Bruising
Exam Tips
- Bruise colour is unreliable for timing; avoid claiming exact age of lesions in exams/OSCEs.
- Any bruising in a non-mobile infant is highly concerning and requires urgent safeguarding assessment.
- Pattern and site are high-yield: accidental bruises are usually over bony prominences; bruises on ears, neck, torso, genitalia, or with clear imprints are red flags.
- A bleeding disorder does not exclude abuse; both can coexist.
- In a bruising child, always document a full bleeding history (epistaxis, gum bleeding, menorrhagia, family history, medications) and perform baseline labs (FBC, film, PT/APTT).
Definition
A bruise (ecchymosis/haematoma) is bleeding into subcutaneous tissue under intact skin after disruption of small blood vessels. In children, bruising is common after minor trauma once mobile, but bruising that is excessive, occurs with minimal trauma, appears in unusual sites, or is present in non-mobile infants should prompt assessment for bleeding disorders and possible non-accidental injury.
Pathophysiology
Bruising occurs when capillaries and venules rupture, allowing red cells to leak into skin and soft tissue; haemoglobin is then metabolised over days, producing evolving colour change (red/purple to yellow-brown), although colour is unreliable for ageing a bruise. Bleeding tendency increases when primary haemostasis is impaired (platelet number/function disorders such as ITP), secondary haemostasis is impaired (coagulation factor defects such as haemophilia/von Willebrand disease), or vessel/connective tissue integrity is reduced (for example Ehlers-Danlos syndrome, scurvy). In paediatrics, trauma pattern matters: accidental bruises are usually small and over bony prominences, whereas patterned, clustered, or atypically located bruises raise concern for inflicted injury. See Figure: distribution of typical accidental vs concerning bruising sites in paediatric safeguarding texts.
Risk Factors
- Normal childhood mobility and play-related minor trauma (especially shins, knees, forehead)
- Non-accidental injury risk contexts (inconsistent history, delayed presentation, social safeguarding concerns)
- Platelet disorders (for example ITP, inherited platelet dysfunction)
- Coagulation disorders (for example haemophilia, von Willebrand disease, liver disease-related coagulopathy)
- Vascular/connective tissue disorders (Ehlers-Danlos syndrome, osteogenesis imperfecta, hereditary haemorrhagic telangiectasia)
- Nutritional deficiency (vitamin C deficiency/scurvy)
- Drugs that increase bleeding risk (aspirin, anticoagulants, corticosteroids, some SSRIs)
Clinical Features
Symptoms
- History of bruising after minimal or no remembered trauma
- Recurrent epistaxis, gum bleeding, prolonged bleeding from cuts, or heavy menstrual bleeding (adolescents)
- Joint swelling/pain suggesting haemarthrosis in coagulation disorders
- Abdominal pain, arthralgia, or dark urine with palpable purpura suggesting IgA vasculitis (HSP)
- Systemic symptoms (fatigue, weight loss, fever, bone pain) suggesting marrow pathology such as leukaemia/aplastic anaemia
Signs
- Bruises of different sizes/sites; accidental bruises are commonly small, round/oval, and over bony prominences on the front of the body
- Concerning patterns: bruises in non-mobile infants, ears/neck/torso/soft tissues, patterned marks (belt, hand, bite), or clustered injuries
- Petechiae/purpura, mucosal bleeding, or widespread ecchymoses
- Hepatosplenomegaly, lymphadenopathy, pallor (possible haematological disease)
- Features of connective tissue/genetic disease (hypermobile joints, hyperextensible skin, blue sclerae, dentinogenesis imperfecta)
- Signs of scurvy (perifollicular haemorrhage, gingival changes, poor wound healing, corkscrew hairs)
Investigations
Management
Lifestyle Modifications
- If bruising is clearly minor and accidental: reassurance, safety-net advice, and review if frequency/severity increases
- Avoid further trauma/contact sports when significant thrombocytopenia or bleeding disorder is suspected
- Correct nutritional deficiency (increase fruit/vegetable intake; dietetic support if restrictive eating)
- Urgent safeguarding escalation if non-accidental injury is suspected; follow local child protection procedures
Pharmacological Treatment
Analgesia for painful bruising
- Paracetamol 15 mg/kg per dose orally every 4-6 hours (max 4 doses in 24 hours)
Prefer paracetamol; avoid aspirin in children under 16 years (except specialist indications) and use NSAIDs cautiously if bleeding tendency is present.
Immune thrombocytopenia (ITP) with clinically significant bleeding
- Prednisolone 1-2 mg/kg once daily orally (usual max 60 mg/day, short course)
- Intravenous immunoglobulin (IVIg) 0.8-1 g/kg as a single dose (or 1 g/kg/day for 1-2 days in severe bleeding)
Observation alone is appropriate for many well children with mild/no bleeding. Use treatment when bleeding burden is clinically important; involve paediatrics/haematology.
Adjunct for mucosal bleeding
- Tranexamic acid 15-25 mg/kg orally 2-3 times daily (maximum 1 g per dose)
Useful for epistaxis/oral bleeding/menorrhagia in selected patients; caution in haematuria and thromboembolic risk.
Vitamin C deficiency (scurvy)
- Ascorbic acid 100 mg orally three times daily for 1 week, then 100 mg daily for 1-3 months
Pair with dietary rehabilitation and investigate associated nutritional deficiencies.
Surgical / Interventional
- No routine surgical treatment for simple bruising
- Urgent surgical/orthopaedic input for expanding haematoma, compartment syndrome, or associated internal injury
- Evacuation of significant haematoma is rare and case-dependent
Complications
- Missed non-accidental injury with ongoing harm
- Severe haemorrhage (including intracranial bleeding in profound thrombocytopenia/coagulopathy)
- Iron-deficiency anaemia from recurrent blood loss
- Chronic kidney involvement after IgA vasculitis
- Psychological trauma for child/family when safeguarding concerns are present
Prognosis
Prognosis depends on cause: uncomplicated traumatic bruising resolves over 2-3 weeks, while many childhood ITP cases remit within months. Outcomes are generally good when bleeding disorders and safeguarding concerns are identified early, but delayed recognition can lead to serious morbidity.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Bruising[overview]
📖Textbook References(2)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1364, 1365)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1365)[context]