Skeletal and radiological manifestations of child abuse: Implications for study in past populations

Diagnostic accuracies of CTs, X-rays and Lodox to detect blunt force trauma in adults, using a pig model

The accurate radiological detection of skeletal trauma is crucial for the investigation of blunt force trauma (BFT) cases. The sensitivities of CTs, X-rays and Lodox in identifying BFT fractures and minimum number of impacts in pigs, used as proxies for adult humans, were assessed. Ten human sized pig carcasses were struck with a mallet and scanned, after which the number of fractures and minimum number of impacts detected radiologically were recorded. Pig carcasses were then macerated, and the defleshed, skeletonized remains were considered the gold standard as far as number and location of fractures were concerned. CTs were most sensitive in identifying fractures and impacts in all body regions, with overall sensitivities of 55.4% and 71.5% respectively, while X-rays and Lodox had sensitivities of 25.8% and 29.3% for fractures, and 43.5% and 41.1% for impacts, respectively. All modalities were highly specific for identifying fractures (CT: 99.1%; X-ray: 98.9%; Lodox: 99.4%). CTs should be used to analyze blunt force trauma when a radiological assessment is required, but an examination of the defleshed bones remains the gold standard for the deceased whenever feasible. X-rays and Lodox have limited diagnostic value in these cases and relying on them to detect fractures may compromise the accurate forensic investigation of blunt trauma victims. However, the use of Lodox for initial screening of major trauma is still of value. Sensitivities are generally higher for detecting fractures in pigs compared to piglets, indicating that increased diagnostic value is achieved when imaging pigs compared to piglets.

Posttraumatic Cranial Suture Diastasis in Pediatric Temporal Bone Fractures

OBJECTIVE

Only a handful of case reports exist describing posttraumatic sutural diastasis in the calvarium and none report concurrent temporal bone involvement. We aim to describe diastasis along the temporal bone suture lines in the setting of temporal bone trauma and to identify clinical sequelae.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary Level 1 trauma center.

PATIENTS

Forty-four patients aged 18 and younger who suffered a temporal bone fracture from 2013 to 2018 were identified. Diastasis and diastasis with displacement at the occipitomastoid, lambdoid, sphenosquamosal and petro-occipital sutures, and synchondroses were determined.

MAIN OUTCOME MEASURES

The presence of temporal bone suture and synchondrosal diastasis following temporal bone trauma. Diastasis was defined as sutural separation of a distance greater than 1 mm in comparison to the contralateral side.

RESULTS

Using our diastasis diagnostic criteria, diastasis occurred in 41.5% of temporal bone fractures. Transverse fracture types were significantly associated with diastasis (p ≤ 0.001). Lower Glasgow Coma Scale (GCS) and loss of consciousness (LOC) were associated with the presence of diastasis with displacement and diastasis (p = 0.034 and p = 0.042, respectively). Otic capsule violation was more common in fractures with diastasis but did not reach statistical significance. There were two cases of cerebrospinal fluid otorrhea and three deaths in cases that featured diastasis.

CONCLUSION

Our findings indicate that diastasis is a positive predictor for higher disruptive force injuries and more severe outcomes and complications. Posttraumatic temporal bone suture diastasis may represent a separate clinico-pathologic entity in addition to the usual temporal bone fracture classification types.

Undetected traumatic diastasis of cranial sutures: a case of child abuse

Traumatic diastasis of cranial sutures is a type of bone fracture more common in children than in adults, but little attention has been paid to this skull damage. Differentiation between inflicted and accidental traumatic head injury is still a challenge in forensic pathology, particularly in pediatric population. In fact, diastasis of cranial sutures may occur with or without other skull fractures and may be the only evidence of an abusive head trauma (AHT). This is a case study dealing with undetected traumatic diastasis of cranial sutures in child abuse. The skeletonized juvenile remains were found inside a suitcase. A diastasis of the coronal and sagittal sutures was the only finding recorded at the autopsy with no other relevant bone defects. The diastasis was originally attributed by the medical examiner to a physiological unfused stage of the calvarial bones. Therefore, the cause of death was undetermined. Twelve years later an anthropological revision of the cold case showed that diastasis of the coronal and sagittal sutures was assessed as the evidence of an AHT. Analysis of skull fractures in child abuse can be challenging as normal skull suture variants mimicking intentional injury are reported. Diastasis of the cranial sutures can be also a post-mortem effect of burning or freezing. Therefore, a differential diagnosis between natural, accidental or inflicted skull defects is mandatory in death investigation. A multidisciplinary approach in such circumstances is strongly recommended in order to reduce the risk of misdiagnosis.

Decomposition of juvenile-sized remains: a macro- and microscopic perspective

There is currently a dearth of research investigating the progression and rate of decomposition for juvenile remains. It is thought that juveniles and infants decompose at an increased rate relative to adults due simply to body mass and that skeletal preservation is commonly dependent on intrinsic levels of bone mineral density (BMD). This study investigates the environmental variables important in driving juvenile decomposition as well as examining if currently accepted methodology for quantifying adult decomposition can be applied to juvenile remains. Furthermore, histological analysis is undertaken to test the Histological Index (HI) as a semi-quantitative indicator of decomposition. Thirty-five Sus scrofa ranging between 1.8 and 22.7 kg were deposited to simulate body mass of human infant and juvenile remains. Pigs were deposited every season over two years in the southeastern US with five depositional types: bagged, blanket wrapped, and surface control foetal remains, surface, and buried juvenile remains. Remains were scored quantitatively throughout soft tissue decomposition. Following study completion and skeletonization, a femur was selected from each set of remains for histological analysis. Thick sections were assessed under standard brightfield light and scored using Oxford Histological Index (OHI). Results indicate that seasonal variation is an important factor to consider even when using a standardized time variable such as accumulated degree days (ADD), particularly variation in soil moisture. Soil moisture was a consistent significant variable in the mixed effects model. The pattern of decomposition using total body score (TBS) was similar to that observed by others prior to log transformation with a rapid incline early in decomposition with levelling off. The correlation between time in days, ADD, and TBS was not as strong as those previously reported (R ² = 0.317 and 0.499, respectively) suggesting that TBS as it is currently formulated cannot be directly applied to juvenile remains. Finally, the OHI model performed moderately well, but was variable even within seasons across multiple years.

Scanning Skeletal Remains for Bone Mineral Density in Forensic Contexts

The purpose of this paper is to introduce a promising, novel method to aid in the assessment of bone quality in forensically relevant skeletal remains. BMD is an important component of bone's nutritional status and in skeletal remains of both juveniles and adults, and it can provide information about bone quality. For adults remains, it can provide information on pathological conditions or when bone insufficiency may have occurred. In juveniles, it provides a useful metric to elucidate cases of fatal starvation or neglect, which are generally difficult to identify. This paper provides a protocol for the anatomical orientation and analysis of skeletal remains for scanning via dual-energy X-ray absorptiometry (DXA). Three case studies are presented to illustrate when DXA scans can be informative to the forensic practitioner. The first case study presents an individual with observed longitudinal fractures in the weight bearing bones and DXA is used to assess bone insufficiency. BMD is found to be normal suggesting another etiology for the fracture pattern present. The second case study employed DXA to investigate suspected chronic malnutrition. The BMD results are consistent with results from long bone lengths and suggest the juvenile had suffered from chronic malnutrition. The final case study provides an example where fatal starvation in a fourteen-month infant is suspected, which supports autopsy findings of fatal starvation. DXA scans showed low bone mineral density for chronological age and is substantiated by traditional assessments of infant health. However, when dealing with skeletal remains taphonomic alterations should be considered before applying this method.