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Bui JK, Naing P, Cathers PH, Ahmad M, Cohen B. Chest wall bruising from 5-point car seat harness as a mimicker of child abuse. Pediatr Dermatol 2024; 41:718-721. [PMID: 38500253 DOI: 10.1111/pde.15587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/24/2024] [Indexed: 03/20/2024]
Abstract
Bruising rarely presents in infants younger than 9 months who are not ambulatory and is more prevalent among children beginning to walk, or "cruisers." We present the case of a healthy 3-month-old infant with asymptomatic, symmetric, bilateral, large bruises on the bony chest sparing the mid-chest/sternum with a negative non-accidental trauma work-up. The noted pattern of bruises matched the bilateral shoulder straps of a 5-point harness of the car seat belt designed for infants. Awareness of this unique pattern of bruises will help elicit a better-informed history to guide care in an appropriate setting.
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Affiliation(s)
- Jordan K Bui
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Pyae Naing
- Sinai Hospital, Baltimore, Maryland, USA
| | - Phillip H Cathers
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | | | - Bernard Cohen
- Dermatology and Pediatrics, John Hopkins School of Medicine, Baltimore, Maryland, USA
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2
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Eg MB, Graesholt-Knudsen T, Madsen KB, Obel C, Charles AV, Ingemann-Hansen O. Distinct age-related differences among victims in cases of suspected child abuse. J Forensic Sci 2024; 69:252-263. [PMID: 37792506 DOI: 10.1111/1556-4029.15398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/10/2023] [Accepted: 09/20/2023] [Indexed: 10/06/2023]
Abstract
Evidence describing age-related differences among children with suspected physical and sexual child abuse is lacking. We describe findings in severe cases of suspected abuse. Cases with 756 children <15 years old were included during 2001-2013 at the Department of Forensic Medicine, Aarhus University, using forensic evaluation documents, medical records, and court proceedings. Eight percent of children <4 years old died from child abuse, 36% through violence resulting in death, and 64% by manslaughter, whereas 1% > 4 years old died, solely by manslaughter. External injuries were mainly located to head and torso in children <4 years old, changing to the upper and lower extremities in older children. Child sexual abuse was suspected in 52% of cases with living children <4 years old, 83% of children 4-7 years of age, 88% of children 8-11 years of age, and 93% of children >12 years old. Anogenital findings were mainly caused by other medical conditions in children <4 years old, hymenal clefts in the superior half of the hymenal rim were almost exclusively found in children between 8 and 11 years of age, whereas both superficial and complete hymenal clefts in the inferior half of the hymenal rim were found in children >12 years old. The present study describes age-related differences in victims of suspected child abuse. Fatal versus nonfatal child physical abuse and the significance of hymenal findings in child sexual abuse could be studied further.
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Affiliation(s)
- Marlene Beyer Eg
- Department of Forensic Medicine, Aarhus University, Aarhus N, Denmark
| | | | - Kathrine Bang Madsen
- National Centre for Register-based Research, Department of Economics and Business Economics, Aarhus BSS, Aarhus University, Aarhus V, Denmark
| | - Carsten Obel
- Department of Public Health, Aarhus University, Aarhus C, Denmark
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Bentivegna K, Grant-Kels JM, Livingston N. Cutaneous Manifestations of Child Abuse & Neglect: Part I. J Am Acad Dermatol 2022; 87:503-516. [PMID: 35339586 DOI: 10.1016/j.jaad.2021.11.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 11/15/2022]
Abstract
Child abuse and neglect remains a significant cause of morbidity and mortality in children. Dermatologists may not fully conceptualize their crucial role in the evaluation of child abuse and neglect as both mandated reporters and experts in skin pathology. This CME summarizes the current information on cutaneous signs and clinical simulants of abuse for dermatologists so that dermatologists gain more insight into the skin examination for child abuse and neglect, develop confidence in their ability to distinguish dermatologic signs of accidental versus inflicted trauma, and more frequently consider abuse and neglect in their differential diagnosis.
