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Bone Pathology and Antemortem Trauma

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DOI: 10.1016/B978-0-12-382165-2.00014-3

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 Bone Pathology and Antemortem Trauma
E Cunha, University of Coimbra, Coimbra, Portugal
J Pinheiro, Instituto Nacional de Medicina Legal, Coimbra, Portugal
ã 2013 Elsevier Ltd. All rights reserved.
Nomenclature
DISH Diffuse idiopathic skeletal hyperostosis
FA Forensic anthropology
FP Forensic pathology
Introduction
This article provides a summary of some bone pathologies that
are useful for forensic anthropology (FA), focusing on aspects
related to identification (ID). Antemortem trauma is also
reviewed, with an emphasis on its benefits for forensic anthro-
pology, particularly in cases of child abuse or torture.
During the reconstructive phase of identification, forensic
anthropologists – besides generating a biological profile of the
victim – have to read the skeleton and/or body in order to
identify factors of individualization. These factors make it pos-
sible to discriminate one individual from another; no two
skeletons are alike.
Among the particularities of skeletons with the potential to
discriminate, anthropologists must be particularly careful to
distinguish between morphological and pathological traits.
This is important because some of the so-called discrete traits –
that is, nonmetric skeletal traits – can be misdiagnosed as le-
sions. Examples include sternal perforation or septal aperture in
the humerus. The frontiers between morphology and pathology
are fluid, and only solid determinations of anatomical variants
can lead to reliable diagnoses.
Anthropologists also deal with paleopathology, which is
the use of sources such as skeletons and iconography to study
the history and evolution of diseases, although skeletons are the
common elements between FA and paleopathology. However,
while in FA one has the possibility to verify the diagnosis,
this almost never occurs with past populations. The bridge
between these two sciences is indeed important. Only with
a strong background on reading and interpreting dry bones
would one be able to recognize some pathologies.
Yet, in FA, the most important issue is not the diagnosis of
the pathology itself, but more importantly the description of
their consequences on the individual’s life. A particular gait or
an abnormal limb shape will be more easily recalled and/or
confirmed by the relatives of the victim than the pathology
itself. Spondyloarthropathy (SP) is a good example of this:
although the family might not know the name of the disease,
they may recognize the effects of this disorder on the limited
mobility of the individual.
On the other hand, one has to bear in mind that forensic
anthropologists can deal with cases where the bones are not dry.
This means that a paleopathology background is not enough for
reading the variety of bone lesions that can occur in FA.
A broader knowledge is necessary, namely an understanding of
76 Encyclopedia of Forensic Sciences, Second Edition
ID Identification
OA Osteoarthritis
SP Spondyloarthropathy
TB Tuberculosis
the whole reaction and healing process, including the bones, the
vessels, muscles, ligaments, and skin. The interpretation of hem-
orrhagic signs, such as discoloration or other chromatic alter-
ations and the recognition of ossified cartilages, can escape the
attention of those who deal exclusively with dry bones.
While paleopathology is fundamental, reading lesions in
FA is not a simple transposition of paleopathology techniques
to more recent remains. Precisely because the bones are more
recent, they may also preserve other tissues besides the hard
ones; the main object of analysis can therefore be quite differ-
ent between paleopathology and FA. Yet, some principles/rules
are absolutely identical, the most important of which is that
when trying to infer pathologies from the bone, the absence of
evidence is not evidence of absence. Only some pathologies
leave signs on the skeleton, which is one of the last systems of
our body to respond to an aggression. (Aggression here refers
to the action of any type of agent, physic or not, exterior to the
body. Bacteria and virus are also examples of aggression
agents.) Chronic diseases are much more likely to be visible
postmortem; the exceptions are those diseases that initially
focus on the bones themselves, such as a primary bone neo-
plasia. As a consequence, the majority of acute diseases will be
imperceptible upon a simple visual examination and may thus
escape the attention of the expert. Simultaneously, this implies
that a majority of causes of death cannot be inferred from the
skeleton.
