The multitudes of injuries that can be caused by blunt trauma are well beyond the scope of this chapter. However, a few deserve special mention.
Periorbital ecchymosis is a not uncommon result of blunt trauma. However, the presence of bilateral involvement does not prove abuse. A blunt injury (accidental or nonaccidental) to the forehead can result in bilateral periocular ecchymosis. Bilateral ecchymosis can also result from systemic disease such as neuroblastoma.
Abuse should never be reported on the basis of bruising or bleeding alone unless appropriate history and testing has been conducted to rule out coagulopathy. A basic panel should include at least a complete blood count with differential and platelet count, prothrombin time, partial thromboplastin time, and perhaps tests to rule out factor deficiencies or INR and von Willebrand disease. Bruising of the skin is difficult to date and particularly unreliable when located in the loose periocular and eyelid skin, which can allow for excessive accumulation of blood, thus changing color-related dating patterns. It is probably best not to attempt dating of peri-ocular ecchymosis.
This author has now observed eight cases in which a child's eye was injured "accidentally" during a beating with a belt directed at other parts of the body. All sustained hyphema, one also had commotio of the macula, one required enucleation, and another resulted in a permanently legally blind eye. In each case, the diagnosis was made by history obtained from the parent or the child. Indeed, children may be interviewed directly by the physician. It may be helpful when suspicion arises to ask the child if they would like to speak to the ophthalmologist alone or to make an encouraging statement such as "I sometimes see children who have injuries like this because someone has hurt them. I can help make it so that they don't get hurt like this again. Might someone have hurt you?" Despite the parent's remorse and lack of intent to injure the eye, these cases do require reporting to child protective services to help the parent learn alternative means of discipline and prevent another episode where control is lost resulting in such serious injury.
Summary for the Clinician
• Dating of periocular ecchymosis is imprecise and should be avoided
• Accidental forehead injury (with ecchymosis), coagulopathy and neuroblastoma are part of the differential diagnosis of unilateral or bilateral periorbital ecchymosis
• Unintended eye injury that occurs during discipline is a measure of the caretaker's loss of control and should be reported as suspected physical abuse
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