- Email: [email protected]
Ultrasound characteristics of bruises and their correlation to cutaneous appearance
Forensic Science International 266 (2016) 160–163
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Ultrasound characteristics of bruises and their correlation to cutaneous appearance Travis Helm a, Cynthia Bir b, Mikaela Chilstrom b, Ilene Claudius b,* a b
USC, School of Medicine, 1975 Zonal, KAM 500, Los Angeles, CA 90089-9034, United States Department of Emergency Medicine, USC, Keck School of Medicine 1200 North State Street, 1011 , Los Angeles, CA 90033, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 January 2016 Received in revised form 23 May 2016 Accepted 25 May 2016 Available online 2 June 2016
Objective: The primary objective of this study was to compare the cutaneous size of a bruise on gross exam to the subcutaneous depth and height of the hematoma ascertained by ultrasound. The hypothesis was that there would be little correlation between the area of the bruise on cutaneous exam and the height when measured with ultrasound. Methods: Adult and pediatric patients with bruising were prospectively identified in the emergency department. Photographs and ultrasound images were collected of the bruises and epidemiologic information collected from the patients. The cutaneous area of the bruise was compared with the sonographic characteristics. Results: The subcutaneous depth and height of the hematomas defined by ultrasound did not correlate with the cutaneous area. Conclusions: The cutaneous appearance of a bruise gives little indication of the depth and size of the subcutaneous bruise. Ultrasound can add information regarding these parameters. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Contusion Ultrasound Abuse
1. Introduction On average approximately three million cases of child abuse are reported annually in the United States [1] with nearly twenty percent of the proven cases to be physical abuse [2]. Studies also suggest that for every case of child abuse reported there are two to four cases that go unreported [1]. Abuse is most prevalent in children under the age of one year and more common in intellectually disabled children, populations which may have difficulty clearly describing the cause of their injury [2]. Despite the prevalence of child abuse, it often goes undetected in the medical setting [3]. There are many reasons for this; however, one barrier to diagnosis of abuse is the difficulty in distinguishing between abuse and accidental injuries. Like the skeletal survey, additional objective criteria to help diagnose and document an injury could be a valuable adjunct to the current paradigm.
* Corresponding author. Tel.: +1 310 625 2918; fax: +1 323 226 6454. E-mail addresses: [email protected] (T. Helm), [email protected] (C. Bir), [email protected] (M. Chilstrom), [email protected] (I. Claudius). http://dx.doi.org/10.1016/j.forsciint.2016.05.022 0379-0738/ß 2016 Elsevier Ireland Ltd. All rights reserved.
The most common sentinel injury associated with physical abuse is skin disturbance, seen in up to ninety percent of physical abuse victims [4]. Therefore, skin abnormalities, such as bruises, are potential targets for developing objective clinical testing to distinguish these injuries as accidental or abusive. A bruise is defined as an injury producing a hematoma or diffuse extravasation of blood without rupture of the skin [5]. Often bruises are photographed for law enforcement, but this yields little information about the subcutaneous size and depth of the bruising, which may give some insight into the severity of the mechanism. Ultrasound has become widely available in many clinical settings, yet very little research has been performed evaluating the sonographic appearance of bruises. It is possible that this modality might give us an additional way to objectively document cutaneous injuries and assess the amount and type of inflicted force. The primary objective of this study was to compare the area of a bruise on gross exam to the subcutaneous depth and height of the hematoma ascertained by ultrasound. The hypothesis was that there would be little correlation between the cutaneous area of the bruise on gross exam and the subcutaneous depth and height when measured by ultrasound. A secondary outcome was to compare epidemiologic and historic information for sonographically visualized hematomas versus those not visualized by ultrasound.
