Bruises In Children Research Articles

Erratum

[This corrects the article DOI: 10.1177/2325967118786960.].

A comparison of four different imaging modalities – Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising

BackgroundIt is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images. MethodsChildren aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a ‘plug in’ of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05. ResultsTwenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality. ConclusionsConventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually.

Bone Bruises in Children and Adolescents Not Associated With Ligament Ruptures [corrected

Background:Clinical characteristics of uncomplicated bone bruises (ie, not associated with a ligament rupture, meniscal tear, or fracture of the knee) in young athletes have scarcely been reported.Purpose:To identify mechanisms of injury, characterize bone bruise patterns, and identify clinical factors relating to recovery in young patients suffering uncomplicated bone bruises about the knee.Study Design:Case series; Level of evidence, 4.Methods:A review of clinical records and magnetic resonance imaging (MRI) findings of patients seen at a single institution was completed.Results:We identified 62 children and teenagers (mean age, 13.9 years; range, 8-18 years) who had a total of 101 bone bruises on MRI. The injuries occurred during a variety of organized and recreational sporting activities, the most common being football, basketball, and soccer. The majority (61.4%) of bone bruises occurred as a result of noncontact mechanisms. Patients reported a mean pain scale score of 6.3 of 10 (range, 2-10) on presentation. Frequent clinical findings included non–joint-line tenderness (64.5%), limited range of motion (58.1%), joint-line tenderness (54.8%), and positive meniscal signs (50.0%). The majority of bone bruises (61.4%) were located medially, and the most common bone bruise type was subcortical (58.4%), followed by medullary/reticular (35.6%) and articular impaction (5.9%). The only factor related to time to recovery was mechanism of injury; patients reporting a noncontact mechanism required significantly more time to recover than those reporting a contact mechanism (mean, 99.7 ± 74.8 vs 65.7 ± 38.8 days, respectively; F = 3.753, P = .049).Conclusion:In this case series of 62 pediatric patients with non–anterior cruciate ligament (ACL) bone bruises, the majority occurred in the medial compartment, suggesting that these bone bruises result from a mechanism distinct from the pivot-shift mechanism, classically thought to cause ACL injuries.

Optimising the measurement of bruises in children across conventional and cross polarized images using segmentation analysis techniques in Image J, Photoshop and circle diameter measurements

BackgroundBruising is a common abusive injury in children, and it is standard practice to image and measure them, yet there is no current standard for measuring bruise size consistently. We aim to identify the optimal method of measuring photographic images of bruises, including computerised measurement techniques. Methods24 children aged <11 years (mean age of 6.9, range 2.5–10 years) with a bruise were recruited from the community. Demographics and bruise details were recorded. Each bruise was measured in vivo using a paper measuring tape. Standardised conventional and cross polarized digital images were obtained. The diameter of bruise images were measured by three computer aided measurement techniques: Image J (segmentation with Simple Interactive Object Extraction (maximum Feret diameter), ‘Circular Selection Tool’ (Circle diameter), & the Photoshop ‘ruler’ software (Photoshop diameter)). Inter and intra-observer effects were determined by two individuals repeating 11 electronic measurements, and relevant Intraclass Correlation Coefficient's (ICC's) were used to establish reliability. Spearman's rank correlation was used to compare in vivo with computerised measurements; a comparison of measurement techniques across imaging modalities was conducted using Kolmogorov-Smirnov tests. Significance was set at p < 0.05 for all tests. ResultsImages were available for 38 bruises in vivo, with 48 bruises visible on cross polarized imaging and 46 on conventional imaging (some bruises interpreted as being single in vivo appeared to be multiple in digital images). Correlation coefficients were >0.5 for all techniques, with maximum Feret diameter and maximum Photoshop diameter on conventional images having the strongest correlation with in vivo measurements. There were significant differences between in vivo and computer-aided measurements, but none between different computer-aided measurement techniques. Overall, computer aided measurements appeared larger than in vivo. Inter- and intra-observer agreement was high for all maximum diameter measurements (ICC's > 0.7). ConclusionsWhilst there are minimal differences between measurements of images obtained, the most consistent results were obtained when conventional images, segmented by Image J Software, were measured with a Feret diameter. This is therefore proposed as a standard for future research, and forensic practice, with the proviso that all computer aided measurements appear larger than in vivo.

