FORENSIC RADIOLOGY The forensic pathologist’s main duty is the postmortem examination; therefore, he or she deals primarily with Lois Romans, BS, RT (R) (CT) the dead. Because of the managing role of the forensic pathologist, the term forensic medicine is often considered University of Michigan Hospitals synonymous with forensic pathology. Many other medical Ann Arbor, MI specialists, such as forensic dentists and anthropologists, E-mail: [email protected] play an important role on the forensic team, but these professionals are often consultants, working only part- INTRODUCTION time in the field of forensics. The word forensic is derived from the Latin forens, Popular television programs such as CSI: Crime Scene which translates to “public.”3 In Webster’s New World Investigation and Forensic Files have piqued the public’s Dictionary, the word forensics is defined as “characteristic interest in forensic science and put terms such as blood of, or suitable for a law court, public debate, or formal spatter analysis and alternative light source (ALS) into the argument.” Therefore, forensic science applies highly spe- American lexicon. The popularity of these programs cialized scientific and/or technical knowledge to answer attests to the fascinating nature of forensic science. The questions with regard to civil and criminal law. When forensic scientist is, in the truest sense of the word, a medical facts and knowledge are required to deal with detective—solving a mystery, telling a story, and often legal issues, the special discipline is referred to as forensic uncovering a crime. Dr. Gary Telgenhoff, the real-life medicine. In one text, legal medicine is defined as “the medical examiner whose expertise is used by the cre- application of medical knowledge to the administration ators of CSI, explains what attracted him to the field of of law and to the furthering of justice and, in addition, forensic medicine: the legal relations of the medical man.”4 Therefore, in addition forensic pathology, the terms legal medicine, or I liked the combination of the medicine, pathology, medical jurisprudence, may be used synonymously with mystery, challenge and the brand new world of the forensic medicine. courtroom. This required some street smarts, common The definition of forensic medicine is broad, to encom- sense and performance ability. This is the combina- pass the large array of legal issues in which it is applied. tion of all things I was interested in: science, perfor- These include age determination, assault, civil rights vio- mance and a life left at the end of the day.1 lations, inheritance, larceny, malpractice, parentage, per- sonal injury, product liability, sexual offenses, smuggling, Forensic science is a unique scientific discipline requiring virginity, and wrongful birth or death.2 its practitioners to have, in addition to technical skills and Forensic science can be used in civil cases such as forg- knowledge, critical and analytical thinking skills, com- eries, fraud, or negligence. It can help law-enforcement munication skills, and an awareness of the role of the sci- officials determine whether any laws have been violated entist in our criminal justice system. in the marketing of food and drinks, the manufacture of Perhaps one of the appeals of forensics is its wide medicines, or the use of pesticides on crops. It can also array of subspecialties. The American Academy of Forensic determine whether automobile emissions are within a per- Sciences (AAFS) lists nine primary disciplines in the missible level and whether drinking water meets legal field of forensics: criminalistics, engineering sciences, purity requirements. Forensic science is used in monitoring jurisprudence, odontology, pathology/biology, physical the compliance of various countries with such international anthropology, psychiatry/behavioral sciences, questioned agreements as the Nuclear Non-Proliferation Treaty and documents, and toxicology. the Chemical Weapons Convention and to learn whether The multidisciplinary nature of forensic medicine a country is developing a secret nuclear weapons program. necessitates a team approach. The forensic pathologist is However, forensic science is most commonly used to inves- most often the leader of that team and is typically the tigate criminal cases involving a victim, such as assault, only physician devoted full-time to forensic activity.2 robbery, kidnapping, rape, or murder.

