Linear Skin Lesions of Unknown Cause on the Extremities of Young Children

Pediatric Pathways

Linear Skin Lesions of Unknown Cause on the Extremities of Young Children

Author

American Family Children's Hospital Pediatric Pathways: Barbara Knox, MD

Barbara Knox, MD

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Child Protection

After reading this article and answering the review questions, the reader will be able to:

  1. Recognize skin findings that may mimic abusive lesions in children
  2. Understand the mechanism for development of skin findings that mimic dry contact burns/ligature tie markings in children
  3. Differentiate these skin findings from abusive lesions

Case 1

A 2-month-old female accompanied by her grandparents, a caseworker, and police officer presented for evaluation of an erythematous, non-palpable horizontal curvilinear lesion noted on the left calf. The lesion was originally noted two days before by the maternal grandmother after she removed the child’s socks. The night preceding lesion discovery, her grandmother reported changing the child’s clothing, placing the child into pants with elastic cuffs at the ankles. The grandparents did not remove or change the infant’s socks at that time. The grandparents reported that the child was unusually fussy on the morning they discovered the lesion, but attributed this to recent immunizations.

Physical examination revealed a non-raised horizontal curvilinear lesion on her distal left calf, measuring 5.5 cm in length by 4 mm in diameter (figure 1-A).

Figure 1-A

The socks the child was reported to be wearing for the preceding 24 to 36 hours did not align with the lesion; however, the child’s pant legs had large distal elastic cuffs. The left elastic band was noted to align perfectly with the lesion.

This child had been born at term to a 15-year-old mother whose pregnancy was complicated by maternal drug use. At birth, the infant’s meconium tested positive for cocaine and the first urine screen was positive for benzodiazepines. Given the history of maternal drug use and young maternal age, Child Protective Services (CPS) has been involved in the child’s safety planning since birth.

The infant was primarily cared for by the maternal grandparents due to both biologic parents reported drug use. Because of this, biologic mother was not to have unsupervised contact with the child. The biologic mother lived with maternal grandparents and the biologic father visited overnight. The grandmother reported hearing frequent verbal altercations between mother and father regarding who had to get up to feed the baby at night. The grandmother also reported hearing a startled cry during an instance when the baby was left alone with the mother; she suspected the child might have been physically injured.

The Child Protection Program was consulted to evaluate this leg lesion as well as concerns of maternal neglect and physical abuse toward this child. The infant was hospitalized for a nonaccidental trauma evaluation. A head CT and skeletal survey were negative. A dilated ophthalmologic examination was negative for retinal hemorrhages. Hepatocellular enzymes (AST and ALT) were normal.

The patient was seen for follow-up three weeks later. The exam showed a stable appearing erythematous lesion that was essentially unchanged from the prior exam. The lesion was diagnosed as an innocent pressure injury (figure 1-B).

Figure 1-B

 

Case 2

A 10-week-old female was brought to a general pediatric clinic accompanied by her father for a curvilinear erythematous lesion on her right anterior shin. It measured 7 cm at its greatest length and 0.5 cm at its greatest width (Figure 1-C).

Figure 1-C

The father stated that he first noticed the lesion five days prior to the visit when he was changing the baby’s clothes. The father reported that the lesion was in the exact location of the top of a tube sock, which was placed on the infant 24 hours previously. The father reported the lesion initially appeared red and was non-palpable and looked like “when you sleep on your sleeve and have a red mark from it.” The child was reported to be in good health since birth except for this lesion.

The pediatrician suspected a dry contact burn injury and subsequently consulted the Child Protection Program for further evaluation. The history and the physical exam findings were consistent with an elastic band constriction ischemic injury. No further work-up was performed and the child was discharged home with the family.

Case 3

A 2-year-old female presented on two separate occasions to her primary care physician for evaluation of curvilinear lesions on her distal left leg. Her mother first noted three curvilinear lesions at different heights two days before the initial presentation. The lesions were described as small, non-raised crescents on the anterior portion of the lower left leg and aligned with the inner elastic lining of the child’s snow pants. After an evaluation by the primary care physician, the child’s mother was reassured that the lesion appeared benign and the patient was discharged home. The lesion resolved one week after the initial visit, leaving no residual mark.

