the use of radiography in forensic medicine

Radiography (1997) 3, 311-320

REVIEW A R T I C L E

T H i L L E G E O F R A ;IIRAPHERS

THE USE OF R A D I O G R A P H Y IN FORENSIC MEDIC INE Nigel Hughes and Mary Baker

West Midlands' School of Radiography, Faculty of Health & Community Care, University of Central England, Perry Barr, Birmingham B42 2SU, U.K.

(Received 18 July 1996; accepted 21 March 1997)

Forensic radiography has traditionally been carried out within imaging depart- ments or mortuaries by radiographers on a voluntary basis. This paper presents an overview of traditional and newer techniques, together with an insight into some techniques carried out internationally, which may influence future develop- ments in the United Kingdom, as uncovered in a search of the literature using CD-ROM and manual methods.

Key words: identification; cause of death; forensic radiography.

'The X-ray examination of corpses is a most useful tool in the field of medicolegal diagnosis' Schmidt & Kallieris [1]

INTRODUCTION

Forensic medicine can be defined as the application of medical knowledge to questions of law [2]. It should be remembered that this can apply to living as well as dead subjects, and may include aspects of archaeology and anthropology. The main link between the law and medicine in cases where death is involved is provided by the Coroner. Gee [3] describes the origins of the role of the Coroner f rom Norman times, and comments that the medical side of the investigation is in fact a comparatively recent development, occurring only within the last 200 years. This paper is primarily concerned with the use of radiography in the forensic context where death is involved. Pilling [4] comments that ' the law uses radiography mainly to further the ends of justice'. In England and Wales, about a third of the deaths per year cannot be certified by the attending doctor and have to be referred to the coroner [5]. There are several areas where radiography may be useful in the investigation of death. These are outlined in more detail below. The literature search was carried out using Medline and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases for the past 15 years, and by a manual search of Radiography and Radiography today from 1960 to present date.

It is interesting to note that the earliest recorded use of forensic radiography was on the 29 April 1986--not long after the discovery of X-rays. This occurred in Nelson, Lancashire where X-rays were utilized to detect bullets in the brain of Ann Hattley, shot by her husband. The equipment was battery-powered and two exposures were made, one of 60 min and one of 70 min [5].

1078-8174/97/0403I l + 10 $18.00/0 © 1997 The College of Radiographers

312 Hughes and Baker

INVESTIGATION OF IDENTITY

A fuller review of techniques for sexing and identifying can be found in texts such as Simpson's Forensic Medicine [6]. When a deceased person is found, papers carried on the body or its location may help in its identification. However, with badly decomposed or destroyed bodies, those found in unusual locations, large civilian disasters (e.g. Lockerbie air crash, December 1988) and where attempts have been made to deliber- ately conceal the identity of the body, it may be more difficult to establish identity. Fingerprints are often able to be taken, even from quite badly decomposed bodies, as areas of the dermal ridges may be maintained. These can then be checked against a search of criminal records or confirmed from items at the suspected victim's home. Dental appearances can be charted and compared with records of suspected victims [7].

R A D I O G R A P H Y IN IDENTIF ICATION

Knight [5] notes that two avenues of investigation exist where radiography can be used. Firstly, a general classification can be made by species, sex, age, race and stature--age determination being particularly aided by radiography. Secondly, comparison of a variety of pre- and post-mortem films may be of use in particular cases.

Ludes et al. [8] describe the use of radiography in assisting identification of victims of the A320 airbus crash at Mount-St-Joule, France, and point out the importance of a skilled, multidisciplinary team for investigation. Similarly, Owsley et al. [9] stressed the importance of radiography in the identification of the Branch Davidian Compound victims in Mount Carmel, Texas. In particular, they comment on the importance of radiography to preserve information crucial to identity in rapidly decomposing material and prior to autopsy.

In terms of reliability, Hogge et al. [10] investigated how interpreter experience-level affects identification. Those with training in radiographic interpretation performed significantly better than other medical groups, but were still not completely accurate. They conclude that trained interpreters are needed for forensic identification.

