E-learning topics in forensic medicine

Medico-Legal Responsibility in Emergency Room Causes of Ethical concern in Emergency and Critical Medicine: a) Little time to discuss alternative treatment with the presence of predetermined treatment protocols b) Patients are unable to participate in decisions c) Patients often arrive to the ER against their will d) Patientphysician relationship is weak and lacks confidence e) Stressful situation for both physician and patient Ethical principles in emergency and critical medicine a) Informed consent. In medical emergency, physicians supply all relevant information required for an informed decision. But, sometimes under emergency circumstances, patients are not even capable of expressing consent or refusal. Accordingly, emergency physicians usually request consent from a surrogate or substitute. Examples include young children and mentally incapacitated persons. b) Confidentiality and respect of patients privacy. Examples of disclosing patients secrecy: i. Disclosing serious disease to relatives against patients will ii. Disclosing critical status of an ICU patient by phone to a person that is going to gain profit iii. Disclosing shameful disease of a patient as disdain and criticism e.g. addiction, TB, STDs. iv. Disclosing non medical patient information as attitudes, behavior and very personal description c) Technical competence. This means rapid expert response and access to quality medical care. Examples of unethical response: i. Directing the patient to a hospital deficient of a particular medical service or expert consultant ii. Impaired or incompetent physicians iii. Ignoring an available expert consultation in the first few hours iv. Omitting a life saving drug d) Fairness in the provision of emergency care. Provision of emergency medical treatment should not be based on gender, age, race, socioeconomic status, financial, religious, political, or cultural background. No patient should ever be abused, or given substandard care. e) Practice of medicine in a cost-conscious manner. Professionals are obligated to use their best clinical judgment to determine the need for testing, medical interventions, and hospital admission. The patient's welfare

and economic considerations must take precedence over gain of physician or hospital. However, cost-conscious practice should not interfere with life resuscitation measures nor should be on the expense of the patients health. f) Act on the best benefit of the patient and avoid non medically justified abortion, infanticide and euthanasia. g) Referral or cooperation with other physicians should be at the best for patients benefit. If the patient with an emergency condition needs to be transferred to another facility, the following should be done: i. The patient must be stabilized first. ii. The physician should sign a certificate saying that the medical benefits provided by transferring the patient to another hospital outweigh the risks of the transfer. iii. The physician should ensure that the receiving hospital has room and qualified personnel. iv. A copy of the patients medical record should be sent. h) Ethical principles in medical interventions and procedures e.g. mechanical ventilation, catheterization. The following must be considered: i. Consent limits ii. Rigid protocol for initiation and weaning iii. High technical competence iv. Functioning and sterility v. Monitoring and alarms must be respected i) Respect of patients dignity and avoid abuse of power, unjustified restraints and punitive actions. Patients dignity is sometimes affected: i. Exposed body parts ii. Improper nutrition, especially in ICU iii. Negligence of patients personal cleanliness iv. Lack of psychological support v. Partial or total omission of coma care Restraints are frequently unjustified. They are usually used in agitated and/or noncompliant patients. Restrains are either physical (wrist and ankle) or chemical (sedatives). The following conditions must be considered: i. Restrains are used based on assessed needs: 1- If the patient imposes an immediate danger to those in the area, the patient may be physically restrained only for the time needed to maintain the safety of the area and manage any associated lesions of the patient. 2- Re-assess the patient, if restrains are no longer necessary, remove them; otherwise take steps for an involuntary admission. This involuntary admission should follow specific guidelines and procedures;

