Journal of Forensic and Legal Medicine 69 (2020) 101893

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Journal of Forensic and Legal Medicine

journal homepage: http://www.elsevier.com/locate/yjflm

Bruise detection and visibility under alternate light during the first three
days post-trauma
Katherine N. Scafide a, *, Shashi Sharma a, Natalie E. Tripp b, Matthew J. Hayat b
a
George Mason University, College of Health and Human Services, 4400 University Drive, Mail Stop Number 3C4, Fairfax, Virigina, 22030, United States
b
Georgia State University, School of Public Health, PO Box 3995, Atlanta, GA, 30302, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Cutaneous bruises are often hard to detect particularly on individuals with a darker complexion.
Bruises Researchers and federal agencies have recommended the use of alternate light to aide in the assessment of subtle
Alternate light injury. However, studies are limited in their evaluation of wavelength performance during the first few days of
Detection
bruise healing. The purpose of this pilot study was to examine whether an alternate light source (ALS) improves
Ultraviolet
Visible spectrum
detection of bruises when compared to normal light typical of clinical practice during the first three days
Forensic assessment following induction.
Methods: A sample of eight healthy adults between 22 and 36 years of age with diverse skin color were recruited
for this study. One bruise was induced on each participant by dropping a 4-oz (113g) steel ball through a 5-ft
(1.5 m) vertical pipe onto the anterior surface of the forearm. Using the ALS, bruises were assessed under 14
different combinations of ultraviolet and short narrowband visible wavelengths and filters along with overhead
fluorescent “examination” lighting. Participants were examined 3 to 4 times per day at approximately 4-h in­
tervals for three consecutive days post induction.
Results: Repeated bruise assessments on 8 subjects resulted in 59 bruise assessments and 885 total observations
under the different wavelengths and filters combinations. A bruise was detectable in 46 (78%) of the assessments,
with bruise ages ranging from 30 min to 57 h. Twenty (34%) bruises not detectable under normal light were
visible with ASL. Multilevel modeling revealed a strong association between time and detection for shorter
wavelengths, such as 365 nm (ultraviolet) and 450 nm.
Conclusion: The results of our study suggest alternate light is more likely to detect faint bruises than normal
lighting during the first three days post injury. However, more research is needed to determine which wave­
lengths and filter combinations are most effective during that time frame.

1. Introduction narrowband visible or ultraviolet spectrums.8 Generally, light is either

Bruises are the most common soft tissue injury among victims of
violence.1–4 The clinical evaluation of bruises by forensic practitioners is
usually limited to visual and tactile assessment.5 However, a bruise’s
visibility is often hampered by skin color or the depth and age of the
injury.6 The resulting challenge is that many bruises often go unnoticed
and undocumented on individuals with dark skin or who delay
treatment.
In the United States, the Department of Justice recommends incor­
porating technology, such as an alternate light source (ALS), to assist in
identifying “subtle injury”7 (see pp 67–68). Alternate light involves the
projection of light of a specific wavelength, usually within the
reflected by the skin’s surface or penetrates the skin at varying depths
depending on the wavelength.9 Hemoglobin and its breakdown products
absorb light at certain wavelengths,10 resulting in a darker appearance
under ALS compared to the surrounding tissue.11 To view the absorbed
light, the reflected light must be filtered either through goggles worn by
the observer or using camera equipment.
Recent studies have demonstrated the potential for using ALS to
detect or enhance the visibility of bruises.12–14 However, research has
yet to thoroughly explore how wavelength performance may change
during the first few days post injury while controlling for variation in
trauma. It also remains unclear whether light within the 550 nm
bandwidth may improve bruise detection given the broad absorption

* Corresponding author.
E-mail address: kscafide@gmu.edu (K.N. Scafide).

