medico-legal investigations bruising. what is a contusion? bleeding under intact skin due to heavy...

Medico-Legal InvestigationsMedico-Legal Investigations

BruisingBruising

What is a Contusion?What is a Contusion?

Bleeding under intact skin due to heavy Bleeding under intact skin due to heavy blunt instrumentblunt instrument– Hemorrhage into the skin, the tissues under the Hemorrhage into the skin, the tissues under the

skin or bothskin or both– Caused by crushing or squeezing of tissueCaused by crushing or squeezing of tissue

DefinitionDefinition

Bruising is caused when an impact Bruising is caused when an impact damages blood vessels such that the damages blood vessels such that the blood leaks into the perivascular tissues, blood leaks into the perivascular tissues, and is evident on the skin surface as and is evident on the skin surface as discoloration.discoloration.– Could be in skin (external bruising), muscles, Could be in skin (external bruising), muscles,

or internal organs (internal bruising) or internal organs (internal bruising)

Initial color of the bruise is the product of Initial color of the bruise is the product of natural natural skin pigmentskin pigment, , the color of pigment in the the color of pigment in the extravasated blood extravasated blood and and any color added by the any color added by the inflammatory reaction.inflammatory reaction.

ChangesChanges in color, shape and location of the blood in color, shape and location of the blood as the pigment is broken down and resorbed.as the pigment is broken down and resorbed.

In some cases although blood vessels may be In some cases although blood vessels may be damaged, there may be no visible evidence on the damaged, there may be no visible evidence on the skin.skin.

In certain cases, it may take hours or days for a In certain cases, it may take hours or days for a bruise to become apparent (as the blood diffuses bruise to become apparent (as the blood diffuses through damaged tissue)through damaged tissue)

Extravasated blood will follow the path of least resistance and seep along natural or traumatic planes of cleavage of the tissues under the influence of gravity and body movements.

One study (Langlois & Gresham1991) One study (Langlois & Gresham1991) concluded that it was only possible to state that concluded that it was only possible to state that a bruise with a yellow color was more than 18 a bruise with a yellow color was more than 18 hour old and that the colors red, blue and hour old and that the colors red, blue and purple/black could occur anytime within 1 hour purple/black could occur anytime within 1 hour of bruising to resolution (up to 21 day in the of bruising to resolution (up to 21 day in the study)study)

The color of a bruise is further confused by the The color of a bruise is further confused by the fact that many bruises exhibit multiple colors at fact that many bruises exhibit multiple colors at the same site despite being caused at the the same site despite being caused at the same time.same time.

Bruise after I.V injection taken 24 hours after Bruise after I.V injection taken 24 hours after injectioninjection

The site of bruising doesn’t necessarily reflect The site of bruising doesn’t necessarily reflect the site of trauma because blood tends to the site of trauma because blood tends to spread out in diffused manner from the site of spread out in diffused manner from the site of injury, for example a deep bruise in the mid injury, for example a deep bruise in the mid thigh may later appear at the knee and a black thigh may later appear at the knee and a black eye may be high on the scalp (eye may be high on the scalp (intra-dermal intra-dermal bruises provide an exception to this rulebruises provide an exception to this rule))

1st day1st day- red- red 2nd day2nd day- - 3rd day 3rd day -bluish-bluish 4th day4th day- brown day(hemosiderin)- brown day(hemosiderin) 5th-6th day5th-6th day- green(hematoidin = - green(hematoidin =

bilirubin)bilirubin) 7th-12th day7th-12th day- yellow(biliverdin)- yellow(biliverdin) 13th-15th day13th-15th day– normal– normal

– These changes give only a rough These changes give only a rough estimation of the bruise.estimation of the bruise.

Color changes in a bruise:

Factors that affect the appearance of Factors that affect the appearance of a bruise a bruise

The severity of the force applied to the The severity of the force applied to the area.area.


Site Site


Conditions that affect the fragility of blood vessels.Conditions that affect the fragility of blood vessels.

Conditions which slow or prevent blood clotting Conditions which slow or prevent blood clotting

Including :Including :

underlying disease (e.g.hemophilia)underlying disease (e.g.hemophilia)

drugs (anticoagulants, aspirin, steroids)drugs (anticoagulants, aspirin, steroids)

Age Age

Advanced age may predispose to an increased Advanced age may predispose to an increased tendecy to bruise, as will as relatively young age.tendecy to bruise, as will as relatively young age.


AlcoholismAlcoholism

Hepatobiliary dysfunctionHepatobiliary dysfunction

Skin colorSkin color

Bruising is more visible in pale skin.Bruising is more visible in pale skin.

