ABSTRACT
A 17-year-old girl was brought to your office for a routine evaluation prior to attending school. She wished to continue playing tennis at school, but had experienced pain in her right upper extremity related to using her racquet. You noticed in her chart that there was an incident last year in which she had a fight with her boyfriend. As you examine her, you noticed several bruises as shown in Image 48. She stated they are bruises that occurred after she received some physical therapy for her arm pain last week. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig48.jpg"/>
Is the distribution of lesions in Image 48 concerning for abusive trauma?
What non-abusive mechanisms can cause this pattern of bruising?
112The teenager had multiple areas of discolouration over her arm and forearm which were consistent with bruises or contusions. They were located above the elbow posteriorly as well and laterally over the forearm. This location has been associated with defensive wounds after a fight. The lesions did not depict a specific pattern and were generally absent over bone prominences. No lacerations or scarring were noted. This could be concerning for inflicted trauma during physical altercation, but additional mechanisms should be explored. Furthermore, if an appropriate mechanism is not identified, studies to assess for a coagulation disorder should be considered. 1
Direct trauma to the skin over the areas of bruising and contusion could cause these lesions and a history of falls, sports or other blunt trauma should be sought. A bleeding diathesis with associated minor trauma can also cause these types of lesions. Additional information is needed to assess the physical therapy procedures which the child has reported caused the bruising. Upon contacting the therapist with the mother’s consent, you find out that a particular type of deep massage was used. Using a plastic implement, the skin was squeezed and rubbed directly over muscles and tendons in an attempt to regenerate healthy soft tissues and to eliminate or reduce unwanted scar tissue that may be causing pain or movement restriction. The therapist tells you that bruising and swelling is a common effect of the treatment, and the procedure does produce unusual lesions which can persist for several weeks. The teenager says that the bruises appeared a few hours after the procedure, but her pain on movement has improved.
