8 Asse ss ment, class ification and do cumentation of injury
■ beating of the soles of the feet (falanga, falaka or bastinado; Figure 8.33)
■ amputation (Figure 8.34)
■ positional torture – e.g. cheera (legs stretched apart) or Parrot’s Perch (wrists tied over knees – a pole placed under the knees)
■ suspension – e.g. Palestinian hanging (arms and wrists tied and elevated behind the back;
figure 8.35), which can result in disruption of shoulder joint complexes and subsequent deformity.
■ electrical burns (Figure 8.36)
■ wet submarine – immersing the victim’s head in a container full of water until the person almost drowns
■ dry submarino – placing the victim’s head inside a plastic bag until nearly suffocated.
Each of these may have short and long-term sequelae.
It is important to recognize that there may be no physical evidence of torture. Where scars or marks are present it is important, for the credibility of the examination to distinguish between alleged tor- ture scars and injuries and non-torture scars and injuries.
D ocumentation of injur y or mark s of injur y
and for reporting such findings to the judiciary and any other investigative body. It is the most appropriate means by which robust evidence can be presented in a standardized manner to the relevant authorities.
Interpretation of findings regarding scars or marks is undertaken using the following gradation:
■ Not consistent: could not have been caused by the trauma described
■ Consistent with: the lesion could have been caused by the trauma described but it is non- specific and there are many other possible causes
■ Highly consistent: the lesion could have been caused by the trauma described, and there are few other possible causes
■ Typical of: this is an appearance that is usually found with this type of trauma
■ Diagnostic of: this appearance could not have been caused in any way other than that described.
■ Documentation of injury or marks of injury
There is a great temptation for doctors and other healthcare professionals to use medical termino- logy to imbue a sense of professionalism and exper- tise to reports and statements. This approach is generally not helpful, either to colleagues attempt- ing to interpret their meaning or to courts unless a concurrent explanation in lay terms is provided.
Forensic pathologists have to use all available information, from police, from witnesses, from med- ical records, from family and many other sources to determine what may or may not have caused fatal injury. Forensic physicians dealing with the injured living person may be able to get a history directly from that person. If it is possible to take a history, then the relevance of factors such as those listed below should be considered:
■ Time of injury or injuries
■ Has injury been treated (e.g. at hospital or at home)?
■ Pre-existing illnesses (e.g. skin disease)
■ Regular physical activity (e.g. contact sports)
■ Regular medication (e.g. anticoagulants, steroids)
■ Handedness of victim and suspect
■ Use of drugs and alcohol
■ Weapon or weapons used (if still available)
■ Clothing worn
This information should be easily obtainable and documented in the contemporaneous medical notes. There is often an ‘evidence gap’ for those seriously injured, and who require resuscitation and immediate surgery or ventilation, when com- pared with relatively minor interpersonal assaults, where the complainant can give a full account and injuries can be documented, and the deceased, who will have a post-mortem examination carried out by a forensic pathologist. The duty of care in the critically injured rightly outweighs the need to document injury accurately, or to retrieve crucial evidence, and lack of forensic skills mean that often hugely important evidence (e.g. nature of injury or important trace materials) is lost. There is a clear argument for (1) increasing the level of forensic skills of those involved in the care of the severely or critically injured or (2) have available forensic physicians who can (with the consent of the clinical teams) gather evidence at the earliest opportunity.
The following characteristics should be recorded wherever possible for each injury:
■ Location (anatomical – measure distance from landmarks)
■ Pain
■ Tenderness
■ Reduced mobility
■ Type (e.g. bruise, laceration, abrasion)
■ Size (use metric values – use a ruler, do not esti- mate)
■ Shape
■ Colour
■ Orientation
■ Age
■ Causation
■ Handedness
■ Time
■ Transientness (of injury).
The recording of such information in the clinical setting should ideally be in three forms. First in a written form, appropriately describing the injury, second as a hand-drawn body diagram and, idea lly, to supplement the first two, in digital image form.
Such documentation will ensure that the opportu- nity for proper interpretation is maximized. Thus any clinical notes should: record the appropriate history; record accurately and clearly all findings – positive and negative; record legibly; summarize findings with clarity; use consistent terminology;
and interpret within the limits of your experience.
8 Asse ss ment, class ification and do cumentation of injury
If you cannot, or should not give opinion on your clinical findings, state this clearly.