otherwise the physician could be guilty of false imprisonment. ii. The restrain order should be written by ICU or ER physician and should include cause of restraint, duration, type, time, monitoring, protection, documentation. Punitive actions recorded by nurses (that need correction of abuse) i. Restraints ii. Isolation iii. Starvation iv. Beating In emergency situations, emergency care should be started immediately (a consent is presumed). A physician should report cases of physical violence to the police, e.g. gun shot and stab wounds. Cases of head injuries should be kept under close supervision for at least 48 hours. The treating physician should record all vital signs on frequent periods of time (of at least 30 minutes) and under any condition of deterioration (especially pulse rate), a neurosurgeon should be requested at once. The physician should make sure that a nurse is present when the patient is female. The physician should check the patient posture because pressure over vulnerable nerves cause serious neurological sequelae. The physician should ensure that the injection is applied into the vein by palpating the vessel for pulsation as some drugs such as barbiturates cause necrosis of tissue and nerve damage if injected extra-vascular. The physician should ensure blood compatibility before blood transfusion (cross-matching). Medico-Legal Responsibility in Pediatrics A physician must obtain consent from the parents before providing nonemergency treatment, except in: a) Emergency situations, e.g. those which threatens the child life. b) Treatment of mental illness, drug and alcohol abuse. c) Treatment of a child with sexually transmitted disease. The physician should report suspected child abuse or neglect. This must be made within 48 hours of the time of abuse or neglect. When a physician is faced with a child in an emergency: a) Assess the emergency situation and get him the supportive measures. b) Reassure the child (minor).

c) Contact the parents. d) Make the best clinical judgment. Medico-Legal Responsibility in Obstetrics and Gynecology If a raped woman comes to the physician private office, the best thing is to send her to an ER where the following steps should be done: a) Comforting and consoling the patient. b) Notifying the police. c) A careful gloved examination must be done using a rape kit. d) Samples are collected with extreme care (semen, blood, hair). They should be protected from adulteration whether intentional or unintentional. A physician who intended to induce abortion of a pregnant woman by any means (instrumental or medical), will be guilty of felony unless for the purpose of preserving the gravidas life. The physician should notify the authorities about pregnant woman using illegal drugs during pregnancy. The physician should report a diagnosis of sexually transmitted disease (STD) to the health authority with the patients name and address. Otherwise, the physician will be liable for negligence if the other partner becomes infected. In cases of domestic violence and abuse, the physician should encourage the patient to seek help from the authorities. Medico-Legal Responsibility in Surgery When an operation to be done, the surgeon must obtain the patients written consent. A surgeon has the duty to worn the patient of risks inherent in the procedure, so that the patient can make an informed decision as to consent or not. The responsibility of both anesthetist and the surgeon to ensure that the correct patient is being operated upon; and that the correct part of the right patient is being operated upon (especially if patients possess identical names). An anesthetic should never be administered to patient with known full stomach. If possible delay the operation for 4 hours or have the stomach aspirated. The anesthetic machine should work properly. Syringes, spinal sets, regional block sets, and other instruments should be sterilized. Record preoperative, operative, and postoperative vital data. Before general anesthesia, the patient must be strapped on the table to avoid bone fracture resulting from falling off the operating table.

 In cases of transplantation of organs and tissues, there are two ways to obtain a full, free informed consent: a) The patient can make his wish known before death by an act as signing an organ donation card. b) If the deceased has not expressed his own wishes, the next of kin may give the required consent. [N.B. Harvesting organs from the dead is not yet legislated in Egypt.] The surgeon should perform the operations according to the standards accredited in his hospital. The surgeon shouldnt close the surgical wound of the operation until he is completely sure of leaving the site of operation aseptic, free of any foreign body, and no evidence of leakage. The timing of the discharge of the patient from the hospital is only the decision of the surgeon. Medicolegal responsibility in cases of death The doctor has to report to the local health authority in cases of doubt and suspicion as follows: Accidents in any way contributing to the cause of death. When an anesthetic or surgical procedure is suspected to be contributing to the death. Alcoholism (acute or chronic) contributing to the cause of death. Drug-related deaths. Death related to any form of poisoning. Death of a foster child. Stillbirths where there was any possibility of the child being born alive. Death related to an industrial disease. The registered physician (medical practitioner) who attended the patient during his last illness must sign a death certificate. The certificate must contain a statement by the doctor recording the cause of death to the best of his knowledge, and then the doctor must deliver the certificate to the registrar as early as possible.

