Importance of bruising associated with paediatric fractures: prospective observational study

BMJ 1998; 317 doi: (Published 24 October 1998) Cite this as: BMJ 1998;317:1117
  1. M O Mathew, specialist registrar in orthopaedics,
  2. N Ramamohan, specialist registrar in orthopaedics,
  3. G C Bennet, consultant orthopaedic surgeon
  1. Department of Orthopaedics, Royal Hospital for Sick Children, Glasgow G3 8SJ
  1. Correspondence to: Mr Bennet
  • Accepted 5 May 1998

Editorial by Eastwood

Few data are published on the bruising seen in association with paediatric fractures. What little can be found is set in the context of non-accidental injury. Differing opinions about the importance of bruising have been expressed by those working on medicolegal cases. 13 The force necessary to fracture a normal bone is thought to result invariably in external evidence of trauma. 1 The absence of such bruising has been taken to imply that minimalforce was required to produce the fracture—that is, the fracture occurred because of metabolic bone disease or osteogenesis imperfecta. 2 3

Subjects, methods, and results

We prospectively assessed 93 acute fractures in 88 normal children(49 boys and 39 girls; age range 12 months to 13 years11 months) at presentation and before definitive treatment,looking for evidence of bruising around the fracture site.The prevalence of bruising at initial presentation and its incidence during early follow up was evaluated in subsets of fractures grouped according to displacement and extent of soft tissue cover.All the children were seen within 24 hours of injury.

There were 17 undisplaced, 46 displaced, and 30 angulated (>15=B0) fractures.Simple falls accounted for 70 fractures(15 undisplaced, 25 angulated, 30 displaced);23 fractures were the result of falls from heights(2 undisplaced, 5 angulated, 16 displaced). Bruising was seen at initial presentation in 8 fractures (9%), which wereeither displaced or superficially located, or both. Bruising wasnot present at initial presentation in undisplaced fractures orthose well covered by soft tissues.

Seventy three fractures were examined at the time of primary treatment under anaesthesia in the first 24 hours after admission to hospital.This group included the 8 fractures with bruisingevident at initial presentation. Thirteen other fractures in this group(without evidence of bruising at initial presentation) had developed overt bruising by the time of definitive treatment within24 hours of hospital admission. Sixteen fractures were reviewed later in the first weekfor various reasons (for example, change of plaster casts,remanipulations); 4 of these had developed localbruising. Four fractures were reviewed at three weeks when a plaster castwas removed.They were all undisplaced distal radial fracturesthat had not required manipulative treatment, andbruising was not evident in any of them. Thus 25 fractures (28%) developed bruising during the first week after trauma


The absence of bruising in children with fractures has been cited as supporting evidence that the force required to fracture the bone was minimal, which implies weakness of the underlying bone—perhaps due to a temporary abnormality such as copper deficiencyor subtle forms of osteogenesis imperfecta. 1 3 In our study of normal children most fractures (91%) were not associated with bruising at the timeof presentation. Most (72%) remained without evident bruising in the first week after injury. We therefore suggest that the absence of bruising cannot be taken to imply either underlying bone disease or an increased possibility of non-accidental injury.

Local bruising in acute fractures in childhood is perhaps less common than might be expected. When present it implies that any underlying fracture is likely to be displaced. Its absence is an unreliable sign on which to base a diagnosis of non-accidental injury.


Contributors: GCB had the original idea for this work, checked the analysis of data, and edited the article. NR and MOM jointly collected and analysed data. MOM wrote the article. GCB is guarantor for the study.

Funding: No external funding.

Conflict of interest: None.


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