Forensic pathologists must document and record all injuries identified at post-mortem examination in detail, sufficient to enable subsequent review of their findings, and to demonstrate the reliability of their conclusions in any legal forum.
■ Further information sources
Betz P. Pathophysiology of wound healing, Chapter 8. In:
Payne-James J, Busuttil A, Smock W eds. Forensic Medicine. Clinical and Pathological Aspects. London:
Greenwich Medical Media, 2003.
Bleetman A, Watson CH, Horsfall I, Champion SM. Wounding patterns and human performance in knife attacks:
optimising the protection provided by knife resistant body armour. Journal of Clinical Forensic Medicine 2003; 10:
243–8.
Bleetman A, Hughes Lt H, Gupta V. Assailant technique in knife slash attacks. Journal of Clinical Forensic Medicine 2003;10: 1–3.
Byard RW, Gehl A, Tsokos M. Skin tension and cleavage lines (Langer’s lines) causing distortion of ante- and post mortem wound morphology. International Journal of Legal Medicine 2005; 119: 226–30.
Chadwick EK, Nicol AC, Lane JV, Gray TG. Biomechanics of knife stab attacks. Forensic Science International 1999;
105: 35–44.
Deodhar AK, Rana RE. Surgical physiology of wound healing:
a review. Journal of Postgraduate Medicine 1997; 43:
52–56.
Dolinak D, Matshes E. Blunt force injury, Chapter 5. In: Dolinak D, Matshes EW, Lew EO (eds). Forensic Pathology – Principles and Practice. London, UK: Elsevier Academic Press, 2005.
European Convention on Human Rights, Article 3. http://www.
hri.org/docs/ECHR50.html#C.Art3 (accessed 22 November 2010).
Gall JAM, Boos SC, Payne-James JJ, Culliford EJ. Forensic Medicine Colour Guide. Edinburgh: Churchill Livingstone, 2003.
Gall J, Payne-James JJ ( ). Injury interpretation – possible errors and fallacies. In: Gall J, Payne-James JJ (eds) Current Practice in Forensic Medicine. London: Wiley, 2011.
Gall J, Payne-James JJ, Goldney RD (2011). Self-infl icted Injuries and Associated Psychological Profi les. In: Gall J, Payne-James JJ (eds) Current Practice in Forensic Medicine. London: Wiley, 2011.
Green MA. Stab wound dynamics – a recording technique for use in medico-legal investigations. Journal of the Forensic Science Society 1978; 18: 161–3.
Henn V, Lignitz E. Kicking and trampling to death: pathological features, biomechanical mechanisms, and aspects of
victims and perpetrators, Chapter 2. In: Tsokos M (ed.), Forensic Pathology Reviews Volume 1. Totowa, NJ, USA:
Humana Press Inc., 2004.
Horsfall I, Prosser PD, Watson CH, Champion SM. An assessment of human performance in stabbing. Forensic Science International 1999; 102: 79–89.
Hughes VK, Ellis PS, Langlois NE. The perception of yellow in bruises.Journal of Clinical Forensic Medicine 2004; 11:
257–9.
Hunt AC, Cowling RJ. Murder by stabbing. Forensic Science International 1991; 52:107–12.
Jaffe FA. Petechial haemorrhages. A review of pathogenesis.
American Journal of Forensic Medicine and Pathology 1994;15: 203–7.
Jones R. Wound and injury awareness amongst students and doctors.Journal of Clinical Forensic Medicine 2003; 10:
231–4.
Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force:
typical and atypical features. International Journal of Legal Medicine 2000; 113: 259–62.
Karger B, Rothschild MA, Pfeiffer H. Accidental sharp force fatalities – beware of architectural glass, not knives.
Forensic Science International 2001; 123: 135–9.
Karlsson T. Homicidal and suicidal sharp force fatalities in Stockholm, Sweden. Orientation of entrance wounds in stabs gives information in the classifi cation. Forensic Science International 1998; 93: 21–32.
Knight B. The dynamics of stab wounds. Forensic Science 1975;6: 249–55.
Langlois NE, Gresham GA The ageing of bruises: a review and a study of the colour changes with time. Forensic Science International1991;50: 227–38.
Levy V, Rao VJ. Survival time in gunshot and stab wound victims.American Journal of Forensic Medicine and Pathology 1988; 9: 215–17.
Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Archives of Diseases in Childhood 2005; 90:182–6.
Maguire S, Mann MK, Sibert J, Kemp A. Can you age bruises accurately in children? A systematic review. Archives of Diseases in Childhood 2005; 90: 187–9.
Munang LA, Leonard PA, Mok JY. Lack of agreement on colour description between clinicians examining childhood bruising.
Journal of Clinical Forensic Medicine 2002; 9: 171–4.
O’Callaghan PT, Jones MD, James DS et al. Dynamics of stab wounds: force required for penetration of various cadaveric human tissues. Forensic Science International 1999;104: 173–8.
Offences against the Person Act 1861. http://www.statutelaw.
gov.uk/content.aspx?activeTextDocId=1043854 (accessed 22 November 2010).
Ong BB. The pattern of homicidal slash/chop injuries: a 10 year retrospective study in University Hospital Kuala Lumpur.
Journal of Clinical Forensic Medicine 1999; 6: 24–9.
Ormstad K, Karlsson T, Enkler L, Law B, Rajs J. Patterns in sharp force fatalities – a comprehensive forensic medical study. Journal of Forensic Sciences 1986;31: 529–42.
F urther information sourc es
Pilling ML, Vanezis P, Perrett D, Johnston A. Visual
assessment of the timing of bruising by forensic experts.
Journal of Forensic and Legal Medicine 2010; 17:
143–9.
Polson CJ, Gee DJ. Injuries: general features. In: Polson CJ, Gee DJ, Knight B (eds). The Essentials of Forensic Medicine, 4th edn. Oxford: Pergamon Press, 1985.
Pretty IA. Development and validation of a human bitemark severity and signifi cance scale. Journal of Forensic Sciences52: 687–91.
Purdue B.N. Cutting and piercing wounds. Chapter 9. In: Mason JK, Purdue BN (eds) The Pathology of Trauma, 3rd edn.
London: Arnold, 2000.
Rutty GN. Bruising: concepts of ageing and interpretation. In:
Rutty GN (ed.). Essentials of Autopsy Practice. London:
Springer-Verlag, 2001.
Robinson S. The examination of the adult victim of assault.
Chapter 10. In: Mason JK, Purdue BN (eds) The Pathology of Trauma, 3rd edn. London: Arnold, 2000.
Sexual Offences Act 2003. http://www.legislation.gov.uk/
ukpga/2003/42/contents (accessed 22 November 2010).
Spitz W.U. Blunt force injury. Chapter 7 In: Spitz WU (ed.) Spitz and Fisher’s Medico-legal investigation of death – Guidelines to the Application of Pathology to Crime Investigation, 3rd edn. Springfi eld, IL: Charles C Thomas Publishers, 1993.
Sweet D, Lorente M, Lorente JA et al. An improved method to recover saliva from human skin: the double swab technique.Journal of Forensic Sciences 1997; 42: 320–2.
Thoresen SO, Rognum TO. Survival time and acting capability after fatal injury by sharp weapons.Forensic Science International 1986; 31: 181–7.
Vanezis P, West IE. Tentative injuries in self stabbing. Forensic Science International 1983; 21: 65–70.
Vanezis P, Payne-James JJ. Sharp force trauma, Chapter 22 In: Payne-James JJ, Busuttil A, Smock W (eds). Forensic Medicine – Clinical and Pathological Aspects. London:
Greenwich Medical Media, 2003.
Chapter
9
Regional injuries Chapter
■ Introduction
Specific regions of the body may be particularly susceptible to types of trauma that may not cause serious or fatal injury elsewhere. A good example of this may the single stab wound. If this penetrates the limbs then a serious or fatal outcome is unlikely, unless a large artery is injured. If a single stab wound penetrates the heart or the abdominal aorta a fatal outcome is much more likely. Consideration of patterns of injuries according to the body region, and the potential complications of those injuries, is therefore an important component in both the clini- cal and pathological evaluation of trauma.
■ Head injuries
Any trauma to the head or face that has the potential for damaging the brain can have devastating conse- quences. Normally the brain is protected within the bony skull, but it is not well restrained within this compartment and injuries to the brain result from dif- ferences between the motion of the solid skull and the relatively ‘fluid’ brain. There are three main com- ponents of the head: the scalp, the skull and the brain.