Physical abuse: clinical detection and imaging of contusions in suspected.
Contusions (Physiological aspects)
Bertolli, Eugene R.
Brown, Clifford D.
Pannone, Dominic R.
Bartles, Thaddeus W.
|Publication:||Name: The Forensic Examiner Publisher: American College of Forensic Examiners Audience: Professional Format: Magazine/Journal Subject: Health; Law; Science and technology Copyright: COPYRIGHT 2011 American College of Forensic Examiners ISSN: 1084-5569|
|Issue:||Date: Winter, 2011 Source Volume: 20 Source Issue: 3|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Abuse is an issue that all healthcare practitioners must be aware of. Observation is one of the skills the practitioner must have. When abuse is reported or suspected, and contusions may be present, documentation is essential. The practitioner should be familiar with bruising, causes of bruising including non abuse, if lesions are consistent with the patient/patients representative's story(ies), reporting protocols, and available imaging techniques. This work provides a brief review of the basic information, and explores fairly inexpensive methods of imaging contusions. The techniques include the use of infrared digital imaging through cosmetic cover, visible digital imaging, imaging under the Wood's lamp, imaging with 390 peak nanometer torch with and without yellow filter, and image enhancement via digital contrast manipulation. Of the ultraviolet techniques, the authors found the 390 namometer illumination coupled with the yellow filter provided more distinct imaging than the 365 peak nanometer Wood's lamp.
Many states have mandatory reporting laws (State Statutes Search). The following are excerpts of the law for the State of Connecticut as an example: Sections 17a-101 through 17a-103a, inclusive of the Connecticut General Statutes, "Connecticut law requires certain citizens to report suspected child abuse and neglect. These mandated reporters are people in professions or occupations that have contact with children or whose primary focus is children." "The law requires that they report suspected child abuse or neglect." "Reporters must report orally to the Department of Children and Families' (DCF) Hotline or a law enforcement agency within 12 hours of suspecting that a child has been abused or neglected and must submit a written report (DCF-136 form) to DCF within 48 hours of making the oral report. DCF is required to tape record all reports to the Hotline." (Department of Children and Families)
Clinical manifestations of abuse may include many systems. The healthcare practitioner may encounter signs of trauma (which may be associated with abuse), such as ocular based: (Portable Guides) hyphema, orbital fracture, blow out fracture, entrapment, purtchers, shaken impact injury (formerly referred to as shaken baby syndrome) (Morad, et al., 2002), traumatic brain injury (TBI), and cutaneous contusions of the face, arms, and neck (areas typically exposed during an exam). Other findings include: oral injuries (broken teeth, torn frenulum) (Kellogg 2005, Naidoo 2000), scalp and facial injuries, fractures of the maxilla and mandibula, scalds, burns, cigarette burns, ligature marks, and more (Barriere 2008).
SUSPICIOUS PATTERNS OF CONTUSIONS VS. TYPICAL NON-SUSPICIOUS CONTUSIONS
According to the Welsh Child Protection Systematic Review Group, bruises may be suspicious, especially in a non-mobile individual such as a baby or invalid. Once the individual/child becomes mobile, accidental bruising becomes more common (Welsch Child Protection 2009; Sugar, Taylor, and Feldman 1999). Non-accidental bruising is more common to the head, flesh not covering any bony protuberances, and on the face, back, buttocks, abdomen, arms, ears and hands. Ninety percent of abused children exhibit bruising (World Health Organization 2004). A pattern bruise, for instance, made by a coat hangar, cord, belt, spoon, etc, or multiple bruises similar in shape and size is suspect. Petechiae are more common in abuse than in accidental origin (Nayak, et al., 2006). Marks from gripping, pinching, slapping, biting, or finger imprinting (around throat) are more often than not associated with abuse, as are the simultaneous appearance of old and new bruising along and with other injuries (Merck Manual). Suspicions should be raised when the patient or the caregiver has no explanation for the injury, the details of the injury change, the explanation is not consistent with the injury, the explanation is not consistent with the level of development of the patient, or different witnesses provide differing accounts (Kellogg 2005).
