Medicolegal Significance Research Articles

The symmetry of self mutilation and the chess board pattern

The assessment of injury patterns in forensic practice sometimes requires separation of self inflicted injuries from those that have been inflicted by another, as the medicolegal significance of each is entirely different. Certain repetitive features are found in self inflicted injuries that may assist in identifying these cases. Non-lethal self inflicted injuries are usually incised, and are located in areas of the body that are accessible. Common areas include the forearms, anterior thighs, forehead, cheeks, upper chest and abdomen [1]. The lesions tend to occur on the opposite side to the dominant hand and are not found in sensitive areas such as the eyelids, genitalia or nipples, unless there is a serious underlying psychiatric disturbance. Typically the clothing has been carefully lifted before the wounds are inflicted in contrast to assaults where stab and slash wounds often cut through overlying fabric [2, 3]. The wounds also tend to have characteristic pathological features, occurring in clusters of superficial incised lesions of similar depth [4]. Healed scars from self infliction may also serve as an indication of previous self harming actions and may record the pattern of the original injury. One of the most telling features is symmetry, with similar lesions sometimes being cut into opposite limbs. Fig. 1 illustrates this symmetry with a series of faint paired scars on the anterior aspect of the lower leg. The lesions are uniformly spaced and parallel, similar to a second case where the scars were found in an orderly pattern on the anterior thigh (Fig. 2). On occasion, words or designs may be cut into the skin with the intention of focussing blame on a particular individual or group. For example, incised swastikas have been used by individuals pretending to be victims of right wing violence [5]. A case of a teenage girl has also been reported, who alleged that she had been assaulted and had the word ‘‘whore’’ cut into her arm and forehead. Careful examination of the letters on the forehead revealed that they were reversed as they had been cut by the victim using a mirror [6]. Another very distinctive feature of self inflicted incised wounds is the so-called ‘‘chess board’’ pattern [4]. This refers to clusters of incised wounds that run parallel and at right angles to each other, creating a series of ‘‘squares.’’ Again, this is a feature that is very strongly suggestive of self infliction, as movement of a victim who is frightened and in pain from a knife attack means that individual lesions are rarely so controlled, unless the victim has been incapacitated in some way, or is already unconscious or dead. Figure 3 demonstrates a typical chess board pattern, in this case formed by a series of uniformly spaced horizontal incisions across a forearm, intersected by parallel longitudinal cuts. In Fig. 4 a series of fine closely spaced incisions on the wrist and hand demonstrate a more subtle chess board effect. In the case of deeper incisions, healing may result in scarification. This is shown in Fig. 5 where scarring of a forearm following self inflicted wounding acts as a record of the original chess board pattern revealing squares of varying sizes. R. W. Byard (&) Discipline of Anatomy and Pathology, Level 3 Medical School North Building, The University of Adelaide, Frome Road, Adelaide, SA 5005, Australia e-mail: roger.byard@sa.gov.au

The assessment of lethal propeller strike injuries in sea mammals

Assessment of injuries in marine mammals may be required to help authorities determine whether human activity was involved. Three cases of marine animal deaths involving propeller blade strikes are reported to demonstrate characteristic features of such cases and diagnostic difficulties that may occur. Case 1: A juvenile New Zealand fur seal (Arctocephalus forsteri) suffered two parallel linear incised wounds of the flank and died following small intestinal herniation. Case 2: An Indo-Pacific bottlenose dolphin neonate (Tursiops aduncus) died from a deeply incised wound of the left side of the head with shattering of the skull and laceration of the underlying brain.Case 3: An adult female Indo-Pacific bottlenose dolphin (T. aduncus) died from two parallel chop wounds to the torso with opening of the thoracic and abdominal cavities with fractures of the ribs and vertebrae. Given that some animals may recover, and that the carcasses of those that are killed may simply not be found or reported, it is impossible to provide an estimate of the incidence of this type of injury amongst wild sea mammals. In cases that do come to forensic attention accurate evaluation of the type of injury may potentially have great medicolegal significance. Post-mortem putrefaction and post-mortem feeding by other sea animals may complicate assessments.