A second lesion was noted on the left lower leg approximately one month later. It was a curvilinear non-palpable lesion (Figure 1-D).

Figure 1-D

The child’s mother brought her in to see her primary care physician three days after the lesion appeared. Unlike the previous occurrence, the child had not recently worn her snow pants. After investigating the child’s clothing, the mother was not able to identify a specific article that could have caused the lesion. Mother stated that the child sleeps wearing socks at night. Other than the lesion, the child has been in good health. She was once again evaluated in the primary care office and was discharged home after consultation with the Child Protection Program. The lesion was diagnosed as an innocent pressure injury.

Case 4

A 2-month-old African American male with a history of social concerns presented with bronchiolitis. His mother had a history of illicit substance abuse and possible bipolar disorder vs. schizoaffective disorder. There was previous CPS involvement with this family regarding medical neglect for an older sibling who was not given medications for mental health conditions. During his physical exam, it was noticed that there was a horizontal hyperpigmented line that traversed the anterior half of his right lower leg. A blue-black 1-1.5cm band traversed the back of his leg in the same region. (Figure 1-E, below) At the time it was questionable whether this blue-black lesion was part of the same injury or if it was a Mongolian spot. After further review, this lesion was determined to be from a constriction injury from clothing.

Figure 1-E

Case 5

A 13-month-old African American male presented for evaluation of a red curvilinear mark on the volar aspect of his right arm (Figure 1-F).

Figure 1-F

Per report, he had removed a rubber band that had been in his hair and put it on his arm. Today his mother noted skin breakdown where the rubber band had been. On exam there were two faint linear marks noted on the back lateral upper arm and one deeper sharply inscribed oblique line with dead skin crusting over volar upper forearm (Figure 1-G). 

Figure 1-G

This mark could easily have been mistaken for ligature marks. This case was referred to a child abuse specialist for further evaluation. It was determined that the physical exam findings were consistent with the injury.

Case 6

An 8-month-old white male was referred to CPS by a concerned nurse/friend of the family for possible old burn scars on his posterior legs and poor nutrition. The following is summarized from the history obtained by CPS from the reporting nurse. When the infant was 2-3 months old, he had red marks on his posterior legs, which his mother explained were from his socks (Figure 1-F).

Figure 1-F

The mother was known to have bipolar disorder, was an illicit substance abuser, and was in a complicated relationship with the suspected father of the infant, who was also an illicit substance abuser. The mother was unemployed and often left her infant with her foster sister (who is also known to have untreated bipolar disorder) for a week at a time. The father left the family approximately 1-2 months after the injury was first noticed. The mother then moved out of town to be with the father of this infant, but came back to town a few short months later. At that time, the reporting nurse noticed that the red marks that were previously seen were now well healed scars. She was concerned that these scars resembled healed burn wounds that were in a circular pattern as seen with burns from a stove-heating element.

CPS referred this patient to a child abuse specialist for further evaluation of the skin findings. A chart review was performed which revealed three documented well child visits, none of which documented these skin findings. The last documented well child check reported a healthy male growing and developing normally with no serious concerns. During this evaluation, the mother was interviewed. She clarified that at the time of the injury he was being care for by her foster sister. The marks were described as partially denuded skin with a small blister, which eventually scabbed over. She reported that while he was staying with her foster sister, he was left in the bouncing seat too long and his socks rubbed against his skin leaving these marks. In this case it was determined by the child abuse specialist that these scars could have been due to constriction band injury from his socks.