Gender. (Females more)Gender. (Females more)

Obesity. (more in obese)Obesity. (more in obese)

Blunt Trauma WoundBlunt Trauma Wound

Fresh Bruises & Trauma:Fresh Bruises & Trauma:– Age and color a bruise presents depends on certain factorsAge and color a bruise presents depends on certain factors– Bruises can vary in color (depending on person)Bruises can vary in color (depending on person)

Age (Children and elderly bruise easier)Age (Children and elderly bruise easier)– A bruise can appear or disappear depending on:A bruise can appear or disappear depending on:

Oxygen levelsOxygen levels Blood pigment & breakdown of hemoglobinBlood pigment & breakdown of hemoglobin Physical Health AntemortemPhysical Health Antemortem Localized area of injuryLocalized area of injury Cancer leukemiaCancer leukemia ScurvyScurvy AspirinAspirin Anticoagulants (cumadine, heparin, warfarin, etc.)Anticoagulants (cumadine, heparin, warfarin, etc.) TemperatureTemperature HemophiliaHemophilia


Dating Contusions:Dating Contusions:– This is not an exact scienceThis is not an exact science

Hemosiderin in macrophageHemosiderin in macrophage Bruises usually follow a Bruises usually follow a

color pattern but not color pattern but not alwaysalways

– Reddish-purple or Reddish-purple or bluish-purple to violet, bluish-purple to violet, green, dark yellow to green, dark yellow to greenish-yellow and greenish-yellow and then disappearsthen disappears

– The edges of the The edges of the bruise have the oldest bruise have the oldest colorscolors

Can you Differentiate Ante- and Can you Differentiate Ante- and Postmortem Contusions?Postmortem Contusions?

Yes,Yes, Ante mortemAnte mortem

– Swelling presentSwelling present– Color changeColor change– Not washableNot washable– More tissue infiltration (diffuse)More tissue infiltration (diffuse)

Can you Differentiate Ante- and Can you Differentiate Ante- and Postmortem Contusions?Postmortem Contusions?

AntemortemAntemortem– Swelling presentSwelling present– Color changeColor change– Not washableNot washable– More tissue infiltration More tissue infiltration

(diffuse)(diffuse)

Postmortem Postmortem – Not presentNot present– Not presentNot present– Not presentNot present– Not presentNot present


BruisingBruising– May take minutes to May take minutes to

days to presentdays to present Take photograph Take photograph

incrementally during incrementally during this timethis time

– Bruises can mask Bruises can mask natural colornatural color

– Estimation of age of Estimation of age of bruise can be difficult bruise can be difficult after deathafter death

Deep bruises may require as long as 12 or 24 hours to become apparent – some may never do so.

In a living victim, a second examination after an interval of one or two days may disclose bruising where previously there had been only swelling or tenderness on pressure.

In the dead, a further examination one or two days after the original autopsy may disclose bruises which were not previously evident– Revealing more distinctly bruises which previously appeared

faint.


BruisingBruising– Bruises can formulate easier in:Bruises can formulate easier in:

Loose tissueLoose tissue FatFat Older adults and/or childrenOlder adults and/or children Women (less muscle mass)Women (less muscle mass) Disease of the vascular systemDisease of the vascular system

Types & patterns of bruisesTypes & patterns of bruises

Types and patternsTypes and patternsHand marksHand marks

Finger bruises Finger bruises -Consisting of circular or oval bruises from -Consisting of circular or oval bruises from

squeezing, poking, gripping or grabbing squeezing, poking, gripping or grabbing injuries.injuries.

Upper arm of a male who was gripped hard.Upper arm of a male who was gripped hard.

Sometimes a clean pattern of four-fingers or Sometimes a clean pattern of four-fingers or

fingertip bruises and a thumb bruise on the fingertip bruises and a thumb bruise on the

opposite side of the arm may be seen.opposite side of the arm may be seen.

In this case, abrasions are also evident In this case, abrasions are also evident

from fingernail scratches.from fingernail scratches.

Grip marks Grip marks – May be present when a young child has been gripped May be present when a young child has been gripped

and force fed.and force fed.

Note the round thumb imprint on one cheek Note the round thumb imprint on one cheek

with 3 or 4 finger-tip bruises on the other.with 3 or 4 finger-tip bruises on the other.

You should also examine for You should also examine for

intra-oral injuries.intra-oral injuries.


Linear Petechial BruisesLinear Petechial Bruises In the shape of a hand caused by capillary rupturing at In the shape of a hand caused by capillary rupturing at

the edge of the injury from high velocity impact of the the edge of the injury from high velocity impact of the hand slap.hand slap.

