Bruising in non-accidental head injured children; a retrospective study ofthe prevalence, distribution and pathological associations in 24 cases

Non-accidental head injury, be it shaking, impact(s) or a combination of th e two, is characterised by subdural and/or subarachnoid haemorrhages with r etinal haemorrhages, but minimal or absent external cranio-facial trauma. T he classical assault scenario depicts the infant being gripped around the h ead, face, chest and abdomen and shaken or being gripped by a limb and swun g. This gripping might be expected to leave physical evidence in the form o f bruising. A study was undertaken to establish the prevalence, distributio n and pathological associations of external bruising in 24 cases of fatal n on-accidental head injury in children. At autopsy, 17 cases had new externa l bruises, 15 old external bruises and 13, a combination of both. However, seven (29%) cases showed no fresh external bruising and five (21%) showed n o external bruising at all. Thus, external bruising may be absent in childr en with fatal intracranial injury. The face was shown to be the commonest s ite of bruising followed by the forehead and buttocks. Limb, chest and abdo minal bruising were found to be uncommon. Retinal haemorrhages were confirm ed in 23 (96%) cases. It is hypothesised that bruising, when present, may b e a result of abuse in the form of punches and slaps rather than due to gri pping during the assault. We discuss why gripping does not necessarily resu lt in external bruising. (C) 1998 Elsevier Science Ireland Ltd. All rights reserved.