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Forensic science is an applied science based on the laws before the onset of a fire.8 of physics and chemistry. Over time, a set of fundamental The development of the medicolegal system of the concepts has developed that apply specifically to a forensic United States can be traced back to the early coroner analysis. Traditionally, five concepts have been enumer- system of England, established in the year 925.6,9 The ated: transfer, identification, individualization, associa- early immigrants to America brought the English cor- tion between source and target, and reconstruction.5 oner system with them. Records of medicolegal cases in the colonies date from 1635. The separate discipline of HISTORICAL DEVELOPMENT forensic medicine began to emerge in the seventeenth century in the United States and throughout the world. Evidence of legal medicine, in one form or another, New codes of law required expert medical testimony in extends throughout human history. Ancient Egyptian trials of certain types of crime or civil action. Textbooks, writings have shown that the scholar, physician, and lectures, and formal educational programs in forensic sci- pyramid architect, Imhotep (2980 BCE) applied medical ences were created. At this time, the earliest version of the principles to legal issues of the day.2 In ancient Babylon modern structure of forensic medicine took shape. This (modern-day Iraq) in approximately 2200 BCE, the king structure is now the multidisciplined, sometimes loosely Hammurabi set formal medical laws into practice. related, family of subspecialties that share the common Another early application of forensic medicine con- interest of using science to solve legal controversies. cerned the determination of suicide in the first cen- tury of the Christian era (CE).6 At the time, suicide History of Forensic Radiology was regarded as a crime against the public interest. It is assumed that this idea stemmed from the primitive The forensic radiologist is an essential member of the belief that the individual who took his or her own life forensic team. Forensic radiology encompasses the per- was possessed by evil spirits that would be passed on to formance, interpretation, and reporting of radiological other members of the community. Because of this belief, examinations and procedures connected to the courts and it was necessary for a medical expert to decide whether the law. By its nature, the science of radiology solves mys- a deceased person committed suicide and should there- teries as it reveals secrets that may be hidden within the fore be punished. (Punishment typically consisted of the body. However, unlike standard diagnostic medical radi- denial of a funeral.) ology, forensic radiology is not limited to the human body. The Germanic and Slavic peoples that overthrew the It has also proven useful in a wide range of nonhuman Roman Empire in Western Europe in the fifth cen- applications, such as uncovering faked art, authenticating tury provide another example of the early practice of antiques, and detecting forged documents. forensic medicine.7 Considered by the rest of Western Soon after Wilhelm Conrad Roentgen discovered the Europe to be barbarian and the destroyers of culture x-ray in 1895, physicians, scientists, jurists, and journal- and civilization, ironically, these tribes (the Salian ists realized the potential Roentgen’s “new kind of ray” Franks, the Alemanni, the Goths, the Vandals, and the might have in legal medicine. In the October 1898 issue Lombards) were the first to specify by law that medical of the American X-ray Journal, Dr. Fovau d’Courmelles experts should be used to determine the cause of death. wrote, “Knowing the existence of a fracture in a person Forbidding the then-common practice of personal ven- who has been burned or mutilated beyond recognition, dettas, these people implemented an established legal we can hope to identify him by the x-ray.”10 system, thereby demanding individual and community In North America, the first court case that uti- responsibility. The Wergeld, or blood-price, was paid to lized x-ray occurred in Montreal on Christmas Eve, the victim by the criminal, or in the case of murder, 1895. In this case, Mr. George Holder was accused of to the victim’s family and relatives. The price assessed shooting Mr. Tolson Cunning in the leg. The bullet depended on the type of injury and on whom the assault could not be found by physical examination or probe. was committed. For example, the fee levied was greater Although the wound healed, it remained symptomatic. if the injured party was of a higher class. The more Mr. Holder’s physician requested that the professor of gruesome the wound, the higher the payment required. physics at McGill University create an image of the For instance, if the wound exposed brain or bowel, the leg using the newly discovered technique of x-ray. A fee was higher than if only blood was shed. This system 45-minute exposure resulted in an image that showed necessitated that a medical specialist who worked with the flattened bullet lying between the tibia and fibula. the courts examine wounds. The bullet was removed, the x-ray image was sub- Early forensic medicine was not limited to Europe and mitted to the court at trial, and Mr. Holder was subse- the Middle East, however. A Chinese textbook called quently convicted of attempted murder and sentenced Hsi Duan Yu (the washing away of wrongs), published to 14 years in prison.10 in 1248, contains a description of how to distinguish In spite of the success of forensic radiology in the drowning from strangulation. It also commented on how Montreal case, there was considerable controversy in the to ascertain whether a burned individual had been dead US courts concerning the admissibility of x-ray images. forensic radiology CEWebSource.com PAGE  OF 20 expirES August 15, 2013

