Bruises, Welts, and Scars

Bruises are the most common clinical finding in cases of physical abuse, seen in up to 75% of victims, and their presence should prompt a search for other, deeper injuries. Inflicted bruises and welts may be the result of direct blows or of impacts with firm objects when pushed, shoved, thrown, or swung into them. They frequently involve more than one plane of an extremity, the torso, and/or head, and are often found in places that are unusual sites for accidental injury (see the section Differential Diagnosis of Inflicted Injuries versus Findings Caused by Accident or Illness, later). These include the back, buttocks, upper arms, thighs, abdomen, perineum, and feet, all of which are typically covered by clothing and, thereby, hidden from public view (Figs. 6-1 and 6-2). When due to slaps or blows, these locations suggest some forethought in site selection. Among other unusual sites are the face (including the periorbital area and eyelids, cheeks, sides of the forehead, lateral aspects of the chin and mouth), ears, neck, hands, calves, and volar or ulnar (defensive posture) aspects of the forearms. Being more exposed, bruises in these areas may reflect greater impulsivity on the part of the perpetrator.

Figure 6-1 Inflicted bruises found in unusual locations. A, Multiple ecchymoses are evident over the back and upper chest of this child who presented in a poorly nourished condition. B, The same patient with multiple bruises involving differing planes of the face and forehead. Note the fingerprint bruise on the cheek. C and D, This child had severe contusions over the hands and feet, which were inflicted with a ruler. E, He also had a markedly swollen and contused ear and patches of hair loss where the perpetrator had pulled out hanks of hair. Both boys had been removed from abusive mothers and placed with maternal grandmothers who had physically abused their daughters in the past.

Figure 6-2 This toddler, the victim of repetitive beatings by her mother’s boyfriend while the mother was hospitalized, had A, postauricular bruising, B, a line of fingerprint or knuckle bruises over the posterior left shoulder, and C, extensive bruising over the lower back in a pattern suggestive of knuckle marks, along with a large contusion over the right iliac crest. D, Rounded bruises over the lower abdomen and mons pubis may represent grab or punch marks. Some of her injuries were due to impacts against stairs and furniture when thrown forcefully by the perpetrator. Other injuries included a healing left radius fracture, refracture through a healing distal clavicle fracture, and evidence of old CNS trauma (see Fig. 6-26; Fig. 6-39, B; and Fig. 6-55).

Bruises involving the head, face, mouth, neck, and ears (Fig. 6-3) are seen in a substantial percentage of physical abuse victims: approximately 50% of infants and 38% of toddlers. Subgaleal hematomas and contusions and petechiae involving the scalp may be the result of direct blows or impacts against hard surfaces. On occasion they are caused by forceful hair pulling (Fig. 6-4). Slaps of moderate force may produce diffuse bruising with petechiae (Fig. 6-5). More forceful slaps leave handprint marks, consisting of petechial outlines of the fingers of the perpetrator as maximal capillary distortion occurs at the margins of the fingers on impact (Fig. 6-6). Periorbital and eyelid bruises in the absence of evidence of an overlying forehead hematoma or abrasion, or of an accidentally incurred frontal skull fracture, are likely to be inflicted and caused by direct blows to the face (Fig. 6-7, A and B).

Figure 6-3 Ear bruising. This infant was hit so forcibly on the side of his head that he has an impression bruise on his scalp in the shape of his external ear. The linear bruise over the top rim of his ear is the result of capillary distortion caused by compression between the impacting hand and the child’s skull.

Figure 6-4 Subgaleal hematomas. This toddler, in the care of mother’s paramour, was reportedly well until about 45 minutes after being put to bed, when she “woke up screaming.” On being picked up, she was noted to have a “mushy head.” At the hospital, she was found to have large bilateral subgaleal hematomas, with surface bruising and petechiae over the occipitoparietal scalp. She also had semicircular bruises behind her left ear consistent with fingernail marks. Skull radiographs and a head CT scan showed no evidence of skull fracture or intracranial injury. Further examination revealed extensive bruising and lacerations of the introitus consistent with sexual assault (see Fig. 6-92 B). The perpetrator apparently grabbed her by her hair and by her head, leaving fingernail marks while in the process of assaulting her. Her hair was pulled so forcibly that the scalp was pulled away from the skull, leading to the extensive subgaleal bleeding, which continued to expand over the ensuing 72 hours. A, Thinning of the hair from hair loss and bruising of the scalp are evident, and the subgaleal hematoma over her left temporal area is so large that it is pushing her external ear out laterally. B, Curvilinear marks behind her left ear are fingernail impressions.