DNA Profiling
Basic Principles:

DNA (Deoxyribonucleic acid) represents the human genome which is located in the nucleus of the cell. DNA is composed of 2 strands of sugar and phosphate molecules that are twisted into a double helix that is bound together by links formed from (adenine thymine), and (cytosine guanine), as shown in figure (3.8). The DNA long ribbon is folded times and times on itself to form thicker folds and parts as chromosomes (each chromosome carries 100s-1000s genes on it). Then these chromosomes are crowded on each other forming the chromatin mass in the nucleus.

Figure 3.8: Structure of DNA

Genes are present as specific coding parts on DNA strand where each gene is responsible for a particular protein formation. But only 10% of DNA is used for genetic coding, the rest being silent segments with no known functions (inert areas) but in Forensic field they represent a very important role in personal identification. These segments vary greatly in base sequence, but are constant for a given individual and are inherited from parents to children. So, they are unique for every person, except the uniovular twins as they share the same DNA in the fertilized ovum. The chance of sharing the same sequence between two persons is one in a million billion, and among siblings it is one in ten thousand billion. The locus is an area on DNA strand particularly in silent areas which is defined for analytical purposes in DNA profiling. There are 16 loci defined for forensic identification, all are on intergenic areas in autosomal chromosomes except for one,

which is present on the sex chromosome (X or Y) and serves for identification of sex and named Amelogenin locus. Y chromosome, being inherited by the father only so it already carries a paternal DNA only and thats why it is linked with the surname of the male person. Also it could help in crimes of multiple rape (mixed semen) investigations. Mitochondrial DNA, is present on the mitochondria (which is a cytoplasmic inclusion body i.e. not in the nucleus), so it is present as well in non nucleated cells like RBCs, hair and nails. Mitochondrial DNA is inherited from maternal side only as it is transmitted through the ovum and persists to serve for the zygote cellular respiration. It identifies maternal origin only.

Steps of DNA Typing:

1- Collection of samples: DNA is searched for in samples containing nucleated cells e.g. semen, soft tissues, hair roots, and nucleated blood cells. Either fresh samples or dried stains must be collected and handled with precautions to prevent sample contamination which will affect DNA analysis. 2- Preservation of fresh samples in a suitable temperature relevant to period of storage to prevent DNA degradation. 3- DNA extraction from the biological sample. 4- PCR (polymerase chain reaction) to amplify the amount of DNA in the sample and produce thousands of copies of the loci. 5- Agar gel electrophoresis to examine and compare the amplified locus. 6- Interpret the results and documenting it by a laser camera connected to computer for saving and displaying data.

Medicolegal applications of DNA typing:

1- Identification or elimination of crime suspects in: murder, robbery, rapeetc. 2- Cases of disputed paternity: as it is a definitive paternity test unlike other tests which are all good negative ones, so it can help in the solution of these cases. 3- Identification of body remains. 4- Identification of sex and species, which is achieved by examining polymorphism in the non-coding areas within the X or Y chromosome.

Sudden Natural Death

Definition:
Sudden death is unexpected death of an apparently healthy person in less than 24 hours of onset of symptoms. Violent death, drug overdose, or natural death following an illness more than 24 hours of onset of symptoms are not considered as sudden deaths.

Causes
I- CVS: most common A) Coronary artery disease: reduced blood flow to the myocardium can lead to sudden death by the following different forms: 1- Coronary insufficiency chronic ischemia arrhythmias with normal myocardium 2- Myocardial infarction 3- Rupture of a myocardial infarct cardiac tamponade, usually in old males 4- Myocardial fibrosis arrhythmias, HF or ruptured aneurysm 5- Papillary muscle rupture valve insufficiency B) Hypertension myocardial ischemia due to: 1- Myocardial hypertrophy 2- Associated coronary artery disease C) Valvular heart disease: 1- Stenosis 2- Bacterial endocarditis D) Primary myocardial disease 1- Myocarditis 2- Cardiomyopathies 3- Senile myocardial degeneration E) Diseases of the arteries: The most common lesion in the arteries associated with sudden death is the aneurysm, which may be: 1- Atheromatous aneurysm of the aorta: commonest at abdominal segment hemorrhage 2- Dissecting aneurysm of aorta: due to medial necrosis cardiac tamponade 3- Syphilitic aneurysms: common at arch hemorrhage in mediastinum, pleura, trachea or esophagus F) Thromboembolic disease, e.g. acute mesenteric vascular occlusion or Leriche syndrome (aorto-bi-iliac thrombosis) II- CNS: A) Status epilepticus asphyxia B) Cerebrovascular accidents: 1- Intracranial hemorrhage: a) Intracerebral hemorrhage: old people (more in females) with hypertension and atherosclerosis

