StephensonBialasTable2EstimationoftheageofbruisesfromphotographsFreshhoursintermediatex48 Txj Fx1 9x60 Txf 55x56 xTz 1x668x 0 Txd 0048hourss7daysoldx48 ID: 938410
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ArchivesofDiseaseinChildhood1996;74:53-55EstimationoftheageofbruisingTerenceStephenson,YvonaBialasAbstractPaediatriciansareoftenrequestedtogiveanopinionontheageofanon-accidentalbruise.Inforensictextbooks,thecolourchangeswhichabruiseundergoeswithtimearenotbasedonresearchinchild-ren.Thepurposeofthisstudywastodocumentthesequenceofcolourchangesinphotographstakenfollowingaccidentalbruisinginchildren.Fiftyaccidentalbruisesofknownagein23childrenwerephotographedbyamedicalphotographerusingthesameequipmentthroughout.Thephotographswerereviewedbyasingleobserver,blindtothetrueageoftheinjury,whodescribedthecolourspresentinthebruise.Redcolourationwasseenin15outof37bruiseswhichwerelessthanoneweekold.Yeliowcolourationwasseenin10outof42bruisesoveronedayold.Agingofbruisesfromphotographswasmuchlessprecisethantextbooksimply.(ArchDisChild1996;74:53-55)Keywords:bruising,aging,non-accidental.Incasesofsuspectednon-accidentalinjury,paediatriciansareoftenrequestedtogiveanopinionontheageofsofttissueinjuries,espe-ciallyifacasecomestocourt,whenseveralexpertwitnessesmaybecalledtogivetheiropiniononwhethertheinjuriesareconsistentwiththeexplanationofferedandwiththeallegedtimingoftheevents.Theageofbruisesthenhastobededucedfromphotographsoftheinjuriestakenatthetime.Publishedreportsontheagingofbruisesisconfusing.Forensictextbookswhichcitethecolourchangeswhichabruiseundergoeswithtimedonotappeartobebasedonresearchinchildrenandthereisnogeneralconsensusonthedurationofeachstageofcolour,norevenanyagreementontheexactsequenceofcolourchangesl-6(table1).Thepurposeofthisstudywastodocumentthesequenceofcolourchangesinphotographstakenafteraccidentalbruisinginchildren.MethodsWhitechildrenwithaccidentalbruisingfromaknowntimedinjurywererecruitedfromtheDepartmentofChildHealth,UniversityHospital,NottinghamNG72UHTStephensonYBialasCorrespondenceto:DrStephenson.Accepted5September1995orthopaedicward.Childrenwithsuspectednon-accidentalinjurieswereexcludedfromthestudy.Parentalconsentwasobtainedforrecruitmentandthedateandtimeoftheinjuryascertained.Thebruisewasthenphotographedbyasingleprofessionalmedicalphotographer,usingaNikonF3singlelensreflexcamera,witha105mmMacrolens,KodakVPS(160ASA)film,Metzprofessionalflashgun(tostandardiseambientlighting),andarepro-duciblecolourscaleincludedinthefieldofeachphotograph.Ifthechildremainedinhospitalformorethanthreedays,asecondsetofphotographswastakentooffsetthefactthatmostchildrenwereadmittedanddischargedsoonaftertheirinjuryandthereforethesamplewasbiasedtowardsfresherinjuries.Thephotographswerereviewedbyoneofus(TMS)withpersonalexperienceofover300casesofnon-accidentalinjury,andthisobserverwasblindtothetrueageoftheinjury.The'blind'observerwasaskedtorecordthecolourspresentinthephotographoftheinjury(describedasoneormoreofred,blue,purple,grey,brown,green,yellow)andtoestimatetheageoftheinjuryasfresh(48hoursorless),intermediate(between48hoursandsevendays),orold(morethansevendays).Thestudywasapprovedbytheethicscom-mitteeoftheUniversityHospital,Nottingham.ResultsWerecruited23children(13boys,10girls)aged8monthsto13yearsold,withatotalof36bruises.Twelvewerepedestriansorcyclistsinvolvedinroadtrafficaccidentsandtheremaining11sustainedfallsfromheightsof05to2metres.Ofthe36bruises,12involvedtheupperlimb,12thelowerlimb,fivethetrunk,andseventheface.Tenofthese23childrenhadasinglefractureinadditiontothesofttissueinjuriesbutnochildhadmultiplefractures.Tenofthe23children,with14bruisesbetweenthem,remainedasinpatientsandwerethereforephotographedasecondtimethreetoninedayslater.Therewerethus50photographsofbruises.Sixofthesechild-renhadfracturesandfourhadbruisingonly.Atthetimeofphotography,theactualagesofthebruisesvariedfrom15hoursto14days(48hoursorless,34%;48hourstosevendays,39%;morethansevendays,27%).Table1Schemesfortheagingofbruises(forfullreferences,seeendoftext)Adelson2RentouleandSmith3Camps4PolsonandGee5SpitzandFisher6InitialRed/blueVioletRedRed,blackBlue/red1-3daysBlue/
