ORIGINAL ARTICLE

Can one accurately date a bruise? State of the science

Katherine R. Nash, MSN, RN, FNE-A, SANE-A, D-ABMDI and Daniel J. Sheridan, PhD, RN, FNE-A, FAAN
Johns Hopkins University School of Nursing, Baltimore, Maryland

Keywords
Age of bruises; color of bruises; dating bruises;
forensic nursing; injury.
Correspondence
Katherine R. Nash, MSN, RN, FNE-A, SANE-A,
D-ABMDI, 525 N. Wolfe Street, Baltimore, MD
21205. Tel: 240-418-1656; E-mail:
knash3@son.jhmi.edu
Received: April 27, 2007; accepted: May 28,
2007
doi: 10.1111/j.1939-3938.2009.01028.x
Abstract
Forensic nursing experts and other health professionals often testify regarding
the injuries women and men receive from violence. Bruise discoloration can
provide an opportunity for health professionals to grossly estimate the age of
impact and determine if it is consistent with a given reported history. How-
ever, there is much confusion in the literature and clinical practice as to the
accuracy of dating bruises. This article will demonstrate that using the color of
the bruise as the primary criteria to determine its age is not the best practice.
The limited available research and related literature on the topic are flawed
and inconsistent. Finally, recommendations will be made for future research
and clinical practice.

ence around the assessment and documentation of bruis-

Case example
A female patient came to the emergency department ac-
companied by her roommate reporting that she was sex-
ually assaulted in the middle of the night. A sexual assault
examination was performed by a forensically educated
sexual assault nurse examiner. After obtaining a history,
the nurse conducted a head-to-toe physical examination.
The nurse assessed and documented in the medical record
three purplish, patterned, finger tip-like bruises to the
patient’s inner, lower thighs that were not reported to
be painful to the touch. The patient stated she was un-
aware of these injuries. After the examination, a police
detective asked the forensic nurse whether the bruises
were from an assault by a former boyfriend hours ear-
lier or from 5 days prior when the woman had “rough
sex” with her current boyfriend.
Introduction
Violence is a significant health problem affecting men and
women of all races throughout the United States. Foren-
sic nurses and other health professionals are frequently
asked by law enforcement officials and attorneys to assess
injured victims of violence and determine the approxi-
mate age of their injuries. Written and photographic doc-
umentation of injuries is an important role of the forensic
nurse when assessing patients who report being victims
of violence. This article will explore the literature and sci-
ing in patients who have survived physical and/or sexual
assault.
Bruising is one of the most common types of physi-
cal injury observed in victims of domestic violence, sex-
ual assault, child abuse, and elder abuse (Dyer, Con-
nolly, & McFeeley, 2003; Kaczor et al., 2006; Muelleman,
Lenaghan, & Pakieser, 1996; Palmer et al., 2004; Sheri-
dan & Nash, 2007). Because bruises usually change color
during the healing process, health professionals are of-
ten tempted to use color as a primary means to estimate
the age of impact and determine if it is consistent with a
reported history. What health professionals document in
the medical record is often used as evidence by opposing
attorneys in criminal and/or civil trials. Therefore, accu-
rate documentation is critical, including any documenta-
tion of a bruise’s estimated age.
The purpose of this article is to use a case example to
discuss the physiology of bruising and presenting factors
associated with the discoloration(s) or bruising caused
through forceful impact injury to the person. Four stud-
ies have analyzed the process of determining the age of a
bruise through assessment of the bruise color. These will
be summarized and briefly critiqued. Recommendations
for further research and clinical implications for objective
measurements of bruise color in the case of impact injury
will then be proposed. The effective assessment and doc-
umentation of bruising by forensically educated nurses
is important to advancing practice, thus supporting

Journal of Forensic Nursing 5 (2009) 31–37 

c 2009 International Association of Forensic Nurses 31
Can one accurately date a bruise
compassionate care of the patient and appropriate out-
comes in criminal or civil proceedings.