b) Subarachnoid hemorrhage: ruptured berry aneurysm in young and middle aged people 2- Cerebral thrombosis and infarction following carotid artery thrombosis C) Infections as encephalitis D) Brain neoplasm III- Respiratory system: A) Pulmonary embolism: the most under-diagnosed cause of death B) Hemoptysis: TB or malignancy C) Acute respiratory infections D) Status asthmaticus E) Laryngeal obstruction by edema, vomitus or foreign body F) Acute pulmonary edema G) Acute Respiratory Distress Syndrome (ARDS) of any cause H) Lung collapse following pneumothorax I) Inhalation of gastric contents (Mendelsons Syndrome) or a foreign body IV- GIT: A) Severe hemorrhage with shock secondary to: 1- Malignancy 2- Ruptured varices 3- Perforated ulcer B) Fulminant hepatitis C) Acute pancreatitis D) Acute cholangitis E) Causes of acute abdomen: acute appendicitis, rupture peptic ulcer, peritonitis, intestinal obstruction F) Severe gastroenteritis with significant hypovolemia (especially in infants) V- Urogenital: A) Uremia B) Ruptured ectopic gestation C) Twisted ovarian cyst D) Eclampsia E) Antepartum and postpartum hemorrhage F) Amniotic fluid embolism G) Hemorrhage from neoplasm of the genital tract VI- Endocrinal and metabolic: A) Diabetes complications as hypoglycemia, diabetic ketoacidosis or hyperosmolar coma B) Unrecognized thyroid diseases: thyroid storm or myxedema coma C) Acute hypopituitarism with acute adrenal insufficiency D) Pheochromocytom VII- Blood diseases: A) Hemophilia B) Leukemia C) Disseminated intravascular coagulation (DIC) D) Acute hemolytic crises VIII- Other Causes:

A) Systemic Infections: septicemia and septicemic shock, acute hemorrhagic fever. B) Neoplastic Diseases: hemorrhage, rupture of viscus, invasion and dysfunction of metastasized organs IX- Undiagnosed sudden death

Factors affecting the severity of electrocution

(I) Factors related to the electric current: 1-Amperage (flow of the current): Electricity is defined as the flow of electrons from atom to atom. Electrons, which comprise the current, are passed along from atom to atom. Amperage is the term used for the rate of flow of electrons. Every time 6.242 x 1015 electrons pass a given point in 1 second, 1 ampere of current has passed 2-Voltage (electric tension): Electrons are free to move about at random until a driving force termed voltage propels them to move in one direction. A large voltage exerts a greater force, which moves more electrons through the wire at a given rate of time. The voltage is either: o Low voltage: < 600 V o High voltage: > 600 The higher the voltage, the more the dangerous is the current. Residential voltage in Egypt is 210-220 V. High-voltage lines in suburban and urban areas are approximately 75008000 V with transcontinental high-tension lines 100,000 V or greater. For electrocution from low-voltage household current, there must be direct contact with the electrical circuit. In high-voltage accidents, direct contact with the wire is not necessary, and as the body approaches the high voltage line, an electric current (arc) may jump from the line to the body. The temperature generated by an arc current can be as high as 40,000C, which can melt bone and volatilize metal. 3- Type of the current: Commercial electric currents usually are generated with a cyclic reversal of the direction of electric pressure (voltage). Pressure in the line first pushes and then pulls electrons, resulting in alternating current. Frequency of current in hertz (Hz) or cycles per second is the number of complete cycles of positive and negative pressure in 1 second Alternating current (AC) is more dangerous than direct current (DC) where: o AC is more in use than DC o Humans are sensitive to AC 4-6 times as to DC. Alternating currents between 39 and 150 Hz have the greatest lethality. In Egypt, alternating current is generated at a 50 Hz frequency.