Comparison o f pre- and pos t -mor tem radiographs Radiography may be useful in confirming suspected identity by comparison of pre- and post-mortem radiographs, and Riepert et al. [11] describe the identification of 30 unknown bodies by this means. They conclude that radiographic investigation provides a useful, rapid and cheap method to assist identification. Owsley and Mann [12] describe how acceptance or rejection of identity can be made using comparative pre- and post-mortem radiographs of the chest and abdomen. Features such as contours of bony elements, skeletal anomalies, radiodensities and radiolucencies all play essential parts in comparison.

Sanders et al. [13] describe an example of the use of the clavicle, which was the only surviving bone from a burnt-out car and comparison with the clavicle on an antemor- tern chest film allowed confirmation of identity. Simpson [14] and Salgado et al. [15] describe the use of comparative views of older healed fractures or deformities, and the use of dental radiographs--particularly in destructive fires or air crashes.

Buitrag-Tellez et al. [16] describe a method for digitizing ante- and post-mortem films to enhance bone detail on poorly preserved or technically deficient films, and hence aid confidence in comparison. With advances in computer technology and digital image processing, this technique may develop further.

Radiography in Forensic Medicine 313

One perceived problem of comparison of pre- and post-mortem films may be the effect of ageing on the victim, and Sauer et al. [17] collected early and late exposed abdominal radiographs from a series of patients. The range of the treatment period was from 10 to 23 years but by comparing lumbar vertebrae, they found that the ability to make positive diagnosis, even after 23 years, was not diminished.

Skeletal features used in identification--skull and face It is interesting to note the variety of bones and features used to assist in identification. Pilling [4] suggests that apart from the skull, the other bones which are most useful for identification purposes by radiography are the thoracic vertebrae.

In 1921, Schuller [18] first postulated the use of frontal sinus radiographs for identification and this was further developed to form a grid system which is still in use today. Poole [19] pointed out that the outlines of the frontal sinuses are not identical in any two persons. A further skull identification technique developed by Sassouni [20] took measurements from a series of subjects, from whom eight specific areas were chosen for comparison. Using a series of 100 pre- and post-mortem films, all were able to be matched. Rhine and Sperry [21] demonstrated that where only a pre-mortem lateral skull film is available, comparison of mastoid sinuses and arterial pattern is successful in identification of the victim.

Glaister and Brash [22] describe the skull-upon-portrait superimposition technique, first practised in the Ruxton case in Scotland (R v Ruxton, 1938). Several examples of well known cases in which comparative radiographs were crucial in establishing the identity of the deceased are also cited by Simpson [14]. Craniofacial superimposition was evaluated further by Yoshino et al. [23]. They conclude that the ideal situation is to use photographs of the suspected victim in frontal, oblique and lateral projections. Minaguchi et al. [24] report a case where craniofacial superimposition combined with computed tomography (CT) confirmed the identity of a subject following discovery of the suspect's dentures. The significance of dental prostheses in identification of a victim is also highlighted by Jensen [25].

Skeletal features used in identification--vertebral column and pelvis Sinclair [26] identifies vertebral column findings such as spinal fusion and laminectomy, as being helpful for comparative purposes. This was further corroborated by Ludolph and Hering [27] who investigated the significance of degenerative and occupational disease of the lumbar spine. A recent case of particular interest is described by Owsley et al. [28], in which the only relatively complete bone found from one of American serial killer Jeffrey Dahmer's victims was a cervical vertebra. Osteological and radiological features were able to be matched using pre- and post-mortem radiographs and resulted in positive identification of the victim.

Vertebral characteristics and anomalies which are useful for personal identification are also described by Frayer and Bridgens [29]. Varga and Takacs [30] report a case where a body was identified mainly from the radiographic evidence of congenital acetabular dysplasia.