Visualization of old bruises in children: Use of violet light to record long-term bruises

When a child consultation center evaluates abused children, evidence of the abuse must be documented. Children who have suffered physical abuse often have bruises, which cannot be confirmed by visualization when the bruise has healed. In forensics, a method to confirm an old bruise by ultraviolet radiation is possible. However, long-term ultraviolet exposure can be harmful. In this study, we observed 15 bruises on healthy volunteer children using four kinds of light sources, including ultraviolet radiation, over time. The violet light source enabled observation of a bruise for a longer time than ultraviolet radiation. Although other studies have shown that violet light is superior for enhancing bruises, this is the first report to evaluate data concerning the ability to identify bruises over time in living children. These results might help to identify evidence of past violence suffered by children.

Blunt abdominal trauma in child: Epidemiological, diagnostic, and therapeutic analysis of 55 cases

Objective: The objective of this study was to report the epidemiological, diagnostic, therapeutic, and evolutionary aspects of blunt abdominal trauma in children. Patients and Methods: We carried out a descriptive retrospective study which collected between 55 children of victims of abdominal bruises and the children's surgery department of the Aristide Le Dantec hospital in Dakar between January 1, 2009, and December 31, 2015. The parameters studied were as follows: age, sex, circumstances and mechanisms, hemodynamic status, abdominal table, imaging, associated lesions, and treatment. Results: The mean age was 7.2 years. Boys were more affected with a sex ratio of 3.58. Road accidents were the most frequent cause of accidents with 50.9%. Thirty-six lesions of solid and hollow organs were recorded. The liver was the most affected organ (23.63% of patients), followed by spleen (9.1%) and kidney (7.3%). Multiple trauma was observed in 30.9% of patients with extra-abdominal lesions involving the thorax (64.7%), the skull (35.3%), and the pelvis (35.3%). Forty-seven patients (85.45%) received conservative treatment with a success rate of 93.62%; 11 patients (20%) underwent surgery. The overall morbidity rate was 14.54%, and mortality was 1.81%. Conclusion: Abdominal bruising in children is more common than wounds in the abdomen. Road accidents are the main etiology. Conservative treatment is in vogue in the service and gives very good results.

Bruising and child protection investigation outcomes

Journal of Paediatrics and Child HealthVolume 50, Issue 2 p. 161-161 Heads UpFree Access Bruising and child protection investigation outcomes First published: 16 February 2014 https://doi.org/10.1111/jpc.12521_2AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Building on previous work by this esteemed group of child protection researchers, this study explores the relationship between bruising characteristics and outcomes of child protection investigations of children referred for suspected physical abuse (PA). This work used complete assessment and multiagency case conferences to determine outcomes of cases referred for witnessed abuse, alleged abuse, unexplained injuries, concerning histories, domestic abuse or sibling abuse. Of those with bruising, there was no effect of developmental stage between cases where PA was confirmed and cases where PA was excluded. Confirmed abuse cases had more bruises and more sites affected than the PA-excluded group. Odds of PA-confirmed bruises on buttocks, genitalia, cheeks, neck, trunk, head, front of thighs or upper arms were significantly greater than in PA-excluded children. Petechiae, linear or patterned bruises and clustered bruising were significantly greater in the PA-confirmed group. The strength of this study is the decision made by multiagency assessment in determining outcome, which minimises circular reasoning where outcome is based on characteristics of the bruises themselves. The authors put this study into context as a population study highlighting distinct patterns of bruising emerging that differ between children with confirmed PA and those where is PA excluded after assessment. Reference 1 Kemp AM, Maguire SA, Nuttall D, Collins P, Dunstan F. Bruising in children who are assessed for suspected physical abuse. Arch. Dis. Child. 2014; 99: 108– 113. Reviewer: Catherine Skellern, Catherine_Skellern@health.qld.gov.au Volume50, Issue2February 2014Pages 161-161 ReferencesRelatedInformation