T. Helm et al. / Forensic Science International 266 (2016) 160–163
161
2. Materials and methods 2.1. Setting and patients Adult and pediatric patients from a level one trauma emergency department were prospectively enrolled from June 2015 to August 2015. To be included in the study, patients required a visible cutaneous bruise acquired through any mechanism. Patients were excluded if they were not fluent in English or Spanish, if they had altered mental status (due to need for consent), or if they could not give a mechanism and time of onset of the bruise. Patients taking aspirin or non-steroidal anti-inflammatory drugs were included, but those on anticoagulants (Vitamin K, factor Xa, or direct thrombin inhibitors) were not. If a patient had multiple bruises, each bruise was included. Patient demographic and injury information were collected including height, weight, age, sex, time of injury, mechanism of injury, and modifying factors, such as medications and mobility since the injury. The study was approved by the Institutional Review Board and informed consent was obtained from each participant. Fig. 1. Example of ultrasound bruise with diameter B representing height.
2.2. Data collection After demographic information was obtained, each cutaneous bruise was measured in two dimensions and photographs were taken. Ultrasounds were performed in the emergency department during the patient’s initial evaluation. Ultrasounds were performed by either a medical student who had been trained by an attending emergency physician, an attending emergency physician, or an ultrasound technologist. For the vast majority of cases, all three providers were present. Initial images were obtained with a 7–10 MHz linear array probe in two planes; however, the operator had the option of using a water bath or step-off pad for better superficial resolution, or using the 5–2 MHz curvilinear probe to visualize deeper structures. The area of the cutaneous bruise was scanned end to end to identify the deepest portion, and still images of this region were saved with calipers for measurements, as well as a video clip to confirm this represented the deepest portion. Sonographic evidence of a hematoma was defined as hypoechoic or anechoic changes within the subcutaneous tissue or muscle. While it is recognized that deep bruises can organize and parts can appear hyperechoic, there were no bruises in this study that contained a clear hyperechoic region, therefore only the hypoechoic or anechoic regions were measured. 2.3. Analysis An RDMS-certified ultrasound fellowship-trained emergency physician reviewed each ultrasound image to evaluate the technique, confirm the presence or absence of a subcutaneous hematoma, and to verify the measurements. Inadequate studies were eliminated. The patients were divided into two groups: those with sonographic evidence of a subcutaneous hematoma and those without. The groups were compared for age, time from injury, mechanism of injury, location of bruise, and cutaneous size of bruise. The sonographic height (diameter of the bruise in the plane perpendicular to the skin) and depth of the hematoma (distance from the skin to the beginning of the bruise) were compared with the cutaneous area, calculated based on the assumption that the area of cutaneous bruise was ovoid. Fig. 1 demonstrates a representative ultrasound image with the relevant measurements. 2.4. Statistics Data was compared using Fischer’s exact due to the small size. Correlation was done using a parametric correlation coefficient.
3. Results Twenty-nine cutaneous bruises were studied. Two patients (three bruises) were excluded as it was discovered they were taking warfarin, and four more were excluded due to technical issues with proper acquisition or storage of adequate images (downloaded images did not clearly demonstrate at least one border of the bruise). This left 22 remaining cutaneous bruises in 18 patients for evaluation. In ten, the bruise could not be visualized with ultrasound. In the remaining 12 cutaneous bruises, a sonographic hematoma was identified and measurements were obtained. In the group without sonographic evidence of a subcutaneous hematoma, 80% were male, the average age was 38.7 years (range 1–95 years), and the average time from injury was 120.1 h (range 3–717 h). In the group with sonographic evidence of a subcutaneous hematoma, 83% were male, the average age was 43.9 years (range 11–76 years), and the average time from injury was 17 h (range 3–48 h) (Table 1). The patient age (p = 0.266) and cutaneous area of the bruise (p = 0.266) were not significantly different between the patients in whom a hematoma was visualized on ultrasound and those that were not visualized. The majority of patients in both groups were discharged home from the emergency department. While six bruises that presented prior to 2 days after the injury had no sonographic changes, no subcutaneous changes were visible on ultrasound when more than 2 days had elapsed between the time of injury and the ultrasound. There was no association between the area of the bruise visible on gross exam and the depth of the injury determined by ultrasound (Table 2). The height of the sonographic hematoma Table 1 Demographic information in patients with sonographically visualized and nonvisualized bruises.