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Affiliation(s)
| | - Jane M Grant-Kels
- Department of Dermatology, UConn Health, Farmington, CT; Department of Dermatology, University of Florida, Gainesville, FL
| | - Nina Livingston
- Department of Pediatrics, University of Connecticut School of Medicine, Connecticut Children's Medical Center Hartford, CT
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Abstract
ABSTRACT Bruising is the most common presentation of child physical abuse. Many patterns of abusive bruising result in positive or negative imprints of the implement used (eg, fingertips in "grab mark" contusions or hand in slap injury). However, bruising may also form along the lines of greatest anatomical stress (eg, gluteal cleft or pinna bruising). Bruising due to abusive squeezing also forms along lines of greatest anatomical stress, resulting in a negative imprint of the flexural folds of the hand. Four cases of children with this unique pattern of bruising due to abusive squeezing are presented. Recognition of these bruises as inflicted represents an opportunity for early identification and intervention in cases of child physical abuse.
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Affiliation(s)
| | - Lori D Frasier
- Penn State Milton S. Hershey Children's Hospital, Hershey, PA
| | - Nina Livingston
- University of Connecticut School of Medicine, Connecticut Children's Medical Center, Hartford, CT
| | - Rebecca Moles
- University of Connecticut School of Medicine, Connecticut Children's Medical Center, Hartford, CT
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5
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Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Netw Open 2021; 4:e215832. [PMID: 33852003 PMCID: PMC8047759 DOI: 10.1001/jamanetworkopen.2021.5832] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. OBJECTIVE To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. DESIGN, SETTING, AND PARTICIPANTS This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. EXPOSURES Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. MAIN OUTCOMES AND MEASURES Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. RESULTS A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). CONCLUSIONS AND RELEVANCE In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.
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Affiliation(s)
- Mary Clyde Pierce
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kim Kaczor
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Douglas J. Lorenz
- Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky
| | - Gina Bertocci
- Department of Bioengineering, J.B. Speed School of Engineering, University of Louisville, Louisville, Kentucky
| | - Amanda K. Fingarson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kathi Makoroff
- Mayerson Center for Safe and Healthy Children, Cincinnati Children’s Hospital, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rachel P. Berger
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Berkeley Bennett
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, The Ohio State University, Nationwide Children’s Hospital, Columbus
| | - Julia Magana
- Department of Pediatrics, University of California San Diego School of Medicine, La Jolla
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento
| | - Shannon Staley
- Department of Pediatrics, University of Chicago, Chicago, Illinois
- Division of Pediatric Emergency Medicine, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Veena Ramaiah
- Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Kristine Fortin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Division of General Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Melissa Currie
- Norton Children’s Pediatric Protection Specialists Affiliated with the University of Louisville School of Medicine, Louisville, Kentucky
| | - Bruce E. Herman
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Sandra Herr
- Division of Pediatric Emergency Medicine, University of Louisville, Louisville, Kentucky
| | - Kent P. Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | - Carole Jenny
- Department of Pediatrics, University of Washington, Seattle Children’s Hospital, Seattle
| | - Karen Sheehan
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Noel Zuckerbraun
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sheila Hickey
- Department of Social Work, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Gabriel Meyers
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - John M. Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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6
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On the relationships between applied force, photography technique, and the quantification of bruise appearance. Forensic Sci Int 2019; 305:109998. [DOI: 10.1016/j.forsciint.2019.109998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/20/2019] [Accepted: 10/16/2019] [Indexed: 11/18/2022]
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Trefan L, Harris C, Evans S, Nuttall D, Maguire S, Kemp AM. A comparison of four different imaging modalities - Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising. J Forensic Leg Med 2018; 59:30-35. [PMID: 30096460 PMCID: PMC6125673 DOI: 10.1016/j.jflm.2018.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/23/2018] [Accepted: 07/31/2018] [Indexed: 01/24/2023]
Abstract
Background It is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images. Methods Children aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a ‘plug in’ of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05. Results Twenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality. Conclusions Conventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually. Diffuse bruises may be measured on conventional & cross polarized imaging. Infrared or ultraviolet imaging may not show bruises which are difficult to see in vivo. Measurements of bruises using infrared imaging may be smaller than other modalities.
