Reliability of tristimulus colourimetry in the assessment of cutaneous bruise colour
Introduction
Bruising is one of the most common types of soft tissue injury from accidental and non-accidental blunt or squeezing force mechanisms of injury [1]. Bruising from non-accidental blunt or squeezing force trauma is a common sequelae to being a victim of interpersonal violence, including intimate partner violence, sexual assault, child abuse, and vulnerable adult abuse [1], [2], [3], [4]. The prevalence of this type of injury ranges from 50% among injured victims of sexual assault to 89% of injured victims of child abuse [2], [3]. Overall, the identification and documentation of violence-related injuries, such as bruises, are associated with more successful prosecution [5]. Therefore, it is vital these types of injuries are properly assessed and documented in a consistent and reliable manner.
Visual inspection of colour is a complex, psychophysical process of both colour perception and qualitative operationalisation [6]. Thus, research has shown describing the subtle colour changes of bruising via the naked eye is a subjective and unreliable practice with poor inter- and intra-observer reliability [7], [8]. This visual practice has often led to a disparity in the recognition of bruises on various skin types, in particular dark skinned individuals [9].
The use of tristimulus colourimetry as an accurate and objective measure of colour is well established in the field of dermatology, including the pigmentation of skin and scars [10]. However, the reliability of this technology applied to measuring bruise coloration has not been formally evaluated, despite its potential clinical and research applications [11], [12], [13], [14]. The purpose of our study was to examine the test–retest (intra-rater) and inter-rater reliability of using tristimulus colourimetry in the assessment of cutaneous bruise colour on a diverse group of healthy, adult subjects. In addition, we evaluated whether it is necessary to lift the head of the instrument from the skin's surface between measures in order to prevent venous congestion.
Section snippets
Participants
This research was performed as part of a larger, longitudinal study on bruise colour change [15]. Participants were a convenience sample of 27 healthy adult men and women who had 31 bruise examinations conducted for the test–retest evaluation portion of this study (Phase 1). To examine inter-rater reliability (Phase 2), 22 bruise examinations were performed on 10 adult subjects. The participants were primarily young (mean age = 27 years), female (69%), but with diverse skin colour (Table 1). Skin
Phase 1
The overall mean L*a*b* values for Measures 1 and 2 are presented in Table 2. The median (range) overall colour difference (ΔEab) was 0.34 (0.01–1.28). Only two of the 31 sets of measurements demonstrated an overall colour difference of ΔEab ≥ 1 (Fig. 2). However, paired t-tests demonstrated no statistically significant difference between Measures 1 and 2 for all three L*a*b* values (Table 2).
The ICCs for test–retest reliability of the CR-400 for bruise colour demonstrated excellent single and
Discussion
To our knowledge, our study is the first to thoroughly evaluate both the intra- and inter-observer reliability of a tristimulus colorimeter on bruises. The Minolta Chromameter® CR-400 demonstrated excellent reproducibility and precision on bruises for all three colour parameters, L*, a*, and b*. During repeated testing, the colour difference between average measures was not statistically (p < 0.05) nor clinically (ΔEab < 1.0), significant. Our findings are consistent with the work of Hughes et al.
Practice application
Experts at the U.S. Food and Drug Administration have long recommended using colourimetry for measuring subtle colour changes in skin [26]. Current trauma-relevant applications of this technology noted in the literature include assessing erythema [27], documenting bruise healing [15], and evaluating scar vascularity [28]. In addition, research has demonstrated the use of this technology for detecting early stage pressure ulcers [29] and granulation tissue [30]. The interest in accurate
Limitations
There are a few limitations to this study. First, the observers were not blinded to the colorimeter readings. However, no systematic bias was evident when evaluating the mean difference between observers. Since some subjects participated more than once, one could argue there may be bias with the high correlation between subjects’ repeated participation. Each set of scans was treated as independent because time trend was not the focus of this study. However, if the sample was viewed as more
Conclusion
Using a colorimeter to accurately assess bruise colour greatly decreases, if not eliminates, subjectivity in the interpretation and description of bruise appearance. The Minolta Chromameter® CR-400 demonstrated excellent test–retest and inter-observer reliability on the assessment of bruise colour. During repeated measurements, the colorimeter's application should be consistent in location while limiting contact pressure. When obtaining an average of multiple scans, it is not necessary to lift
Conflict of interest
The authors of this manuscript (Reliability of tristimulus colourimetry in the assessment of cutaneous bruise colour) have no conflicts of interest to declare. No funding was received for this study. Study equipment was on loan from Konica Minolta®.
