Objective. The objective of our study was to collect data on the totality of recent skin injuries in normal children and adolescents, and to determine the relationship between the number of injuries, the age of the child, and the time of year in a temperate climate.
Methods. The participants in this study were children and adolescents seen successively for a reason other than trauma over a period of 1 year, by the first author (J.L.), in a university medical center in Québec City, Canada. The total body surface, with the exception of the anal-genital area, was examined systematically. The characteristics and location of all recent injuries (bruises, abrasions, scratches, cuts, burns, etc) were recorded. Scars from old injuries were ignored. The statistical method used for comparison was the Fisher's exact test.
Results. Two thousand forty examinations were done on 1467 youngsters from 0 to 17 years of age. Nine hundred thirty-one examinations were done on boys and 1109 on girls. The majority of children 9 months and older (76.6%) had at least 1 recent skin injury, without a significant difference between the sexes. Seventeen percent of the total sample of children had at least 5 injuries, whereas 4% had 10 or more, <1% had 15 or more, and 0.2% had 20 or more. The sites involved were mostly the lower limbs. Less than 2% of the total sample of children had injuries to the thorax, abdomen, pelvis, or buttocks, and <1% to the chin, ears, or neck. The majority of injuries observed were bruises, regardless of the time of year. There were, however, more skin injuries during the summer and the proportion of abrasions was higher at this time of the year. The 0- to 8-month age group was unique from all points of view. Skin injuries were rare in this age group (11.4%); they did not vary with the season, and they were mainly on the head and the face. Their injuries were mostly scratches. Bruises were found in only 1.2% of this group.
Conclusions. The majority of normal children (after the age of 9 months) and adolescents, who do not consult for trauma, had 1 or more recent skin injuries. These injuries, mostly bruises, are more prevalent in the summer in a region with a temperate climate and can be present on all parts of the body, although they are most frequently observed on the limbs, especially on the shins and knees. Even if there are no recognizable marks on the skin, physicians must pay particular attention to children who have injuries with other unusual characteristics (uncommon location, ≥15 injuries, bruises in a child <9 months of age, numerous injuries elsewhere than the lower limbs, numerous injuries in the cold seasons in a temperate climate, injuries other than bruises, abrasions or scratches) because they could be a sign of a bleeding disorder or physical abuse.bruising, child abuse, accidental injury.
Skin injuries are the most common and the most easily recognizable signs of abuse in children.1 Up to 90% of victims of physical abuse present skin injuries.2 Only 8% of these injuries are pathognomonic because of their shape (recognizable imprints).3 In the other cases, the physician must rely on the other characteristics of the injuries and on other elements to identify physical abuse: delay in consulting, injuries incompatible with the history or the developmental stage, association with specific injuries in other systems (eg, classical metaphyseal fractures, extensive retinal hemorrhages, subdural hematomas), suspicious attitude of the parents, absence of symptoms or signs of a medical condition that could cause the observed injuries, etc.
Although severe physical abuse has a greater chance of being identified, minor physical abuse is more difficult to distinguish from accidental injury. The most difficult situation is when the physician observes recent skin injuries in a child who is not consulting for trauma. Could these be signs of physical abuse or, on the contrary, are these injuries a result of normal physical activity in children? This question is important because the severity of physical abuse often increases with time and the physician could contribute to prevention by reporting the situation.4 On the other hand, reporting innocent parents can have regrettable consequences for them.
Studies conducted in victims of physical abuse and accidents led to the identification of certain characteristics of injuries that, although not specific, facilitate their distinction, especially with regards to their site.5–8 Few studies, however, were devoted to skin injuries in “normal” children.FNa At the time our study was conducted, the authors could find only 5 articles in the literature between 1977 and 1997.9–13 Since then, 2 other studies have been published.14,,15 However, as seen in Table 1, despite their usefulness, they do not give an overall view of skin injuries in normal children, either because they are comprised of a small cohort of children, they only concentrate on a particular age group, or they are interested in bruises only. Few data are available on the absolute number of skin injuries in normal children. Wedgwood13 reported a mean of 5 bruises in children <4 years old who could walk and who could also climb stairs. Sugar et al15 described up to 11 bruises in children <3 years old who could walk.