The clinician should be cognizant of the entities, such as platelet disorders, coagulation disorders, or defects in blood vessels, which promote an increase in bleed times, and the potential increased ease of bruising (Excessive Bleeding). If the area of bruising is out of proportion to the injury, such possibilities should be considered. These may include vitamin K (Medline Plus) and vitamin C (Medline Plus) deficiency, leukemia (Acute Leukemia 2008), von Willebrand disease (Von Willebrand), Marfan syndrome and connective tissue disorders (Ehlers-Danlos Syndrome 2008), Henoch-Schlonlein purpura (Henoch-Schonlein), hemophilia (Hemophilia 2006), cirrhosis (Cirrhosis 2007), hepatitis, liver failure, (Liver Failure), bone marrow disorders, and qualitative platelet disorder (Low Platelet Count). Pharmaceutical etiolology include aspirin, non steroidal anti inflammatories (NSAIDS), platelet inhi bition medicines such as Plavix (clopidogal), coagulopathy (Coumadin), and cortico steroids (Ballas and Kraut 2008). Senile purpura occurs with fragility of the capillaries (Senile Purpura 2009). O'Hare and Eden, 1984, suggest that, "non-accidental injury and bleeding disorders are in no way mutually exclusive." (O'Hare and Eden 1984) If found, bleeding disorders must be addressed, if abuse is found, that situation must be addressed.
Bruise mechanics/chromophores--Blunt force trauma (BFT) damages blood vessel/ capillary walls in the epidermis, dermis or subcutaneous tissues, allowing blood to escape from the vessels into the surrounding tissues (The skin depth varies on different areas of the body (Moore, Lunt, McManus, Andersen, and Herrick 2003). This is a bruise or contusion. The blood appears reddish close to the skin surface, yet appears blue deeper in the tissues due to Rayleigh scattering (Bohnert, Baumgarmer, and Pollak S 2000). Initial redness is from the erythrocytes, and from vessel dilation with the associated inflammatory process. As the red erythrocytes and hemoglobin are degraded into the biliverdin chromophore, a greenish hue develops. Further degradation to bilirubin shifts to yellow/orange (Freeman & Co. 2003). Further changes in color are to brown with the increase in hemosiderin. The age of a bruise may be compared to another bruise, but studies reveal that the accurate assignment of age to bruises is not possible at this time (Nash 2009). Typical color changes progress from a range of red to blue; then green, to yellow to brown.
DETECTION AND IMAGING OF CONTUSIONS
A subclinical bruise detected via infrared or UV may be new or old--the area should be inspected over time, with careful documentation made of the size, location, patterns, and changes as they occur. It is reported that an old bruise may be made apparent via alternative imaging for months post trauma. (Vogeley and Pierce 2002)
Robert Wood, who developed the Wood's Lamp and Wood's Glass, was the first to image ultraviolet and infrared with emulsion photography, exploring invisible radiation photography (Abrahams and Wood). There are portions of the spectrum existing adjacent to the visible spectrum, above and below, particularly those with wavelengths in the near infrared and near ultraviolet, which emit photons the human eye cannot detect without artificial means. The human range of vision typically runs from 400 nanometers to 700 nm (Merriam Webster). Filters and digital imaging allow the human eye to detect emission from these sources of invisible radiation, and effectively expand the viewing range, therefore, allowing the visual detection of otherwise unnoticed formations (Peca Scientific).
The Wood lamp emissions do overlap into the visible spectrum, as do some UV "forensic" lamps. The Wood's, with a peak wavelength of 365, emits over the range of 320-400 nanometers (Gupta and Singhi 2004). When imaging true UV, a digital camera equipped to image said spectra might employ a visible blocking filter, allowing exposure of only true UV to the camera sensor (Schneider 2006). Lights and filters have a peak wavelength, yet allow percentages of adjacent wavelengths to pass. Some allow a wide range of wavelengths, and some rather narrow. Wavelength emissions specifics (lamps) and wavelength passage specifics (filters) are often available from the manufacturer or supplier (Peca Filter, LED Museum, and Arrowhead Forensics).
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ENHANCING VISIBILITY OF SUBCLINICAL AND CLINICAL BRUISING
Infrared wavelengths penetrate deeper into the skin than ultraviolet wavelengths (Anderson and Parrish 1981). The authors' experience demonstrates that a bruise covered with makeup is better viewed with infrared imaging. Titanium dioxide and zinc oxide are ingredients often found in cosmetics (FDA VCRP). These compounds do attenuate the transmission of UVB and UVA. UVA encompasses the emission of the Wood's lamp and a 390nm light source. A digital camera that is infrared capable is more convenient than a film camera and infrared emulsion photography (DeBroux, McCarl, Shimamoto, and Brooks 2009). The digital infrared camera may be equipped with "live view," where the image sensor provides a real time view of the subject (Gupta and Singhi 2004 Fujifilm 2006). The Olympus IR camera used allows live view, so the image may be viewed through the video screen, allowing a view before exposing the shot. Without the live view, the infrared image would not be visible in the Single Lens Reflex (SLR) camera viewfinder. Once the exposure is made, the recorded digital image may be transferred, for instance, to a computer, and viewed in the larger format often needed to locate bruising. Initial inspection of the exposure may be reviewed in the digital camera's display screen.