Skeletal features used in identification--extremities and other bones Owsley and Mann [31] illustrate a case where a burned, skeletonized victim was identified using feet and leg radiographs and point out in the paper the importance of clinical radiography in medicolegal investigation.


Tsunenari et al. [32] describe a case where the sternum was used to identify a body without upper extremities, feet and head or neck, found on the seashore in which the radiographic examination showed a prominence of the manubrium with some characteristic shadowing. This was successfully matched with a pre-mortem film of a 58-year-old fisherman who had been missing at sea for 21 days.

Bertelsen et al. [33] looked at 195 mid-shaft femoral bone samples in transverse section. Microradiographs were used to look at the number of Haversian systems, and although changes were noted with age, it was concluded that the range was too wide for accurate age determination.

Riepert et aI. [34] report a retrospective study of the incidence, age dependence and sex distribution of the calcaneal spur. From a sample of 1027 Caucasian patients in central Europe, 161 (15.7%) had calcaneal spurs. From analysis of the results, they concluded that the spurs can provide evidence for identity and age, and to a certain extent the profession, physical activity and constitution during life.

An interesting investigation into sexual determination by scapular measurement is described by Di Vella et al. [35] who found that the association of two glenoid measurements allowed determination of skeletal sex with a 10% misclassification rate. The conclusion was that measurements could be considered quite useful in forensic investigation when just fragmented scapular remains are recovered.

Loth et al. [36] describe further development of their initial work in the use of the fourth rib for assessment of the age of death in the adult skeleton and in a sample of 135 Caucasians, ribs 3, 4 and 5 were removed at autopsy. They concluded that age could also be assessed from the adjacent ribs. Russell et al. [37] independently tested the original 4th rib ageing technique described by Iscan and Loth [38], concluding that it could be reliably included in multifactorial age estimation.

D e n t a l i d e n t i f i c a t i o n Dental radiography is frequently used for identification and ageing purposes, either with the teeth in situ or from a removed and sanitized mandible. MacLean et al. [39] found an accuracy rate of 93% for identification of subjects from dental radiographs using observers with varying degrees of experience. Kvaal et al. [40] investigated the use of measurement of pulp size to estimate chronological age of adults since it is already known that the size of the dental pulp cavity is reduced as a result of secondary dentine deposition. They describe a technique looking at various ratios of measurements, concluding that this may be a useful non-invasive technique for age estimation, but requires further corroboration. The accuracy of inter-observer measurements and determination of age from dental radiographs was investigated by Borrman et al. [41]. Age estimation using statistical techniques was found to be dependent on the experience of the observer and they point out that care should be taken not to rely too heavily on odontological age estimation. It is interesting to note from a report by Kullman et al. [42] that in Sweden, a computerized register is kept of dental records of all missing persons, which is useful in rapid identification of remains.

CAUSE OF DEATH INVESTIGATION

Radiographic investigation of either the lull cadaver or specimens from it forms a useful adjunct to autopsy examination in the determination or confirmation of the cause of death. The identification of old or multiple fractures, particularly in cases of suspected


non-accidental injury (NAI) may have significance. Gee [3] describes a case in which X-rays of suspected NAI were conclusive in proving the innocence of the parent. A child, according to the father, rolled from a settee, banged its head and died. At autopsy, fractured ribs were found and the police were suspicious of NAI. However, radiographs demonstrated gross congenital bone abnormalities with hemivertebra, webbed ribs and pronounced osteoporosis resulting in fragility of the ribs. Norman et al. [43] present a good overview of pathological, radiographic and legal aspects of the morphology of injuries in abused children.