https://doi.org/10.1016/j.jflm.2019.101893
Received 13 November 2018; Received in revised form 5 June 2019; Accepted 17 December 2019
Available online 19 December 2019
1752-928X/© 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
K.N. Scafide et al.
peak of hemoglobin within that range.15 The purpose of this pilot study
was to compare bruise detection using an ALS to normal lighting typical
of practice settings on a diverse sample with identical injuries.
2. Materials and methods
2.1. Sample
A convenience sample of 8 healthy adults participated in this study,
including five males and three females. The mean age was 28 (SD ¼ 5.3)
years. Three of the subjects had light skin tone (white/Caucasian), while
the other five subjects had a dark complexion (originating from South­
ern India or Africa). Because this study involved the creation of a bruise,
subjects were excluded if they had certain medical conditions or took
medications that interfered with coagulation or inflammation. Each
study participant provided informed consent and was compensated
$5.00 USD per assessment visit. This study was approved and conducted
in accordance to the Institutional Review Board (IRB) ethics committee
at George Mason University (Protocol# 841009).
2.2. Bruise induction
The body location and methodology chosen for bruise induction was
previously published by Lombardi et al.13 The method was chosen due to
its limited risk to participants and ease of controlled anatomical place­
ment, which allowed us to avoid vessels or other structures that could
interfere with bruise assessment. The bruise site was the anterior fore­
arm approximately 5–7 cm from the antecubital fossa. Five participants
opted to have the bruise created on the right arm, while three on the left.
The skin at the bruising site was screened for pre-existing injuries, le­
sions (e.g., tattoos), or artifact visible under normal illumination (i.e.,
fluorescent lighting) or alternative light. If an injury or lesion was
identified, the opposite arm was screened. Subjects were excluded if
both anterior forearms screened positive for injuries, lesions, or artifact.
While seated, the subject’s arm was placed horizontally, palm-up, on
a table surface, at or just below chest level. A 4-ounce (113 g) steel ball
was dropped through a vertical, 5-ft (1.5 m) polyvinyl chloride (PVC)
pipe onto the ventral surface of the forearm at the desired location. The
end of the pipe was held close to, but not touching, the skin’s surface.
2.3. Equipment and data collection
The HandScope® Xenon FLS HSX-5000 (SPEX Forensics, Edison, NJ)
was used as the alternate light source. This handheld unit uses a drum of
internal, bandwidth filters to control the emitted xenon arc light. To
visualize light absorption, long pass filter goggles were worn by the
investigator to block shorter wavelengths being reflected by the skin’s
surface. The specific wavelengths and filters evaluated are presented in
Table 1. Overhead fluorescent lighting typical of a clinical practice
environment provided the “normal” light comparison.
After the bruise was created, the injury site was assessed 3 to 4 times
a day, each day, for a period extending over 3 days. Bruise assessments
were conducted by either author K.S. or S.S. who have a combined 40
years of experience performing skin assessments as part of their nursing
practice. Both were trained on the equipment. The skin was first
Table 1
Alternate light source wavelengths and filters measured in this study.
Wavelength (nm) Longpass Filters
Color 50% Transmission (nm)a
365 (ultraviolet) Clear 418
415, 450, 475, 495 Yellow 515
450, 475, 495, 515, 535 Orange 562
495, 515, 535, 555 Red 602
a 555 nm
Transmission of Safety Goggles, SPEX Forensics.
2
Journal of Forensic and Legal Medicine 69 (2020) 101893
examined under normal fluorescence lighting for the presence of visible
bruising at the induction site. Subsequently, the room was darkened,
and the examiner observed the same area of the skin using ALS for the
presence of visible absorption. The order of the ALS application of the
fourteen different wavelengths/filters combinations is the same as pre­
sented in Table 1. The participants were provided UV filtering goggles to
protect their eyes during the assessment. The first bruise assessment was
conducted 30 min post-trauma to allow for the immediate histamine
response to subside. Subsequent bruise assessments were scheduled
approximately 4 h apart; however, the actual amount of time between
visits varied.
2.4. Data analysis
Data were analyzed with IBM SPSS for Windows, version 23.0 (IBM
Corp., Armonk, NY), and the SAS Software System, version 9.4 (SAS
Institute Inc., Cary, NC). Frequency distributions were used to summa­
rize bruise visibility by wavelength and filter. A visual representation
with a stacked bar chart is used to display frequency of bruise detection
over time using normal lighting and ALS. Data were collected on
repeated bruise assessments using multiple wavelengths and filters. In
order to account for the correlation inherent in repeated measures on a
bruise, a multilevel marginal model was applied with generalized esti­
mating equations used for estimation. This modeling framework ac­
counts for repeated measures data and enables comparison of light
source performance and quantifies factors associated with bruise
detection16
3. Results
As a result of the bruise induction, each of the subjects had a
detectible bruise, either under ALS or normal lighting, within 1-h, post-
trauma. The bruises were very faint in appearance. Participants
completed 59 bruise assessments, averaging 7 to 8 assessments (range
3–10) per subject. One subject withdrew from the study early due to an
unrelated illness. A total of 885 bruise observations were completed,
with 59 under normal lighting and 826 under the different ALS lighting
conditions. The age of the bruise at time of assessment ranged from 30
min to 56.75 h post-induction.
Table 2 presents the frequency of bruise detection by light and filter
combination. A bruise was detectable during 46 (78%) of the 59 as­
sessments. Of the 46 assessments in which a bruise was detected, 45
(98%) were detected by the ALS while only 11 (24%) were by normal
light. Bruises not detectable under normal light were visible under ALS
during 20 (34%) of the 59 assessments. The frequency of bruise detec­
tion over time using normal lighting and ALS is displayed in Fig. 1.
Normal lighting was more effective in visualizing bruises closer in time
to bruise creation; whereas, ALS detected bruises more consistently over
time.
The multilevel marginal model results are presented in Table 3.
Table 2
Frequency of bruise detection during assessment visits based on light and filter
combination (n ¼ 59 assessments).
Light Filter
Clear/None Yellow Orange Red
Normal Light 11
Alternate Light
Ultraviolet 23
415 nm 11
450 nm 12 14
475 nm 8 13
495 nm 1 6 5
515 nm 10 22
535 nm 16
3
K.N. Scafide et al. Journal of Forensic and Legal Medicine 69 (2020) 101893

Fig. 1. Frequency of bruise detection over time using normal lighting and an alternate light source. No measures were obtained between 12-18 h and 36–45 h.

