Hematomas in Children L

Hematomas in children L. van Duurling, forensic specialist KNMG / manager FPKM

Subcutaneous bruising (hematoma) A so-called hematoma (‘black and blue spot’) is caused by a haemorrhage in the skin after collision and/or compressive external force with or by a blunt object. Hematomas are the result of the presence of blood in the space between the cells of the skin (interstitial space), often as a result of the tearing (off) of blood vessels (then there is a hematoma, whereby the discoloration of the skin sharp is clearly demarcated), or as a consequence of the leakage of blood from blood vessels (then there is a bruise whereby the discoloration of the skin is more diffuse). A local inflammatory response and the dilation of capillaries (small blood vessels) may contribute to the redness of a recent hematoma.1 Hematomas usually disappear completely within about 2 weeks.2

Distinction between accidental and non-accidental hematomas Hematomas are extremely rare in children younger than 6 months. The stage of development plays an important role: children who are not mobile rarely have hematomas. The frequency of the occurrence of hematoma increases as children become older (and therefore more mobile) and enterprising.3

Accidental hematomas in children who can walk are generally small and are located at locations on the skin where bone protrudes slightly and/or is relatively close to the skin surface (such as the tibia). This usually involves locations at the front of the body, because the child is moving forward. Accidental injuries occur during sports and play or from (traffic) accidents. The explanation given for these injuries is usually adequate.

Non-accidental hematomas are often located at locations where no bone is just under the skin, such as the neck, face (cheeks), the buttocks, torso (abdomen) and the (upper) arms. Non-accidental hematomas are often larger than accidental ones, and are more often clustered, sometimes showing an impression of an object (for example fingers, ‘fingerprint bruising’).4 5

Hematomas in the anogenital region (at the penis and the vulva), on the inner side of the upper and lower arms and the thighs (for example in the form of 'fingerprint bruising’), in the armpits and at the point of the shoulder blade may be indicative of sexual and/or physical abuse. Encountering multiple hematomas close to each other (clustered) in the form of ‘fingerprints' on the chest and/or (simultaneously) on the back may indicate a mechanism

1 Kollias N. The physical basis of skin color and its evaluation. Clin Dermatol 1995;13:361-7. 2 Taitz LS. Child abuse: some myths and shibboleths. Hospital Update 1991 May:400-4. 3 Labbe J, Caouette G. Recent skin injuries in normal children. Pediatrics 2001;108:271-6. 4 Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? Arch Dis Child 2005; 90:182-6. 5 Naidoo NS. A profile of the orofacial injuries in child physical abuse at a children's hospital. Child Abuse Neglect. 2000;24:521-34.

www.thenextpage.nl whereby the chest cage is firmly enclosed, such as in roughly executed care procedures or after a violent shaking incident.6

6 Hobbs CJ, Osman J. Genital injuries in boys and abuse. Arch Dis Child 2007;92:328-31.

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Compression of the trunk and/or neck, such as in an attempt at strangling, leads to a pressure increase in the blood flow toward the heart (increased venous pressure), which can result in punctiform haemorrhages (petechiae), specifically on the face, neck and/or in the conjunctiva of the eyes.7 A blow to the side of the face can cause punctiform haemorrhages (petechiae) or small skin discolorations (purpura) on, in or behind the ear.8.

In the figure below it is shown at which locations hematomas are suspicious for child abuse.

Minimally Very suspicious suspicious

7 Reece RM, Christian CW. Child abuse, medical diagnosis and management. AAP, third edition, 2009:19-51 8 Feldman KW. Patterned abusive bruises of the buttocks and pinnae. Pediatrics 1992;90:633-6.

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Tramline bruising If an object is used for inflicting injury, the object can cause injury with visible edges. From hitting with the flat of the hand it is possible that capillaries in the skin between the fingers tear, because the blood is pushed away under the fingers. Solid objects that encounter the skin with force can result, by the stretching of the skin at the location of the edges from these objects, in stripe-like skin discolorations at the site of the edges of the object, leaving behind a pattern of tracks (‘tramline bruising), see figure 2).9

Fig. 2: Tramline bruising

9 Stark MM, Payne-James J, Crane J, Hincliffe JA. Clinical Forensic Medicine. Humana Press, Second edition, 2005.