It is important to recall that a lesion is not a pathology, but
it is a conjunction of lesions in a skeleton, their pattern, distri-
bution, and type which can eventually lead to the diagnosis of
a pathology. Differential diagnosis, which is always manda-
tory, will be done on the basis of these lesion characteristics.
Bone Pathology
Types of Lesions and Bone Reaction
To interpret a lesion one has to understand bone reaction as an
aggression against the tissue. While alive, bone tissue will react
by bone destruction (osteoclastic activity) and/or bone forma-
tion (osteoblastic formation). Pathognomonic reactions are very
rare; that is, bone is monotonous in the way it reacts to external
agents, which can limit the diagnosis of a specific disease,
particularly when the skeleton is incomplete (common in
forensic cases).
http://dx.doi.org/10.1016/B978-0-12-382165-2.00014-3
 Anthropology/Odontology | Bone Pathology and Antemortem Trauma
Keeping lesion description separate from lesion interpreta-
tion is a delicate balance. In any formal report, the description
of the lesion should be detailed enough to permit a second
opinion by another expert. An objective, descriptive approach
is useful: location, size, type of lesion (e.g., lytic and exostosis),
and pattern distribution within the skeleton (unifocal or
symmetric, for instance) are obligatory (Table 1).
In the eventuality that a missing person is known to
suffer from a disease easily diagnosed by skeletal analysis
(e.g., tuberculosis), the fact that the skeleton does not display
any signs of that disease does not necessarily mean that the
individual did not suffer from that illness. The developmental
stage of the disease may be too early in the cycle to permit a full
diagnosis: initial stages may be much less susceptible to affect
bone and it will also depend upon the type of disease. For
example, osseous TB will be more visible than a secondary
bone lesion due to pulmonary TB.
The epidemiological data on the various disorders which
affect the skeleton can be paramount to the forensic case by
helping to clarify issues such as postmortem interval, sex, and
age. A very advanced and therefore severe case of spondyloar-
thropathy will probably date before the use of corticoids;
osteoporosis is more prevalent in women after the menopause;
Paget’s disease is more frequent in Europe than in Asia. The type
of treatment, especially surgical intervention or a prosthesis,
might also help a lot to assess the chronological context.
Pathologies Useful for Forensic Anthropology
Among congenital and genetic conditions, while some are rare
but obvious (as is the case of nanism and acromegalia), others,
such as congenital fusions, supernumerary bones or their con-
genital absence, parietal foramina enlargement, and the failure
of fusion of the neural arches, might require a differential
diagnosis with other pathologies. Other conditions, such as
cleft palate, craniosynostosis, or bone hypoplasia, which cause
limb deficiencies might be easily recognizable by their conse-
quences on face physiognomy or gait, respectively, by both the
expert and the victim’s relatives.
Table 1 Lesions’ description
Lesions’ location Indicate the affected bone
Specify the site on the bone, related to the
anatomical position:
Shaft, epiphysis, metaphysis; anterior/
posterior, medial/lateral aspects; superior/
medium/inferior third, etc.
Measure the distance (cm/mm) from lesion to
reference anatomical points:
Midclavicular line, nearest joint or epiphysis,
etc.
Type of lesion Lytic, hypertrofic, depressed, with cloaca,
porosity, necrotic bone, etc.
Distribution pattern Unifocal, symmetric, randomly distributed,
diffuse widely distributed
Size and shape of Overall shape
the lesion Pyramidal, elliptical, spherical
Size (cm/mm) according to shape
Height and base, diameter, perimeter,
width, etc.
77
Metabolic disorders, such as rickets (lack of vitamin D) and
scurvy (lack of vitamin C), produce reactions in the bone
which, in conjunction, can allow their diagnosis. While these
disorders are very rare in developed countries, in the context of
crimes against humanity, a forensic anthropologist has to be
aware of the possibility of finding them in less-developed
countries. Rickets is characterized by a deformity in the long
bones, particularly those of the lower limbs, accompanied by
bone porosity. In relation to scurvy, though it requires a pro-
longed deprivation of vitamin C and is therefore rare, when
present, it attacks metaphyses which can easily fracture.