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Affiliation(s)
- L Trefan
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - C Harris
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - S Evans
- Chief Clinical Photographer, Dental Photography, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK.
| | - D Nuttall
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - S Maguire
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - A M Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
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8
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Harris C, Alcock A, Trefan L, Nuttall D, Evans ST, Maguire S, Kemp AM. Optimising the measurement of bruises in children across conventional and cross polarized images using segmentation analysis techniques in Image J, Photoshop and circle diameter measurements. J Forensic Leg Med 2018; 54:114-120. [PMID: 29413952 DOI: 10.1016/j.jflm.2017.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 08/25/2017] [Accepted: 12/31/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bruising is a common abusive injury in children, and it is standard practice to image and measure them, yet there is no current standard for measuring bruise size consistently. We aim to identify the optimal method of measuring photographic images of bruises, including computerised measurement techniques. METHODS 24 children aged <11 years (mean age of 6.9, range 2.5-10 years) with a bruise were recruited from the community. Demographics and bruise details were recorded. Each bruise was measured in vivo using a paper measuring tape. Standardised conventional and cross polarized digital images were obtained. The diameter of bruise images were measured by three computer aided measurement techniques: Image J (segmentation with Simple Interactive Object Extraction (maximum Feret diameter), 'Circular Selection Tool' (Circle diameter), & the Photoshop 'ruler' software (Photoshop diameter)). Inter and intra-observer effects were determined by two individuals repeating 11 electronic measurements, and relevant Intraclass Correlation Coefficient's (ICC's) were used to establish reliability. Spearman's rank correlation was used to compare in vivo with computerised measurements; a comparison of measurement techniques across imaging modalities was conducted using Kolmogorov-Smirnov tests. Significance was set at p < 0.05 for all tests. RESULTS Images were available for 38 bruises in vivo, with 48 bruises visible on cross polarized imaging and 46 on conventional imaging (some bruises interpreted as being single in vivo appeared to be multiple in digital images). Correlation coefficients were >0.5 for all techniques, with maximum Feret diameter and maximum Photoshop diameter on conventional images having the strongest correlation with in vivo measurements. There were significant differences between in vivo and computer-aided measurements, but none between different computer-aided measurement techniques. Overall, computer aided measurements appeared larger than in vivo. Inter- and intra-observer agreement was high for all maximum diameter measurements (ICC's > 0.7). CONCLUSIONS Whilst there are minimal differences between measurements of images obtained, the most consistent results were obtained when conventional images, segmented by Image J Software, were measured with a Feret diameter. This is therefore proposed as a standard for future research, and forensic practice, with the proviso that all computer aided measurements appear larger than in vivo.
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Affiliation(s)
- C Harris
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK.
| | - A Alcock
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK.
| | - L Trefan
- School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, UK.
| | - D Nuttall
- School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, UK.
| | - S T Evans
- Dental Photography, School of Dentistry, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, UK.
| | - S Maguire
- School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, UK; Division of Population Medicine, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff CF14 4YS, UK.
| | - A M Kemp
- Division of Population Medicine, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff CF14 4YS, UK.
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Validation of alternate light sources for detection of bruises in non-embalmed and embalmed cadavers. Forensic Sci Med Pathol 2016; 13:28-33. [PMID: 28019003 DOI: 10.1007/s12024-016-9822-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 10/20/2022]
Abstract
Bruising is frequently documented in cases of violence for use as forensic evidence. However, bruises can be overlooked if they are not visible to the naked eye. Alternate light sources such as ultraviolet, narrow band, and infrared have been used in an attempt to reveal the presence of bruising that is not otherwise apparent. However, there is a significant gap in knowledge surrounding this technique as it has not been validated against histology to confirm that bruising is genuinely being enhanced. A recent study evaluated the ability of alternate light sources to enhance visibility of bruises using a pigskin model. However, histological confirmation of bruising in humans using these light sources has not yet been performed. In this study, embalmed and non-embalmed human cadavers were used. Bodies were surveyed with alternate light sources, and enhanced regions that were unapparent under white light were photographed with the alternate light sources and sampled for histological assessment. Immunohistochemical staining for the red blood cell surface protein glycophorin was used determine if the enhanced area was a bruise (defined by the presence of extravasated erythrocytes). Photographs of areas confirmed to be bruises were analyzed using the program Fiji to measure enhancement, which was defined as an increase in the measured transverse diameter. In the non-embalmed and the embalmed cadavers violet alternate light produced the greatest enhancement of histologically confirmed bruises, followed by blue (both p < 0.0001). Regions that were not confirmed as bruises also enhanced, indicating that light sources may not be specific. This suggests that the use of light sources to enhance the visibility of bruising should be undertaken with caution and further studies are required.