Our study was conducted to obtain data on skin injuries in normal children, as well as in normal adolescents, and to bring to light aspects that have not been treated previously, notably the relationship between the number of skin injuries according to the age of the child and the time of year in a temperate climate.
Design and Population Studied
The study was conducted over a period of 1 year—between July 15, 1997, and July 14, 1998. The study participants were all children and adolescents (from birth to 17 years old) consecutively examined by the first author (J.L.) during this period at the outpatient clinic and at the medical section of the emergency department of the Centre hospitalier de l'Université Laval, where this author practiced general pediatrics part-time. The examiner has 25 years of experience as a consultant in child abuse cases. Québec City is located in Canada in a temperate climate with 4 seasons, including a particularly rigorous winter. All of the youngsters seen in consultation for a reason other than trauma were admissible to participate in the study if they did not have 1 of the following criteria for exclusion: neurologic problems that prevent independent mobility; generalized skin problems that prevent an adequate evaluation of skin injuries; a medical condition or medication associated with easy bruising; unstable condition; and suspicion of physical abuse. The suspicion of physical abuse was based on their characteristics (recognizable imprints), history incongruous or implausible with the injuries, lesions incompatible with child's development, or the observation of a pathologic parent-child interaction. Because consecutive visits to the doctor were involved, the same child could participate in the study more than once. As bruises can take up to 1 month to disappear, each visit for the same child at an interval of <1 month was excluded from the study to avoid counting the same injuries more than once.
The following data were collected during each visit: age of the child, sex, race, personal and familial history of medical conditions that could affect coagulation, and medication. An explanation was sought for all injuries (cause, circumstances, time). After obtaining parental authorization or consent from adolescents 14 years and older, the author proceeded with a visual examination of the skin over the entire body surface (including buttocks), with the exception of the anal-genital region. This examination was incorporated into the complete examination done during the visit. The anal-genital region was not examined systematically for fear of refusals to participate in the study, particularly among school-aged children and adolescents. The characteristics (size, color, aspect, location) of all skin injuries were recorded on a printed body diagram. Scars from old injuries were ignored. A predominance of girls in the study was foreseeable because of the fact that the first author held a clinic for urinary tract infections and this pathology is more prevalent in girls after their first year. Blood tests (complete blood count, coagulation tests) were not performed systematically, but they were requested if needed, according to the clinical situation.
In total, the first author made 2389 encounters with children and adolescents during the period of the study. Two hundred fifty-three of these youngsters had already been seen less than a month before and were already registered in the study. Twenty-nine had a major neurologic handicap. Physical abuse was suspected in 23 cases. The unstable condition of 19 children was not conducive to a complete examination of the skin. Nine children had vasculitis or a coagulation problem. Eight children had a generalized skin problem that made it difficult to evaluate soft-tissue injuries. In 7 children, 1 of the reasons for consultation was trauma. One child was brought to see the doctor for easy bruising. All of these cases, 349 in total, were excluded from the study. There were no refusals to participate in the study.
Statistical analysis of data were performed using the Fisher's exact test to compare different proportions. The softwareStatistical Analysis System for Windows Release 6-12 (SAS Institute Inc, Cary, NC) was used. Statistical significance was set at 0.05.
A basic definition of physical abuse is the nonaccidental injury of a child inflicted by a caregiver. This includes corporal punishment that results in injuries. Recent injuries to the skin were classified in the following manner:
Bruises (ecchymoses, contusions, hematomas): escape of blood into the skin or subcutaneous tissue, or both, following the rupture of blood vessels, usually capillaries, by the application of a blunt force.
Abrasion: skin injury caused by a tangential impact, bringing about a separation or an excision of small superficial skin fragments.