One judge in the eastern United States had refused to These earlier films were compared with those taken of admit x-rays as evidence citing, “It is like offering the the burned remains found in the ruins of the chancellery photograph of a ghost.”10 garden, and a positive identification was possible. Arguments on both sides of the issue continued until Similarly, the notorious Dr. Josef Mengele, one of Judge LeFevre finally settled the matter in December of Hitler’s cohorts, escaped at the end of the war. Much 1896. A Civil War veteran and alumnus of the University effort went into tracking him down for extradition to of Michigan, LeFevre was a well-known and respected West Germany, where he could be tried and punished judge. He handed down the landmark decision: for his crimes. Authorities suspected that family influ- ence allowed him to live hidden in Germany for some We have been presented with a photograph time. He then went to South America, where he prac- taken by means of a new scientific discovery. It ticed medicine in various places with various assumed knocks for admission at the temple of learning: identities. It was reported that he lived in Paraguay for What shall we do or say? Close fast the door or some time, where he advised the dictator on how to open wide the portals? annihilate the indigenous population. He disappeared The photographs are offered in evidence to from Argentina just in time to escape capture and was show the present condition of the head and neck purportedly involved in the drug trade. Finally, in 1985, of the femur bone, which is entirely hidden from reports surfaced of a body found in Brazil believed to the eye of the surgeon. Modern science has made be that of Mengele. An extensive team of forensic sci- it possible to look beneath the tissues of the human entists, representing many disciplines, was involved in body, and has aided surgery in telling of the the complex identification process. Skeletal abnormali- hidden mysteries. We believe it is our duty to be ties were discovered on radiographs that were consistent the first . . . in admitting in evidence a process with accidents and illnesses documented in Mengele’s known and acknowledged as a determinate sci- history, but no antemortem (before death) radiographs ence. The exhibits will be admitted in evidence.10 were found for comparison. Finally, with the family’s reluctant cooperation, antemortem dental radiographs Thus, radiographs were accepted into the US courts. were recovered and compared with those of the corpse, In the precedent-setting instance cited above, the x-rays resulting in a positive identification. were introduced to argue a malpractice case, but soon In the case of President John F. Kennedy, the post- x-rays were being entered into court in a wide variety of mortem radiographs seem to create more questions cases, from murder to forgery. than they answer. The x-rays are central to the con- troversy about the number of shots, their direction of Celebrity Forensics Cases travel, and their trajectory, as well as the number and the location of the shooter(s). However, the x-rays, a Well before the OJ Simpson case, forensic radi- frontal and two lateral views of the skull, are overex- ology of famous (and sometimes infamous) celebri- posed, and their poor quality reduces their usefulness. ties has long held a special fascination for the public. Paradoxically, these images have been used as evidence Such high profile cases have contributed to the public’s to support opposing theories. awareness of the field. Perhaps one of the earliest celebrity cases that utilized Radiologic Techniques in Forensics radiology was that of President Theodore Roosevelt. On October 14, 1912, while running for a third term, Until recently, forensic radiology depended almost a fanatic shot President Roosevelt in the chest. The exclusively on the x-ray and the static image captured bullet passed through Roosevelt’s overcoat, suit, shirt, on the radiograph. The newer modalities, such as com- the folded manuscript for his speech, and a steel eyeglass puted tomography (CT) and magnetic resonance imaging case. These many layers, as well as Roosevelt’s heavily (MRI) are only gradually being added to the forensic muscled chest, probably saved his life. An x-ray exami- arsenal. Problems of accessibility and cost have kept nation showed that the bullet had entered his right chest newer techniques, so extensively used in clinical practice, medial and inferior to the nipple and was embedded in from widespread use in forensics. a rib, splintering its internal surface so that the pleura As early as the late 1800s, a technique was introduced was compromised. The bullet was not extracted for fear in which the skin of the fingers is lightly coated with of complication, and Roosevelt carried it with him to his powered lead tetroxide and exposed to soft x-rays. The grave some years later. x-ray that results reveals fine fingerprints. This system Another famous forensic case was that of Adolph was replaced by the much cheaper and more rapid ink Hitler. After the war, speculation and rumors suggested print. More recently, the x-ray fingerprint method has that Hitler was not really dead and that he had somehow been resurrected in the recovery of latent prints from dif- escaped. Fortunately, a radiographic study of Hitler’s ficult surfaces. This method is known as x-ray fluores- skull taken years before revealed distinctive dental work. cence radiography (XFR) or backscatter radiography. It forensic radiology CEWebSource.com PAGE  OF 20 expirES August 15, 2013 relies on the emission of secondary or Compton scatter Radiology mostly became involved by happenstance, (low-energy photons) from heavy particles (lead dust) circumstance, curiosity, or just plain good luck. when bombarded with suitable high-energy x-rays. The XFR method is employed when prints are suspected of It is much the same for radiologic technologists who resting on problematical materials such as multicolored work in forensic radiology. Currently, there is no course- documents, cloth, polythene, wax, cardboard, hardboard, work for forensic radiography. Again, Dr. Brogdon: varnished and untreated wood, rubber pigskin, and the skin of human corpses or nonvital separated body parts. Anybody who is adequately trained in radiologic This method is not used frequently because it requires technology can do forensic technology if they’re so special equipment and the lead dust can expose forensic inclined. There is no coursework because the technical workers to a health risk.10 work is easier than clinical work for very simple rea- sons. The [deceased] patients hold still. They don’t Other Uses of Radiography in Forensics breathe. They don’t move. Exposure times are not a problem and repeat work is