Bruise defined
In general, a bruise is discoloration resulting from in-
jury transmitted through the skin to its underlying struc-
tures and occasionally to other organs, causing bleed-
ing from ruptured blood vessels. It is accompanied by
pain, swelling, and inflammation (Stedman, 2005; Venes
& Thomas, 2001). Bruising of the dermis is often specified
as being caused by blunt and/or squeezing force trauma
(Venes & Thomas, 2001). A bruise is synonymous with
the word contusion. However, a bruise is different from
ecchymosis, petechiae, and purpura, because these cuta-
neous hemorrhages are best categorized as rashes or leak-
ages of blood under the skin not directly caused by blunt
force trauma (Sheridan, 2003). In fact, Stedman’s Medical
Dictionary (2005) actually cautions the reader to not use
the term bruise to describe hemorrhagic lesions unrelated
to blunt force injuries. Bruises to skin can vary in pain,
tenderness, color, distinction of margins, and induration
(Sheridan, 2003). Color is the only constant that should
be present for a dermal bruise to be externally identified
without dissection or histological analysis.
Pathophysiology of bruise discoloration
The red discoloration in a bruise/contusion following
blunt or squeezing force trauma is caused by the release
of hemoglobin and/or red blood cells from damaged ves-
sels into the subcutaneous tissue. The extravasation of
blood is followed by an inflammatory reaction that causes
vasodilation and attracts macrophages to the site of in-
jury. The erythema, secondary to vasodilation and fresh
escape of blood, is quickly replaced by a blue or purple
appearance due to the further extravasation of deoxy-
genated venous blood into the interstitial tissue.
Over time, these macrophages ingest the escaped
erythrocytes and degrade the attached hemoglobin.
Hemoglobin is first broken down into biliverdin, which
accounts for the green color often seen in a healing bruise
(Hughes et al., 2004). Biliverdin is then quickly broken
down into bilirubin, which accounts for the yellow color
of a healing bruise (Vanezis, 2001b). As hemoglobin is
broken down, some of its contained iron is released and
it combines with ferritin. This gives rise to hemosiderin,
which appears brown in the tissue (Hughes et al., 2004).
This may explain why many bruises take on a yellow-
brown to purely brown appearance late in the healing
process.
32
K. R. Nash and D. J. Sheridan
Factors affecting bruise appearance
Numerous factors have been thought to affect bruise dis-
coloration and its change over time but few have been
actually studied. Low levels of connective tissue support
and high levels of vascularity and adipose tissue can con-
tribute to larger quantities of extravasated hemoglobin,
such as in the periorbital and genital regions (Johnson,
1990; Langlois & Gresham, 1991; Vanezis, 2001b). In
other words, more adipose tissue (fat), as compared with
muscle, can contribute to an increase in bleeding. Skin
color can affect how bruise discoloration is perceived
by the naked eye (Schwartz & Ricci, 1996; Stephenson,
1997; Vanezis, 2001a, b).
The depth of the injury can affect how soon bruise
discoloration appears. Although superficial bruises may
present immediately, deep bruises may take hours or
even several days to appear, if at all (Langlois & Gresham,
1991; Randeberg et al., 2007; Schwartz & Ricci, 1996).
The characteristics of the inflicting object, including its
surface and force of impact against the body, can also
affect a bruise’s size, shape, and pattern of appearance
(Randeberg et al., 2007; Vanezis, 2001a). Bleeding from
some deep bruises or muscle tears can be totally or par-
tially reabsorbed by the body prior to reaching the outer
layers of the skin. Therefore, it is possible that when the
bruise is first visible, it has the appearance of being older.
Age can also impact bruising due to characteristic
changes typical of different age groups. The elderly (es-
pecially frail elderly) tend to bruise easily due to: (a)
thinning skin, (b) weakening of the tissue surround-
ing and supporting blood vessels, and (c) side effects of
medications (Vanezis, 2001a). Children are also more
easily bruised than adults because of their delicate skin
and increased adipose tissue (Langlois & Gresham, 1991;
Vanezis, 2001a, b).