Kawasaki Disease − Tissue Scurvy Misdiagnosed as Non-accidental Injury

Kawasaki Disease is an illness of unknown aetiology,occurs worldwide,and mainly affects Japanese or Asian children under 5 years of age. One feature of the disease, extensive bruising, suggested the possibility of Vitamin C deficiency since it is one of the main causes of bruises in children. Vitamin C deficiency may present in the form of “Tissue Scurvy” – an autoimmune disorder in which there is an abundance of Vitamin C in the body(unlike the Seafarer Scurvy of yesteryear)but it is inhibited from entering the cell to perform its functions because of the lack of insulin which is essential for the transfer of Vitamin C into the cell.Here it is shown a child presenting with the signs and symptoms of Kawasaki Disease was found to have hyperglycaemia, implying insulin deficiency.It is concluded that Kawasaki Disease is an autoimmune disorderfollowing antigenic stimulation in a genetically susceptible child.

Which is the preferred image modality for paediatricians when assessing photographs of bruises in children?

Images of bruises serve as a clinical record and may facilitate forensic analysis in the assessment of suspected physical child abuse. Currently, only conventional imaging techniques are employed; however, alternative imaging modalities using visible and non-visible light may provide additional information. We sought to determine the image modality preferences of paediatricians and the between-observer agreement therein. Nine paediatricians who work in child protection independently compared five image modalities (conventional colour, conventional grey-scale, cross-Polarised, ultraviolet, and infrared) of four bruises, with a compliance rate of 95%. All images were taken using a standardised set of protocols with Nikon D90 cameras and 105-mm macro-lenses. The paediatricians almost unanimously chose cross-Polarised as their preferred modality for all four bruises when assessing boundary, shape, colour, size, and absence of light reflectance. Conventional colour and grey-scale imaging were typically ranked second and third. Ultraviolet and infrared were consistently ranked in the least two favourable positions. Between-observer agreement on ranking order was high, with coefficients of concordance ranging from 0.76 to 0.96. Combinations of imaging modalities chosen to give the most complete picture of the bruise predominantly consisted of cross-Polarised and conventional (colour and grey-scale). This pilot study demonstrated that clinicians collectively favoured cross-Polarised in addition to conventional imaging. Further studies are required to determine the value of ultraviolet and infrared imaging in the assessment of childhood bruises.

Spectrophotometric Evaluation of the Age of Bruises in Children: Measuring Changes in Bruise Color as an Indicator of Child Physical Abuse

Physical abuse of children is a severe social problem and is usually identified by the presence of bruises of various ages. The visual appearance of bruises is widely used to identify victims of abuse. Therefore, to objectively evaluate the age of bruises, we used a spectrophotometer to examine 86 bruises that occurred accidentally in healthy child volunteers, with consent from appropriate guardians. The bruise color was measured using a spectrophotometer and plotted using the CIE-L*a*b* color system, a method that expresses color numerically. The differences [Delta] in L* (lightness), a* (red and green content) and b* (yellow and blue content) color values relative to neighboring healthy/unbruised skin were measured for 7-10 days until the bruise disappeared. A characteristic pattern was observed in 21 bruises; DeltaL* increased from the negative peak and returned to baseline, Deltaa* decreased from the positive peak to baseline, and Deltab* increased above baseline and then slowly returned to baseline. The pattern of these color changes could be classified into three phases according to the time between bruising and the peak values for DeltaL* (negative peak, 38.9 +/- 19.5 hours), Deltaa* (positive peak, 37.6 +/- 21.7 hours), and Deltab* (negative and positive peak, 43.5 +/- 18.7 and 132.6 +/- 40.4 hours). Thus, spectrophotometric measurement of the color of bruises is helpful to estimate the approximate age of bruises and to distinguish between old and new bruises. This objective method could be introduced to clinical practice and social care to evaluate possible cases of child abuse.