Osteoporosis is a well-known metabolic disease affecting in
particular women past middle age. The loss of bone is percep-
tible by vertebral compression, or, in more severe cases, by
vertebral fractures. Kyphosis is a symptom recognizable by
relatives. In the appendicular skeleton, fractures of the forearm
and the femoral neck are the pathognomonic signs. Bone
densitometry and X-rays are valuable tools for the diagnosis
which, in the case of preexisting antemortem elements of
comparison, can facilitate positive ID. Furthermore, the fragil-
ity of the bones and their low weight can be good clues to this
disease, although they can be confounded with taphonomical
effects or even by other diseases, such as rheumatoid arthritis
and spondyloarthropathy.
Concerning infectious diseases, bacterial infections are
much more likely to lead to bone lesions than viral ones.
Some infections may be identified, as with periostitis, where
only the more external bone layer (the periosteum) is infected.
In more severe cases, when the infection goes deeper into the
medullar cavity of the bone, osteomyelitis results. This condi-
tion is more readily identifiable since necrotic bone, bone
enlargement, and cloaca are almost unequivocal signs. Further-
more, it would be difficult for someone to suffer from osteo-
myelitis without a close relative knowing about it; moreover,
the infection will typically be only in one bone and thus the
pathology will be specific. Other infectious diseases which can
be specifically diagnosed in the bone include tuberculosis,
brucellosis, leprosy, and treponemostosis.
Mycobacterium tuberculosis (and also M. bovis) mainly affects
spongy bone, leading to the destruction of vertebral bodies
(mainly adjoining thoracic ones), sometimes producing a
kyphosis. The long-bone epiphyses can also be involved as
well as the ribs.
Rhinomaxillary syndrome is one of the main features of
leprosy: the loss of upper anterior dentition and destruction of
the palate. Bones of the extremities, typically distal phalanges,
are also affected. Physiognomic key traits will be noticed and
remembered by the familiars of the persons who suffered from
leprosy which will facilitate identification.
Congenital syphilis is a type of treponemal disease which
leaves typical marks on the bones, in particular on the skull
with characteristic aspects due to caries sicca. When the post-
cranial skeleton is implicated, normally it is one long bone
such as the tibia, whose enlargement (the so-called saber shin,
which is more common in yaws) will be observed in the
absence of antibiotic treatment.
Finally, brucellosis appears in the skeleton with osteoarti-
cular localizations typically in the superior anterior portion of
the lumbar vertebrae. This very contagious disease might be
confounded with TB. Its forensic relevance relies on the vector
78 Anthropology/Odontology | Bone Pathology and Antemortem Trauma
of contagious contact with animals and its higher prevalence in
the Mediterranean countries.
Regarding degenerative disorders, osteoarthritis (OA) is the
most common articular degenerative disease, affecting a signif-
icant percentage of individuals after the fourth decade of life.
Osteophytes, porosity, and eburnation are the lesions which,
particularly in conjunction, will allow the diagnosis of OA.
Although the more common a disease is, the less chances it
has to provide a positive ID; OA is nevertheless a paradigmatic
example of the contrary. The fact that no two individuals can
develop exactly the same osteophytes, of the same size, shape,
and location, makes them valuable factors of identification,
whenever antemortem X-rays are available to perform the
mandatory comparison. The compatibility among at least
four different points, among the ante- and postmortem
X-rays, is considered to provide a positive identification.
Within nonarticular degenerative diseases, enthesopathies,
now more appropriately designated as entheseal changes, play
a major role in what FA is concerned. The lesions on the
insertion sites of muscles, tendons, and ligaments can function
as markers of occupational stress providing clues for the
amount of physical effort done by certain individuals. Repeti-
tive microtraumatisms on the sites of muscular insertions will
provoke calcifications. Entheseal change on the tendon inser-
tions of the Achilles, patella, or the calcification on the head of
the ulna where triceps brachial inserts are some good exam-
ples. However, attention should be paid since some diseases,
such as diffuse idiopathic skeletal hyperostosis (DISH) or SP,
can cause these types of lesions; therefore, the diagnosis is not
straightforward.
