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The teacher of a 6-year-old noticed suspicious bruises on the child’s leg and notified Children’s Protective Services. Arrangements were made to see the child at school. The social worker noted 2 complete and 2 partial hand imprints on the child.
The teacher of a 6-year-old noticed suspicious bruises on the child’s leg and notified Children’s Protective Services. Arrangements were made to see the child at school.
The social worker noted 2 complete and 2 partial hand imprints on the child. It was the common practice of this CPS office to trace the image of the bruise onto a piece of paper for comparisons with potential perpetrators (Figure).
The child was interviewed but denied any trauma at home or school. The family also denied any issues at home and was unaware of any source of trauma. The family showed appropriate concern and agreed to take the child to a physician.
The physician provided CPS with a letter stating that there were no medical issues that would cause bruising. He documented an additional bruise on the buttock.
Do you suspect abuse, or is there another possible explanation for the bruising? (Answer and discussion on next page)
CPS started the process of trying to identify the person who inflicted the bruises. They began by trying to find a match to the handprint traced from the child’s body. They found no one in the home or the school with a hand even remotely the same size as the tracing (Figure). They allowed the child to remain in the home during the investigation since the family had no previous interaction with CPS, either locally or in previous places of residence.
Several weeks after the initial bruising incident, the mother called the social worker to express her concerns that she had found new bruises on her daughter. This time there were more large bruises; the most unusual were those on the bridge of the child’s nose and behind the ears where the child’s glasses rested. A second medical opinion was sought. The second examination was more complete, and a diagnosis of idiopathic thrombocytopenic purpura (ITP) was made.
The new diagnosis answered the question as to why there were bruises, but there was still the unanswered issue of the source of the large handprint bruises. The case remained open.
Weeks later the mother called the social worker to tell him that she had found the source. The mother had stripped the mattress cover off the child’s bed and found a hand-shaped toy at the foot of the bed. It was hypothesized that the child had unknowingly laid on the toy in different positions, and that the toy was the source of the patterned bruising.
The toy matched the tracing the social worker had made on his first encounter with the child.
The case was closed as a true mimic of abuse.
This case, as it was told to me, was full of unexpected twists. It also offers several points with which the clinician doing abuse exams needs to be concerned.
1. Most diagnoses can be made with a good history and physical. In retrospect, there were there some historical facts that would have led a physician to the diagnosis in this case.
2. Routine screening lab tests are a necessity in cases involving abnormal bruising. There is no definitive set of tests that must be done, but I prefer a CBC, PT, INR, and PTT. These tests will identify the most common medical conditions that can cause bruising. Some situations may require a hematology consult for additional testing.
3. The care of possibly abused children is real medicine and should be taken seriously. We have an ethical obligation to address the medical needs of the child. We also have a responsibility to society to do our best not to propagate unfounded allegations of abuse.
Acknowledgement: A special thanks to Eric Flannery, the social worker who shared this case.
1. Lee A. Bruises, blood coagulation tests and the battered child syndrome. Singapore Med J. http://smj.sma.org.sg/4906/4906ra1.pdf
This article provides a good review on coagulation and bruising as they relate to child abuse. IT also intersects with the case presented here because it points out that abnormal coagulation factors do not exclude abuse. In this case ITP was the diagnosis, but the large pattern bruising also had to be explained.