Acknowledgements
Jacquelyn Campbell, PhD, RN, FAAN, Valerie DeLeon, PhD, MA, JD, Elizabeth Jordan, DNSc, RN, and Sharon Olsen, PhD, RN, AOCN are acknowledged for their critical review of the study proposal. Jane Fall-Dickson, PhD, RN is also recognised for her assistance in the preparation of this manuscript.
References (34)
- et al.
Severity of injuries among sexual assault victims
J Forensic Leg Med
(2007) The relationship of victim injury to the progression of sexual crimes through the criminal justice system
J Forensic Leg Med
(2012)- et al.
The perception of yellow in bruises
J Clin Forensic Med
(2004) - et al.
Lack of agreement on colour description between clinicians examining childhood bruising
J Clin Forensic Med
(2002) - et al.
Forensic sexual assault examination and genital injury: is skin color a source of health disparity?
Am J Emerg Med
(2008) - et al.
tristimulus analysis of the colors of subcutaneous bleeding in living persons
Forensic Sci Int
(2006) - et al.
Colour evaluation in scars: tristimulus colorimeter, narrow-band simple reflectance meter or subjective evaluation?
Burns
(2004) - et al.
Statistical methods for assessing agreement between two methods of clinical measurement
Int J Nurs Stud
(2010) - et al.
A note on the use of the intraclass correlation coefficient in the evaluation of agreement between two methods of measurement
Comput Biol Med
(1990;) - et al.
Acute injury patterns of intimate partner violence victims
Trauma Violence Abuse
(2007)
Bruising in children who are assessed for suspected physical abuse
Arch Dis Child
Bruising as a marker of physical elder abuse
J Am Geriatr Soc
Objective color measurements: clinimetric performance of three devices on normal skin and scar tissue
J Burn Care Res
Use of reflectance spectrophotometry and colorimetry in a general linear model for the determination of the age of bruises
Forensic Sci Med Pathol
Spectrophotometric evaluation of the age of bruises in children: measuring changes in bruise color as an indicator of child physical abuse
Tohoku J Exp Med
Assessment of bruise age on dark-skinned individuals using tristimulus colorimetry
Med Sci Law
Cited by (9)
Current trends in digital camera-based bioassays for point-of-care tests
2024, Clinica Chimica ActaOn the relationships between applied force, photography technique, and the quantification of bruise appearance
2019, Forensic Science InternationalCitation Excerpt :Individuals perceive colours differently [13], particularly the colour yellow, which is considered one of the most important colours in bruising supposedly indicating an older bruise as haemoglobin is broken down to billirubin during the healing process. Numerous studies have attempted to improve visual bruise interpretation and remove subjectivity: including colour charts as a visual aid [14]; utilising specific colour measurement tools [15–18]; and using histology and measuring the chemical components of a bruise via hyperspectral imaging [19,20]. However there has been little success.
Development and Pilot Analysis of the Bruise Visibility Scale
2021, SAGE Open NursingTreatment of port wine birthmarks in sturge-weber syndrome using topical timolol
2021, Journal of Pediatric Ophthalmology and StrabismusQuantifying the Degree of Bruise Visibility Observed Under White Light and an Alternate Light Source
2021, Journal of Forensic Nursing