4- Duration of passage of the current: the longer the duration, the more the destructive effect. (II) Factors related to the person: 1- Earthing: if the victim is earthed the circuit will be complete (figure 10.5). 2- Resistance: Resistance is a measure of how difficult it is for electrons to pass through a material and is expressed in a unit of measurement termed an ohm. Skin resistance also varies depending on moisture content, thickness, and cleanliness. Resistance offered by the callused palm may reach 1,000,000 ohms/cm2, while the average resistance of dry normal skin is 5000 ohms/cm2. This resistance may decrease to 1000 ohms/cm2 if hands are wet. Skin resistance is encountered primarily in the stratum corneum that serves as an insulator for the body. The resistance of skin is not indefinite and breaks down at low voltages. Exposure of the skin to 50 volts for 6-7 seconds results in blisters that have a considerably diminished resistance. The dermis offers low resistance, as do almost all internal tissues except bone, which is a poor conductor of electricity. Other factors that affect the flow of electrons are the nature. The relationship between current flow (amperage), pressure (voltage), and resistance is described in Ohm's law, which states that the amount of current flowing through a conductor is directly proportional to voltage and inversely related to resistance. Current (I) = Voltage (E)/Resistance (R) When the current flow through a certain material face resistance, power (heat) is lost. The heat produced is proportional to the resistance and the square of the current.

Power (P) = Voltage (E) x Current (I) Because E = I x R (resistance), the above equation becomes P = I2R
3- Age: children are more susceptible. 4- State of health: ill persons are more affected. 5- Pathway of the current (figure 10.6): Low-voltage current generally follows the path of least resistance (i.e., nerves, blood vessels), yet high-voltage current takes a direct path between entrance and ground

It is more dangerous if the current passes through vital organs. Peripheral passage leads to burn injury. When an electric current passes between the power source and the anatomic point of contact (entrance wound), and between the patient (exit wound) and the grounding mechanism, causing hidden destruction of deeper tissues. Such electrically conductive burns are simply thermal injuries occurring when the electric energy is converted to thermal energy. The extent of the electric burn is related to the magnitude, frequency, and duration of the current flow and the resistance of the tissue. Passage through chest lead to arrhythmias or respiratory paralysis. Passage through head lead to respiratory center depression. 6- Degree of anticipation: anticipation decreases the effect.

Figure 10.1: Pathways of current in electrocution

Differences between ante mortem and postmortem burns

An assailant may try to conceal his murder by burning the cadaver and the scene of the crime, in this case differentiation must be made between AM and PM burns (table 4).
Table 1: Differences between AM and PM burns

Vesicles

AM Burns Tense with fluid rich in albumin and chloride

Hyperemia Present Hemoconcentration Present Soot in air passage and Present in open fires CO-Hb Sepsis or healing Present if death is delayed Causes of death The burn or its complications

PM Burns If present, are small, contain gas, little fluid, poor in albumin and chloride Absent Absent Absent Absent AM injury

Pregnancy
Medicolegal importance of diagnosis of pregnancy
Divorce: a divorced woman may allege pregnancy to get more alimony. Inheritance: a widow may allege pregnancy to dominate the heritage. Adultery: when a female gets pregnant in absence of her husband. Rape: it is a routine to investigate for pregnancy 4 weeks after a crime of rape, as the victim may receive more compensation. 5. Execution: pregnancy must be excluded before judicial execution in females in the child bearing period. If pregnancy is proved, the execution is delayed till delivery and weaning of the infant. 6. Blackmail: a woman may allege pregnancy to blackmail a man. 7. Sudden unexpected death of a woman in the child bearing age, we should consider the complications of pregnancy (e.g. ruptured ectopic pregnancy). N.B. In all the previous cases the women tries to deceive the examiner, so that all the subjective symptoms are of no value. The diagnosis should be based on the sure signs of pregnancy. 1. 2. 3. 4.