Bruises in Children: Normal or Child Abuse?

Bruises in active children are common and often are considered “normal” childhood injuries. However, bruises also may be the result of physical abuse or other conditions. The evaluation of a child with bruising should include a thorough history and physical examination to determine the cause. When abuse is suspected, prompt reporting is necessary to protect the child from further injury. This article provides information intended to assist nurse practitioners and other pediatric health care providers in their decision making when assessing a child with bruises.

Histologic dating of bruises in moribund infants and young children

It is generally held that leukocytes are found within bruised subcutaneous tissues within 4-12 h of injury as part of a standard cellular response to trauma. As a corollary, the absence of leukocytes is often cited as evidence of more recent injury. To investigate how long after injury it may be before a leukocyte response occurs selected bruises from three children aged 27, 11, and 3 months, respectively, were examined microscopically. All of the children had sustained lethal head trauma, with survival on life-support equipment for some time in hospital, and with bruises of at least 24-h duration confirmed by medical evaluation (at 30, 44, and 79 h from the time of initial medical evaluation to death). Histologic examination of selected lesions in all three cases revealed extravasation of red blood cells within subcutaneous tissues, but no leukocyte infiltration or other cellular reaction. Other bruises in these children exhibited a standard inflammatory response. This study has shown that selected bruises in three children were present for at least 30 h without a leukocyte infiltrate. Caution should, therefore, be exercised in assigning too rigid a time course to bruising in infants and young children based on a lack of a vital reaction, as the absence of leukocytes within soft tissues of bruised skin in these cases may not necessarily indicate that the injuries are recent. Variability in tissue response may also occur in different bruises in the same individual. Whether severe craniocerebral trauma played a role in delaying the cellular response in these particular injuries is unclear.

Management of children with bleeding disorders

Bleeding and easy bruising in children may be due to one of the many inherited or acquired disorders of hemostasis. An understanding of normal hemostasis is essential for evaluation of a child with abnormal bleeding. A complex interaction between vascular endothelium, von Willebrand factor and procoagulant protein Factor I to XIII results in formation of a fibrin clot at the site of injury and bleeding stops. Conditions causing quantitative or qualitative defects of platelets, von Willebrand factor or various procoagulant protein will result in abnormal bleeding. Patients with hemophilia experience more severe bleeding and are diagnosed early in life. von Willebrand disease on the contrary has a variable presentation and therefore the diagnosis is delayed in some cases. Morbidity and mortality due to bleeding may be reduced with appropriate management in the majority of patients with bleeding disorders. A systematic approach to a patient with bleeding is discussed. Management of hemophilia and von Willebrand disease is also reviewed.

"Suspicious" Bruising in Children May Not Be Abuse

Unexplained bruising in children may raise the question of abuse, but this paper reminds us to consider coagulation disorders. The authors report several patients with unexplained bruising who were initially thought to be victims of abuse, but had abnormal screening tests for coagulation disorders. A succinct discussion of …

Estimation of the age of bruising.

Paediatricians are often requested to give an opinion on the age of a non-accidental bruise. In forensic textbooks, the colour changes which a bruise undergoes with time are not based on research in children. The purpose of this study was to document the sequence of colour changes in photographs taken following accidental bruising in children. Fifty accidental bruises of known age in 23 children were photographed by a medical photographer using the same equipment throughout. The photographs were reviewed by a single observer, blind to the true age of the injury, who described the colours present in the bruise. Red colouration was seen in 15 out of 37 bruises which were less than one week old. Yellow colouration was seen in 10 out of 42 bruises over one day old. Aging of bruises from photographs was much less precise than textbooks imply.

Pediatrics. Easy bruising in children

Pediatrics. Easy bruising in children

Easy bruising in children.

It is necessary to determine whether easy bruising in children is caused by a hemorrhagic disorder. A careful history for the patient and family should be obtained and a physical examination should be done. Any positive indications of hemorrhagic diathesis call for basic coagulation screening tests.