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10
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Impact sites representing potential bruising locations associated with rearward falls in children. Forensic Sci Int 2016; 261:129-36. [DOI: 10.1016/j.forsciint.2016.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/06/2015] [Accepted: 02/07/2016] [Indexed: 11/22/2022]
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11
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How useful are ultraviolet, infrared, and narrow band light sources for enhancing occult bruises in cases of assault? Forensic Sci Med Pathol 2016; 12:209-10. [PMID: 26945745 DOI: 10.1007/s12024-016-9756-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2016] [Indexed: 10/22/2022]
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12
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The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med 2015; 67:1-8. [PMID: 26233923 DOI: 10.1016/j.annemergmed.2015.06.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 06/02/2015] [Accepted: 06/18/2015] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Bruising can indicate abuse for infants. Bruise prevalence among infants in the pediatric emergency department (ED) setting is unknown. Our objective is to determine prevalence of bruising, associated chief complaints, and frequency of abuse evaluations in previously healthy infants presenting to pediatric EDs. METHODS We conducted a prospective, observational, multicenter study of infants aged 12 months or younger presenting to pediatric EDs. Structured sampling was used. Pediatric emergency medicine clinicians performed complete skin examinations to screen for bruising. Study investigators documented skin findings, date of visit, patient's age, chief complaint, and abuse evaluation. The primary outcome was prevalence of bruising. Secondary outcomes were prevalence of bruising based on chief complaint and frequency of abuse evaluation. Point estimates of bruise prevalence and differences in bruise prevalence between patient subgroups were calculated with 95% confidence intervals (CIs). RESULTS Bruising was identified in 88 of 2,488 infants (3.5%; 95% CI 2.9% to 4.4%). Rates of bruising for infants 5 months and younger and older than 5 months were 1.3% and 6.4%, respectively (difference 5.1%; 95% CI 3.6% to 6.8%). For infants 5 months and younger, 83% of bruising was associated with a trauma chief complaint and only 0.2% of infants presenting with a medical chief complaint had bruising. Pediatric emergency medicine clinicians obtained abuse evaluations on 23% of infants with bruising, and that rate increased to 50% for infants 5 months and younger. CONCLUSION Bruising prevalence in children 12 months and younger who were evaluated in pediatric EDs was low, increased within age strata, and was most often associated with a trauma chief complaint. Most bruised infants did not undergo an abuse evaluation.
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13
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Garcia JE, Wilksch PA, Spring G, Philp P, Dyer A. Characterization of Digital Cameras for Reflected Ultraviolet Photography; Implications for Qualitative and Quantitative Image Analysis During Forensic Examination. J Forensic Sci 2013; 59:117-22. [DOI: 10.1111/1556-4029.12274] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 10/12/2012] [Accepted: 10/24/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Jair E. Garcia
- School of Applied Sciences; RMIT University; Building 3 Level 1 Bowen Lane Melbourne Vic. 3001 Australia
| | - Philip A. Wilksch
- School of Applied Sciences; RMIT University; Building 3 Level 1 Bowen Lane Melbourne Vic. 3001 Australia
| | - Gale Spring
- School of Applied Sciences; RMIT University; Building 3 Level 1 Bowen Lane Melbourne Vic. 3001 Australia
| | - Peta Philp
- Deparment of Clinical Photography; Austin Health; 145 Studley Road PO Box 555 Heidelberg Vic. 3084 Australia
| | - Adrian Dyer
- School of Media and Communication; RMIT University; 124 La Trobe Street Melbourne Vic. 3000 Australia
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Lecomte MMJ, Holmes T, Kay DP, Simons JL, Vintiner SK. The use of photographs to record variation in bruising response in humans. Forensic Sci Int 2013; 231:213-8. [PMID: 23890640 DOI: 10.1016/j.forsciint.2013.04.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 04/24/2013] [Accepted: 04/25/2013] [Indexed: 10/26/2022]
Abstract
There is considerable value in developing tools capable of accurately and reliably determining when bruises were inflicted in humans. Previous work has focused on the visual changes observed in a bruise as the injury develops and heals. However, due to variables such as how and where on the body the bruise was inflicted, differing tissue compositions at the injured skin site between individuals and inter- and intra-observer variation; a technique sufficiently robust for use in a clinical or medicolegal setting has not yet been identified. In this study we present a series of photographs taken under controlled conditions illustrating standardised bruises induced on participants using a weight dropping mechanism. We show that variation in the appearance of bruises over time across individuals is large and, although photography may be a suitable technique for the recording of injuries, it is not sufficiently reliable for determining the age of a bruise.