Gender also affects bruising, as women tend to bruise
more easily due to increased adipose tissue distribution
(Vanezis, 2001a). Specifically, women with red hair have
been found to report higher levels of bruising as com-
pared with women with brown or black hair; how-
ever, coagulation tests have not been found to differ
(Liem et al., 2006). Numerous diseases and medica-
tions can affect coagulation, macrophage production, and
hemoglobin degradation, ultimately changing the bruise
discoloration process (Langlois & Gresham, 1991; Valente
& Abramson, 2006; Vanezis, 2001a, b). Medications af-
fecting bruising include prescription drugs, over-the-
counter drugs, and certain herbs (Valente & Abramson,
2006).
In the 1950s and 1960s, several studies by researchers
explored bruising of animals from inflicted trauma.
This research cannot be ethically replicated by current
K. R. Nash and D. J. Sheridan
research standards in regard to the use of human sub-
jects. Hamdy et al. (1957) found that, when multiple
bruises were present, the bruises tended to resolve on av-
erage 2 days faster. This could be an important fact to
consider when examining chronically abused victims of
violence. Bruising of animals was also found to be af-
fected by environmental temperatures, in which those
animals kept in colder climates resolved their bruises
more slowly and overall the bruises had a more yellow
appearance (Hamdy et al., 1961). Putting ice on a new
injury may cause a similar affect in slowing bruise resolu-
tion and altering bruise appearance in humans. Also, the
color progression of bruising was found to differ between
species (Hamdy, Deatherage, & Shinowara, 1956; Lan-
glois & Gresham, 1991; McCausland & Dougherty, 1978).
Research on dating bruises
A literature search was performed using two com-
puterized databases: CINAHL (1982–2006), consisting
of nursing and allied health literature, and PubMed
(1950–2006), consisting of biomedical and life sciences
literature. The search keywords included individual and
combinations of the following words: bruise, bruising,
contusion, skin, dermal, dermis, age, dating, aging, age-
ing, discoloration, color, colour, and change. Four stud-
ies exploring bruise color as assessed with the naked eye
and the age of injury in human subjects were included in
this review: Langlois and Gresham (1991), Stephenson
and Bialas (1996), Bariciak et al. (2003), and Mosqueda,
Burnight, and Liao (2005). Animal studies were not in-
cluded because of the significant difference in physiology
between species and humans on both a gross and a histo-
logical level.
Langlois and Gresham (1991)
Langlois and Gresham (1991) based their study on the
observation of 369 photographs of bruises from 89 Cau-
casian subjects of ages 10–100 years. The mean age of the
subjects is unknown. For statistical analysis using logis-
tic regression, the subjects were dichotomized for an un-
specified reason into two groups: older and younger than
65 years. The gender of the subjects was not reported.
Some bruises were followed up and re-photographed to
examine progression. Green, orange, and brown were not
included in the study because of the problem in differen-
tiating between these colors with combinations of others.
Self-reported ages of these bruises ranged from 6 hours to
21 days. The procedure for examining the photographs
is unclear. The number of observers and whether they
were blinded to the bruise’s history is unknown, raising
concerns about intra/interobserver reliability.
Can one accurately date a bruise
No subjects displayed yellow discoloration during the
first 18 hours. However, the absence of yellow did not
necessarily mean that the bruise was less than 18 hours
old. Some bruises never achieved a yellow discoloration.
Red, blue, purple, and black were found to appear at any
point of age progression. Yellow also developed signifi-
cantly faster in subjects less than 65 years of age (p <
0.001). Two surprising observations made by the authors,
but not statistically examined, are important to mention
here. First, a given color could appear, disappear, and
then reappear at a later date. Second, two bruises on the
same subject with the same location, age, and etiology
could display different colors and color progression. De-
spite this study’s significant limitations, the authors con-
cluded that, “it would seem unlikely to be able to accu-
rately age a bruise from appearance alone” (Langlois &
Gresham, 1991, p. 236).
