Can you age bruises accurately in children? A systematic review.

AIMS To investigate whether it is possible to determine the age of a bruise in a child in clinical practice by means of a systematic review. METHODS An all language literature search up to 2004. Included studies assessed the age of bruises in live children less than 18 years old. Excluded: review articles, expert opinion, and single case reports. Standardised data extraction and critical appraisal forms were used. Two reviewers independently reviewed studies. RESULTS Of 167 studies reviewed, three were included: two studies described colour assessment in vivo and one from photographs. Although the Bariciak et al study showed a significant association between red/blue/purple colour and recent bruising and yellow/brown and green with older bruising, both this study and Stephenson and Bialas reported that any colour could be present in fresh, intermediate, and old bruises. Results on yellow colouration were conflicting. Stephenson and Bialas showed yellow colour in 10 bruises only after 24 hours, Carpenter after 48 hours, and Bariciak et al noted yellow/green/brown within 48 hours. Stephenson and Bialas reported that red was only seen in those of one week or less. The accuracy with which clinicians correctly aged a bruise to within 24 hours of its occurrence was less than 40%. The accuracy with which they could identify fresh, intermediate, or old bruises was 55-63%. Intra- and inter-observer reliability was poor. CONCLUSION A bruise cannot accurately be aged from clinical assessment in vivo or on a photograph. At this point in time the practice of estimating the age of a bruise from its colour has no scientific basis and should be avoided in child protection proceedings.