Number Age (years) Gender (% male) Time since injury (hours) Cause of bruise (%fall/blunt trauma/vehicular collision) Not/minimally active since injury (%) Cutaneous area (cm2)
Visualized bruise Mean (range)
Non-visualized bruise Mean (range)
12 43.9 (11–76) 83 17 (3–48) 67/17/17
10 38.7 (1–95) 80 120.1 (3–717) 50/30/20
91
60
19 (2.4–56.5)
29.7 (4.7–75.4)
T. Helm et al. / Forensic Science International 266 (2016) 160–163
162
Table 2 Sonographically visualized bruises comparing cutaneous area with sonographic height and depth of hematoma. Body part
Mechanism
Cutaneous area (cm2)
Height of bruise (cm)
Depth from surface to bruise (cm)
Eye Arm Face Brow Brow Eye Eye Scalp Wrist Forehead Forehead Brow
Fall Fall Fall Direct blow Assault MVC Assault Fall Fall Fall Fall Fall
56.5 55 28.9 20.4 13.7 12.4 11.8 9.7 7.4 6.2 3.5 2.4
1.8 0.2 0.8 1.7 0.5 0.7 0.1 0.3 0.3 0.6 0.7 1.1
0.1 0.1 0.3 0.3 0.1 0.2 0.8 0.6 0.2 0.1 0.2 0.4
ranged from 0.1 to 1.8 cm, and the depth from the skin surface to the top of the hematoma ranged from 0.1 to 0.8 cm. When only the bruises with ultrasound findings were considered, the correlation between cutaneous area and height of bruise was .288 (Fig. 2). When all bruises 48 h or less from time of injury were considered, and non-visualized bruises were assumed to have a depth of zero, the correlation was .005 (Fig. 3). Table 2 shows the bruises in descending order of area with the height and depth of the bruise for the sonographically visualized hematomas. Figs. 2 and 3 demonstrate scatter plots of this relationship, clearly failing to show a linear relationship. Fig. 2 depicts all visible sonographic hematomas, while Fig. 3 looks at all cutaneous bruises incurred within 2 days of presentation, assuming a depth of zero for non-visualized acute bruises.
4. Discussion Ultrasound as a technique to identify and characterize bruises has been minimally studied; however, its use in evaluation of sports-related muscle injuries is increasing [6]. Focusing on muscle injuries, Draghi et al. described muscle hematomas visualized in more severe contusions with use of a high frequency probe. They noted both a hyper and hypoechoic appearance in the first 24 h followed by a hypo or anechoic appearance [7]. With a focus on child abuse, Mimasaka et al. looked at 8 healthy children with bruising as well as 10 adult post mortem cases and characterized the size and appearance of the bruises. They were able to determine both the subcutaneous depth of the bruise and thickness of the bruise itself with a 5–10 MHz probe, both of which may impact the cutaneous appearance [8]. This study corroborates these findings and begins to identify potential clinical features associated with sonographic visualization of bruises. Currently, there are limitations to the modalities which exist to document a bruise to forensic or law enforcement specialists. Many are simply photographed or described in the medical record, however, this is not helpful in determining mechanism or timing. While the location of bruises may be helpful in the determination of an abusive injury, the color of a bruise has been shown not reliable in ‘‘dating’’ the bruise [9,10]. Spectrophotometry may be useful for this purpose [11,12], but is not a technology that is often available to initial providers, nor does it provide insight into the mechanism of the bruise. This study demonstrates that the cutaneous area of a bruise correlates poorly with the subcutaneous depth, indicating that subcutaneous sonographic measurements may add to the forensic evaluation.
2 1.8 1.6
Height (cm)
1.4 1.2 1 0.8 0.6 0.4 0.2 0
0
10
20
30
40
50
60
Area (cm2) Fig. 2. Visualized bruises only.
2 1.8 1.6 Height (cm)
1.4 1.2 1 0.8 0.6 0.4 0.2 0
0
10
20
30
40 Area (cm2)
Fig. 3. All bruises under 48 h.