Use of reflectance spectrophotometry and colorimetry in a general linear model for the determination of the age of bruises

Bruises can have medicolegal significance such that the age of a bruise may be an important issue. This study sought to determine if colorimetry or reflectance spectrophotometry could be employed to objectively estimate the age of bruises. Based on a previously described method, reflectance spectrophotometric scans were obtained from bruises using a Cary 100 Bio spectrophotometer fitted with a fibre-optic reflectance probe. Measurements were taken from the bruise and a control area. Software was used to calculate the first derivative at 490 and 480nm; the proportion of oxygenated hemoglobin was calculated using an isobestic point method and a software application converted the scan data into colorimetry data. In addition, data on factors that might be associated with the determination of the age of a bruise: subject age, subject sex, degree of trauma, bruise size, skin color, body build, and depth of bruise were recorded. From 147 subjects, 233 reflectance spectrophotometry scans were obtained for analysis. The age of the bruises ranged from 0.5 to 231.5h. A General Linear Model analysis method was used. This revealed that colorimetric measurement of the yellowness of a bruise accounted for 13% of the bruise age. By incorporation of the other recorded data (as above), yellowness could predict up to 32% of the age of a bruise-implying that 68% of the variation was dependent on other factors. However, critical appraisal of the model revealed that the colorimetry method of determining the age of a bruise was affected by skin tone and required a measure of the proportion of oxygenated hemoglobin, which is obtained by spectrophotometric methods. Using spectrophotometry, the first derivative at 490nm alone accounted for 18% of the bruise age estimate. When additional factors (subject sex, bruise depth and oxygenation of hemoglobin) were included in the General Linear Model this increased to 31%-implying that 69% of the variation was dependent on other factors. This indicates that spectrophotometry would be of more use that colorimetry for assessing the age of bruises, but the spectrophotometric method used needs to be refined to provide useful data regarding the estimated age of a bruise. Such refinements might include the use of multiple readings or utilizing a comprehensive mathematical model of the optics of skin.

Medicolegal significance of asymmetrical hearing loss in cases of industrial noise exposure

In Australia, the current guidelines for evaluation of noise-induced hearing loss suggest that, in cases of asymmetrical loss, 'the worse ear be equated to the better ear' for purposes of compensation. This study aimed to establish that such a method was prejudicial to the worker (i.e. the plaintiff). In consideration of the legal duty 'to co-construct the ideas of truth and the ideas of justice in the context of legal proceedings', our study objectives were (1) to document the incidence of asymmetrical hearing loss in compensation cases seen in our practice, and (2) to provide a reasoned argument for inclusion of the same for compensation considerations. Open, retrospective, clinical study. Australian plaintiffs with asymmetrical hearing loss (who comprise a significant percentage of industrial hearing loss legal cases) may be excluded from full consideration of their hearing loss as a result of the current guidelines. In contrast to the process of medical diagnosis and treatment, it appeared that the application of accepted probability standards within the legal process may permit inclusion of such clients' hearing loss in compensation considerations. This study included 208 consecutive clients referred by legal practitioners for assessment of hearing loss for compensation purposes. A total of 22.6 per cent of clients (47 of 208) had asymmetrical hearing loss, with the left side having the greater loss in 60 per cent of cases. We believe that asymmetrical hearing loss should be included in compensation considerations, both on medical and legal grounds.

Bilateral calcified stylohyoid ligament: An incidental autopsy finding with medicolegal significance

Eagle’s syndrome occurs due to elongation of the styloid process or calcification of the stylohyoid ligament, which then may produce a pain sensation due to pressure exerted on various structures in the head and neck region. A case report of calcified stylohyoid ligament found incidentally at autopsy and further confirmed by computed tomography scan and histopathology is herein discussed with associated medicolegal significance.

Infantile Perineal Protrusion

Infantile perineal protrusion is a recently described dermatologic entity that resembles a skin tag and can be confused with evidence of sexual child abuse. Although well-described by the pediatric and dermatologic community in small case series and case reports, we found little reference to this abnormality in the forensic literature despite its medicolegal significance. Therefore, we present a case of a 3-month-old infant who had a representative example of this lesion.