With an estimated 200 deaths per year, long-term physical injuries in 2000 and permanent cerebral damage in about 300 others [44], non-accidental injury (NAI) is one area where radiographers are frequently involved in imaging. Cameron [45] pointed out that the severity of injuries can range from minimal trauma to fatality, and maybe cutaneous, visceral, neurological or skeletal. He recommends that a combined clinical and radiological approach is usually essential to make the diagnosis. Hall [46] provides a comprehensive review of the sociological, psychological, physical and radiological aspects of NAI. He also suggests a sequence to be followed for skeletal surveys in children under 2 years old--Antero-posterior (AP) and Lateral (LAT) skull to include cervical spine lateral, AP and LAT chest, AP pelvis, LAT dorsal and lumbar spine, AP upper and lower limbs to include hands and feet. In common with other sources, the single shot 'babygram' (complete child radiographed on one film with one exposure technique) is decried, particularly for its lack of detail, especially in the limbs. From personal experience and in discussion with radiologists and radiographers, we have found that similar protocols to that suggested by Hall are in fact carried out. Slightly different protocols are suggested by Hall for older children ( ~ 5 years) more selective skeletal survey concentrating particularly on areas of clinical interest or concern, whilst for children over 5 years, radiographic studies are confined to areas of clinical injury [47, 48]. Imaging of the cadavers of older children should be carried out as a basic skeletal survey, as obviously clinical examination will be limited, and preferably prior to post-mortem examination! Merten and Carpenter [48] describe the use of cranial computed tomography (CT) to detect cerebral haemorrhage in infants. In neonates, ultrasound is often used to detect intracranial and intraventricular bleeding. It is possible that this may also be used post-mortem, but no specific references were uncovered to this fact in the search.

H e a d and n e c k Simpson [14] notes that radiography may be of use in determining the shape of weapons, direction of impact, nature and dating of injury in for example, skull fractures.

Sinclair [26] describes the use of radiography in the investigation of traumatic sub-arachnoid haemorrhage (SAH). The post-mortem finding is sometimes accompanied by a fracture of the transverse process of the first cervical vertebra (C1). Fatal SAH can be caused by relatively minor trauma where no cause or reason for the origin of the haemorrhage can be found, and radiography of the atlas and upper cervical spine should be performed in these cases.

Kondo et al. [49] studied nine forensic autopsy cases in which injuries of the brain stem and upper cervical spinal cord due to road traffic accident (RTA) had occurred. Of these, five had atlanto-occipital dislocation, and a ring fracture of the foramen magnum was found in two other cases.


Foreign body location The location of foreign bodies prior to autopsy, and the tracing of wound tracts can both be of use and Knight [5] makes several observations on the use of radiography in locating radiopaque foreign bodies. In order that bullets may be compared with test bullets for rifling marks, it is essential that they are recovered without marking them. Often, the only way to do this is under radiographic control. Where terrorist bombs are concerned, location and recovery of fragments can assist in determining the type and mechanism--and from this the source of the explosive device. Explosive tipped bullets need to be recovered carefully under X-ray control to safeguard the pathologist or surgeon. Russell et al. [50] describe the hazards from a new design of bullet--the Black Talon which produces a controlled expansion upon impact with the target and this raises six sharp edges from its copper jacket. This can provide a significant danger to the pathologist. Oliver et al. [51] describe a method for validation of a bullet path using CT, following use of a radiation planning system to provide visual reconstruction in three dimensions of a contact gunshot wound to the head. Sigrist et al. [52] describe an unusual case in which radiography was used to determine the line of a gunshot within a body and the cause of death from a skeleton and a few lumps of adipocere found in a liquid manure pit.

Cross sectional i m a g i n g - - C T and M R 1 CT has been utilized and compared with conventional autopsy by Donchin et al. [53]. Within 6 h of death, post-mortem total body CT (PMCT) was performed on 25 trauma victims, followed by autopsy, and the findings of PMCT plus autopsy provided more information than either examination alone. It was concluded that PMCT may be useful to determine the mechanism and extent of injury where conventional autopsy is unattainable. Besenski et al. [54] described CT analysis of 13 corpus callosum lesions, outlining a technique of linear translation to determine the site of the blow causing the trauma.