50
60
70
T. Helm et al. / Forensic Science International 266 (2016) 160–163
There are some limitations to this data set. We did not note any distinct hyperechoic portions of the sonographic bruises; however, subtle areas may have been missed. Sonographic resolution, while important for documentation, does not imply that a bruise is completely resolved, and lack of sonographic hematoma should not imply lack of pathology. The sample size, the reliance on patient history for timing, and the use of primarily adult patients limit the generalizability of this study to use in non-accidental trauma cases at this point. However, two outcomes are important to note. Firstly, the superficial area of the bruise is a poor marker of the extent of the injury below the skin, both the depth and the height of the hematoma. Further study is required to determine whether the mechanism of the bruise alters the sonographic depth and height; however, logically it seems plausible that the strike of an adult may cause a larger subcutaneous injury than that of another small child. Secondly, while the time from injury did not reach significance and individual patients were not followed for hematoma resolution, in this cohort, sonographic bruises were more often visualized if the patient presented within the 2 days following injury. In most cases of abuse, capturing an early ultrasound image would require the test to be performed by frontline providers. Point-of-care ultrasound is commonly used in emergency medicine and could prove a valuable and easy adjunct to the work-up of a patient with bruising of unclear etiology. 5. Conclusion The cutaneous size of bruises did not correlate with the subcutaneous depth or height of the contusion determined by ultrasound. Ultrasound may add additional information regarding the depth and subcutaneous size of bruises.
163
Acknowledgements Michael Menchine for his statistical consultation. Hope Velarde for her assistance with data collection and management. Kenji Inaba for his support and assistance with conception of the project.
References [1] American Humane Association. http://www.americanhumane.org/children/ stop-child-abuse/fact-sheets/child-abuse-and-neglect-statistics.html (accessed 12.18.15). [2] Children’s Bureau of the US Department of Health and Human Services. http://www. acf.hhs.gov/sites/default/files/cb/cm2012.pdf#page=16 (accessed 12.18.15). [3] E.L. Thorpe, N.S. Zuckerbraun, J.E. Wolford, R.P. Berger, Missed opportunities to diagnose child physical abuse, PEC 30 (11) (2014) 771–776. [4] L. Kos, T. Shwayder, Cutaneous manifestations of child abuse, Pediatr. Dermatol. 23 (2006) 311–320. [5] Stedman’s Medical Dictionary for the Health Professions and Nursing: Illustrated, fifth ed., Lippincott Williams & Wilkins, Philadelphia (PA), 2005. [6] J.C. Lee, A.W.M. Mitchell, J.C. Healy, Imaging of muscle injury in the elite athlete, BJR 85 (1016) (2012) 1173–1185. [7] F. Draghi, M. Zacchino, M. Canepari, P. Nucci, F. Alessandrino, Muscle injuries: ultrasound evaluation in the acute phase, J. Ultrasound 16 (2013) 209–214. [8] S. Mimasaka, T. Oshima, M. Ohtani, Characterization of bruises using ultrasonography for potential application in diagnosis of child abuse, Leg. Med. 14 (2012) 6–10. [9] S.E. Grossman, A. Johnston, P. Vanezis, D. Perrett, Can we assess the age of bruises? An attempt to develop an objective technique, Med. Sci. Law 51 (3) (2011) 170–176. [10] S. Maguire, M.K. Mann, J. Silbert, A. Kemp, Can you age bruises accurately in children? A systematic review, Arch. Dis. Child. 90 (2) (2005) 187–189. [11] V.K. Hughes, P.S. Ellis, T. Burt, N.E. Langlois, The practical application of reflectance spectrophotometry for the demonstration of haemoglobin and its degradation in bruises, J. Clin. Pathol. 57 (2004) 355–359. [12] S. Mimasaka, M. Ohtani, N. Kuroda, S. Tsunenari, Spectrophotometric evaluation of the age of bruises in children: measuring changes in bruise color as an indicator of child physical abuse, Tohoku J. Exp. Med. 220 (2010) 171–175.