Figure 6-5 Facial slap marks. A, Diffuse facial bruising and petechiae seen over the side of the face and head of this 3-week-old infant were the result of repeated slaps by his father, a paranoid schizophrenic who had stopped taking his medication. He acknowledged slapping his son to make him cry, after which he would give him his bottle, the purpose being to teach him to cry when hungry. The baby also had metaphyseal chip fractures due to forced hyperextension of the knees to the point of screaming because “his muscles were tight” and “needed to be loosened up.” B, This older infant has even more extensive petechiae and bruises that were tender on palpation.

Figure 6-6 Handprints. A and B, These children were slapped so forcefully that the outlines of their abuser’s fingers are clearly evident.

Figure 6-7 A, Bilateral black eyes are seen in this 12-day-old baby. His father, who was well-to-do, well dressed, and sophisticated, reported that he had fallen on the stairs while holding the baby in a football hold and that in the fall, the baby hit the steps face first with father landing on top of him. Bruises involving multiple planes of the face, the absence of an associated forehead hematoma or frontal fracture, and the presence of an occipital fracture consistent with impact against a hard surface (not the father’s chest) belied this story. Nevertheless, abuse was not suspected, and the baby was sent home. He returned 6 weeks later in extremis with massive intracranial injury and died. On this occasion, the father said he had found the infant choking and gasping for breath and had picked him up and shaken him to revive him. B, This infant’s bilateral black eyes are the result of direct blows to the periorbital areas bilaterally.

Surface injuries involving more than one plane of the head or face are highly suspicious for abuse. It is also important to recognize that contusions of the head, face, and ears are often associated with underlying intracranial injury, especially in infants. Such injuries are indicative of severe loss of control and intent to harm on the part of the perpetrating caregiver and have serious implications for the child’s future safety unless he or she is removed from contact with the offender.

Round impressions of the thumb and forefinger may be seen on the cheeks, sides of the forehead, or sides of the chin in infants and young children who have been grasped and forcefully squeezed (see Fig. 6-1, B). Similar fingerprint bruises may be noted on the upper arms, trunk, abdomen, or extremities where the infant has been grasped and held tightly while being shaken or forcibly restrained (see Fig. 6-13). More elongated grab marks may also be found on the extremities (Fig. 6-8). When round bruises similar to fingerprint marks are found in a linear pattern, they may be fingertip impressions or knuckle marks from punching (see Fig. 6-2, B and C). In the latter instance, one may note partial central clearing of the rounded contusions. Fingerprints or grab marks located on the thighs, especially the medial surfaces, should prompt careful examination for signs of concurrent sexual abuse. Pinching produces apposed fingerprint marks with a shape that may be reminiscent of a butterfly or figure-of-eight. These may be seen singly or in rows, usually on clothing-covered areas (Fig. 6-9).

Figure 6-8 Linear finger grab marks are seen on the outer aspect of this infant’s upper arm. A thumbprint bruise was present medially.

(Courtesy Kent Hymel, MD, Inova Fairfax Hospital for Children, Falls Church, Va.)

Figure 6-9 Pinch marks. A row of fading bruises secondary to pinching, used as a method of discipline by his mother, is seen on the lateral aspect of the thigh of this preschool-age boy. More than a year later, his sister nearly died of multiple stab wounds also inflicted by their psychotic and delusional mother (see Fig. 6-16).

Attempted smothering, choking, or severe and prolonged thoracic compression may produce showers of petechiae over the shoulders, neck, and face (Fig. 6-10, A–D). The oral and conjunctival mucosa may be involved as well and should be carefully inspected. If a hand or other object is held forcefully over the nose and mouth of a child with erupted teeth, imprint bruises, abrasions, or lacerations left by the teeth on the labial mucosa may be noted in addition to facial petechiae (see Fig. 6-10, E). When strangulation is the mechanism, neck bruises are usually visible (see Fig. 6-10, B). These petechiae may range from florid to faint and may be especially subtle when there has been a delay in seeking care. They can be mistaken for a rash if the examiner fails to check for blanching. Failure to detect such lesions has resulted in a number of subsequent deaths.