Scratch (scrape): wound resulting from light tearing of the skin.
Others: all other recent injuries to the skin (cuts, bites, burns, etc).
A total of 1467 youngsters (719 boys and 748 girls) were included in the study for a total of 2040 examinations. One thousand one hundred thirty-two were examined only once, 188 twice, and 84 on 3 occasions. Forty-two, 14, and 7 children were seen on 4, 5, and 6 occasions, respectively. For the purpose of the study, each encounter with the examiner contributed 1 data point each to the whole study sample. The results are described as 2040 different physical examinations during a year.
There were 931 visits for boys and 1109 for girls. The majority of the visits, that is 1912 or 93.7%, were by white children. The others were divided up as follows: 96 for children of Asian origin (4.7%), 30 for black children (1.5%), and 2 for Amerindian children (0.2%). One thousand four hundred fifty-one examinations (71.1%) were done at the outpatient clinic by appointment (general pediatrics, urinary tract infection clinic), and 589 (28.9%) at the medical section of the emergency department. One thousand one hundred forty-five visits (56.3%) were by children already known to the examiner. For reasons of comparison, the patients studied were divided into 4 age groups: 0 to 8 months, 9 months to 4 years, 5 to 9 years, and 10 to 17 years. The category 0 to 8 months was preferred rather than the usual classification of 0 to 11 months because many infants become independently mobile from the age of 9 months and this has been shown to have a clear influence on skin injuries.14,,15
Number of Injuries by Age and Sex
Table 2 shows the percentage of all children with skin injuries by age and sex. It also indicates the number of injuries in each of the categories. No significant difference was found between boys and girls regarding the number of injuries, regardless of the age group. In the study population, 2040 patients had a total of 5686 recent skin injuries. Considering only those children and adolescents who had injuries, the mean number of lesions was 1.3 in the 0- to 8-month age group (range: 1–3), 3.9 in the 9-months to 4-years age group (range: 1–39), 4.5 in the 5- to 9-years age group (range: 1–21), and 3.6 in the 10- to 17-years age group (range: 1–12). The 0- to 8-month age group was clearly unique from all the other age groups because of the few injuries observed. The majority of these infants (88.6%) did not have any skin injuries. Among those who had injuries (11.4%), no child had >3. In the other age groups, including the adolescents, the majority of youngsters (76.6%) had at least 1 skin injury. Children 5 to 9 years old are the most susceptible to having at least 1 injury (87.2%). It is also this group that has the largest number of injuries. In fact, 32.6% of the children in this group had 5 or more injuries as compared with 19.6% for the group 9 months to 4 years and 19.7% for the group of 10- to 17-year-olds. Four percent of the total sample of children and adolescents had 10 or more injuries and <1% had 15 or more. Only 4 children (0.2% of the total sample) had 20 or more injuries.
Site of Injuries
The body sites affected by skin injuries are listed by order of frequency in Table 3. Although half of all of the children seen had at least 1 injury on the legs (the vast majority on the shins), <2% of the entire group of children presented injuries to the thorax, abdomen, pelvis, or buttocks and <1% to the chin, ears, or neck. Table 4 provides more details on the sites of injuries with regards to the sex and the age of the children. No significant difference was found between the sexes of children with regards to the sites of the injuries. It is a different story for age. The 0- to 8-month age group distinguishes itself clearly from the other age groups by a predominance of injuries to the head and to the face rather than to the limbs. The group of 5- to 9-year-olds presents the greatest number of injuries and has the highest proportion of sites implicated. For example, 3.6% of the children in this group had injuries to the buttocks and 3.9% to the lumbar region. The group of 10- to 17-year-olds distinguishes itself from the other groups by a quasi absence of injuries to the head and to the face.