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Ultrasound characteristics of bruises and their correlation to cutaneous appearance Travis Helm a, Cynthia Bir b, Mikaela Chilstrom b, Ilene Claudius b,* a b
USC, School of Medicine, 1975 Zonal, KAM 500, Los Angeles, CA 90089-9034, United States Department of Emergency Medicine, USC, Keck School of Medicine 1200 North State Street, 1011 , Los Angeles, CA 90033, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 January 2016 Received in revised form 23 May 2016 Accepted 25 May 2016 Available online 2 June 2016
Objective: The primary objective of this study was to compare the cutaneous size of a bruise on gross exam to the subcutaneous depth and height of the hematoma ascertained by ultrasound. The hypothesis was that there would be little correlation between the area of the bruise on cutaneous exam and the height when measured with ultrasound. Methods: Adult and pediatric patients with bruising were prospectively identified in the emergency department. Photographs and ultrasound images were collected of the bruises and epidemiologic information collected from the patients. The cutaneous area of the bruise was compared with the sonographic characteristics. Results: The subcutaneous depth and height of the hematomas defined by ultrasound did not correlate with the cutaneous area. Conclusions: The cutaneous appearance of a bruise gives little indication of the depth and size of the subcutaneous bruise. Ultrasound can add information regarding these parameters. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Contusion Ultrasound Abuse
1. Introduction On average approximately three million cases of child abuse are reported annually in the United States [1] with nearly twenty percent of the proven cases to be physical abuse [2]. Studies also suggest that for every case of child abuse reported there are two to four cases that go unreported [1]. Abuse is most prevalent in children under the age of one year and more common in intellectually disabled children, populations which may have difficulty clearly describing the cause of their injury [2]. Despite the prevalence of child abuse, it often goes undetected in the medical setting [3]. There are many reasons for this; however, one barrier to diagnosis of abuse is the difficulty in distinguishing between abuse and accidental injuries. Like the skeletal survey, additional objective criteria to help diagnose and document an injury could be a valuable adjunct to the current paradigm.
* Corresponding author. Tel.: +1 310 625 2918; fax: +1 323 226 6454. E-mail addresses: [email protected] (T. Helm), [email protected] (C. Bir), [email protected] (M. Chilstrom), [email protected] (I. Claudius). http://dx.doi.org/10.1016/j.forsciint.2016.05.022 0379-0738/ß 2016 Elsevier Ireland Ltd. All rights reserved.
The most common sentinel injury associated with physical abuse is skin disturbance, seen in up to ninety percent of physical abuse victims [4]. Therefore, skin abnormalities, such as bruises, are potential targets for developing objective clinical testing to distinguish these injuries as accidental or abusive. A bruise is defined as an injury producing a hematoma or diffuse extravasation of blood without rupture of the skin [5]. Often bruises are photographed for law enforcement, but this yields little information about the subcutaneous size and depth of the bruising, which may give some insight into the severity of the mechanism. Ultrasound has become widely available in many clinical settings, yet very little research has been performed evaluating the sonographic appearance of bruises. It is possible that this modality might give us an additional way to objectively document cutaneous injuries and assess the amount and type of inflicted force. The primary objective of this study was to compare the area of a bruise on gross exam to the subcutaneous depth and height of the hematoma ascertained by ultrasound. The hypothesis was that there would be little correlation between the cutaneous area of the bruise on gross exam and the subcutaneous depth and height when measured by ultrasound. A secondary outcome was to compare epidemiologic and historic information for sonographically visualized hematomas versus those not visualized by ultrasound.