Boyko et al. [55] describe the use of post-mortem MRI for investigation of brain injuries. They concluded that post-mortem MR images proved an invaluable aid that complemented standard pathological examination. Major advantages were found to be the three-dimensional aspects of the images, the ability to detect mineral deposits (e.g. iron), small focal lesion determination and the ability to determine the extent of cerebral oedema.

Angiography and venography Angiography and venography may be of use in determining blood flow to organs either in situ or in vivo, often to assess the mechanism for interruption of blood supply and although not common, two specific papers were found describing such techniques. Resnick et al. [56] describe the use of post-mortem angiography to confirm pulmonary artery perforation following placement of a Swan-Ganz catheter, and Picard et al. [57] describe the use of venous angiography to confirm brain stem death in 125 cases.

Post-mortem angiographic imaging of the vertebral arteries either in situ or in vivo is a technique rapidly gaining credibility and use in the diagnosis of possible vertebral artery tears, particularly in cases of sub-arachnoid haemorrhage of unknown aetiology. Kerner et al. [58] describe creating numerous acrylic castings of the vertebral arteries and basilar artery in a case of lethal basilar artery aneurysm. Using the casts, contrast-filled images were taken, simulating the effects of partially occluding one


vertebral artery, excluding the aneurysm from the circulation and during normal flow. Flow dynamics measurement and comparison with pre-mortem films demonstrated 'chaotic slipstreams entering the apex of the aneurysm', possibly contributing to the final rupture of the lesion.

Determination o f air embolism Other traumatic conditions that benefit from radiography in autopsy include air embolism and pneumothorax determination [5]. Evans and Knight [59] suggest that air embolism may be much more frequent than suspected following surgical intervention, and that deaths during, or soon after, surgery should be radiographically screened routinely to exclude its presence. Similarly, deaths after open-heart surgery, neck surgery and penetrating injuries of the neck and thorax, it is suggested, should also b~ routinely screened radiographically. Calder [60] points out that post-mortem radiographs prior to autopsy are useful in identifying gas in cavities in cases of underwater and hyperbaric deaths.

Other legal usage It should be remembered that forensic radiography is not exclusively limited to examination of the deceased or pathological specimens, medico-legal investigations also fall within the scope. A fuller investigation of these areas can be found in appropriate texts such as Forensic Radiology by Evans and Knight [59].

Customs evasion is a particular area of use, in the investigation and location of hidden contraband in clothing, footwear, luggage or body cavities. Radiography and ultrasound were investigated retrospectively for effectiveness in a study of 'body packers' (persons who swallow or insert drug packages to smuggle through customs) by Hierholzer et al. [61]. Both methods showed equally high sensitivity. Personal experience with a recent case in which the patient had ingested six 'wraps' of heroin, each of about 1 cm diameter, demonstrated that even when wrapped in clingfilm covering, careful radiographic technique and selection of exposure factors can locate the items.

A possible future use for radiography? Avrahami et al. [62, 63] describe the techniques of thorascopic and laparoscopic autopsy. It is felt that this may be an option where consent for conventional autopsy is withheld or there is reluctance for religious reasons. This could be combined with radiographic examination, CT, MR or ultrasound, and may be instrumental in a further decrease in the number of conventional autopsies performed. Benefits from this technique would include decreased risk of transmission of disease (e.g. hepatitis, CJD), as well as improved cosmetic appearance of the cadaver for the family, particularly where religious or cultural objections may exist.

Conclusion The potential scope for forensic radiographic practice has been shown to be wide and research into the provision and use of forensic radiography services in the United Kingdom is currently being undertaken.

Meserve [64] and Green [65] suggest that Accident and Emergency practitioners may inadvertently destroy vital forensic evidence through lack of awareness. One of the aims of this current research is therefore to investigate the level of knowledge and education


of radiographers in this area and hopefully this paper has provided an overview of some developing areas and has stimulated some interest. Contac t f rom interested individuals is welcomed.

Acknowledgements

Bursary support for this research from the College of Radiographers is gratefully acknowledged. Thanks to Rosemary Klem for proof reading and for valuable comments in preparing this paper.

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