The Wood's lamp has been useful not only in fluorescence of fluorescein for ocular surface inspection, but additionally for examination of numerous dermatological conditions and medical applications (Gupta and Singhi 2004). Visible digital photography coupled with ultraviolet wavelength illumination is described in (Vogeley and Pierce 2002). A Wood's lamp is used to reveal and/or enhance viewing of subclinical and visible bruises with the naked eye. A digital image of the subject area illuminated by the Wood's lamp may be transferred to a computer, and enhanced by manipulating the image contrast, typically by 30-40% to better view the area of interest.
Digital images were procured of the area in question prior to trauma as seen in Image #1. Figure 82 was captured immediately after the trauma, induced by several strikes by a rod. Figure #3 was captured under Wood's Lamp illumination, and Figure #4 is a digitally enhanced version of Figure #2. Three hours post trauma, Image #5 was captured, revealing decreased erythema. The tramline contusions are less apparent. Image #6 was captured under Wood's Lamp illumination, and Image #7 is the digitally enhanced version of Image #6, with greater contrast of the tramline markings.
The authors found that bruises are more apparent when illuminated by an ultraviolet light and viewed through yellow filter goggles (The authors found that a LED UV lamp, peak wavelength of 390nm, appears to provide a stronger beam compared to the performance of 3 different Wood's lamps, peak emission at 365nm, for direct viewing and imaging of subclinical and apparent bruising). The longer wavelength in theory should penetrate the skin deeper than the Wood's lamp. This method appears to be clinically efficient for screening and digital imaging. Therefore illuminating the area in question with a 390 nanometer LED lamp coupled with applying a yellow (blue-free) barrier filter to the camera lens provides a prominent appearance of a bruise if present. Figure #8 was captured under 390 nanometer Light Emitting Diode lamp, coupled with the yellow camera lens filter. No digital enhancements were made of the image. The superficial tramline bruises are apparent, and the deeper underlying roundish bruise is as well.
Makeup was applied over the area of question and captured in Image #10, and Image #9 is of the bruise area prior to cosmetic cover. Neither the tramline nor the deeper bruise are apparent under visible or Wood's Lamp illumination (see Image #11). Image #12 is the area illuminated with infrared light (720 nanometers) and imaged by an infrared-capable digital camera. The deeper roundish bruise is apparent under infrared imaging. Image #13 is of a second bruise, visible imaging. Image #14 is of the bruise with cosmetic cover. The cosmetic covered area is imaged with infrared in Image #15 revealing the underlying bruise, and then enhanced with approximately 40% increase in contrast seen in Image #16. (Infrared digital imaging reveals bruises covered with makeup when utilizing the "live view" camera feature or digital imaging.)
Figure #17 is the contusion area image via Optical Coherence Tomography as an example of other imaging technology (The OCT used for this image is designed for ocular use, where dermal OCT imaging would require a unit capable of deeper tissue penetration). Optical Coherence Tomography has successfully demonstrated intra-dermal imaging of tattoos (Todorovic et al., 2008), burns (Morsy, Mogensen, Thrane and Jemec 2007), and other cutaneous manifestations.
In summary, a 390 nanometer LED lamp coupled with yellow filter goggles allows sub clinical bruise and enhanced clinical bruise viewing. The same 390nm light source with a yellow camera lens filter allows digital imaging, typically not requiring digital enhancement to reveal the contusion. The 390nm light source with the yellow filter appears superior to the Wood lamp technique, and superior to the Wood's lamp technique with digital image enhancement. Infrared imaging allows deeper bruises to be viewed, either through the camera video screen or from digital photographs. Additionally, infrared imaging allows viewing of bruising through applied makeup. The Wood's Lamp is useful for viewing non-clinical bruising, and in enhancing visible bruising, but is not as sensitive as the 390 nm light source coupled with the yellow filter. The authors would recommend that it would be desirable to have available a 390nm torch/yellow filter goggle combination for direct viewing and yellow camera filter for digital imaging/documentation of contusions, apparent and subclinical. Additionally, an infrared digital camera would provide useful for situations of detection and documentation of bruising beneath cosmetic cover.
REVIEW of ABUSE
The CAPTA (Child Abuse Prevention Treatment Act) defines child abuse as "Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm" ("Child Welfare" 2007)
According To the NCANDS (National Child Abuse and Neglect Data System):
* In the year 2007, there were 294,000 child abuse cases reported, of which 10:8% involved physical harm.