S118 Testicular injuries, conseqences and medicolegal significance

S118 Testicular injuries, conseqences and medicolegal significance

The Challenge of Identifying Commingled Skeletal Remains via CT Imaging and Morphometric Analysis

Human skeletal remains were discovered at a construction site in lower Manhattan. Officially determined that the post‐cranial material was not of medicolegal significance, our team undertook an anatomically driven forensic evaluation of the remains. Post‐cranial isolated bony elements were identified (n = 52), digitally photodocumented, morphometrically assessed and CT scanned for graphical examination. Post‐cranial commingled remains consisted mostly of lower limb bones from at least 3 distinct individuals based on three left cuboid bones found. 31 foot bones were measured and classified using bony landmarks. Comparison to homologous bones of known stature individuals was used to approximate the size differences found among the unknown sample. Maximum a‐p lengths of the three left cuboids measured 44.5, 35.8 and 35.6 mm while the two left calcaneal bones measured 89.2 and 77.5 mm. Size difference was used to group the tarsal bones to either the larger or two smaller individuals. CT imaging of adult femurs revealed their intensity of femoral curvature to fall within the Caucasian spectrum while overall rugosity of the larger bones indicated that the larger individual was male. A combination of CT, comparative and morphometric assessment was the key to overcoming the challenge of cataloging and identifying commingled skeletal remains, and may be the ideal approach for similar future forensic investigations.Grant Funding SourceNone

Amnesia for violent crime among young offenders

Amnesia for the perpetration of violent offences is an important issue in medico-legal proceedings. Previous studies of amnesia have mainly relied on selected groups of unconvicted offenders, which raises the question of how reliable the findings are. The purpose of this study was to examine the prevalence and phenomenological qualities of amnesia in violent offenders. In semi-structured interviews with 105 young offenders convicted of serious violence, 20 (19%) reported partial amnesia for their offence and only one (1%) reported complete amnesia. Amnesia was associated with high alcohol intake, emotional ties to the victim, and cognitive processing during the assault. Complete amnesia for violent crime appears to be less frequent than suggested by previous reports using unconvicted samples. The findings have implications for the clinical assessment of claimed amnesia for violent crime and are potentially of medico-legal significance.

Diurnal variation in stature – Is it more in children or adults?

Stature is the most often used anthropometric measure in the nutritional, growth and development, anthropological and forensic oriented studies. Its estimate is considered to be an important assessment in the identification of unknown human remains and its medico-legal significance is obvious in forensic examinations. Diurnal variation in stature is a biological norm in the human body and its effects can be reflected in the reliability of height data in these studies. We hypothesize that the extent of diurnal variation is more in children as compared to adults in a population.

Iatrogenic injuries leading to suspicion of homicide

Injuries produced as a result of medical intervention may lead to confusion in certain cases during investigation and postmortem examination. Proper documentation of all interventions with the injuries, if produced, is of vital importance. The present case is a rare case where the iatrogenic injuries produced by a medical practitioner during the course of treatment of a case of suicidal hanging resulted in a suspicion being raised as to the nature of death. The suspicion was further strengthened by the lack of proper documentation and inappropriate/improper use of terminology of medicolegal significance.

The science behind the quest to determine the age of bruises-a review of the English language literature.

Bruises are common injuries that can have medicolegal significance. There are those that maintain it is not possible to estimate the age of bruises. However, appreciation of the biological processes related to the resolution of a bruise suggests that these may provide information regarding the age of a bruise. Potential methods for determining the age of bruises-visual observation, colorimetry, spectrophotometry and histology-are reviewed. The observation of yellow (not orange or brown) indicates a bruise is not recent, but the abilities of visual observation are limited by the physiology of the human eye. Analysis of spectrophotometric data may provide more useful and objective information. Histological examination may be appropriate only in the postmortem situation. The lack of published information limits this as a tool for estimating the age of bruises. It is not known how the wide range of factors that can influence bruise formation and resolution could affect estimation of bruise age.

Reducing Diagnostic Errors in Musculoskeletal Trauma by Reviewing Non-Admission Orthopaedic Referrals in the Next-Day Trauma Meeting

