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Black and Blue – What Your Bruise Tells You

When 4 year old Kaden signed in to see me, I knew just from looking at him across the room that there was quite a story to go along with the marks on his face.

4 year old Kaden with facial bruising after injuring his face

Pretty dramatic, no-? When we met in the exam room, he was lively and in a great mood; walking around a bit to check out the equipment and chatting with his brother. Based on this I had a vibe in the early innings that he was OK. More or less. I asked his mom what happened, and she told the story of how several days earlier he had “face planted” onto a hard exterior surface when he was sitting on a high counter stool outside. He sustained a large swollen “goose egg” on his forehead but had no loss of consciousness or vomiting. Being a #smartmomma, she did the right thing and took him to Emergency immediately where he was assessed and (thankfully) released. Fast forward several days to our visit when she was alarmed by his discolored, swollen face that made him look like he had been in a bar fight, and she wanted to make sure that there “wasn’t blood trapped somewhere in his face or brain.” A reasonable concern given Kaden’s appearance.

Even before speaking with Kaden’s mom, upon noting the impressive bruising and colorful palette of purple, green and yellow across his forehead and cheeks I concluded that his injury didn’t just happen yesterday.  His situation and his mother’s concern several days after the injury got me thinking that his story is one that should be shared. So the topic of bruising is what I think is worth spending some time on today: the meaning of their colors and locations, and timing and resolution.

The 25 cent word for bruise is contusion. Also described as “ecchymosis.” We can define it as the rupture of blood vessels directly under the surface of the skin without a break in the skin itself. We all get that, right? So what’s the big deal? Sometimes, NBD at all. We’ve all seen shin bruises on ourselves or our kids that look like a bump or knot and are sore for several days until they just eventually go away.

But what about Kaden and his forehead “goose egg”?

Let’s talk about locations of bruises first. Contusions that occur at common points of contact trauma at certain ages are not associated with significant injury, thank goodness. I’m talking about shins and yes, foreheads, especially in (relatively) new walkers. Even if the exact mechanism of injury isn’t known, as long as the individual is clinically well otherwise (other than soreness at the site) then we don’t get too concerned about bruises in those places. You read that right: big, impressive forehead bruises on their own in the setting of a normal neurological clinical exam don’t often indicate serious injury, even to the brain. Typically no xrays or other radiology tests are necessary. These bruises go away on their own.

The tricky part about Kaden’s forehead bruise is that due to gravity from him standing up, the blood from the contusion started to track downward along the tissue planes of the face, causing the impressive swelling around his nose and eyes. Something to be concerned about? No, actually. It’s just what happens with time, and while it looks concerning, usually the only things required for treatment are some symptom support and patience. I gave examined Kaden thoroughly, including assessment of his neurological status and gait, and when all that checked out ok, he and his mom left with smiles. They felt reassured, and I made some new friends. We talked about getting some key photos for use later in his life, maybe senior prom, maybe his wedding. He did well.

Here’s the first take home point from this blog:

-bruises, even big ones or several of them, on body parts that are common points of contact for blunt trauma (like elbows and shins and foreheads) are typically not concerning and will resolve on their own. There must be a reasonable history to explain the trauma.

-spontaneous bruises in places that don’t usually sustain tough contact like the abdomen or back (without a history of a fall or hit) can be cause for further inquiry, especially if there are multiple bruises or if they happen frequently. Certain medicines and blood disorders can cause easy bruising in unusual places on the body. Repeated, unexplained bruises should be noted and investigated.

One of the questions Kaden’s mom asked me was “how long will this bruise take to do away?”

Bruises change color as they resolve, and while everyone is a little different, many typically follow this pattern:

  1. Initially the bruised area looks red as the blood from the broken blood vessels appears under the skin.
  2. After about 48 hours the bruise often darkens to a purplish hue, sometimes even so dark that it looks black. This color change happens as the blood loses any amount of oxygen that was in it before the break happened.
  3. Sometime between day 5 and 10 (depending on the size of the bruise) the bruise may turn a yellow or green tint as the hemoglobin gets broken down during the body’s normal healing process; and
  4. By days 10-14 the remnants of the blood from the bruise are nearly fully broken down and almost fully absorbed so the final color can look yellow-brown before it completely fades away.

So it can routinely take around 2 weeks for a bruise to go away.

Not all bruises will go through each stage of color change; it depends on the location  and amount of blood collected in the bruise. 2 weeks seems like a long time doesn’t it? I think this ballpark figure is a good one to know; people are always surprised that it takes as long as it does.

Second take home point from this blog:

-bruises don’t often go away within 2-3 days. Expect much longer.

-a bruise that lasts longer than 2 weeks or so should be checked out by a clinician.

So what can be done to optimize the healing time of a bruise?

Once the bruise happens, the blood is definitely out of the vessel as it were, and there’s no going back. One way to help minimize the size of the bruise is to apply ice immediately. This slows down the flow of blood to the area, and thus the amount of blood that pools at the site of the rupture. Same rationale behind elevating the bruised area.  Less blood flowing to the point of injury, the smaller the contusion. Once the volume of ecchymosis is controlled as much as possible, taking a pain reducer like acetaminophen (Tylenol and others) helps take away some of the inevitable soreness that occurs after a force sufficient to cause the bruising is sustained.

I’m not trying to be overly dramatic with this post, and I’m acknowledging that it’s not critical care medicine. But sometimes a simple bruise can be very frightening to look at for a child (and parent!) and can raise the concern level even further when it seems to hang around without obviously getting better. Bearing the mechanism, history, timing, colors, and location in mind when a bruise happens is actually fairly important when considering whether or not there could be significant injury. Cases of child abuse have been picked up by unexplained bruising. As with nearly everything, parent/caregiver concern should trump all of these other indicators, and getting checked out is wise to be sure that nothing gets missed. But at least now that you’ve read this you’ll be less surprised about what your clinician tells you should you find yourself or your child in situation like my new friend Kaden. At the very least, the pictures will be worth saving.

(Special thanks to Kaden and his mom who felt comfortable sharing his story in the hopes it might reassure other parents and kids.)