brownDarkbluePurple,blackPurple,blackDarkpurple1weekYellow/greenGreenGreenGreenGreen/yellow8-10daysYellowYellowBrown2weeksNormalNormalYellowNormal53 Stephenson,BialasTable2Estimationoftheageofbruisesfromphotographs:'Fresh''hours;'intermediate'H T;&#xj /F; 9.;` T; 55;&#x.56 ;&#xTz 1;.68;&#x 0 T; 00;48hours,s7days;'old'H T;&#xj /F; 9.;` T; 55;&#x.56 ;&#xTz 1;.68;&#x 0 T; 00;7days;24correct,20wrongEstimatedEstimatedEstimatedfreshintermediateoldTruefresh753Trueintennediate0107Trueold057Themostsalientresultsareshowninthefigureandintable2.Purple,blue,grey,andbrowncolourationwereascribedtophoto-graphstakenfromthedayoftheinjuryanduptotwoweekslater.Theywerethereforenotdiscriminatoryinagingthebruises.Purple,grey,andbrownwereequallylikelytobeascribedtoinjurieslessthanormorethanoneweekold.Bluecolourationwasascribedtofiveoutofthe37bruiseslessthanoneweekoldandinonebruisemorethanoneweekold.Redcolourationwasascribedonlytophotographsofinjuriesoneweekoldorless,andwasdescribedin15outofthe37bruisesthatwereoneweekoldorless(seefigure).Yellowcolourationwasnotseeninphotographsofinjurieslessthanonedayold(butwasseenin10outof42bruisesmorethanonedayold,seefigure),andgreencolourationwasnotascribedtophotographsofinjurieslessthantwodaysold(butwasseeninnineoutof32bruisesmorethantwodaysold,datanotshown).Theblindobserverfeltthatitwaspossibletoage44ofthe50bruisesphotographed(36atpresentionand14onfollowupphotographs).Sixcouldnotbeagedbecausethecolourgreywasnotcitedinanyofthereferencetexts.Itcanbeseenfromtable2thattheestimatewascorrectin24outofthe44casesandincorrectin20.Nophotographofaninjuryolderthan48hourswasestimatedasbeingfresh.Apartfromthisobservation,therewereerrorsforallotherpermutationsofagingasshownintable2.Theaccuracyofthe'blind'observer'sestimatesofageofbruisingwasunrelatedtotheageofthechild(24correctestimates,medianageofchild8years;20incorrectestimates,medianageofchild10years),thepresenceofafracture(incor-rectinsevenoutof17bruisesassociatedwithafracture,incorrectin13outof27bruisesnotassociatedwithafracture),ortothesiteofthebruise(incorrectinsixoutof16bruisesontheupperlimb,nineoutof18bruisesonthelowerlimb,fiveoutof10bruisesonthefaceortrunk).12-10-|*Redcoloura8-Yellowcolour*Othercolours00z42-0-1234567891011121314Ageofbruise(days)Theheightofthebarsshowsthetotalnumberofbruisesateachage.DiscussionAbruiseisanescapeofbloodintotheskin,subcutaneoustissue,orbothfollowingtheruptureofbloodvessels,usuallycapillaries,bytheapplicationofbluntforce.Theremaybeassociatedswelling,inwhichcasetheinjurymaybereferredtoasahaematoma.Theappearanceofthebruise(andpresumablytheevolutionoftheappearancewithtime)maybeinfluencedbytheseverityofthebluntforce,thevascularityoftheunderlyingtissues,diseaseswhichaffecttheconnectivetissuesortheabilityofthebloodtoclot,age,possiblysex,andthecolouroftheskin.Bruisingshowsmoreeasilythepalertheskin.Iftheskinislooseatthesiteofinjury,asforexamplearoundtheeyeorgenitalia,bruisingwilloccurmoreeasily;conversely,iftheskinisstronglysupportedandmuscletoneisgood,bruisingmaybeminimal.Tosomeextentthesefactorsmaybetakenintoaccountwhenanobserveragesbruisesbutoftenthisinformationwillnotbeapparentfromaphotograph.Forexample,thepresenceofswellingmaybeverydifficulttodiscernfromaphotograph.Theextentofabruisemayincreasecon-siderablyaftertheinjurywhichcausedit,becauseofcontinuedextravasationofbloodandtrackingbetweentissueplanes.Gravitymayresultinabruiseappearinginaplaceremotefromthepointofinjury,suchasmaybeseenwhenbruisingappearsontheoutersideofthethighfollowingafracturedfemuroroverthelowerchestwallfollowingafracturedclavicle.Petechiaemayalsoariseinchildrenwithnormalclottingandplateletcountsasaresultoftrauma.Examplesarethepetechialbruisingwhichoccursasaresultofasuctionbite(a'lovebite'onthesofttissuesoftheneck),petechialbruisingwhichmayaffectthepinnaoftheearwhenitissqueezedorslapped,andpetechialbruisingonthecheekoraroun