Diagnosis of pregnancy in the living

A. Probable signs: by external examination: 1. Breasts: a. Large, soft breasts b. Areolas: Montgomery follicles c. Nipples: large and dark 2. Abdomen: a. Large, fundal levels b. Tense c. Stria gravidarum d. Linea nigra 3. Genitalia: soft and dark B. Sure signs: 1. Early: only by investigations: a. Ultrasonography: Gestational sac becomes visible at 5-6 weeks Fetal heartbeat is detectable at 7-8 weeks. b. Detection of human chorionic gonadotropin (hCG): hCG is composed of alpha and beta subunits. The alpha subunit of hCG is similar to the alpha subunit of FSH, LH, and thyrotropin. The free beta subunit of hCG differs from the others. Free beta subunits are degraded by macrophage enzymes in the kidney to make a beta subunit core fragment, which is primarily detected in urine samples. Detection in maternal serum and urine is evident only after implantation and vascular communication has been

established with the decidua by the syncytiotrophoblast 810 days after conception. Optimally, tests used for early pregnancy detection should be able to recognize all forms of intact hCG, including the free beta subunit and the beta core fragment. Blood tests: hCG detection assays antibodies directed against the hCG molecule. Currently, 4 main hCG assays are used: (1) radioimmunoassay, (2) immunoradiometric assay, (3) enzyme-linked immunosorbent assay (ELISA), and (4) fluoroimmunoassay. These tests are very sensitive (can detect concentration of 1 mIU/mL) and can detect conception as early as 10 days postconception. Urine tests: Home pregnancy tests are used to detect urine hCG. They are sensitive for hCG concentrations ranging from 25 mIU/mL to 100 mIU/mL. Home pregnancy tests are most commonly used in the week after the missed menstrual period (fourth completed gestational week). 2. Late: after the 4th gestational month, by clinical examination: a. Inspection of fatal movements b. Palpation of fetal parts c. Auscultation of fetal heart sounds.

Period of gestation
The normal period of gestation is about 280 days (10 menstrual cycles). The shortest gestation period is estimated to be 6 months.

Delivery
Conditions in which a female is examined for signs of recent delivery:
1. Inheritance: when a widow alleges delivery to inherit a dead husband. 2. Infanticide: when a murdered newly born infant is found necessitating examination of the suspected woman.

Infant Death (e-learning)

Manner of infant death
Infant death may be: 1. Homicidal: infanticide 2. Unknown cause: Sudden Infant Death Syndrome (SIDS)

3. Natural cause: a. Pathological condition: prematurity, congenital anomalies, hyaline membrane disease, Rh incompatibility. b. Complications of labor: asphyxia neonatorum, cord prolapse, precipitate labor.

Infanticide
Definitions Infanticide is the deliberate killing of a live born, viable infant (during first year of life). A live born infant is the one who was born alive. A viable infant is the one who is able to survive after birth. The age of viability is the age at which a newborn is considered viable. It is about 28 weeks of intrauterine life. Methods of killing: 1. Choking or smothering. 2. Strangulation either manual or using ligature. 3. Blows on the head or dashing the child against the wall. The condition should be differentiated from difficult and precipitate labor that may be claimed by the defense of the accused mother. 4. Submersion. 5. Omission: by neglecting to do what is absolutely necessary for the newly born infant, e.g. feeding or warming. Examination of a victim of infanticide The killed infant should be examined for: 1. Identification of the infant: e.g. from wraps, blood group, features 2. Signs of viability (age of infant). 3. Signs of live birth a. External signs: e.g. changes of umbilicus b. Internal signs: e.g. signs of respiration, circulation, and feeding 4. Period of life after delivery 5. Circumstances of labor 6. Possible causes of death 7. Time passed since death

Sudden infant death syndrome (SIDS) (Cot death)

Definition It is sudden death of an infant younger than one year which remains unexplained after thorough case investigation, including performance of complete autopsy, death scene examination and review of medical history. Risk factors: I. Infantile: a. Low birth weight b. Low Apgar score (a score used to assess the health of newborn children

II.