Stephenson and Bialas (1996)
Stephenson and Bialas (1996) examined 36 accidental
bruises in 23 Caucasian children of ages 8 months to 13
years (13 male and 10 female). Photographs were taken
using a standardized color chart. Some bruises were fol-
lowed up and rephotographed to examine progression.
Only a single observer (one of the authors) who was blind
to the time of injury examined the photographs, prevent-
ing assessment of interobserver reliability. The observer
was asked to estimate the age of the bruise by category:
fresh (within 48 hours), intermediate (2–7 days), and
old (greater than 7 days). No statistical analysis was per-
formed on the data.
The authors determined that aging bruises was inaccu-
rate when examining photographs.
Blue, gray, brown, and purple were observed anytime
within 1–14 days after impact. Red was found to occur
only in injuries 7 or fewer days old. Yellow occurred only
in bruises more than 24 hours old. The observer did not
estimate any bruise more than 48 hours old as fresh. But
in total, the observer was only correct in estimating the
age of the bruise 50% of the time. No relationship was
found by the authors between the accuracy of the esti-
mation and the age or location of a bruise. The authors
conclude that, “ageing of injuries from photographs is im-
precise, even in a controlled research setting” (Stephen-
son & Bialas, 1996, p. 55).
Bariciak et al. (2003)
Another study on bruising involving children was done
by Bariciak et al. (2003). Observers blind to the actual age
of impact examined the bruises of 50 children between
the ages of 1 week and 18 years (mean = 6.5 years).
33
Can one accurately date a bruise
Bariciak et al. described the skin tone of the partici-
pants as 66% fair, 12% medium, and 12% unknown.
For each bruise, one to three observers from a pool of
63 examined it and offered an age estimation. Evaluation
of the bruises was done in vivo (in person), as opposed
to via photograph, and bruise progression was not fol-
lowed. K-statistics were performed to evaluate interob-
server reliability.
Red, blue, and purple colors were significantly associ-
ated with bruises less than 48 hours old (p < 0.001), but
they were also observed in 30% of bruises older than
7 days. Yellow, brown, and green colors were signifi-
cantly associated with bruises more than 7 days of age
(p < 0.001), but were also seen in 23% of bruises less
than 48 hours old. Poor interobserver reliability was
noted (k = −0.03). The accuracy of individual observer’s
attempts at estimating a bruise’s age ranged from 0%
to 100%, with only 40% of estimations correct within
24 hours of the actual age. The authors recommended
the use of “extreme caution in estimating bruise age, even
when such estimates are based on direct examination of
the injured area (Bariciak et al., 2003, p. 807).
Mosqueda, Burnight, and Liao (2005)
A more recent study, Mosqueda, Burnight, and Liao
(2005), examined bruise progression longitudinally in
101 Caucasian elderly subjects over age of 65 years (mean
78, 35 male and 66 female). A total of 108 bruises were
followed for 6 weeks with daily head-to-toe evaluation
(in vivo) by one of the two observers. According to
Mosqueda, Burnight, and Liao, self-report of the bruise’s
age was obtained but was not required due to daily obser-
vation of the subjects. In addition to bruise descriptions,
other variables collected in the research included the type
of residence, the ability to perform activities of daily liv-
ing (ADLs), mobility, the number of falls, medications,
and medical conditions.
Statistical analyses were performed, including t-tests,
chi-square tests, and correlations; however, the results
were provided to the reader using only basic descrip-
tives (percentages) in the section “Timing and Sequence
of Color Change” (Mosqueda, Burnight, & Liao, 2005,
p. 1341). Almost 20% of the bruises were yellow within
the first 24 hours. Purple and red were observed at all
ages of bruises. Despite daily examinations, the accu-
racy of the ages of the bruises is questionable due to
the bruises’ unknown depth. As discussed earlier, deep
bruises can take hours or even days to appear at the skin
surface. Medications affecting coagulation did not signif-
icantly correlate with the duration of bruise or discol-
oration with age. Decreased ADLs and residential setting
also did not affect the number of days until bruise resolu-
34
K. R. Nash and D. J. Sheridan
tion. Mosqueda, Burnight, and Liao concluded that, “one
cannot reliably predict the age of a bruise by its color”
(p.1339).