T. Helm et al. / Forensic Science International 266 (2016) 160–163
161
2. Materials and methods 2.1. Setting and patients Adult and pediatric patients from a level one trauma emergency department were prospectively enrolled from June 2015 to August 2015. To be included in the study, patients required a visible cutaneous bruise acquired through any mechanism. Patients were excluded if they were not fluent in English or Spanish, if they had altered mental status (due to need for consent), or if they could not give a mechanism and time of onset of the bruise. Patients taking aspirin or non-steroidal anti-inflammatory drugs were included, but those on anticoagulants (Vitamin K, factor Xa, or direct thrombin inhibitors) were not. If a patient had multiple bruises, each bruise was included. Patient demographic and injury information were collected including height, weight, age, sex, time of injury, mechanism of injury, and modifying factors, such as medications and mobility since the injury. The study was approved by the Institutional Review Board and informed consent was obtained from each participant. Fig. 1. Example of ultrasound bruise with diameter B representing height.
2.2. Data collection After demographic information was obtained, each cutaneous bruise was measured in two dimensions and photographs were taken. Ultrasounds were performed in the emergency department during the patient’s initial evaluation. Ultrasounds were performed by either a medical student who had been trained by an attending emergency physician, an attending emergency physician, or an ultrasound technologist. For the vast majority of cases, all three providers were present. Initial images were obtained with a 7–10 MHz linear array probe in two planes; however, the operator had the option of using a water bath or step-off pad for better superficial resolution, or using the 5–2 MHz curvilinear probe to visualize deeper structures. The area of the cutaneous bruise was scanned end to end to identify the deepest portion, and still images of this region were saved with calipers for measurements, as well as a video clip to confirm this represented the deepest portion. Sonographic evidence of a hematoma was defined as hypoechoic or anechoic changes within the subcutaneous tissue or muscle. While it is recognized that deep bruises can organize and parts can appear hyperechoic, there were no bruises in this study that contained a clear hyperechoic region, therefore only the hypoechoic or anechoic regions were measured. 2.3. Analysis An RDMS-certified ultrasound fellowship-trained emergency physician reviewed each ultrasound image to evaluate the technique, confirm the presence or absence of a subcutaneous hematoma, and to verify the measurements. Inadequate studies were eliminated. The patients were divided into two groups: those with sonographic evidence of a subcutaneous hematoma and those without. The groups were compared for age, time from injury, mechanism of injury, location of bruise, and cutaneous size of bruise. The sonographic height (diameter of the bruise in the plane perpendicular to the skin) and depth of the hematoma (distance from the skin to the beginning of the bruise) were compared with the cutaneous area, calculated based on the assumption that the area of cutaneous bruise was ovoid. Fig. 1 demonstrates a representative ultrasound image with the relevant measurements. 2.4. Statistics Data was compared using Fischer’s exact due to the small size. Correlation was done using a parametric correlation coefficient.
3. Results Twenty-nine cutaneous bruises were studied. Two patients (three bruises) were excluded as it was discovered they were taking warfarin, and four more were excluded due to technical issues with proper acquisition or storage of adequate images (downloaded images did not clearly demonstrate at least one border of the bruise). This left 22 remaining cutaneous bruises in 18 patients for evaluation. In ten, the bruise could not be visualized with ultrasound. In the remaining 12 cutaneous bruises, a sonographic hematoma was identified and measurements were obtained. In the group without sonographic evidence of a subcutaneous hematoma, 80% were male, the average age was 38.7 years (range 1–95 years), and the average time from injury was 120.1 h (range 3–717 h). In the group with sonographic evidence of a subcutaneous hematoma, 83% were male, the average age was 43.9 years (range 11–76 years), and the average time from injury was 17 h (range 3–48 h) (Table 1). The patient age (p = 0.266) and cutaneous area of the bruise (p = 0.266) were not significantly different between the patients in whom a hematoma was visualized on ultrasound and those that were not visualized. The majority of patients in both groups were discharged home from the emergency department. While six bruises that presented prior to 2 days after the injury had no sonographic changes, no subcutaneous changes were visible on ultrasound when more than 2 days had elapsed between the time of injury and the ultrasound. There was no association between the area of the bruise visible on gross exam and the depth of the injury determined by ultrasound (Table 2). The height of the sonographic hematoma Table 1 Demographic information in patients with sonographically visualized and nonvisualized bruises.