III.

immediately after birth) c. Recent viral illness d. Male sex e. Prone sleeping position Maternal a. Low socioeconomic status b. Smoking mother c. Illicit drug using mother d. Poor prenatal care e. Young maternal age Other factors: a. Crowded household b. Parental unemployment c. Single parent status

Theories of pathophysiology 1. Ion channel abnormalities 2. Autonomic nervous system disturbances 3. The effects of nicotine on the developing brain Clinical recommendations to reduce SIDS To reduce the risk of sudden infant death syndrome, parents should: 1. Place the infant on his or her back when sleeping. Side sleeping position is not recommended. 2. Use a firm sleeping surface for the infant, and keep soft objects and loose bedding out of the crib or bassinet. 3. Avoid overheating the infant (e.g. keep the temperature of the room comfortable, do not overdress the infant, use a light blanket). 4. Not smoke during pregnancy, and make sure the infant's environment is smoke-free. 5. Use a separate sleeping environment for the infant that is nearby, ideally a bassinet or crib near the mother's bed. 6. Consider offering the infant a pacifier at nap or bedtime. Do not use a pacifier before one month of age in infants who are breastfed.

Forensic Radiology
Medicolegal importance of a radiograph
1234Diagnosis of hidden injuries. Diagnosis of hidden foreign bodies. Permanent record. Lacks emotional impact of photographs.

Forensic applications of radiology

(A) Radiology of injury Indications: it should be done: o In every case of trauma. o Before surgical interference or postmortem dissection.

 Radiology is helpful in the following cases: I. Soft tissue injury: a) Swelling, edema or hemorrhage, e.g. subdural hematoma shown by CT brain. b) Laceration of an organ: knife wound to the heart shown by MRI chest. c) Abnormal collection of air: i. In the chest pneumothorax: pneumothorax on plain CXR or CT chest. ii. In the abdomen visceral perforation on plain abdominal XR or abdominal US or CT abdomen. iii. Heart or pulmonary vessels air embolism on plain CXR or CT chest. II. Fractures: a) Hidden fractures, e.g. spine fractures. b) Battered child cases: i. Multiple regional fractures. ii. Unusual types of fractures: o Metaphyseal fractures of long bones (avulsion and dislocation of epiphyseal ends). o Diaphyseal fractures of long bones. o Healed rib fractures. iii. Malunited fractures. iv. Fractures of different ages. III. Foreign bodies: glass, broken blades, bullets, shots, retained instruments after surgery. In localizing bullets, it is important to remember that they can migrate by the effect of gravity, e.g. bullet entering the trachea detected in the bronchus. The path of the bullet can be detected radiologically as minute areas of densities caused by small particles detached from the bullet. (B) Identification
I. Deductive identification:

a) Sex: radiographs of skull, pelvis and sternum. b) Age: a. Appearance of ossific centers. b. Union of epiphysial plates. c. Calcification of laryngeal and costal cartilages. d. Skull radiographs for examination of fontanels, sutures and teeth. c) Race. d) Stature.
II. Comparative Identification:

Depends on comparing antemortem to postmortem X-Rays of a person. Comparison includes: a) Normal structures: comparison of skull sinuses especially frontal sinuses regarding the size and shape.

b) Abnormal structures: congenital anomalies of bones, deformities and/or fractures. c) Dental radiographs: comparing root shapes, teeth fillings and abnormal teeth eruptions. (C) Detection of smuggling
I. Addictive agents (body packer):

Narcotics and similar addictive agents may be enclosed in plastic containers or aluminum foils and swallowed. They appear in radiographs as rounded and ovoid, slightly hyperdense packages, some of which are clearly surrounded by a halo of entrapped gas or air.
II. Jewels (larceny by ingestion).

Summary:
This chapter discussed the forensic application of radiology in cases of injury, identification and smuggling and it highlighted its value in documenting such cases.

Questions:
1. Discuss the forensic application of radiology in case of injury. Discuss the forensic application of radiology in case of personal