Note the parallel lines of petechial Note the parallel lines of petechial

bruising at finger-width spacing, the marks bruising at finger-width spacing, the marks

appearing in the gaps between the fingersappearing in the gaps between the fingers


Pinch marksPinch marks Consisting of paired, crescent-shaped bruises separated by a Consisting of paired, crescent-shaped bruises separated by a

white line.white line.

Pinch mark on the leg of a 7-year-old boy at a site where accidental bruising is unlikely.

Note the two small bruises separated by a clear space

High Velocity Impact High Velocity Impact Implement marksImplement marks

Causing a rim of petechiae Causing a rim of petechiae outlining the pattern of the outlining the pattern of the inflicting instrument. inflicting instrument.

– E.g. parallel sided marks by a stickE.g. parallel sided marks by a stick ““tramline bruisingtramline bruising””

Mechanism:Mechanism: it is caused by the it is caused by the impact of a cylindrical solid object impact of a cylindrical solid object (e.g. baseball bat). (e.g. baseball bat). – The strike of the cylinder expels The strike of the cylinder expels

blood from the center into small blood from the center into small vessels, either side of the point of vessels, either side of the point of impact, which rupture and impact, which rupture and extravasate blood.extravasate blood.

Is represented by 2 linear bruises with a line spacing between them centrally.

Higher velocity impactHigher velocity impact

Implement marksImplement marks

Causes bruising underlying the injury in the shape Causes bruising underlying the injury in the shape of the object used. - of the object used. - E.g. wedge-shaped bruises from E.g. wedge-shaped bruises from kicks with shoes.kicks with shoes.

Demonstrates a right flank bruise in a 60-year-old man who died of an acute MI 20 minutes after being hit with a baseball at a game.

Illustrates a densely hemorrhagic nature of the affected area and the distinct margins between the affected and normal areas.

Pressure necrosis of the skinPressure necrosis of the skin Implement marksImplement marks

From ligatures, causing From ligatures, causing well-demarcated bands well-demarcated bands partially or fully partially or fully encircling limbs or the encircling limbs or the neck.neck.

Types and patternsTypes and patternsImplement marksImplement marks

Coarse speckled (intradermal) bruisesCoarse speckled (intradermal) bruises

From impact injuries through clothing. They lie From impact injuries through clothing. They lie just just beneath the epidermis in the corium and are well beneath the epidermis in the corium and are well

defined.defined.

These bruises may give an indication of the pattern or shape of either the impacting object, or something lying between the impacting object and the skin.

The figure shows an example of a bruise which is patterned of textile material.

55 Petechial bruisesPetechial bruises Pinprick bruises from ruptured capillaries e.g. Pinprick bruises from ruptured capillaries e.g. suction bruises, squeezing, slapping, strangulation, suction bruises, squeezing, slapping, strangulation, and suffocationand suffocation

Some bruises caused by suction or biting, the classic “lovebite” tends to be uniform of color, (as the suction force applied is similar over the area of suction and ovoid in shape). Location is often on the neck but may be elsewhere in the body.

Typical features of accidental injuriesTypical features of accidental injuries

Sites more commonly associated with Sites more commonly associated with non-accidentalnon-accidental injury injury

FacialFacial: : soft tissues of cheek, eye, mouth, ear, mastoid, lower soft tissues of cheek, eye, mouth, ear, mastoid, lower jaw, frenulum and the neck.jaw, frenulum and the neck.

Chest wallChest wall

AbdomenAbdomen

Inner thighs and genitalia Inner thighs and genitalia strongly associated with strongly associated with sexual sexual abuseabuse..

Buttocks and outer thighsButtocks and outer thighs commonly associated with commonly associated with punishment punishment injury.injury.

Multiple sitesMultiple sites..

Typical features of non-accidental injuries Typical features of non-accidental injuries (injuries that should raise concerns)(injuries that should raise concerns)

Differential Diagnosis of BruisingDifferential Diagnosis of Bruising1.1. Accidental injuryAccidental injury: commonly on bony surfaces.: commonly on bony surfaces.

2.2. ArtifactArtifact: dirt, paint, felt tip, dye from clothing or footwear.: dirt, paint, felt tip, dye from clothing or footwear.

3.3. Benign tumorsBenign tumors: halo nevus, blue nevus, hemangiomas.: halo nevus, blue nevus, hemangiomas.

4.4. Vascular and bleeding disordersVascular and bleeding disorders: thrombocytopenic : thrombocytopenic purpora, HSP, hemophilia, purpora in association with purpora, HSP, hemophilia, purpora in association with infection, e.g. meningococcal septicemia.infection, e.g. meningococcal septicemia.