INTRODUCTION Diagnostic errors in orthopaedics are usually caused by missing a fracture or misreading radiographs. The aim of this study was to document the pick-up rate of the wrong diagnoses by reviewing X-rays and casualty notes in the next-day trauma meeting. PATIENTS AND METHODS The casualty notes and radiographs of 503 patients were prospectively reviewed in the daily trauma meeting between August 2002 and December 2002 in a district general hospital. The relevant data were collected and analysed by a single assessor. RESULTS The false positive rate for making an orthopaedic diagnosis was 12.6% (i.e.) diagnosing a fracture, when none existed). The false negative (missing) rate was 4%, while 2.4% incidental findings were missed, or at least not documented, after reading the X-rays. There were 7.8% wrong diagnoses made. The majority of the patients were seen by the senior house officers. CONCLUSIONS The medicolegal significance of false negative diagnosis is obviously greater. In a busy emergency department, where a large number of patients are seen, there is a greater risk. This study shows the importance in a small-to-medium sized accident and emergency unit as well, where there is no senior cover available out-of-hours for final radiological interpretation. A morning trauma meeting which covers reviewing admitted patients as well as non-admission orthopaedic referrals has an effective risk management solution to early detection of missed and wrong diagnoses.

Diurnal Variation of Stature in Three Adults and One Child

Stature is considered as a reliable measure of physical growth and development and its medico-legal significance is obvious in forensic examinations. The present study reports diurnal variation of stature in three adults and one child. The measurements of stature were recorded four times in a day for 56 days in all the subjects i.e. at 0600 hours, 0800 hours, 1800 hours and at 2200 hours. Significant diurnal variation in stature is observed in all the subjects and stature begins to decrease immediately after rising in the morning. A very rapid decrease in stature occurs within first two hours of the day and further loss continues throughout the day in small amounts. The effect of napping, short term lying down and other postural changes, is discussed. A maximum mean daytime loss of stature up to 2.81 cm is observed. The age and body weight seem to affect the diurnal variation in stature to some extent. The results have important implications regarding current practice in the study of growth, development and nutrition as well as in personal identification.

Shaken baby syndrome: A biomechanics analysis of injury mechanisms

Traumatic infant shaking has been associated with the shaken baby syndrome (SBS) diagnosis without verification of the operative mechanisms of injury. Intensities for SBS have been expressed only in qualitative, unsubstantiated terms usually referring to acceleration/deceleration rotational injury and relating to falls from great heights onto hard surfaces or from severe motor vehicle crashes. We conducted an injury biomechanics analysis of the reported SBS levels of rotational velocity and acceleration of the head for their injury effects on the infant head-neck. Resulting forces were compared with experimental data on the structural failure limits of the cervical spine in several animal models as well as human neonate cadaver models. We have determined that an infant head subjected to the levels of rotational velocity and acceleration called for in the SBS literature, would experience forces on the infant neck far exceeding the limits for structural failure of the cervical spine. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for the SBS. These findings are consistent with the physical laws of injury biomechanics as well as our collective understanding of the fragile infant cervical spine from (1) clinical obstetric experience, (2) automotive medicine and crash safety experience, and (3) common parental experience. The findings are not, however, consistent with the current clinical SBS experience and are in stark contradiction with the reported rarity of cervical spine injury in children diagnosed with SBS. In light of the implications of these findings on child protection and their social and medico-legal significance, a re-evaluation of the current diagnostic criteria for the SBS and its application is suggested.

Brain damage and axonal injury in a Scottish cohort of neonatal deaths

Despite the clinical and medicolegal significance attached to perinatal asphyxia, the neuropathological basis of this condition remains obscure. There are very few studies in the literature which correlate the pathological findings in neonatal brains with detailed epidemiological data, and none which are population based. In a Scotland-wide study of neonatal deaths, 70 brains have been examined. On the basis of glial and macrophage reactions, we previously identified infants with putative antepartum brain damage in this cohort and have related these reactions to signs of birth asphyxia. The present study explores the extent of neuronal/axonal injury in these infants since this is likely to be the basis for neurological deficits in surviving infants. We have also investigated these brains for beta-amyloid precursor protein (betaAPP) positivity to determine whether this is a useful marker of neuronal injury in neonates. Neuronal eosinophilia and karyorrhexes were detected in 43% and 27% of the cohort, respectively; maximally in the subiculum and ventral pons, but often present elsewhere. White matter damage was detected in 24% of cases but without classic cystic lesions of periventricular leucomalacia. betaAPP positivity was present in neuronal soma in 52% of cases and, in axons, in 27% of cases, and was seen from as early as 25-weeks gestation. Axonal bulbs were clearly delineated by betaAPP positivity and were usually located in the cerebral white matter and internal capsule, and infrequently in the brain stem. Although white matter damage and betaAPP axonal positivity were often detected in the same cases (P = 0.034), these features also occurred independently of each other. Both neuronal karyorrhexes and white matter betaAPP positivity were significantly correlated with the features of birth asphyxia, particularly a history of seizures. Immunocytochemistry for both betaAPP and glial fibrillary acidic protein proved useful in detecting neuropathological features which escaped detection on routine examination, particularly in preterm infants. The presence together of recent and older damage in individual brains suggests that there is an ongoing neuronal response to cerebral insults. We find that betaAPP is a useful marker of white matter damage in the neonatal brain. Immunopositivity for betaAPP in these circumstances is not attributable to inflicted or accidental trauma. While birth-related trauma cannot be ruled out, hypoxia/ischaemia is a likely cause in these infants. However, the exact pathogenesis of neuronal/axonal injury in the neonatal brain remains unclear.

