Bruising

 

Bruising usually occurs as a result of trauma, which is usually accidental but may be non-accidental, and is the most common injury sustained by children who have been subject to physical abuse.  Excessive bruising, or bruising which occurs as a result of minimal or no recognized trauma, may be caused by, or exacerbated by, an underlying bleeding disorder or medical condition, including: vascular disorders, platelet disorders, coagulation disorders, and drugs.  However, the presence of a bleeding disorder or other underlying medical condition does not rule out non-accidental injury as a cause of abnormal bruising, as the two may co-exist

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Assessment

  1. Ask about symptoms which suggest an underlying platelet or coagulation disorder:
    1. Nosebleeds or gingival bleeding (mucocutaneous bleeding)
    2. Excessive or prolonged bleeding from haemorrhoids, other rectal bleeding, haematuria, or menorrhagia
    3. Previous excessive bruising, or excessive or prolonged bleeding, that:
      1. Occurs soon after trauma (particularly if it is associated with a petechial rash or mucocutaneous bleeding) — suggests a platelet disorder
      2. Is delayed, such as haemorrhage occurring 24 hours after a dental extraction (particularly if it is associated with bruises, haemarthrosis, or muscle haematomas) — suggests a coagulation disorder, such as haemophilia
      3. Is new in onset, following previously normal responses to trauma — suggests an acquired problem
  2. Ask about the person's general health to assess for underlying medical causes:
    1. history of childhood chemotherapy or radiotherapy may result in a bone marrow disorder (such as myelodysplasia or leukaemia)
    2. Hypothyroidism may affect the quality of skin and subcutaneous tissue
    3. Nutritional status — children who only eat a limited diet can develop nutritional deficiencies, leading to a coagulopathy, vascular fragility, and abnormal bruising
    4. Tiredness, weight loss, fever, and night sweats may suggest malignancy
    5. Joint pain, swelling, or reduced range of movement may suggest a haemarthrosis
  3. Ask about alcohol use, and any prescribed or over-the-counter drugs
  4. Ask whether there is a family history of:
    1. A known bleeding disorder (such as haemophilia, von Willebrand disease, or a platelet disorder)
    2. A tendency to bruise or bleed easily or spontaneously
    3. Menorrhagia or postpartum bleeding in females, which may indicate a non-sex-linked disease (such as von Willebrand disease or factor XI deficiency)
    4. Consanguinity — have a lower threshold for suspecting an autosomal recessively inherited bleeding disorder, such as factor X deficiency
    5. Hereditary haemorrhagic telangiectasia, Ehlers-Danlos syndrome, or osteogenesis imperfect
  5. For infants, children, the elderly, or people with learning difficulties, assess bruising in the context of the person's age, mobility and developmental status, and the explanation for injury (if any). For children, ask if:
    1. The child is crawling — bruising is uncommon in infants who are not yet mobile
    2. The child may have taken a drug (such as warfarin) accidentally
    3. There is any history at birth of conditions suggesting an undiagnosed bleeding disorder, such as:
      1. Cephalhaematoma after instrumental delivery
      2. Unexpected bleeding from the umbilical stump or delayed stump separation by up to 4 weeks, suggesting factor XIII deficiency
      3. Haematoma after routine intramuscular vitamin K given at birth
      4. Bleeding from the newborn heel prick test, suggesting factor XIII deficiency, or sometimes haemophilia