Moving now to rheumatic disorders, SP, with the typical
sacro-iliac ankylosis and the ascending fusion of the vertebral
column, when found would mean that the individuals under
analysis were very limited in their motion; the bones will tend
to be more fragile and light because of this. DISH is recogniz-
able in the skeleton by a flowing right antero-lateral ligament
ossification in the vertebral column. Symmetrical and evident
entheseal changes in the appendicular skeleton are also key
elements for the diagnosis. DISH is differentiated from SP
because in DISH the vertebral bodies are not fused to each
other and the intervertebral space is kept. This disorder,
although asymptomatic, is associated with obesity and
diabetes. Finally, a malignant neoplasia might have much
more potential to provide ID, whereas benign lesions, such as
button osteomas, can work as factors of identification in case
there are antemortem examinations for comparison. Typically,
the rarer a lesion is, the more chance it has to promote identity.
Exuberant malignant neoplasms, with their destructive and
irregular pattern, will be valuable tools to ID, especially
because they are age dependent.
Further sources where bone pathologies which may help
identification are discussed and listed in the Further Reading.
Antemortem Trauma
Besides a violent fracture, stress or fatigue fractures, which
originate from the application of repeated forces of low mag-
nitude over a period of time, can be frequent within gymnasts,
athletes, ballet dancers, military recruits, and others who
engage in repetitive physical activity. Stress fractures may assist
with identity or with suggesting an occupation or hobby.
Spondylolisis, which is a complete separation between the
vertebral body and the corresponding arch of the vertebra, is
the best-known type of stress fracture. Finally, pathological
fractures have also to be taken into account, where a disease
or condition, such as osteoporosis, rheumatoid arthritis,
neoplasms, or others, weakens the bone and leads to a fracture.
For FA, a fundamental question remains concerning ante-
mortem trauma: How long did the individual survive the
lesion? Not only does this assist with the timing of the event
and possible identification or elimination of the person in
question, but also the forensic relevance of this issue is signif-
icant since it has serious legal repercussions.
Antemortem lesions do not have the same meaning in FA
and in forensic pathology (FP), as illustrated in Figure 1. In FA,
antemortem trauma will be recognizable macroscopically or
microscopically (the osteogenic response is able to be seen
sooner by microscopic analysis). By a simple visual inspection,
callus formation (gross enlargement of a portion of bone at the
fracture site) (Figure 2) and periosteal reaction or the rounding
of fracture margins will clearly indicate antemortem fracture.
Yet, typical bone responses (osteoblastic, osteoclastic, line of
demarcation, and sequestration) can only be seen through a
microscope. It should be noted that distinguishing between
postmortem and antemortem wounds with little survival time
is still difficult to do histologically. It is indisputable that
woven bone must be present (usually not visible before
2 weeks) to establish a specific antemortem period or even to
determine an antemortem origin. It has to be emphasized that
even radiology may miss fractures which histology, afterward,
detects; histology always provides a more precise dating.
Anthropology
Ante mortem Peri mortem Post mortem
Vital Post mortem
Forensic patology
Figure 1 The different concepts of perimortem between pathology and
anthropology.
Figure 2 Misaligned, although treated, antemortem fracture of the
femoral neck from an identified individual of a recent skeletal identified
collection.
 Anthropology/Odontology | Bone Pathology and Antemortem Trauma 79

Recent studies have yielded important data on the impor- chances of ID are increased. Concerning the second advantage,
tant question of healing after trauma. After only 6 weeks, although the signs of bone remodeling mean that the injuries
osteoclastic and osteoblastic activities were reported in healing did not cause the death, it is possible that subsequent compli-
cranial trauma. Interpretations of time elapsed since death cations might have caused it. The last two benefits of antemor-
evidence benefit from ongoing research on dry bone, such as tem trauma for FA are discussed below.