Discussion
Overall, the research is sparse surrounding dating bruises
based on color. The four studies had a few consistent find-
ings worth noting. Yellow was found most often to de-
velop in bruises after 24 hours. However, this color in
not always noted in bruise progression. Bariciak et al.
(2003) found yellow in almost a quarter of bruises less
than 48 hours old. Only two of the studies discussed
green, which was observed in bruises more than 48 hours
old. No similarity in the results was noted for red, blue,
purple, and black. The color progression of bruises was
only consistently followed up by Mosqueda, Burnight,
and Liao (2005).
There are several limitations of this research review
and studies presented. Only English studies that involved
human subjects were included in this review. The four
studies only included Caucasian participants. It is diffi-
cult to compare findings from pediatric studies with those
whose subjects are adult or elderly. As discussed earlier,
the age of the individual can affect the appearance of
bruises due to physiological changes to the dermal and
underlying structures.
When photographs are reviewed as part of a study,
clear steps must be taken to standardize the process and
then present these steps to the reader. Langlois and Gre-
sham (1991) did not include any details surrounding
their photographic methods. Photography can create sev-
eral additional problems when examining the color of
injuries. Lighting can alter color portrayal in photogra-
phy. Fluorescent light has been found to make bruises ap-
pear green or yellow (Pasqualone, 2006). Having a stan-
dardized color chart, as in the Stephenson and Bialas
(1996) study, can help quality film developers correct
much of the effect of light and film speed on color
(Zercie & Penders, 2006). When color charts are used,
each print can be manually adjusted to match the stan-
dardized color chart as best as the developer can vi-
sually determine. This is true for both digital and film
photography.
Another problem exists with studies that involve both
photographs and in vivo evaluation of bruises. The
question arises, can two people observe and describe
the same color similarly? Is the bruise bluish-black or
blackish-blue? Color perception of bruises has recently
been shown to be a subjective process with poor inter-
and intraobserver reliability. Munang, Leonard, and Mok
(2002) found that only 25% of observers of the same
K. R. Nash and D. J. Sheridan
bruise in vivo described the color similarly and only 24%
agreed by way of photograph. Most surprisingly, only
31% of participants who were shown the same bruise in
vivo and later in a photograph described the color of the
bruise the same way.
Hughes, Ellis, and Langlois (2004) noted a similar re-
sult in their study. They took a single photograph of a
bruise and using a computer slowly increased the per-
centage of yellow until the study participant perceived
the color. The study found that variability exists in peo-
ple’s ability to perceive the color yellow. They noted that
the ability to perceive yellow decreases with age but is not
affected by gender. Both studies found that color percep-
tion and description are subjective and recommend that
objective measurements be used in future research of dat-
ing bruises.
Implications for research
and clinical practice
Research
As the previous studies have noted, new research needs
to be conducted to examine the use of objective color
technology and its applications in dating bruises. Col-
orimetry and spectrophotometry have both been stud-
ied on a small scale and show promise in determin-
ing the age of impact on bruises (Hughes et al., 2004;
Trujillo, Vanezis, & Cermignani, 1996). Because bruise
color can be affected by skin tone, different racial popula-
tions should be included. Gender comparison and con-
trol for locations of bruises should also be studied. By
including other variables, such as the presence of pain
and delineation of bruise margins, one might better be
able to ascertain whether the age of bruises can be accu-
rately estimated. Finally, the ultimate goal in forensics is
to provide objective, evidenced-based healthcare evalua-
tions and interventions for those injured from violence,
so research on bruises that includes people with nonacci-
dental bruises may offer important information.