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Examination

  1. Assess the location and pattern of bruising, using pictorial or photographic records where possible and appropriate (for example in children):
    1. Distribution, number, site, shape, and measured size of bruises
    2. Dependent areas — suggests thrombocytopenia or stasis factors
    3. Atypical areas, such as on the trunk — suggests an underlying bleeding disorder, or non-accidental injury
    4. Patterned bruising, for example, the outline of a hand print or implement (such as a belt)
    5. Only on the arms or legs — suggests trauma or changes in the skin or subcutaneous tissue.
    6. Periorbital — may suggest neuroblastoma in a child or amyloidosis (rare)
    7. Dorsum of the hands, extensor surface of the forearms, and the shins — suggests senile purpura
      1. NOTE:  The age of a bruise cannot be estimated accurately by its colour; if no bruises are currently present, ask the person to return when they reappear
  2. Examine the skin, hair, and nails for:
    1. Age-related changes
    2. Evidence of delayed healing, such as multiple scars or unhealed wounds — suggests corticosteroid use, hypothyroidism, ageing, self-inflicted injury, a collagen defect, or factor XIII deficiency
    3. Laxity — may suggest Ehlers-Danlos syndrome
    4. Pallor — suggests anaemia, which may be associated with malignancy
    5. Jaundice — suggests liver disease
    6. Petechiae (tiny, round, non-blanching, pinpoint flat spots less than 3 mm in diameter) — for example at clothing line pressure sites may indicate a platelet disorder; or if in the distribution of the superior vena cava they may follow coughing, vomiting, or strangulation
    7. Palpable purpura (typically 3–10 mm in diameter) — suggests an underlying systemic vasculitis, such as Henoch-Schonlein purpura
    8. Brittle hair and nails — suggests nutritional factors, ageing, hypothyroidism, or rarely hereditary haemorrhagic telangiectasia
  3. Examine the joints for:
    1. Abnormalities suggestive of an inflammatory arthropathy (such as rheumatoid arthritis)
    2. Hyperextensibility or elasticity — suggestive of Ehlers-Danlos syndrome
    3. Swelling and tenderness — may indicate haemarthrosis, suggesting haemophilia
    4. Tenderness — may be seen in acute leukaemia or neuroblastoma
  4. Examine the abdomen for:
    1. Splenomegaly — suggests malignancy or idiopathic thrombocytopenic purpura (rare)
    2. Hepatomegaly — suggests malignancy or liver disease
    3. Ascites, caput medusa, and spider telangiectasia — suggest chronic liver disease
  5. Examine the head and neck:
    1. The oropharynx — for signs of bleeding, trauma, or healing injury to the frenulae (may suggest other non-accidental injury); gum hypertrophy may occur in monocytic leukaemia; wet purpura on the buccal mucosa or tongue is suggestive of severe thrombocytopenia
    2. The eyes — use fundoscopy to check for retinal haemorrhages (may suggest other non-accidental injury)
  6. Examine for lymphadenopathy:
    1. Suggestive of leukaemia or amyloidosis

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Red flags suggesting non-accidential injury

Suspect non-accidental injury and physical abuse when:

  1. Bruises are on a child who is not yet independently mobile (crawling, cruising, or walking)
    1. Bruising appropriate to learning to walk is common from around 1 year of age when most children have started 'cruising'. It is typically distributed on the anterior tibia and knee, followed by the upper legs and forehead
  2. Bruises have indicative features
    1. Disproportionate to the explanation of injury sustained
    2. Unusually large
    3. Present in multiple sites or in clusters
    4. Of a similar shape and size
    5. Patterned in the shape of a hand print, ligature, stick, tooth (or teeth marks), grip, or implement (such as a belt). Fingertip bruising is often found in children with a bleeding disorder
    6. Associated with petechiae
  3. Bruises are found in indicative places
    1. Sites that are not typical for the age of the child
    2. Any non-bony part of the body or face (including the eyes, ears, cheeks, back, abdomen, buttocks, arms, and genitalia)
    3. On both sides of the face or head
    4. On the neck (consistent with strangulation)
    5. On the ankles and wrists (consistent with use of a ligature)
  4. The explanation for the bruising is implausible, inadequate, or inconsistent:
    1. With the child's presentation, normal activities, existing medical condition, age or developmental stage, or account — compared with that given by parents or carers
    2. Between parents or carers
    3. Between accounts over time
  5. There is a delay in presentation

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When to refer

Admit the person if they have significant active bleeding and are not responding to simple measures (such as local compression)

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If non-accidental injury is suspected in children and young people, the elderly, or other vulnerable people:

  1. Refer immediately to KCC social care services for children and vulnerable adults.  If the person needs admission, ensure the hospital are aware of your concerns
    1. See also Bruising in non-mobile babies notification for details of what to do if you are concerned about possible marks or bruising in a non-mobile baby

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If non-accidental injury is not suspected:

  1. Refer children and young people for immediate specialist assessment for leukaemia if they have:
    1. Unexplained petechiae or
    2. Hepatosplenomegaly or
    3. Full blood count results suggestive of leukaemia
  2. Refer children with periorbital bruising urgently (for appointment within 48 hours) for specialist assessment for neuroblastoma  if they have:
    1. A palpable abdominal mass or
    2. An unexplained enlarged abdominal organ
  3. For all other children, liaise with a paediatrician or paediatric haematologist to arrange venepuncture and further investigations as needed
  4. Refer adults for immediate specialist assessment for leukaemia if they have:
    1. Full blood count results suggestive of leukaemia
  5. Refer all other adults to a haematologist for further investigations, the urgency depending on clinical judgement, if there is:
    1. A low platelet count
    2. An abnormal clotting screen
    3. Normal blood results in primary care but a bleeding disorder is still suspected

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Management in primary care

For simple bruising where there is no suspected underlying bleeding disorder:

  • Prescribe simple analgesia such as paracetamol if required

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For people taking warfarin with an abnormal clotting screen (a prolonged prothrombin time or increased international normalized ratio):

  • If the person is monitored and managed in primary care, alter their warfarin dosage according to local protocols, or liaise with the local warfarin clinic or a haematologist, depending on clinical judgement

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For people taking a drug that may cause thrombocytopenia, withdraw the drug where possible and appropriate, and monitor the person for resolution of symptoms and signs

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Body map of where bruising can occur:

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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