in pilot studies on the detection of microscopic markers of
hemorrhaging and wound age on dry bone. Whereas unequiv-
Child Abuse
ocal signs of long-term survival can be reliably determined,
short-term survival continues to be problematic. Recently Skeletal damage in child abuse is a new and recent challenge in
identified skeletal collections are able to provide important antemortem trauma. If cranial injuries are the most frequent
data on this issue, since the hospitals still keep the patients’ cause of death in child abuse, it is the skeleton that brings the
files concerning antemortem traumas (Figure 2). case to the health-care system and to a possible diagnosis with
Antemortem registration should be as complete and objec- the antemortem lesions assuming a role of extreme relevance.
tive as possible (Table 2). Forces that twist or create torsion in a bone can shear the
The value of antemortem trauma for forensic anthropology periosteum from the bone, even without a fracture, and cause
can be systematized as follows: bleeding with new bone formation over the subperiosteal
hematoma in 1–2 weeks. If it is incipient, it can be seen only
– Identification
in radiographs as a line parallel to the shaft of the cortical
– A possible contribution to the determination of the cause of
bone; if stronger forces are applied, the new bone growth can
death
be observed in a visual examination.
– Diagnosis of child abuse
Limb fractures, in the metaphysis or epiphyses, whether in the
– A tool to document human rights violation
bone or in the periosteum, are often diagnosed in ossified tissues
The benefits for identification are obvious and well known and are highly characteristic of child abuse. Forces of violent
since antemortem fractures are undoubtedly good factors of traction, or torsion of the limbs, are responsible for these injuries.
individualization. When treated with surgical intervention, the Epiphyseal–metaphyseal lesions, considered diagnostic of
child abuse, because of the partial or complete dislocation of
the epiphysis, the metaphysis, and a thin layer of metaphyseal
Table 2 Antemortem trauma registration reaction, can be seen in radiology. Because of the small size of
the fragments, these are occasionally undetectable in a routine
Antemortem feature Registration
analysis. An X-ray is crucial to identify these fragments and to
Bone location Indicate the affected bone orientate the FA examination. Diaphyseal injuries consisting of
See the same item in Table 1 spiral fractures, caused by the twisting of the bone, and trans-
Severity Light, medium, severe verse fractures, caused by a direct blow or bending of the bone,
Trauma etiology Blunt/sharp/perforated/mixed/impossible are easier to observe than the epiphyseal–metaphyseal lesions.
to determine The range of healing stages, from the periosteal thickening to
Trauma mechanism Tension/compression/twisting or torsion/ the callus, can be observed; the lack of treatment may be
bending, angulating/ indicated by possible angulation or inappropriate consolida-
shearing/mixed/impossible to
tion of the fracture elements. Although a spiral fracture
determine
strongly suggests child abuse, it can be accidental.
Trauma classification Simple fracture/comminuted fracture/
according to severity of compound open fracture/refracture The literature is controversial on cranial antemortem injuries
distortion in children. If present, they can be assumed as a putative sign of
Description of fracture Complete/incomplete, direction, child abuse, as accidental trauma in these ages is extremely rare.
orientation, single Falls in domestic accidents, such as from a chair or from a bed,
line/irradiating/‘spider fracture’/‘hinge’ normally do not cause bone damage and, therefore, they rarely
fracture, etc. represent the primary cause of death in children. The parietal
Callus formation Yes or no and temporal bones break more frequently; when severe
If yes: weak, strong, exuberant enough, they may extend to the base of the skull.
Periosteal reaction Yes or no
Rib fractures in a child older than 6 months, if not a victim
If yes: weak, strong, exuberant
of a traffic accident or a major trauma and in the absence of any
Misalignment Yes or no
If yes: light, medium, severe bone disease, strongly point to child abuse. Rib fractures can be
Pseudo-arthrosis Yes or no multiple or bilateral, and of different ages, but are usually
If yes: light, medium, severe located in the posterior arch near the costo-vertebral junction.
