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Experience With Wood Lamp Illumination and Digital Photography in the Documentation of Bruises on Human Skin
Ev Vogeley, MD, JD;
Mary Clyde Pierce, MD;
Gina Bertocci, PhD, PE
Arch Pediatr Adolesc Med. 2002;156:265-268.
ABSTRACT
Bruising is very common in children. Examination of bruising can guide
the clinician in ordering radiographic imaging studies of children who have
suffered trauma. Additionally, bruising in infants and patterns of bruising
that do not match the injury scenario offered by caretakers can raise the
suspicion of abuse. This article reports preliminary experience with Wood
lamp enhancement of faint bruises and visualization of bruises that are not
visible. It describes the method for digital photography of bruises visualized
in this way. Finally, it suggests future applications and areas of further
study.
INTRODUCTION
Although bruising in children is common,1
bruises in unusual locations or in infants who do not yet cruise can be a
physical finding that alerts clinicians to possible child abuse.1-3
Additionally, in children involved in other types of trauma, such as falls
down stairs and motor vehicle collisions, the presence of bruises can guide
the clinician in choosing appropriate imaging studies.
The use of an alternative light source to delineate skin lesions is
an established technique in forensic pathology4-8
and forensic odontology.9-11
Generally, these techniques use specialized film and filters that permit the
recording on 35-mm black-and-white film–reflected light in the infrared
or UV range. The infrared spectrum, which consists of wavelengths that are
longer than the human eye can detect (>700 nm), has the deepest penetration
and has the theoretical possibility of visualizing early bruising through
the ability to detect the pooling of subcutaneous blood.12
In contrast, UV light, which consists of wavelengths that are shorter than
the visible spectrum (<400 nm), has the least penetration, entering only
minimally into epidermal tissue, where it is either reflected or absorbed
by various biochemical compounds (hemoglobin, carotenoids, or bilirubin) that
are part of the healing process of skin.
Reflective UV and infrared photography have limitations that decrease
their practical application in pediatrics. The required specialized filters,
lenses, and films are unavailable in most emergency departments and outpatient
facilities. Exposure times are prolonged that require a child to hold still
for several minutes. Additionally, a tripod is required to hold the camera
still, making applicability in clinical settings cumbersome. Since the camera
is photographing light that is beyond the visible spectrum, detailed photographs
of the entire body must be taken as the location of faded bruises becomes
known only after the film is developed.
Ultraviolet illumination is an alternative to reflective UV and infrared
photography that is more easily adapted for use in pediatrics. Most pediatric
facilities have access to a Wood lamp that is an adequate source of UV light.
If photographs are required, commercially available digital still and video
cameras permit brief exposure times (<1 second) even under low-light conditions
so that the child need not be still for extended periods. Additionally, these
short exposure times permit the camera to be handheld. As UV illumination
allows subclinical bruising to be seen, photographs need only be taken on
specifically identified areas of the body.
Our interest in the use of UV illumination was stimulated when one of
us (E.V.) noted the visualization under Wood lamp illumination of a healed
bruise on the wrist. The bruise had resulted from closing the skin in the
clasp of a watchband 10 days earlier (Figure
1). Our study was undertaken to develop experience with the use
of Wood lamp illumination in conjunction with digital imaging to permit photographic
documentation of subtle and subclinical bruises in children.
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Figure 1. View without (A) and with (B)
Wood lamp illumination of a child's wrist showing a healed bruise resulting
from closing the skin in the clasp of a watchband 10 days earlier.
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SUBJECTS AND METHODS
This study was approved by the Human Rights Committee (institutional
review board) of the Children's Hospital of Pittsburgh, Pittsburgh, Pa. We
studied 4 children who had trauma. In children who had a history of trauma,
the entire skin surface was examined using a Wood lamp. This examination was
conducted under low-light conditions with the Wood lamp held approximately
10 cm from the skin surface. The camera used was a Sony Digital Mavica (model
MVC FD95; Sony Electronics Inc, Park Ridge, NJ). The resulting digital images
were imported into Adobe Photoshop (version 5; Adobe Systems Inc, San Jose,
Calif). The only manipulations of the photographs prior to printing and storing
consisted of resizing the images and adjusting contrast and brightness. Bruises
were most easily seen after contrast boosts of 10% to 40%.
RESULTS
Patient 1
A 6-month-old female infant rolled out of her grandmother's arms and
struck her forehead on the beveled edge of a glass-topped table. The injury
occurred approximately 1 hour prior to her presentation to the emergency department.
Physical examination revealed a superficial laceration on the forehead with
a small amount of surrounding ecchymosis (Figure 2A). More extensive bruising was demonstrated with digitally
photographed Wood lamp illumination (Figure
2B).
