bites rarely tear flesh (AAP, 1999). Adult bite marks can be differentiated from a child's bite mark by the maxillary canine distance. The normal maxillary canine distance in adults is 2.5 to 4.0 cm. If the intercanine distance is less than 2.5 cm, a child probably caused the bite. If the intercanine distance is greater than 3.0 cm, the bite probably was caused by an adult.


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