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Affiliation(s)
- Marie M J Lecomte
- The Institute of Environmental Science & Research Ltd (ESR) - Mt Albert Science Centre, Auckland, New Zealand.
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15
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Langlois NEI, Ross CG, Byard RW. Magnetic resonance imaging (MRI) of bruises: a pilot study. Forensic Sci Med Pathol 2013; 9:363-6. [PMID: 23760862 DOI: 10.1007/s12024-013-9456-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2013] [Indexed: 10/26/2022]
Abstract
The purpose of this study was to investigate if magnetic resonance imaging (MRI) could be used to image the presence of hemosiderin in bruises and if there was the potential for this technique to be applied as a non-invasive method to estimate the age of bruises. To achieve this aim an animal model to produce lesions resembling bruises was created by injecting blood obtained from the tail vein subcutaneously into an area of the abdominal wall. The animals were euthanized at 3, 6, 12 h, 1, 2, 3, 5, and 7 days post injection and the skin of the abdominal wall was excised for MRI scanning and histological examination. The injected blood appeared as hypointense (dark) areas on the T2* MRI at 3 and 6 h. The image of the injected areas became indistinct at 12 h and continued to be indistinct at 1 and 2 days, although there appeared to be transitioning from hypointensity to hyperintensity (light). The magnetic resonance image appeared to better correspond to the histological appearance at 3 and 5 days, with the "bruise" appearing hyperintense (white); however, some hypointense (darker) areas at 3 day possibly corresponded to the development of hemosiderin. At 7 day the injected blood had been converted to hemosiderin with possible correlation between areas of blue staining in Perls' stained histologic sections and areas of extreme hypointensity in the T2* magnetic resonance image. This study has shown that a series of changes occur on MRI of bruises in an animal model that may relate to histological changes. Although variability in the intensity of the MRI signal and considerable soft tissue artifact currently make interpretations difficult, this may be a technique worth pursuing in the non-invasive evaluation of bruises.
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Affiliation(s)
- Neil E I Langlois
- The University of Adelaide School of Medical Sciences, Frome Road, Adelaide, SA, 5005, Australia.
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16
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Bruises, Burns, and Other Blemishes: Diagnostic Considerations of Physical Abuse. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Stam B, Gemert MJCV, Leeuwen TGV, Aalders MCG. How the blood pool properties at onset affect the temporal behavior of simulated bruises. Med Biol Eng Comput 2012; 50:165-71. [PMID: 22261914 PMCID: PMC3272227 DOI: 10.1007/s11517-012-0860-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 01/05/2012] [Indexed: 11/27/2022]
Abstract
The influence of initial blood pool properties on the temporal behavior of bruises is currently unknown. We addressed this important issue by utilizing three typical classes of bruises in our three-layered finite compartment model. We simulated the effects of their initial shapes, regularity of boundaries and initial blood concentration distributions (gaussian vs. homogeneous) on the hemoglobin and bilirubin areas in the dermal top layer. Age determination of bruises with gaussian hemoglobin concentration was also addressed. We found that the initial blood pool properties strongly affect bruise behavior. We determined the age of a 200-h simulated bruise with gaussian hemoglobin concentration with 3 h uncertainty. In conclusion, bruise behavior depends non-intuitively on the initial blood pool properties; hence, a model that includes shape, area and concentration distribution at onset is indispensable. Future age determination, including inhomogeneous hemoglobin distributions, will likely be based on the presented method for gaussian distributions.
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Affiliation(s)
- Barbara Stam
- Biomedical Engineering and Physics, Academic Medical Centre, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands.
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Stam B, van Gemert MJC, van Leeuwen TG, Teeuw AH, van der Wal AC, Aalders MCG. Can color inhomogeneity of bruises be used to establish their age? JOURNAL OF BIOPHOTONICS 2011; 4:759-67. [PMID: 21595043 DOI: 10.1002/jbio.201100021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 04/29/2011] [Accepted: 05/07/2011] [Indexed: 05/11/2023]
Abstract
Bruises become spatially inhomogeneous during the healing process; a smaller red-blue core area, caused by hemoglobin, is surrounded by a larger yellow area, caused by bilirubin, which is enzymatically formed from hemoglobin. These two areas develop at different rates and hence carry information about the age of the bruise. We present a proof of principle demonstration that the age of bruises can be determined via an inverse procedure using a mathematical model and daily measurements of these two areas using a hyperspectral imaging system. The inaccuracy found is 2.3% for fresh bruises and 3 to 24% for bruises up to 3 days old. In conclusion, color inhomogeneity of bruises can be used to determine their age. We expect that future age determination of bruises by the inverse procedure described here, possibly also including the distribution of concentrations in the areas will open up a new phase in clinical bruise classification.