* Of the victims, slightly more than half were female. Ethnicity was reported as 46.1% Caucasian, 21.7% African-American, and 20.8% Hispanic.
* Professionals reported 57.7% of the cases. ("National Child Abuse" 2007)
* Abuse is not limited to children. Elder abuse and intimate partner abuse is another area of concern. (CDC 2006, CDC 2009, CDC 2003)
* A study (Forensic Nursing vol. 5) included information regarding injuries of non-accidental childhood fatalities, grouped by age. Cutaneous contusions, mostly including the areas of head, face, mouth, and also commonly the buttocks and upper arms were common for the listed groups.
CERTIFIED MEDICAL INVESTIGATOR (CMI)
Check out the Certified Medical Investigator program for a more in-depth look at the field of medical investigation, which will examine the main forensic disciplines, crime scene basics, and proper identification of various kinds of abuse and causes of death. Enroll online today at www.acfei.com, or call (800) 423-9737 for more information.
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By Eugene R Bertolli, OD; Clifford D Brown, OD MPH CAPT PHS; Dominic R Pannone, OD; and Thaddeus W Bartles, OD
DR E ROBERT BERTOLLI, an optometric physician, is a Life Fellow of the American College of Forensic Examiners and director of its forensic optometry division. He is an Adjunct Speaker at the Connecticut Police Training Academy (Police Officers Standards and Training) for medical aspects of horizontal gaze nystagmus and vision science for impaired driving enforcement; is on several boards including the Board of Directors of the Connecticut Association of Optometrists; board of directors of American Board for Certification in Homeland Security; editorial board of the Forensic Examiner; vice chair, board of directors of the American Board for Law Enforcement Experts; editorial board for Inside Homeland Security, former vice chair of the American Board of Forensic Examiners. He is in optometric practice in Connecticut, and studied behavioral optometry under Dr. Constantine "Gus" Forkiotis.
CLIFFORD D. BROWN has spent 17 years in the senior ranks of the Public Health Service, three years at the US Air Force Goodfellow Field (Security Services/Cryptology training base) during Viet Nam, and four years in the US Army (during Desert Shield/ Desert Storm). Having been through the Air Force Officer Basic Course, the Army Officer advanced Course, the Army Combined Arms Staff Services School, and functioned as the Deputy Chief of Eye Care and periodically as the Administrative Officer in the 2000 bed Frankfurt Army regional Medical Center.
Within the field of primary and specialty care he has provided diagnosis and treatment of ocular pathology and the provision of service with a strong public health orientation. To this end he was the first PHS officer to successfully gain Diplomate status in the American Academy of Optometry's (AAO) Public Health and Environmental Vision Section (the international scientific and vision research organization), an accomplishment requiring years of testing and research.
The Montana Governor appointed him to serve on his TBI Advisory Board, the MTTBI Association Board of Directors, and as a founding member of the Montana State Traumatic Brain Injury Association.
DR. PANNONE is a behavioral optometrist who has been practicing in Norwich Ct. since 1960. Received B.S. from U.R.I.1953, B.S. O.D. from Mass. College of Optometry 1958 (Beta Sigma Kappa). Studied at Gesell Institute of Child Development 1969 and today deals with children's vision and learning problems. He is a member of American Optometric Association, and for 35 years Optometric Extension Program. He established the vision care and health section for the Haitian Health Foundation, Jeremie, Haiti in 1989 and still serves as its' consultant. In 1990 he became a Connecticut State Police Surgeon and today is an adjunct lecturer at the Connecticut Police Academy on Vision, Drugs and Alcohol and their effects on driving. He is a member of the American College of Forensic Examiners International, and is a Certified Medical Investigator level 5. He has lectured at the ACFEI 2004 national conference on Forensic Optometry. He is a Police Surgeon for the Amtrak Police Department Fraternal Order of Police #189, a member of the Citizens Police academy Troop E, Montville Ct. and has guest lectured on Drugs Alcohol and Driving. He has been a co- author on many peer reviewed articles. Dr. Pannone is a member of the DRE section of the IACP.
THADDEUS W. BARTLES, OD is Academic Chairman for the Connecticut Association of Optometrists. He was named Optometrist of the Year in 2010 and received the President's Award in 2008. He has been in private practice in Bristol, CT since graduating from the Massachusetts College of Optometry in 1974. Dr. Bartles belongs to the American Optometric Association. He is a frequent visitor to area schools and libraries, and has appeared on "The Doctor is In," a production of Nutmeg TV. In his spare time he plays clarinet in a classical wind ensemble and guitar in a rock band.
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