Diagnosis: Elastic Band Constriction Injury Mistaken for Abuse

Discussion

Previous reports suggest elastic band constriction injury is frequently mistaken for child abuse. Causal impressions include dry contact burn injury and ligature constriction injury. Feldman documented four cases of innocent pressure injuries, which had been mistaken for dry contact burns (Table 1). Johnson also reported injuries from tight clothing resembling ligature marks (Table 1). The differential also includes congenital disorders such as raised limb bands of infancy. When presented with lesions such as those described above, the physician must consider abuse in the differential diagnosis. Further history and examination may help distinguish accidental elastic band constriction injury from abusive injury.

Table 1. Summary of Reported Cases of Curvilinear Lesions

Case

Sex/Age at Presentation

Location

Completely Circumferential

Palpable

Suspected Item Causing Lesion

Follow-up

Case 1

F/ 2 mo

Left calf

No

No

Elastic band on pants

Persistent lesion at 3 mo follow-up

Case 2

F/ 10 wks

Right anterior shin

No

No

Tube socks

none

Case 3

F/ 2 yrs

Left lower anterior leg

No

No

Elastic sock band

None

Case 4

M/ 2.5 mo

Right lower leg

No

No

Elastic sock band

Unknown

Case 5

M/ 13 mo

Right arm

Yes

Unknown

Rubber band

Unknown

Case 6

M/ 8 mo

Bilateral calves

No

No

Elastic sock band

Unknown

Johnson (1988)

Patient 3

F/5 mo

Bilateral wrists

Yes

Unknown

Elastic bands in arms of dress

Unknown

Feldman (1995)

Patient 1

Unknown/2 wks

Bilateral calves

No

Yes

Margin of leg holes in infant swing

Unknown

Feldman (1995)

Patient 2

M/ 3 yrs

Bilateral calves

No

Unknown

Top of Cowboy boots

Resolved at 6 month follow-up

Feldman (1995)

Patient 3

Unknown/ 6 mo

Bilateral calves

 

No

Unknown

Elastic of pajama cuffs

Unknown

Feldman (1995)

Patient 4

F/ 3 mo

Left calf

No

Unknown

Unknown

Hyperpigmentation persisted for 15mo

Berk (2007)

Patient 1

F/ 16 mo

Right ankle

Yes

No

Unknown

Resolved within several months

Berk (2007)

Patient 2

M/ 2 mo

Right leg

Yes

No

Unknown

None

Berk (2007)

Patient 3

M/ 7 mo

Right Leg

Yes

Yes

Unknown

Unchanged at 5mo

Berk (2007)

Patient 4

M/ 3 mo

Right leg

No

Yes

Unknown

Slightly atrophic indentation at 20 mo

Berk (2007)

Patient 5

F/ 12 mo

Left leg

No

No

Unknown

None

Ferns (2008)

F/ 4 mo

Bilateral calves

Yes

Yes

Elastic sock band

Unknown

 

Elastic band constriction injury occurs due to constriction pressure on the skin adjacent to the elastic band. This constriction results in ischemia and inflammatory reaction. Panniculitis or subcutaneous fat necrosis may be additional factors. Elastic band constriction injuries usually present initially as hyperpigmented to red non-palpable lesions. In the early healing phase, mummified surface skin may resemble injury caused by contact burns from hot solids. As healing progresses, the injured skin may slough, leaving slick, hypo-pigmented new epithelium. The lesions described in this case series were unilateral, but other authors observed bilateral lesions. Two of the three current lesions were located on the anterior aspect of the leg, in contrast to most other reported lesions being found on the posterior leg (Table 1). These lesions are benign, although prolonged, post-inflammatory hyper-pigmentation may remain.

Elastic band constriction injury lesions appear similar to injuries caused by dry contact burns. Contact burns are the second most common type of inflicted burns after hot water immersion burns. Contact with common objects such as heating grates, curling irons, cigarettes and clothes irons often create dry contact burns reflecting the shape of the injuring object. Burns inflicted with the edge of the preceding objects may cause a linear injury pattern. Due to the similarity between the lesions of elastic band constriction injury and contact burn injuries, a thorough history, physical examination and examination of the child’s environment should be conducted. This history will usually identify the source (elastic band or other object) causing the injury. The cases above identified elastic bands on pants, snow pants, and socks as causative agents of constriction injury (Table 1). The physical findings of a more circumferential lesion may further support elastic band injury rather than burn injury.