Degree and success of Yes or No The classical aspect is the observation of a vertical line of
repair sequential callus down one or both posterior rib arches, near
Estimation of time elapsed Possible/not possible the head of the ribs, having the appearance of a ‘string of beads’
since the trauma (Figure 3). This can be simply palpated and dissected in an
occurrence autopsy or observed in an FA examination. In many forensic
Microscopic analysis Yes or no
settings where radiologic facilities are not available, the direct
Special cases Amputation/surgical
observation of those calluses is sometimes the first alert for a
interventions/prosthesis
child abuse case (Figure 4). Rib fractures are often better
80 Anthropology/Odontology | Bone Pathology and Antemortem Trauma
Figure 3 Radiograph of right ribs with ‘string of bead’. None of the ribs
has fusion between them, despite the large calluses. The bones are
illustrated before final processing. Their condition stimulated concerns
that ribs 6–7, 8–9, and 11–12 may have been conjoined. Radiographs
confirm no fusion (courtesy of Steve Symes).
Figure 4 A child of 2.5 months presented as an SIDS case, whose
autopsy had diagnosed a shaken baby syndrome. The callus osseous
observed in the posterior 8th left rib (first at autopsy and later in this RX),
and a previous hospital internment when he was 1.5 months old, due to a
bruise in the face consistent with a slap, both not explained by the
parents, proved child abuse. A subdural hemorrhage and cerebral edema,
in association with retinal hemorrhages, showed at histology not
explained by the partum, helped in the diagnostic of the shaken baby
syndrome.
recognized after new bone formation than in recent condi-
tions, either by radiology or at autopsy. A discrepancy between
autopsy and radiology may eventually occur. Apart from the
callus formation, refracture of the existing calluses may be
observed (Figure 5). The posterior fractures may be due to
squeezing or shaking the child, while lateral fractures will be
due to antero-posterior compression.
A difficult question arises occasionally when these rib (con-
solidated) fractures are argued to be resuscitation injuries. In
fact, fractures by chest compression are very uncommon in
child because of the elasticity of the immature ribcage. More-
over, if properly applied, chest compression in a child is done
Figure 5 The calluses are large and suggest numerous episodes of
refracture (courtesy of Steve Symes).
with fingers and is unlikely to cause fractures. Normally, these
fractures are observed in the anterior arch in the midclavicular
line or sterno-condral junction, which is an important criterion
for the differential diagnosis. However, the possibility of bro-
ken ribs in resuscitation situation should always be considered
and diagnosed, carefully, on a case-by-case basis.
Fractures of the clavicle are relatively uncommon in chil-
dren. However, those at the distal end may be caused by a
sudden traction of the extremity. Fractures of the scapula
(namely of the acromion) and sternum, although rare, can be
related to child abuse, if other major trauma is excluded.
Vertebrae, especially the lateral processes, should not be
forgotten in an examination.
Wherever the site of the skeletal damage is observed, the
characteristic pattern includes multiple traumas and variation
in the age of the fractures. Accidental injuries usually produce
single lesions, unless some bone disease, such as osteogenesis
imperfecta (especially type V), infantile cortical hyperostosis,
congenital syphilis, copper deficiency, or Menke’s syndrome,
can be proved.
In child abuse, bone damage must be related to any delay or
absence of medical care, inconsistencies with developmental
age, the history of injury changes over time, and to witness
accounts.
Torture
Antemortem bone lesions may also be evidence of torture, as
physical techniques are systematic or repetitive to force another
person to yield information, to make confession, or for any
other reason. However, in cases of torture, the antemortem
lesions co-exist with recent perimortem fractures which
would have probably caused the death of the victim. The
issue will be to establish the right chronology of the injuries
so that a reconstruction of the events may be possible. In order
to achieve this objective, gross observations must be comple-
mented by radiology and histological study. An excellent tool
integrating the three perspectives (macroscopy, histology, and
radiology) for the aging of fractures in human dry bones was
published by Maat who compiled data from different sources
 Anthropology/Odontology | Bone Pathology and Antemortem Trauma
in a single table. The authors made a previous approach to this
issue providing a table with the time needed for the normal
consolidation of fractures of the totality of human bones. CT
and other new imaging techniques will ensure the accuracy of
diagnostics in the near future.