Estimates for the log odds of the outcome are displayed for reproduc­ 4. Discussion
ibility. The likelihood of bruise detection under ALS decreased with an
aging bruise ( 0.01, 95% CI: -0.02, 0.0006). Shorter wavelengths (e.g., In this study, the ALS was able to detect absorption at the bruise site
UV and 415 or 450 nm) had a greater likelihood of detecting bruises more often than normal overhead lighting typically used in clinical
under ALS ( 0.01, 95% CI: -0.02, 0.01). However, an association was practice. These findings are consistent with previous research investi­
not found with the selection of the colored filter. For any given wave­ gating existent bruises on living individuals.12,14,17 However, by
length, the yellow and orange filters were not significantly associated creating bruises, we controlled for baseline artifact that may have
with an increase in likelihood of detection over red (p ¼ 0.453). mimicked bruising under alternate light, such as other skin lesions17 and
certain topical products.18 Such a design improves confidence that the
Table 3 absorption detected is more likely a result of the bruise and its break­
Multilevel modeling results for quantifying factors associated with bruise down products than an existing condition.
detection under alternative light sourcea. The bruises in this study were evaluated frequently during the first
Covariate Parameter Estimate 95% Confidence p-value three days post trauma in order to explore whether the performance of
Interval wavelengths varied as the injury healed. According to animal models,
Lower Upper
the local concentration of macrophage-produced heme-oxygenase peaks
during this time contributing to the catabolism of hemoglobin into its
Intercept 2.32 7.00 11.65 .630
breakdown products.19 In our marginal model, shorter ALS wavelengths
Wavelength 0.01 0.02 0.01 .002
Filter color .528 had a greater likelihood of detecting bruises. These finding are consis­
Yellow 3.83 7.02 14.67 tent with the known, absorption peaks of oxyhemoglobin (415 nm),
Orange 6.42 4.78 17.61 de-oxygemoglobin (430 nm), and bilirubin (460 nm) within this portion
Clear 0.06 3.00 2.87
of the visible spectrum.10,15
Red Reference
Wavelength by filter color .453
Our research findings support prior experiments where the bruise’s
Wavelength x yellow 0.01 0.03 0.01 age is known with confidence. Using the same bruise induction pro­
Wavelength x orange 0.01 0.04 0.01 cedure, Lombardi et al. found no variation in latent bruise detection
Wavelength x clear Reference sensitivity (73–75%) across UV and short narrow-band visible spectrums
Wavelength x red Reference
(300 nm–555nm) one day after trauma.13 Unfortunately, that prospec­
Bruise age 0.01 0.02 0.0006 .035
tive study was limited to one observation during the first three days.
p < 0.05 in bold. Research on simulated fresh bruises also found significant enhancement
a
A marginal model with generalized estimating equations was used to ac­ in visualization compared to white light across bandwidths between 350
count for repeated measurements on each bruise. A total of 8 subjects received
and 510 nm.20 More research is needed to determine whether time is a
repeated bruise assessments amounting to 59 measurements over a period of
factor in which wavelength and filters are most effective in detecting
three days. Results for modeling of log odds of probability of bruise detection
displayed.
bruises on a larger, diverse sample.

3
K.N. Scafide et al.
There are several limitations to our pilot study. First, the bruise in­
duction technique used in this study was developed by its original au­
thors to create “subclinical” (i.e., latent) injuries.13 Thus, the resulting
bruises we created were faint and could have been mistaken for natural
skin artifact. Future use of this technique should include a heavier
weight (>113g). Second, our sample size was diverse but small, which
may have contributed to our inability to identify a recognizable pattern
to filter performance over time. Finally, we did not compare the overall
clarity of bruise visualization between the two sources of light due to a
lack of existing reliable metrics. Using photographic analysis to quantify
the enhanced visibility of faint bruises, such as those used by Olds
et al.,20 may increase the support for the clinical utility of the ALS.
5. Conclusions
Alternate light within ultraviolet and short narrow-band visible
spectrums has been suggested by researchers and agencies to aid in the
assessment of subtle bruising. In this pilot study, we examined whether
an ALS could improve detection of bruises in the first few days after
trauma when compared to normal lighting typical of the clinical practice
setting. The results suggest an ALS has greater likelihood of detecting
faint bruises during the first three days post injury using shorter, visible
wavelengths. However, more research is needed to further determine
which wavelengths and filter combinations are most effective during
that time frame.
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors. The authors
have no real or perceived conflicts of interest when conducting this
research study.
Declaration of competing interest
None.
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