- Bruises go through a cycle of color. They initially are red, violet, black, or blue and later turn brown, green, or yellow. The color is affected by the depth and the placement of the bruise, as well as by the skin color and the quality of the light at the location where the bruise is being viewed.
- Estimating the age of a bruise by its color cannot be done with much precision, but in general:
- A bruise with any yellow is usually older than 18 hours.
- Red, blue, purple, or black colors in a bruise may occur anytime from within 1 hour of bruising to resolution (i.e., when the bruise coloration disappears).
- A red color may be present at any stage of the bruise.
- Bruises of identical age and cause on the same person may not appear with the same coloration and may not change color in the same manner.
- Ears and buttocks usually are not injured accidentally.
- Knees, shins, foreheads, and elbows are normal bruising areas, particularly for toddlers.
- Bruises caused by pinching often have a symmetrical pattern.
- Loop-shaped marks can be caused by whipping a child with a cord or belt; there is no disease or accident that looks like a loop or belt mark.
- Cords or ropes tied around a child's ankles or neck may result in a bruise or a rope burn.
- If a child is slapped or hit, a mark in the shape of the offender's fingers or hand may be left.
- Loose tissues, with little bony structure underneath (e.g., eyelids, genitals), bruise most easily and retain bruises longest; injuries at those locations often are not accidental.
- The first responder should be suspicious if a caretaker delays seeking treatment for a child with a genital injury. For example, the injury may have been caused by pinching a boy's penis to punish him for touching himself or by using a string or rubber band around the penis (causing grooves) to prevent the child from wetting the bed.
- Some individuals mistake the presence of Mongolian spots (birthmarks) as an indicator of abuse. These spots usually are grayish-blue, clearly defined spots on the buttocks, back, or extremities. They are most common in African-American and American Indian babies.
- Lacerations are tears or cuts in the skin.
- In cases of abuse, they often occur on soft tissue areas, such as the abdomen, the throat, the buttocks, and the thighs.
- Some areas of the body are normally protected from lacerations by being inside or covered by other body parts (e.g., the side of the arm that normally lies against the body when in a standing position). It is difficult to fall and injure these areas.
- Lacerations of the ear, the nose, or the throat do not tend to occur accidentally.
- A torn frenulum of the upper lip (the tissue that connects the upper lip to the upper gum) may be an indicator of abuse if there is no reasonable explanation, especially in the case of infants.
- Human bites appear as oval or horseshoe-shaped marks in which tooth impressions look like bruises facing each other.
- If the distance between the canines (the third tooth on each side) is greater than 3 centimeters, the bite is most likely from an adult. Adult bite marks are a sign of serious danger to a child.
- Depending on the location of the bite, the victim's teeth should be examined and measured to exclude the possibility of a self-inflicted bite.
- A forensic odontologist or pathologist should evaluate the size, contour, and color of the bite marks, as well as make molds of the suspected abuser's teeth and of the bite itself, if possible. Each individual has a characteristic bite pattern.
- Immersion burns occur when a child is placed in extremely hot liquid. These burns have a "water line" or sharp demarcation border. Symmetrical burns with sharp edges (e.g., sock-shaped burns of the same height on each leg) are very suspicious. The first responder should document if there is an absence of splash marks, which may indicate that the child did not fall into the liquid and try to get out.
- Doughnut-shaped burns can occur when a child is forced into a bathtub. This causes parts of the body, usually the buttocks, to rest on the bottom of the tub, where they will not burn.
- Splash burns can occur when the offender throws hot liquid at the child. Unintentional splash burns are usually on the head or top of the chest and run downward and may be caused by a child reaching upward to grab a pot handle. Liquids that are thrown at a child hit at a horizontal angle, causing the burns to be concentrated on the child's face or chest and run toward the back of the body. Splash burns on the back or buttocks are highly suspicious.
- Cigarette burns usually appear on the trunk, external genitalia, or extremities. They also often appear on the palms of the hands or soles of the feet. Cigarette burns usually are symmetrical in shape. Impetigo blisters (caused by a bacterial infection) are irregular and can be ruled out by testing for signs of strep. When there are intentional cigarette burns on a child, there often are multiple burns in various stages of healing (i.e., indicating that the burns occurred at various times).
- Chemical burns are caused by household products. Some parents or caretakers force children to drink lye derivatives (toilet bowl cleaner, detergents, or oils), which causes chemical burns of the mouth and throat, vomiting, and esophageal damage.
Fractures and Dislocations
- Fractures usually are inflicted by an abuser on nonambulatory children (i.e., those who are not able to walk).
- Ninety percent of all abusive fractures in children 2 years of age or younger include the ribs.
- The following are types of fractures and dislocations that may be indicative of abuse:
- Metaphyseal fractures, in which a chip of the metaphysis (a piece of bone that grows during childhood) is pulled off by a ligament, can only occur when a jerking force is applied to the extremities (e.g., by shaking or swinging a child by the arms or legs).
- Spiral fractures, which are diagonal fractures usually caused by the twisting of an extremity, are common in children because they have more pliant bones. Spiral fractures can occur in small children by twisting their own leg or ankle in an accidental injury (e.g., getting their feet caught in the slats of a crib). Thus, spiral fractures are not always indicative of abuse.
- Periosteal elevation occurs when an infant's extremities are twisted or shaken, causing the periosteum (a type of connective tissue) to be separated from the bone and blood to collect in the new space.
- Rib fractures can be caused by a caretaker forcefully squeezing the baby. Victims may present with signs of respiratory distress, but they are usually asymptomatic.
- Might be indicated by:
- Abdominal, chest, flank, or back pain;
- Visible bruising of the chest or abdomen;
- Distended, swollen abdomen or tense abdominal muscles;
- Dyspnea (labored breathing);
- Pleuritic pain (a type of chest pain);
- Nausea or vomiting.
Neurological Damage (Skull Fracture, Brain or Spinal Cord Damage, and Intracranial Hemorrhage)
- Serious life-threatening skull injuries, with the exception of epidural hematomas (a type of brain hemorrhage), do not result from a child falling from a short height, such as a bed or crib.
- Skull fractures are more likely in young children. Any pressure from cerebritis (inflammation of the brain) or hemorrhage can separate fontanelles (one of two soft spots on an infant's skull).
- Brain injury in young children is more likely due to their having an increased subarachnoid space (the space between the middle and innermost membranes covering the brain).
- Subgaleal hematoma (bleeding beneath the scalp caused when the scalp separates from the skull) is often a sign of skull fracture. Diagnostic images of the skull should be taken. It may be caused by jerking or twisting a child's hairÃ¢ÃÂÃÂespecially in girls with pigtailsÃ¢ÃÂÃÂand may be indicated by a bald spot.
- Alopecia (a partial or complete loss of hair) may be caused by neglect if the child lies on his back for long periods of time.
Shaken Baby Syndrome
- This occurs when a child has been held around the upper thorax (under the arms) and shaken back and forth with great force. It also occurs when the child is held upside down by the feet and is shaken up and down.
- Many infants die from shaken baby syndrome, especially if there is a delay in getting treatment. Those who survive often have permanent brain damage and may be paralyzed, be developmentally delayed, or develop cerebral palsy.
- There is often an absence of externally visible injuries, but retinal bleeding may occur. Subdural hematoma (a hemorrhage between the brain and its outer lining that is caused by ruptured blood vessels) and metaphyseal lesions (when a piece of a bone that grows during childhood chips off) are common effects of shaken baby syndrome.