5.5. Disturbances of pigmentationDisturbances of pigmentation: café-au-lait patches, : café-au-lait patches, mangolian blue spotsmangolian blue spots

6.6. Erythamtous lesions:Erythamtous lesions: erythema nodosum erythema nodosum

7.7. Hereditary collagen disorders: Hereditary collagen disorders: osteogenesis imperfecta, osteogenesis imperfecta, Ehlers-Danlos syndrome. Ehlers-Danlos syndrome.

Medico-legal importanceMedico-legal importance

Age of injury.Age of injury.

Degree of violence.Degree of violence.

Different colors in the same victim are important Different colors in the same victim are important especially in child abuse. especially in child abuse.


Lacerations (Tears):Lacerations (Tears):– Tears in the skin due to pressure (BFT) are Tears in the skin due to pressure (BFT) are

called lacerationscalled lacerations– Lacerations are distinguished from incisions by Lacerations are distinguished from incisions by

““bridgingbridging””– Lacerations may or may not imprint the object Lacerations may or may not imprint the object

used to create BFTused to create BFT– There may be no external signs of injury but There may be no external signs of injury but

avulsions may occuravulsions may occur

What are the Diagnostic Features of What are the Diagnostic Features of Lacerations?Lacerations?

BridgingBridging Abraded EdgesAbraded Edges Edges irregularEdges irregular Contusions at edgesContusions at edges Hair crushedHair crushed


LacerationsLacerations– BFT injuries often BFT injuries often

contain evidence (trace) contain evidence (trace) embedded in wound embedded in wound Paint, bark, fibers, Paint, bark, fibers,

grease, metals, rubber, grease, metals, rubber, etc.etc.

– May be scrapes and May be scrapes and bruising around the bruising around the wound as wellwound as well

Is This a Blunt Trauma Wound?Is This a Blunt Trauma Wound?

Is This Wound Due To BFT?Is This Wound Due To BFT?

BFTBFT


Defense Wounds Defense Wounds – Due to BFTDue to BFT– Mainly abrasions and contusionsMainly abrasions and contusions

On back of hands, wrists, forearms On back of hands, wrists, forearms

Blunt Trauma WoundBlunt Trauma Wound Fractures of BoneFractures of Bone

– Can determine Can determine ““directionalitydirectionality”” of the impact of the impact– Can present as clean breaksCan present as clean breaks– Can present as compound fractureCan present as compound fracture– Can present as hair-line or stress fractureCan present as hair-line or stress fracture

Hairline FractureHairline Fracture

Compound FractureCompound Fracture


Fractures of the Fractures of the ExtremitiesExtremities– Direct ForceDirect Force

Bone is broken at the Bone is broken at the area of impactarea of impact

Blunt object impacts a Blunt object impacts a long bone causing long bone causing breaking of the bone on breaking of the bone on the opposite side of the opposite side of impact impact

May be crushing on May be crushing on side of impact if force is side of impact if force is great enoughgreat enough

Penetrating FracturesPenetrating Fractures

– Large force acting on Large force acting on a small areaa small area Gun shot or blast Gun shot or blast

woundwound

Penetrating FracturePenetrating Fracture

Focal FracturesFocal Fractures

Small force on a Small force on a small areasmall area - Bat or pipe - Bat or pipe

BFTBFT

Crush FracturesCrush Fractures

Crush fractures Crush fractures in long in long bones result from a bones result from a compression force that compression force that is applied transversely is applied transversely with respect to the long with respect to the long axis of a bone. axis of a bone.

For non-long bones, the For non-long bones, the axis of compression axis of compression could be from any could be from any direction. direction. – The spine is a special The spine is a special

case.case.


Indirect ForceIndirect Force– Bone is broken in an area away from the Bone is broken in an area away from the

point of impact.point of impact. The force is transferred from the point of impact The force is transferred from the point of impact

then along the limb until the force comes across then along the limb until the force comes across a weak bone or a weak spot in a bone.a weak bone or a weak spot in a bone.

– Produced by a force acting at a distance Produced by a force acting at a distance from the fracture sitefrom the fracture site


Indirect FracturesIndirect Fractures– Traction Fractures Traction Fractures – –

Bone is broken by a Bone is broken by a violent contractionviolent contraction

Angulation FracturesAngulation Fractures

Bone is twisted Bone is twisted (spiral fracture)(spiral fracture)

Vertical Compression Fractures Vertical Compression Fractures

Oblique fracture of Oblique fracture of long boneslong bones

medico-legal investigations bruising. what is a contusion? bleeding under intact skin due to heavy...

Documents

bruise conditions

elderly bruise easiera

deep bruise

bruise site factors

color of pigment

color changes

day red2nd day

blood clotting