epidermis (superficial layer of the skin) from the underlying connective tissue resulting in a flap of skin (Malone et al., 1991).

Age-Related Changes

Skin thickness and elasticity decrease with age. Tensile strength also declines, increasing the susceptibility to shearing-force trauma (Griffiths, 1998). Abrasions can occur in older persons with minor trauma. Common lacerations in elderly persons are the skin tears that occur most frequently on the forearms and occasionally on the legs. Persons usually have no more than one or two skin tears at a time, and skin tears often heal completely without scarring.

A primary data study revealed that the annual incidence of skin tears in a large nursing home was a little less than one per year per resident. The majority of tears were approximately 0.75 inches in length, though nearly 6 percent were 1.6 inches or longer. Eighty-five percent of the lacerations occurred on the arms. A known cause was identified in less than half the cases (47 percent), and most known causes were attributed to falls or bumping into something; wheelchairs accounted for 30 percent of the injuries (Malone et al., 1991). In cases in which the cause was unknown (53 percent), the skin tears may have occurred accidentally and may not have been noticed or may have been forgotten by the elder, or they could have been due to rough handling or worse by staff members and others. This study included no analysis of the cases with known causes as compared to those with unknown causes.

Clinical and Forensic Markers Indicating Abuse or Neglect

Abrasions retain the pattern of the causative agent better than any other type of injury, and careful documentation by health care personnel is important for identification of the mode of injury. Skin tears in sites other than the arms and legs or multiple tears or abrasions should raise suspicion. Lacerations often heal with scarring (Knight, 1997), as opposed to skin tears, which heal without scarring. Abrasions or lacerations are most commonly seen in cases involving physical abuse, although they can occur in cases of caregiver neglect.

Bruises

A bruise is the result of blunt force with concomitant rupture of small blood vessels under the skin. Blood escapes to the surrounding tissues propelled by the muscular contractions of the heart. Bruises are most



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