Number Age (years) Gender (% male) Time since injury (hours) Cause of bruise (%fall/blunt trauma/vehicular collision) Not/minimally active since injury (%) Cutaneous area (cm2)
Visualized bruise Mean (range)
Non-visualized bruise Mean (range)
12 43.9 (11–76) 83 17 (3–48) 67/17/17
10 38.7 (1–95) 80 120.1 (3–717) 50/30/20
91
60
19 (2.4–56.5)
29.7 (4.7–75.4)
T. Helm et al. / Forensic Science International 266 (2016) 160–163
162
Table 2 Sonographically visualized bruises comparing cutaneous area with sonographic height and depth of hematoma. Body part
Mechanism
Cutaneous area (cm2)
Height of bruise (cm)
Depth from surface to bruise (cm)
Eye Arm Face Brow Brow Eye Eye Scalp Wrist Forehead Forehead Brow
Fall Fall Fall Direct blow Assault MVC Assault Fall Fall Fall Fall Fall
56.5 55 28.9 20.4 13.7 12.4 11.8 9.7 7.4 6.2 3.5 2.4
1.8 0.2 0.8 1.7 0.5 0.7 0.1 0.3 0.3 0.6 0.7 1.1
0.1 0.1 0.3 0.3 0.1 0.2 0.8 0.6 0.2 0.1 0.2 0.4
ranged from 0.1 to 1.8 cm, and the depth from the skin surface to the top of the hematoma ranged from 0.1 to 0.8 cm. When only the bruises with ultrasound findings were considered, the correlation between cutaneous area and height of bruise was .288 (Fig. 2). When all bruises 48 h or less from time of injury were considered, and non-visualized bruises were assumed to have a depth of zero, the correlation was .005 (Fig. 3). Table 2 shows the bruises in descending order of area with the height and depth of the bruise for the sonographically visualized hematomas. Figs. 2 and 3 demonstrate scatter plots of this relationship, clearly failing to show a linear relationship. Fig. 2 depicts all visible sonographic hematomas, while Fig. 3 looks at all cutaneous bruises incurred within 2 days of presentation, assuming a depth of zero for non-visualized acute bruises.
4. Discussion Ultrasound as a technique to identify and characterize bruises has been minimally studied; however, its use in evaluation of sports-related muscle injuries is increasing [6]. Focusing on muscle injuries, Draghi et al. described muscle hematomas visualized in more severe contusions with use of a high frequency probe. They noted both a hyper and hypoechoic appearance in the first 24 h followed by a hypo or anechoic appearance [7]. With a focus on child abuse, Mimasaka et al. looked at 8 healthy children with bruising as well as 10 adult post mortem cases and characterized the size and appearance of the bruises. They were able to determine both the subcutaneous depth of the bruise and thickness of the bruise itself with a 5–10 MHz probe, both of which may impact the cutaneous appearance [8]. This study corroborates these findings and begins to identify potential clinical features associated with sonographic visualization of bruises. Currently, there are limitations to the modalities which exist to document a bruise to forensic or law enforcement specialists. Many are simply photographed or described in the medical record, however, this is not helpful in determining mechanism or timing. While the location of bruises may be helpful in the determination of an abusive injury, the color of a bruise has been shown not reliable in ‘‘dating’’ the bruise [9,10]. Spectrophotometry may be useful for this purpose [11,12], but is not a technology that is often available to initial providers, nor does it provide insight into the mechanism of the bruise. This study demonstrates that the cutaneous area of a bruise correlates poorly with the subcutaneous depth, indicating that subcutaneous sonographic measurements may add to the forensic evaluation.
2 1.8 1.6
Height (cm)
1.4 1.2 1 0.8 0.6 0.4 0.2 0
0
10
20
30
40
50
60
Area (cm2) Fig. 2. Visualized bruises only.
2 1.8 1.6 Height (cm)
1.4 1.2 1 0.8 0.6 0.4 0.2 0
0
10
20
30
40 Area (cm2)
Fig. 3. All bruises under 48 h.