Reports of torture revealed that 10% of the injuries were
fractures, in the following order: ribs, legs and pelvis, hands
and wrists, spine, jaw, skull, and arms. Foreign bodies such as
needles, wires, or wooden splinters can be found imbedded in
the manual distal phalanxes after fingernail torture. Compres-
sion of the fingers and toes can result from minor bone injuries
or even the loss of hands, fingers, or digits. Cutting off parts of
extremities will show in the examination because of the miss-
ing parts of the bones and the smoothing of the bone borders
with some remodeling if the subject lived long enough. When-
ever more than one adjacent bone is involved (for example, the
metacarpals) fusion between the distal superior surfaces may
occur. Consolidation of fractures of the forearm (ulna and/or
radius) is typical of the defense of the prisoner trying to protect,
intentionally or by reflex, his head. Fracture of the anatomical
neck of the humerus and dislocation of the gleno-humeral
joint may be observed in postural torture by suspension of
the body by the wrists or the arms. The healing of the fractures
mentioned above, apart from the callus formation, is traduced
by thickening of the bones, which is sometimes exuberant in
extreme cases where there is a lack of treatment; positional
abnormalities due to the dislocations of bones and pseudo-
arthrosis that result from the nonfusion of the bones often
occur without treatment. Infectious complications, such as
osteomyelitis, can appear secondarily to soft-tissue lacerations
or exposed fractures.
Ossified fractures of the toes, metatarsals, tarsals, the ankle,
amputations of distal phalanges, as well as ligamentous inju-
ries and flatfoot deformations can be observed in the tech-
nique known as falanga or falaca. This technique consists of
beating the feet, mainly but not exclusively on the sole, to
avoid the recognition of bruises in soft tissues. Thickening of
the plantar aponeurosis (apparent in adipocere bodies) sug-
gests previous torture. Consequently, the impairment of blood
circulation and the necrosis of muscles can extend to the
bones, leading to the necrosis of metatarsal and proximal
phalanges. Fractures may then occur and form exostoses.
Palmatoria, a unique method used in Guinea-Bissau, consisting
of repetitive blows to the shin, create a periosteal thickening of
the tibia apart from endosteal and intramedular changes not
visible in a classic examination (but seen radiologically) and
can result in a fracture seen only in CT. Pellets and bullets may
be found embedded in articulations, especially in the knees, a
method known as kneecapping, which is also associated with
fractures of the neighboring bones (legs and arms). The healing
of these fractures, which may be splintered if high-velocity
projectiles were used, is difficult and delayed; periostitis and
osteomyelitis usually appear as complications. This method
was used in North Ireland conflicts and also by American
gangs that threaten to cripple the victim.
Healed fractures of the ribs and spine because of a beating in
the thorax are common. Biomechanics of these fractures is
complex and needs further research. Fractures by compression
of the chest or pelvis are less known; they are difficult to inter-
pret and occasionally are the object of undesirable speculation.
81
Although frequently mentioned in the literature, as a sign of
manual or ligature strangulations, fracture of the hyoid bone
seems to be very rare as a method of torture, because the time
from torture to death is extremely narrow. Moreover, the real
incidence of these fractures in all the compressions of the neck
is much lower than previous reports in forensic textbooks
which considered it as a classic sign of hanging or
strangulation. In fact, case studies of fractures of the hyoid
bone are scarce in the forensic anthropology literature.
A healing butterfly fracture of the mandible may be ex-
tremely useful to identify beating on the face and possible
torture, such as by the butt or the barrel of a firearm. But in
cases of peri-mortem fractures in this location, when the victim
has been shot to the head, this is a typical fracture; although it
is theoretically consistent with blunt trauma, it is an artifact of
high-velocity projectiles (so-called Kolusayin fractures) and
should be interpreted with caution. The healing stage of the
fracture will be crucial to distinguish between a simple execu-
tion and previous torture before the execution.
See also: Anthropology/Odontology: Biomechanics of Bone
Trauma; Bone Trauma.
Further Reading
Barbian L and Sledzik PS (2008) Healing following cranial trauma. Journal of Forensic
Sciences 53: 2.
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