dtheorbitasaresultofaslapmarktotheface.Therehavebeennostudiesofthechangesinappearanceorcolourofpetechiaewithtime.Inreportsrelatingtonon-accidentalinjury,lessresearchhasbeendevotedtosofttissueinjuriesthantofracturesandheadinjuries.78Thedatafromthisstudysuggestthatascribinganagetochildhoodbruisingfromcolourchangesonthebasisofphotographicevidenceismuchlessprecisethanforensictextbooksimply.Thisstudyshowsthatseveraldifferentcolourscanbepresentatthesametimewithinonebruiseandthatbruisescanchangecolouratverydifferentrates,presumablydependingonthenatureoftheinjuryandthechild'sresponsetothisinjury.Atthetimeofrepeatphotographyinoneparticularchild,thebruiseonherleghadturnedgreen/yellowwhilethatonherarmremainedblue,althoughbothinjurieshadoccurredduringthesameaccident.Thefindingsofthisstudysuggestthataredcolourisonlyseeninaphotographofaninjurylessthanaweekold,whereasgreenoryellowhuessuggesttheinjuryisatleast24to48hoursold.Astudyinadultsshowedthatphotographsofbruiseslessthan18hoursoldnevershowedayellowcolour.Inthatstudy,54 Estimationoftheageofbruising55thecoloursred,blue,andpurple/blackoccurredfromwithinonehourofbruisingupto21days.9Evenusingthecrudecategoriesof'fresh','intermediate',and'old',agingofinjuriesfromphotographsappearstobeunreli-able,exceptthataninjuryover48hoursoldisunlikelytobeestimatedasfreshfromphoto-graphs(table2).Ultravioletphotographycandetectbruisingwhichisnolongervisibletothenakedeyebutthistechniquecannotagetheseolderinjuriesprecisely.10Thisreportmaybecriticisedbecausetherewasonlyone'blind'reviewerandthereforewecannotassessthedegreeofpossibleobservervariation.Itcouldbeallegedthatwemayhavehadavestedinterestinreturninganegativemessage,orhadpreconceptionsbeforeembark-ingonthestudy,thusintroducingbias.Theseissuesshouldbeaddressedinanysubsequentresearchinthisfield.Ourstudymayalsobecriticisedbecausethedegreeoftraumaresultinginachildbeingadmittedtoanorthopaedicwardmaybemoreseverethanthatencounteredinchildrenwhohavebeenthevictimsofnon-accidentalinjuryorchastisement.Itislikelythatthedurationofbruisingisrelatedtotheseverityofthetraumaandperhapsalsotheproximityoffracturesorotherinjuries.Nevertheless,whilethismayinfluencethedurationofbruising,thewidevariabilityofcolourchangefoundinthisstudyisstilllikelytoapplytoanon-accidentalinjurygroupratherthantheprecisecoloursequencescitedinforensictextbooks.16Ourstudyshowsthatdescribingshadesoffleshusing'paintbox'coloursisextremelydifficult.Retrospectiveopinionsontheageofinjuriesfromphotographsmaybelessreliablethanacontemporaneousopinionfromanexperiencedpaediatrician,particularlysincetheeyewitnessmayseeothercluestoagesuchasabrasionsandswelling.Judgesandbarristersshouldbemadeawareofthis.Agingofinjuriesfromphoto-graphsisimprecise,eveninacontrolledresearchsetting,butthisstudydrawsnoconclu-sionsaboutassessingtheageofinjuriesonclinicalexamination.Thiswouldrequireafurtherstudyinwhicha'blind'observerattemptedtoagetheactualinjuriesatpresenta-tionratherthanagingphotographsoftheinjury,aswasdoneinthisstudy.1WilsonEF.Estimationoftheageofcutaneouscontusionsinchildabuse.Pediatrics1977;60:750-2.2AdelsonL.Thepathologyofhomicide.Springfield:CharlesCThomas,1974:382-6.3RentouleE,SmithH.Glaister'smedicaljurisprudenceandtoxicology,13thEd.Edinburgh:ChurchillLivingstone,1973:242-6.4CampsFE.Gradwohl'slegalmedicine,3rdEd.Bristol:JohnWrightandSon,1976:264-7.5PolsonCJ,GeeDJ.Theessentialsofforensicmedicine,4thEd.Oxford:PergamonPress,1984:97-105.6SpitzWU,FisherRS.Medicolegalinvestigationofdeath,2ndEd.Springfield:CharlesCThomas,1980:122-5.7SpeightN.ABCofchildabuse.Non-accidentalinjury.BMJ1989;298:879-81.8HobbsCJ,HanksHGI,WynneJM.Childabuseandneglect.Aclinician'shandbook.Edinburgh:ChurchillLivingstone,1993:53-4.9LangloisNEI,GreshamGA.Theagingofbruises:areviewandstudyofthecolourchangeswithtime.ForensicSciInt1991;50:227-38.10HemplingSM.Theapplicationsofultravioletphotographyinclinicalforensicmedicine.MedSciLaw1981;21:215-22.