Another mechanism of abusive injury causing similar lesions is abusive constriction band injury. In this scenario, constrictive bands are applied deliberately to the child in order to restrain the child or inflict injury. Circumferential lesions can result from binding children’s hands, legs, or genitalia. Similar to elastic band constriction, the constrictive bands used in this type of abuse may cause ischemia and inflammatory changes in the skin. If thorough history and investigation of the child’s environment does not reveal an accidental cause of the injury, child abuse should be strongly considered.

Raised or grooved limb bands of infancy are another entity described in the literature, which present as linear circumferential lesions. Often these lesions are palpable and tend to persist for longer durations than the lesions caused by elastic band constriction. Although these lesions usually are present in the newborn period and associated with “amniotic band syndrome,” they have been described as developing post-natally. They are distinct from the lesions described above, often deeper tissue induration or reduction injuries are associated. However, more minor examples can appear similar to elastic band constriction injury. Such bands of infancy can occur on the ankle, calf, trunk, arms, or thighs, while elastic band constriction injury is limited to the distal aspects of extremities. A history of stable lesions since at or near birth and associated “amnionic band” changes should reduce confusion.

Conclusion

There are few published case reports of elastic band constriction injury. The lesions may have often been mistaken for inflicted dry contact burns or constrictive ligature injuries and sometimes can appear similar to acquired raised bands of infancy. A thorough history and investigation of a child’s environment can help distinguish innocent constriction injuries from situations of abuse or neglect.

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References

  1. Berk D, Tapia B, Lind A, Bayliss S. Sock-line hyperpigmentation: case series and literature review. Arch Dermatol. Mar 2007;143(3):428-430.
  2. Berk DR, Bayliss SJ. Sock-line bands in infancy. British Journal of Dermatology. 2007;157(5):1063-1064.
  3. Feldman KW. Confusion of innocent pressure injuries with inflicted dry contact burns. Clin Pediatr (Phila). Feb 1995;34(2):114-115.
  4. Feldman KW. The bruised premobile infant: should you evaluate further? Pediatr Emerg Care. Jan 2009;25(1):37-39.
  5. Ford LS, Rogers M, Kemp AS, Campbell DE. Persistent linear bands in infancy acquired after local pressure: a consequence of mast cell activation? Pediatr Dermatol. Jul-Aug 2007;24(4):391-393.
  6. Johnson CF. Constricting bands. Manifestations of possible child abuse. Case reports and a review. Clin Pediatr (Phila). Sep 1988;27(9):439-444.
  7. Lateo SA, Taylor AE, Meggitt SJ. Raised limb bands developing in infancy. Br J Dermatol. Apr 2006;154(4):791-792.
  8. Marque MM, Guillot B, Le Gallic G, Bessis D. Raised limb bands in infancy: a post-traumatic aetiology? Br J Dermatol. Mar 2007;156(3):578-579.
  9. Meggitt SJ, Harper J, Lacour M, Taylor AE. Raised limb bands developing in infancy. Br J Dermatol. Aug 2002;147(2):359-363.
  10. Russi DC, Irvine AD, Paller AS. Raised limb bands developing in infancy. Br J Dermatol. Aug 2003;149(2):436-437.
  11. Zhu YI, Fitzpatrick JE, Weston WL. Congenital curvilinear palpable hyperpigmentation. J Am Acad Dermatol. Aug 2005;53(2 Suppl 1):S162-164.
  12. Ferns SJ, Noronha PA. Case: Bands on the calves of a 4-month-old. Contemporary Pediatrics. 2008.
  13. Thompson S. Accidental or inflicted? Pediatr Ann. May 2005;34(5):372-381. 14. Dyer JA, Chamlin S. Acquired raised bands of infancy: association with amniotic bands. Pediatr Dermatol. Jul-Aug 2005;22(4):346-349.