Clinical practice
All nurses in all settings must have the clinical exper-
tise to perform thorough and accurate physical assess-
ments of patients. This is even more critical within the
realm of forensic nursing where injury assessment and
documentation play a major role in criminal and civil le-
gal proceedings. When assessing a bruise (see Table 1),
a forensic nurse needs to document its size (length and
width), shape, location, color(s), distinction of margins,
and whether it is indurated or painful. The bruise should
be described as patterned if it demonstrates characteristics
Can one accurately date a bruise
Table 1. Assessment and documentation of a bruise
1. Written documentation
Patient’s history of bruise’s origin (if known):
Size (length and width) Measure
Shape Describe
Location on the body Describe
Distance of bruise to floor or patient’s Measure
heel (if indicated)
Color(s) Describe
Margins (i.e., distinct, blurred) Describe
Indurated Yes/no
Painful Yes/no
Patterned (if yes, describe in detail): Yes/no
Associated with injuries in various stages of healing? Yes/no
2. Body diagram
3. Photograph (with and without a scale)
4. Repeat assessment at a later date including
serial photographs (if indicated)
similar to the weapon or object that produced it (Smock,
2001).
If multiple bruises in various stages of healing are
present, then they demonstrate a pattern of injury (Besant-
Matthews, 2006; Sheridan, 2007). The patient should be
re-examined at a later date to assess the healing of in-
juries and the appearance of deep bruises that, origi-
nally invisible, could have risen and become visible on
the skin surface. The forensic nurse should always use
proper terminology when describing injuries. Documen-
tation should include body diagrams showing the lo-
cation of the bruise along with a sketch or, if possi-
ble, a photograph of the injury. Such evidence should
then be secured by the nurse and released to the proper
authorities.
In the case example, the forensic nurse has a duty to
properly assess and document the injuries described ear-
lier in this article. If possible, the bruises should be pho-
tographed and re-examined at a later date to further doc-
ument color change and progress of healing. Bruises well
below the skin surface may not appear immediately after
impact. The patient should be instructed to examine her-
self for any new bruises in the coming days and arrange
to have them documented by the forensic nurse. To keep
the assessment and documentation of injuries consistent,
the same forensic nurse should be used.
Examination and documentation of injuries from vio-
lence are made more difficult without a good history. A
forensic nurse should be very cautious to base her/his ex-
pert opinion solely on physical assessment. The color of a
bruise is only one piece of the assessment puzzle. On the
basis of the reviewed research discussed in this article,
the use of color by itself cannot be the primary criterion
35
Can one accurately date a bruise
to provide an accurate determination of the bruise’s age.
However, a conservative, relative estimation of a bruise’s
age as being newer versus older could be given when
combined with other clinical findings, especially in com-
parison with other existing bruises on the same patient. A
red, painful, indurated bruise with well-defined margins
is more consistent with a patient’s given history of re-
cent injury then a bruise that is yellow, nonpainful, and
nonindurated with blurred margins. In the absence of a
reliable history, one could never provide an exact age of
the bruise within hours or even in days, except to de-
scribe the red bruise as being newer than the yellow one.
Even with a reliable history, the forensic nurse could only
testify that the bruise’s appearance is consistent with or
not consistent with the history of when the trauma was
inflicted.
In the case example, it would be difficult, if not im-
possible, to say with any degree of scientific or medical
certainty that the injuries to the patient’s inner thighs
were the direct result of the reported assault or from a
possible trauma from the previous consensual sexual act.
Despite the fact that the police in our earlier case example
may understandably want to hear that the injuries are re-
lated to the recent assault, the current state of the science
in determining the age of bruises does not support that
conclusion.
Forensic health professionals are frequently asked to
examine victims of violence and comment on the time-
line of their injuries. But when judgments are made
purely based on opinion and guesswork rather than re-
search, the results can be disastrous. Children can be in-
appropriately taken away from their parents, and rapists
can be set free to assault again. The studies presented in
this article demonstrate the lack of consistency in findings
between the available research on dating bruises based on
color. The role of the forensic health professional is to re-
main as objective as possible.
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