Types of Injuries
Table 5 indicates the percentage of children that present each type of injury in the different age groups. Globally, bruises are the injuries that were by far the most frequently seen, except in the group 0 to 8 months where scratches predominated. This latter group was also unique by the low proportion of children with bruises or abrasions (1.2%). The group of 5- to 9-year-olds had the largest proportion of children presenting all of the types of skin injuries. Eighty percent of the children in this age group had at least 1 bruise. Skin injuries other than bruises, abrasions, and scratches (cuts, bites, burns, etc) were seen in only 1.9% of the total sample of children and adolescents.
Time of Year
The influence of the time of the year was apparent with regards to the number and type of lesions. Table 6illustrates the relationship between multiple injuries and the time of the year in each age group. There was a significant difference between the warm seasons and the cold seasons. The percentage of children with 5 or more injuries was 18% in the fall and 12% in the winter. This percentage increased to 25% and 33% in the spring and in the summer, respectively. All of the age groups follow this tendency, except for the 0 to 8 months group. In this latter category, the number of injuries did not vary with the time of year, and no child had >3 injuries.
Figure 1 illustrates the different types of injuries according to the time of year. Although bruises clearly predominated throughout the year, a significant variation was noted in the number of abrasions and scrapes according to the time of year. The percentages of these 2 types of injuries were higher during the summer.
The 4 children with 20 or more injuries were all seen in the warm seasons: 2 in the spring and 2 in the summer. A 3-year-old boy had 20 skin injuries (1 scratch, 1 abrasion, and 18 bruises). His lesions were distributed as follows: 2 on the face, 2 in the lumbar region, 8 on the upper limbs, and 8 on the lower limbs. A 6-year-old girl had 20 skin injuries (10 abrasions and 10 bruises). Her lesions were distributed as follows: 4 on the upper limbs and 16 on the lower limbs. Twenty-one skin injuries (9 scratches, 4 abrasions, and 8 bruises) were found in a 7-year-old girl. The distribution of her lesions was as follows: 1 on the face, 4 on the upper limbs, and 16 on the lower limbs. A 4-year-old girl had 39 skin injuries (2 scratches and 37 bruises). Her lesions were distributed as follows: 1 on the posterior thorax, 1 in the lumbar region, 4 on the upper limbs, and 33 on the lower limbs. A total of 100 skin injuries were found in these 4 exceptional cases. Seventy-two of these injuries were located on the lower limbs. A more extensive medical and social evaluation of these cases did not reveal a medical problem or physical abuse.
Our study is the first, to our knowledge, that covers the period of childhood and adolescence for the totality of recent skin injuries in normal children and that also takes into account the time of year. Our results are concordant with previously published studies, but they also provide additional information. The first element to note is that after the age of 9 months, whatever the reason for consultation, a doctor is likely to find at least 1 recent skin injury in 3 out of 4 children. Only 2 studies not confined to very young children are available for comparison. In their study, Roberton et al11found that 50% of children between the age of 10 months and 11 years had at least 1 soft tissue injury. Pascoe et al9 indicated that 73% of their patients from 1 to 12 years of age had soft tissue injuries on the anterior legs. Normal ambulatory children may have multiple recent skin injuries and some may have even have 20 or more. There is no difference between boys and girls with respect to the frequency of injuries, but age makes a difference. Five- to 9-year-olds have the most injuries. In a temperate climate like that of Québec City, the time of year has an influence on the frequency and type of injuries. Children have more injuries during the warm seasons, which is not surprising because they go outside more often and they wear less clothing that can protect them from falls and accidental injuries. Although bruises are the most common type of injuries in all seasons, a higher proportion of abrasions and scrapes can be found in the summer.
As indicated in all previous studies, the most predominant sites for skin injuries in normal children after the age of 9 months are bony prominences of the limbs: shins, knees, elbows, forearms.9,,11,13,15 Concerning the bony prominences of the face, the forehead is not a rare location for injury (6.4%) between 9 months and 4 years. This is a finding similar to Sugar et al15 (5.7%) in their study of toddlers. Certain sites are rarely affected in normal children, whereas they are frequently affected in children who are victims of physical abuse (ears, neck, buttocks, the back or lumbar regions).5–7 Cheeks are usually considered to be a location suspect for physical abuse. We found that 3.2% of infants <8 months old and 4.5% of toddlers had an injury at this site. In our study, there was no difference between boys and girls with regards to the sites of injuries. However, injuries to the head and the face, already rare, were exceptionally seen in adolescence.
