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Personal practice
An approach to investigation of easy bruising
  1. A Vora,
  2. M Makris
  1. Sheffield Children's Hospital, Sheffield S10 2TH, UK
  1. Dr Voraajay.vora{at}

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Easy bruising presents several investigative dilemmas in primary and secondary practice, not least because it raises the spectre of physical abuse. When, and to what extent, should general paediatricians investigate before referral to a specialist? When can it be safely concluded that an underlying bleeding disorder has been excluded, so that further investigations can focus on ruling out suspected non-accidental injury? When, despite an abnormal clotting test, should the latter investigations still be pursued?

The intention of this review is to attempt to answer these questions from the perspective of routine practice without recourse to a comprehensive review of bleeding disorders or non-accidental injury. We intend to address only the patient seen electively in the outpatient clinic for investigation of easy bruising, not an acutely ill child presenting to accident and emergency with purpura, whose differential diagnosis varies from, most often, no cause found, to, less commonly, meningococcal sepsis or Henoch–Schonlein purpura.

Distinguishing “normal” from “abnormal” bruising

Bruising caused by accidental injury is common around the age of 1, when most infants have started “cruising”.1 To distinguish “abnormal” from “normal” bruising requires attention to the pattern of bruising, associated symptoms, and drug and family history.2 As a rule, normal bruising is restricted to the lower limbs,1 not associated with petechiae, purpura, or mucosal bleeding, and the family history is negative. The latter should be interpreted cautiously as it is often negative in disorders of haemostasis, and not infrequently positive in families with unexplained easy bruising or epistaxis, who may carry the nebulous entity of “increased skin fragility” which is usually associated with “hyperextensible” joints, but without the classic features of Ehlers–Danlos syndrome (see below).3 It is also important to obtain a comprehensive family history, which includes grandparents and the extended family, and taking special care to note, where this may be …

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