50
60
70
T. Helm et al. / Forensic Science International 266 (2016) 160–163
There are some limitations to this data set. We did not note any distinct hyperechoic portions of the sonographic bruises; however, subtle areas may have been missed. Sonographic resolution, while important for documentation, does not imply that a bruise is completely resolved, and lack of sonographic hematoma should not imply lack of pathology. The sample size, the reliance on patient history for timing, and the use of primarily adult patients limit the generalizability of this study to use in non-accidental trauma cases at this point. However, two outcomes are important to note. Firstly, the superficial area of the bruise is a poor marker of the extent of the injury below the skin, both the depth and the height of the hematoma. Further study is required to determine whether the mechanism of the bruise alters the sonographic depth and height; however, logically it seems plausible that the strike of an adult may cause a larger subcutaneous injury than that of another small child. Secondly, while the time from injury did not reach significance and individual patients were not followed for hematoma resolution, in this cohort, sonographic bruises were more often visualized if the patient presented within the 2 days following injury. In most cases of abuse, capturing an early ultrasound image would require the test to be performed by frontline providers. Point-of-care ultrasound is commonly used in emergency medicine and could prove a valuable and easy adjunct to the work-up of a patient with bruising of unclear etiology. 5. Conclusion The cutaneous size of bruises did not correlate with the subcutaneous depth or height of the contusion determined by ultrasound. Ultrasound may add additional information regarding the depth and subcutaneous size of bruises.
163
Acknowledgements Michael Menchine for his statistical consultation. Hope Velarde for her assistance with data collection and management. Kenji Inaba for his support and assistance with conception of the project.
References [1] American Humane Association. http://www.americanhumane.org/children/ stop-child-abuse/fact-sheets/child-abuse-and-neglect-statistics.html (accessed 12.18.15). [2] Children’s Bureau of the US Department of Health and Human Services. http://www. acf.hhs.gov/sites/default/files/cb/cm2012.pdf#page=16 (accessed 12.18.15). [3] E.L. Thorpe, N.S. Zuckerbraun, J.E. Wolford, R.P. Berger, Missed opportunities to diagnose child physical abuse, PEC 30 (11) (2014) 771–776. [4] L. Kos, T. Shwayder, Cutaneous manifestations of child abuse, Pediatr. Dermatol. 23 (2006) 311–320. [5] Stedman’s Medical Dictionary for the Health Professions and Nursing: Illustrated, fifth ed., Lippincott Williams & Wilkins, Philadelphia (PA), 2005. [6] J.C. Lee, A.W.M. Mitchell, J.C. Healy, Imaging of muscle injury in the elite athlete, BJR 85 (1016) (2012) 1173–1185. [7] F. Draghi, M. Zacchino, M. Canepari, P. Nucci, F. Alessandrino, Muscle injuries: ultrasound evaluation in the acute phase, J. Ultrasound 16 (2013) 209–214. [8] S. Mimasaka, T. Oshima, M. Ohtani, Characterization of bruises using ultrasonography for potential application in diagnosis of child abuse, Leg. Med. 14 (2012) 6–10. [9] S.E. Grossman, A. Johnston, P. Vanezis, D. Perrett, Can we assess the age of bruises? An attempt to develop an objective technique, Med. Sci. Law 51 (3) (2011) 170–176. [10] S. Maguire, M.K. Mann, J. Silbert, A. Kemp, Can you age bruises accurately in children? A systematic review, Arch. Dis. Child. 90 (2) (2005) 187–189. [11] V.K. Hughes, P.S. Ellis, T. Burt, N.E. Langlois, The practical application of reflectance spectrophotometry for the demonstration of haemoglobin and its degradation in bruises, J. Clin. Pathol. 57 (2004) 355–359. [12] S. Mimasaka, M. Ohtani, N. Kuroda, S. Tsunenari, Spectrophotometric evaluation of the age of bruises in children: measuring changes in bruise color as an indicator of child physical abuse, Tohoku J. Exp. Med. 220 (2010) 171–175.