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Imaging the less seriously head injured child
  1. L LIGHT, Consultant Community Paediatrician and
  1. Designated Doctor, Child Protection
  2. Greenhill Health Centre, Church Street
  3. Lichfield WS13 6JL, UK
    1. J F T GLASGOW
    1. The Queen's University of Belfast
    2. Belfast, N Ireland, UK
    3. The Ulster Hospital
    4. Dundonald, N Ireland, UK
      1. S J MCGOVERN
      1. The Queen's University of Belfast
      2. Belfast, N Ireland, UK
      3. The Ulster Hospital
      4. Dundonald, N Ireland, UK

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        Editor,—I read with interest the recent paper by Glasgow and McGovern which suggested that bruising with a yellow hue suggests that injury occurred at least 48 hours earlier.1Unfortunately, this statement is not referenced. However, I am aware of three papers on the age and colour of bruising.2-4

        Langlois and Gresham4 studied the colour changes of bruises with time and found it was possible to conclude only that a bruise with a yellow colour was more than 18 hours old. The significance of the appearance of other colours in terms of estimating the time of occurrence was not helpful.

        Stevenson and Bialas2 also found that aging of bruises was much less precise than text books imply and found that green or yellow hues suggest an injury that is at least 24–48 hours old. Finally, Schwartz and Ricci3 concluded that the available literature does not permit the estimation of a bruise's age from colour with any precision.

        I should be grateful to know if Glasgow and McGovern found any further research to assist them in aging bruises as I make a particular point of urging extreme caution on statements which specify the age of injuries based on their colouring when I teach child protection and when I write medicolegal reports.

        References

        Dr Glasgow and Mr McGovern comment:

        The general thrust of our review of children with less serious head injuries was to advocate an approach based on clinical factors and, in particular, to use these to identify patients in whom immediate imaging was unnecessary. In the latter context, we made reference to the colour of scalp bruising and the fact that a yellow hue would indicate greater age of an injury than would likely be associated with intracranial bleeding—that is, more than six hours or so after injury.

        The literature makes clear the difficulties in aging bruises.1-1 1-2 The time taken for bruises to appear depends on several factors—for example, the depth of injury and the volume of blood extravasated. Hobbs and colleagues1-3 state that in superficial bruises, yellowish tinges may appear in three days, although in deeper bruises this may take 7–10 days. One interesting study photographed the evolution of bruises in accident and emergency care patients, in patients, and staff over a very wide age range (largely adults). They concluded that a bruise showing a yellow colour must be older than 18 hours.1-4 The converse was not necessarily true—that a bruise not showing this hue is less than 18 hours old. The authors add, however, that “bruises may not develop a visible yellow colour until much later than 18 hours”. Therefore, the presence of such colouration in a bruise suggests that, other factors being equal, immediate imaging is not essential, which reinforces the prime aim of our review. We are indebted to Dr Light for her informed comment, but are unaware of other relevant literature. It seems to us that this area has more to do with the art than the science of medicine.

        References

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