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Affiliation(s)
- Barbara Stam
- Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Lawson Z, Nuttall D, Young S, Evans S, Maguire S, Dunstan F, Kemp AM. Which is the preferred image modality for paediatricians when assessing photographs of bruises in children? Int J Legal Med 2010; 125:825-30. [DOI: 10.1007/s00414-010-0532-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 11/08/2010] [Indexed: 10/18/2022]
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Jayakumar P, Barry M, Ramachandran M. Orthopaedic aspects of paediatric non-accidental injury. ACTA ACUST UNITED AC 2010; 92:189-95. [PMID: 20130307 DOI: 10.1302/0301-620x.92b2.22923] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures. Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death. Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.
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Affiliation(s)
- P. Jayakumar
- The Royal London Hospital, Whitechapel Road, Whitechapel, London E1 1BB, UK
| | - M. Barry
- The Royal London Hospital, Whitechapel Road, Whitechapel, London E1 1BB, UK
| | - M. Ramachandran
- The Royal London Hospital, Whitechapel Road, Whitechapel, London E1 1BB, UK
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Cavalcanti AL. Prevalence and characteristics of injuries to the head and orofacial region in physically abused children and adolescents--a retrospective study in a city of the Northeast of Brazil. Dent Traumatol 2010; 26:149-53. [PMID: 20070347 DOI: 10.1111/j.1600-9657.2009.00859.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to evaluate the prevalence and characteristics of injuries to the head and orofacial region in physically abused children and adolescents from a city of the Northeast of Brazil, based on the review of forensic medical reports. This retrospective study was undertaken by the analysis of expert medical reports derived from medical forensic exams performed at the Department of Forensic Medicine of the city of Campina Grande, PB, Brazil, between January 2003 and December 2006. From a universe of 11 624 reports issued in this time span, the study sample consisted of 1070 reports referring to children and adolescents aged 0-17 years that were confirmedly victims of physical abuse. Male children (52.8%) in the 13- to 17-year-old range (72.4%) were the most frequent victims, with an association between gender and age group (P = 0.039). Most children (58.2%) presented a single type of injury, with a statistically significant association between number of injuries and gender (P = 0.040), but no significant association between number of injuries and age (P = 0.163). The percentage of victims injured in the head and face corresponded to 56.3%, with a statistically significant association between the presence of injury in the head and face and gender (P = 0.046). As much as 12.4% of the children and adolescents presented intraoral injuries, with no significant difference between genders (P = 0.543). However, a statistically significant association was observed between the number of existing injuries and the presence of oral injuries (P = 0.005). The maxilla was predominantly affected (55.6%), most injuries (94.8%) being soft-tissue lacerations located mainly in the upper lip (46.4%). The findings of this survey revealed a high prevalence of injuries to the head and orofacial region of physically abused children and adolescents.
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Affiliation(s)
- Alessandro Leite Cavalcanti
- Department of Pediatric Dentistry, School of Dentistry, State University of Paraíba, Campina Grande, PB, Brazil.
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Abstract
Bruising in the young infant is rare, and if present, this may be a manifestation of physical child abuse. Early signs of abuse, such as bruising, are often overlooked or their significance goes unrecognized resulting in poor patient outcomes. In such cases, the opportunity to intervene and potentially prevent repeat injury is lost, and the child is placed back in harm's way. This brief report presents 3 cases of nonmobile infants who presented to health care providers with bruising before a subsequent fatal or near-fatal event. These cases emphasize the importance of including abusive trauma in the differential diagnosis of an infant with a bruise or a history of easy bruising and the importance of initiating a thorough trauma evaluation immediately and concomitantly with any other workup for the causes of bruising in the noncruising infant.
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Abstract
Infants with the chief complaint of crying can present a diagnostic dilemma to the health care provider. This article discusses the differential diagnosis and management of the crying infant.
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Affiliation(s)
- Martin Herman
- University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN 38103, USA.
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