A scoring system for bruise patterns: A tool of identifying abuse. Arch Dis Child 2002;86:330–333

Abstract

Aims: To determine whether abused and non-abused children differ in the extent and pattern of bruising, and whether any differences which exist are sufficiently great to develop a score to assist in the diagnosis of abuse. Methods: Total length of bruising in 12 areas of the body was determined in 133 physically abused and 189 control children aged 1-14 years. Results: Our method of recording bruises by site, maximum dimension, and shape was easy to use. There were clear differences between cases and controls in the total length of bruises. These differences were at their greatest in the head and neck and were less notable in the limbs. A scoring system was developed using logistic regression analysis using total lengths of bruising in five regions of the body. Good discrimination between the two sets of children was achieved using this score; by including a variable that indicates whether a bruise had a recognisable shape the discrimination could be made even better. Given a prior probability of abuse the score can be used to give posterior odds of abuse, given a particular bruising pattern. Conclusions: The scoring system provides a measure that discriminates between abused and non-abused children, which should be straightforward to implement, though the results must be interpreted carefully. We do not see this score as replacing the complex qualitative analysis of the diagnosis of abuse. This clearly includes history as well as examination, but rather as the beginning of the development of an important aid in this process. P aediatricians are often asked for an opinion on whether a particular pattern of bruising is caused by abuse. This might arise in a variety of settings-clinical, child protection, or in legal proceedings. Although some studies have looked at the age of children and bruising, 1 2 and others have looked at the age of individual bruises, 3-5 the evidence base 6 7 for coming to a conclusion on an individual pattern of bruising is very limited. One reason for this is that child protection is a multidisciplinary activity, led by social workers whose research base is largely qualitative. Another is the difficulty of obtaining data on bruises on non-abused children. There is also the problem of recording information on bruises in a way that is not invasive and yet is in sufficient detail for the results to be analysed statistically. There are two related but separate issues to be investigated. Is the extent and pattern of bruising different in abused and non-abused children? Are any differences sufficiently great to develop a score to assist in the diagnosis of abuse? In a preliminary study METHODS The subjects studied were children aged 1-13 years attending the Llandough Children's Centre, which serves the Vale of Glamorgan and the West of Cardiff. In the centre we see child outpatients, children with special needs, and referrals under child protection procedures but there is no accident and emergency department. We decided to study children under 1 separately as they are not mobile, so bruising in any area has greater significance than in older children. The abused cases were identified from our child protection database. They were children who had attended the centre between 1992 and 1996, whose notes were obtainable, and who were classified as having been physically abused following a case conference or other multidisciplinary meeting. The bruising patterns of control children were obtained from those attending the centre for ambulatory outpatient consultation for reasons other than abuse between 1998 and 1999, during a clinical examination that would have been undertaken anyway. When this study was initially planned the controls were to be children attending the accident department, but this proved impractical because of the extra undressing of children that would be required. The timescale of collection of cases and controls was therefore different, but we do not believe that this invalidates our results. Bruises were measured using paper tape measures. Parental consent was obtained; no parent declined to take part. Cases and controls were examined by consultants or specialist registrars (residents) in community child health. The sex ratios in abused and controls were nearly identical, with 66% boys and 34% girls. The mean age of cases was 7.7 years and of controls 6.4 years. Details of bruises were recorded in each of 12 regions of the body: anterior chest and abdomen, back, buttocks, left and right arms, left and right legs, left and right face, left and right ears, and other head and neck. In each region, the number of bruises was recorded, together with the maximum dimension of each bruise, and whether or not each bruise had a specific shape, such as being linear or shaped like a hand. In order to establish a scoring system we divided regions as follows