As reported by several authors before us, children in the 0- to 8-month age group are different from older children from all points of view.11–15 This is not surprising because normal children hurt themselves by falling and by hitting themselves, which requires that they be independently mobile. Here, it is not a simple question of age that is the cause, but rather the stage of development. Bruises are not seen in children before they start crawling. This explains why this type of injury is rarely seen before the age of 9 months.12,,14,15 Contrary to other age groups, there is no variation in the number and the type of injury in function of the time of year in the 0- to 8-month group. Moreover, injuries in this group are mainly found on the head and the face, and they are most often scratches that the infants make themselves with their fingernails. In our study, none of the 246 children from 0 to 8 months had >3 injuries at a time. The results of a descriptive study such as ours are foreseeable, and therefore its usefulness may be questioned. However, in our opinion, precise data on skin injuries in normal children in different age groups and different situations will help physicians detect real situations of abuse and thus avoid unfounded reports to child protection agencies. From a medicolegal perspective in cases involving skin injuries without adequate explanations, our results could help to persuade a judge of their unusual features (number, location, etc).
Our study has its limits. There was no systematic effort to make sure that the children participating in the study were representative of the general population of children in the Québec City area. The fact that 56.3% of the children were already known to the examiner may have affected their social-class distribution (our hospital is located in a middle-class neighborhood). The children in our study were overwhelmingly white. We cannot infer that our data are applicable to children of other races. The anal-genital region was not examined systematically in all children. Other studies showed the rarity of accidental injuries in this region.9,,11 It is impossible to assert that none of the injuries observed in these normal children were attributable to a medical condition that causes easy bruising because blood tests were not performed systematically in all children. Some of these injuries could also have been of an abusive nature and escaped the attention of the examiner. It is probable, however, that these situations are rare and that they do not interfere with the results presented.
To avoid an unnecessary climate of suspicion, it is important to take into consideration the fact that most normal children have injuries on their bodies once they begin walking. Individually, 20 or more injuries can be found. Although the lesions are most often found on the lower limbs, no site is spared. Thus, the number of injuries or their site does not allow us to reach a conclusion on their origin. Each case is one of a kind. Although certain sites are more frequently affected in cases of abuse, site is not a pathognomonic characteristic in itself. Similarly, injuries in sites more common to accidents can be of an abusive origin. Therefore, the whole picture must always be considered (type and shape of the injuries, location, age, developmental stage, time of the year, injuries of other systems, explanations about the injuries, attitudes of the parents and the child, etc) before passing judgment. Recognizable imprints speak for themselves. In the absence of these pathognomonic signs, the physician must pay particular attention to children who present injuries with other unusual characteristics (uncommon location, ≥15 injuries, bruises in a child <9 months of age, numerous injuries elsewhere than the lower limbs, numerous injuries in the cold seasons in a temperate climate, injuries other than bruises, abrasions or scratches) because they could signify a bleeding disorder16 or physical abuse.
- Received May 18, 2000.
- Accepted November 16, 2000.
Reprint requests to (J.L.) 2705 Laurier Blvd, Sainte-Foy, Québec, Canada G1V 4G2. E-mail:
↵FNa In this article, “normal” signifies children who are not victims of physical abuse and who do not have any known medical condition that can easily cause bleeding.
- Stephenson T
- Schachner LA,
- Hankin D
- Pascoe JM,
- Hildebrandt HM,
- Tarrier A,
- Murphy M
- Keen JH
- Roberton DM,
- Barbor P,
- Hull D
- Mortimer PE,
- Freeman M
- Carpenter RF
- Copyright © 2001 American Academy of Pediatrics