Figure 6-10 A–D, Petechial lesions secondary to choking. A, Numerous petechiae are seen over this boy’s face. B, Linear marks noted on the side of his neck correspond with the hand and finger placement demonstrated in C and D. The boy was choked to a point of near-unconsciousness by his mother’s boyfriend for tracking grass onto a freshly vacuumed carpet. E, Central facial petechiae were present bilaterally in this infant. The perpetrator confessed to holding his hand over her mouth and nose and squeezing her cheeks with thumb and forefinger to stop her crying.

(Courtesy Kent Hymel, MD, Inova Fairfax Hospital for Children, Falls Church, Va.)

Bruises are often seen over the curvature of the buttocks and across the lower back after severe spankings, whether with a hand or an object such as a paddle, belt, or hairbrush (Fig. 6-11). When linear marks from fingers, belt, or brush edges are seen, these tend to be horizontally or diagonally oriented (see Fig. 6-11, B). However, in some cases a linear pattern of petechiae may be noted on either side of the gluteal crease (see Fig. 6-11, C). Despite their vertical orientation, these are also the result of forceful horizontal blows across tightly tensed glutei, as when the blows are delivered, the involved sites are closely apposed along the crease and thus are subject to maximal capillary distortion on impact.

Figure 6-11 Buttock bruises. A, At first glance, this toddler appeared to have a diaper rash, but on closer inspection the lesions were found to be petechiae produced by a severe spanking. B, The severe contusions of the buttocks and lower back seen in this child were inflicted by hand, hairbrush, and belt. C, A linear pattern of petechial hemorrhages is seen on either side of the gluteal cleft in this boy who was subjected to repeated rapid-fire blows across the gluteal crease.

Bruises involving the abdominal wall below the rib cage and above or anterior to the pelvic girdle are rarely seen with accidental injury and are relatively unusual in cases of abuse (see Fig. 6-2, D and Fig. 6-13). This is because of the great flexibility of the abdominal wall and its padding with adipose tissue. In fact, many children with inflicted intraabdominal injuries have little or no cutaneous evidence of trauma over the abdomen, although in some cases their absence may be due to delayed presentation. When abdominal bruises are present, they are indicative of forceful grabbing or pinching or of forceful blunt impact (such as a punch or kick). In these cases, abuse should be strongly suspected and evidence of internal injury should be sought (see the section Abdominal and Intrathoracic Injuries, later; and Fig. 6-57).

In many instances the surface marks are recognizable imprints of the edge of a weapon used to inflict the injury, because the edge causes maximal capillary deformation on impact. Those most commonly seen are looped-cord marks, caused by whipping the child with a looped electrical cord (Fig. 6-12, A and B), belt and belt-buckle marks (see Fig. 6-12, C, D, and F; see also Fig. 6-11, B), and switch marks (see Fig. 6-12, E and F); but almost any implement can be used including hairbrushes (see Fig. 6-11, B), shoes (see Fig. 6-12, G and H), kitchen utensils (see Fig. 6-12, I), and chains (see Fig. 6-12, J).

Figure 6-12 Imprint marks reflecting the weapons used to inflict them. A, Fresh looped-cord marks and B, hypopigmented and hyperpigmented scars that were the result of beatings with a looped electrical cord. C, The characteristic pattern of parallel lines that results from blows with a belt. D, This contusion in the configuration of a closed horseshoe with a central linear abrasion was inflicted with a belt buckle. E, The red linear contusions on this child’s thigh were the result of repeated blows with a switch. F, These acute linear contusions over the back and buttocks were inflicted with a belt and a switch. G, This boy was hit with a slipper with such force that imprints of the heel are evident. H, The heel prints of a running shoe left on this boy’s arm and thigh were distinct enough to enable identification of his abuser. I, This girl was hit forcefully with a spatula because she was acting out while her mother was trying to prepare dinner. J, This boy was struck with a chain, leaving a clear imprint of the links.