Can Suicides be Identified from Case Records? A Case Control Study using Blind Rating

A majority of case control studies of suicide risks in psychiatric patients reveal an excess of risk factors in cases. None of the case control studies has been conducted blind to case identity. The present study examined the possibility that skilled clinicians could identify suicides blind from case records of last episode of care. Records of 39 suicides of psychiatric patients and their matched controls (N = 78) were abstracted blind and dichotomously rated for suicide by seven raters. Success in identification of cases approximated to chance expectation. Pending replication, these disappointing findings call in question the clinical utility of risk factor findings to date, their validity as a basis for significant change in service provision and the medico-legal significance of records in suicide-related civil law suits.

Wound and injury awareness amongst students and doctors

Introduction: Concern has been raised in the medical press regarding the inability of doctors to describe wounds and injuries of medico-legal significance correctly. Methods: Medical students and doctors of all grades, from the Department of Surgery at a London teaching-hospital affiliated unit were shown a series of photographs illustrating wounds and injuries expected to be encountered in emergency medical practice. They were asked to identify the type of wound or injury as well as the manner in which that injury may have been caused. Result: The results indicated that students and doctors of all grades in this unit were not confident at identifying wounds and injuries, using the correct terminology. The term ‘laceration’ was widely used to describe incised wounds, and vice versa. Gun shot wounds were poorly identified as such, and were only correctly described by those who clearly ‘knew’ what they were looking at. Conclusion: In order to provide doctors with the skills with which they need to correctly describe wounds and injuries encountered in an emergency setting, this author proposes the introduction of specific teaching in wound identification at undergraduate and postgraduate levels.

Mummified Trophy Heads from Peru: Diagnostic Features and Medicolegal Significance

Several forms of mummified human trophy heads were produced by prehistoric and historic native groups in South America. This paper describes the diagnostic features of trophy heads produced by the Nasca culture of ancient Peru. A growing interest in these mummified heads among collectors of Pre-Columbian art and antiquities has led to their illegal exportation from Peru, in violation of national and international antiquities laws. Requests from the Peruvian government to protect its cultural patrimony led the United States in 1997 to declare these heads as items subject to U.S. import restriction, along with six other categories of human remains. Despite such restrictions, Nasca trophy heads continue to reach private collectors outside of Peru and thus may be encountered by local, state, or federal law enforcement officials unfamiliar with their characteristic features and origin. The objective of this paper is to describe the features that allow Nasca trophy heads to be identified and distinguished from other archaeological and forensic specimens that may be submitted to a forensic anthropologist for identification.

As Time Goes by

The timing of birth-related events may influence neonatal outcome and is often pivotal in medicolegal cases. This prospective observational study determined the variation in displayed time on timepieces in a regional maternity unit which could result in inaccuracies of time documentation. The mean (95% CI) difference between time displayed and true time was sec (+/- 2 min 4 sec) for delivery room clocks and +1 m 8 s (+/- 7 m 12 s) for resuscitation room clocks. The maximum discrepancy between delivery room and resuscitation room clocks was 7 m 52 s. The abilities of staff to estimate the duration of time passed was also assessed. The mean (95% CI) five-minute estimate was 4 m 52 s (+/- 3 m 12 s). These disparities could have considerable medicolegal significance, and should be taken into consideration in risk management studies. Maternity units should move towards synchronising all timepieces. Meanwhile, statements about the precise timing of events should be regarded with suspicion.