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Figure 2. Patient 1. A, View without Wood
lamp illumination of a superficial laceration on the forehead of a 6-month-old
infant showing a small amount of surrounding ecchymosis. B, Under the illumination
of a Wood lamp the same forehead laceration shows surrounding bruising.
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Patient 2
A 7-month-old female infant was being carried down a flight of carpeted
stairs by her 9-year-old sibling. The infant was facing her sibling, being
supported by her buttocks, with her legs wrapped around the sibling's waist.
At the third stair from the bottom, the older sibling slipped and fell backwards
landing on her buttocks. After an intense bout of crying, the infant was noted
to be fussier than usual with refusal to move her left leg. Radiographic examination
revealed a nondisplaced buckle fracture of the left distal femur. Physical
examination of the knee under normal lighting did not reveal any bruising
(Figure 3A). A digitally photographed
Wood lamp illumination demonstrated a linear bruise consistent with the described
mechanism of injury (Figure 3B).
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Figure 3. Patient 2. View without (A) and
with (B) Wood lamp illumination of the knee of a 7-month-old infant who sustained
a nondisplaced buckle fracture of the left distal femur.
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Patient 3
A 14-year-old boy was admitted to the hospital because of new-onset
insulin-dependent diabetes mellitus. On physical examination, he was noted
to have a very faint, yellow-brown ecchymosis overlying his left scapula (Figure 4A). He revealed that while attending
military school approximately 2 weeks before, he had been bitten on the left
part of his upper back. Wood lamp illumination revealed a pattern of bruises
consistent with a human bite (Figure 4B).
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Figure 4. Patient 3. A, View without Wood
lamp illumination of the left part of the upper back of a 14-year-old boy
who had been bitten by another human. B, View of the same area under Wood
lamp illiumination showed a pattern of bruises consistent with a human bite.
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COMMENT
The evaluation of any injured child requires a thorough examination
to define the extent of injury. Although preliminary, the aforementioned cases
suggest that the use of digital imaging combined with Wood lamp illumination
may provide clinicians with important information regarding the location and
extent of subclinical bruising. For example, the demonstration of abdominal
bruising in a child presenting with head injury would guide the physician
to order appropriate radiographic imaging studies to define the extent of
injury to the intestine or solid organs.
Decisions about whether a given constellation of injuries is consistent
with the explanation offered by caretakers is essential in determining the
likelihood of inflicted vs noninflicted trauma. If the injury scenario described
by a caretaker indicates that injuries occurred in a single plane, the demonstration
of multiple points of contact in multiple planes raises the suspicion of abusive
trauma. Just as important is the visualization of occult bruising that can
add credence to the explanation of injury offered by caretakers allowing a
more objective assessment of the injury event.
Further studies suggested by our preliminary work include histological
correlations and serial Wood lamp illumination with reflective 35-mm UV photography.
There is also the possibility that Wood lamp examination of infants who have
suffered sudden unexplained death or an apparent life-threatening event may
provide important clinical information.
CONCLUSIONS
Our brief experience demonstrates that the examination of the skin surface
of injured children with Wood lamp illumination can permit enhanced visualization
of soft tissue injury. The technique described permits visualization of bruises
that are not otherwise visible and identification of faint bruises that were
not noticed prior to the Wood lamp examination. The identification of these
subclinical bruises may help guide clinicians in selecting laboratory evaluations
and imaging studies in injured children. It may allow more complete comparison
of the caretaker's accounts of injury scenarios with the child's clinical
presentation. Further studies suggested by our preliminary work include histological
correlations, observation of bruises over time, and correlation with techniques
such as reflective UV and infrared photographic techniques.
| What This Study Adds
Forensic scientists have used alternative light sources to elucidate
skin wounds that are not visible. Many of these techniques are limited in
their application to pediatrics because of the requirement for specialized
equipment and the need for subjects to remain still for prolonged periods.
Our work describes the use of the ubiquitously available Wood lamp combined
with digital photography so as to demonstrate subtle and subclinical bruises
in children.
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AUTHOR INFORMATION
Accepted for publication November 8, 2001.
Corresponding author and reprints: Ev Vogeley, MD, JD, Child Advocacy
Center, Department of Pediatrics, Children's Hospital of Pittsburgh, 3705
Fifth Ave, Pittsburgh, PA 15213 (e-mail: vogelee{at}chplink.chp.edu).
From the Child Advocacy Center, Department of Pediatrics, Children's
Hospital of Pittsburgh (Drs Vogeley and Pierce), and the Department of Rehabilitation
Science and Technology, University of Pittsburgh (Dr Bertocci), Pittsburgh,
Pa.
REFERENCES
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ABSTRACT
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