not a problem.12 Radiography has also been employed in nonmedical forensic cases. X-ray has been used in questioned docu- Unfortunately, it is common practice for postmortem ment cases to uncover crimes, such as tampered wills. radiography to be performed by individuals who have no In an early foray into the field, an attorney introduced formal training in radiologic technology; most often by a radiograph of a document into evidence to show the an assistant to the medical examiner.12 This practice is court that the parchment was extremely thin in one area. regrettable, because, as in any radiologic examination, The attorney contended that this was proof that some consistent and accurate positioning is a key element in of the names had been erased to be replaced by others. the overall quality of the radiographic image. This fact is As far back as 1896, x-rays were used to prove the adul- particularly true in forensic radiography because often the teration of foodstuffs, and they are still used by the gov- aim is to match antemortem images to those taken after ernment’s Food and Drug Administration (FDA) today. death. This can be a daunting task when the remains of Both plain-film radiography and CT have been used to an individual are degraded through a myriad of environ- evaluate, noninvasively, mummies for content, age, sex, mental factors. Nevertheless, this difficulty can be over- embalming methods, hidden valuables, injuries, and dis- come if the postmortem images closely approximate those ease. In addition, radiographs have been used to detect taken in the antemortem state. Of course, trained, reg- fake jewels and alterations in paintings. istered radiologic technologists typically perform exams of living patients. Therefore, it makes sense that trained CREDENTIALS OF PROFESSIONALS professionals are best suited for obtaining high-quality WORKING IN FORENSIC RADIOLOGY radiographs on postmortem subjects. In addition to the prospect of poor-quality images, individuals performing exams without the proper training may lack even a basic Although there are approximately 30,000 practicing understanding of radiation protection and thereby pose a radiologists in the United States,11 only a handful risk to themselves and others. have had sufficient involvement or interest in forensic radiology to have become members of the American SCOPE OF FORENSIC RADIOLOGY Academy of Forensic Sciences , and only four of those have satisfied the requirements for fellowships in that The situations in which forensic radiology can be organization.11,12 applied to resolve legal matters are many and varied. The As Dr. Brogdon from the Alabama Department of importance of radiographic techniques in clinical forensic Forensic Sciences and author of Forensic Radiology, medicine is widely recognized. It is common practice to points out, obtain radiographs as part of postmortem examinations in order to locate foreign bodies or document fractures There is no set definition or standard for a or other injuries. The stage at which radiology is imple- “Forensic Radiologist.” There is no specialized mented during autopsy varies according to the individual training or fellowship available in that field; there circumstances, but usually it is after the external exami- is no separate Society for Forensic Radiology, nor nation and prior to the dissection.13 is there certification for a subspecialty or added Foreign bodies, such as bullet fragments or glass, may qualification in Forensic Radiology. It is doubtful be seen and analyzed by radiographic means. This is that any radiologist in North America, regardless of important not only for their detailed examination, but his level of interest, devotes as much as 10% of his also for retrieval of the objects as evidence. Bullets can active practice to Forensic Radiology. migrate from the entry track; therefore, the examina- Those few of us who do maintain some tion must include the whole body for their precise loca- continuing, albeit sporadic, activity in Forensic tions. Different types of bullets (for example, high- and forensic radiology CEWebSource.com PAGE  OF 20 expirES August 15, 2013

The Need to Identify17 low-velocity) can produce different injuries to bone and soft tissue. Radiographs can detect pneumothorax, pneumo-peri- Many forensic scientists look at the task of identifying toneum, and air embolism after abortion. They can also the dead as their greatest challenge and weightiest respon- uncover injury sustained from the failure of the body to sibility. Universally, there is something deeply unsettling equalize the pressure of an air-containing space with that about the loss of identity, even for the deceased. In the of the surrounding environment. These injuries, referred United States, a poignant illustration of the deep desire to as barotraumas, can affect several different areas of the to learn the fate of missing loved ones is evident in the body, including the ear, face, and lungs. Barotraumas are decades-long diplomatic efforts and elaborate forensic commonly associated with air travel and scuba diving. mechanisms to recover and identify remains of Americans In situations in which a traumatic subarachnoid hem- missing in Vietnam and Korea. In the same way, each orrhage is suspected, vertebral angiography can be per- unidentified body brought to the medical examiner rep- formed after death.14 resents a person missing to friends and family. Without Although radiographs for the detection of fractures are the proper identification, loved ones are denied the clo- not routinely required, in some situations they can pro- sure that can come with mourning. vide valuable information. For example, in the case of Identification is also important to enable loved ones to suspected neck pressure, radiographs are valuable because cope with the legal issues associated with death. A death the involved structures are relatively fragile and might be certificate is mandatory for families to probate wills and broken during direct examination. Radiographs of frac- receive death benefits. Without a death certificate, a tures are also common in child abuse cases. spouse is unable to remarry for a period of seven years, at Radiologic examinations play a significant role in diag- which time, in most states, a missing person can legally nosing nonaccidental injuries of children, in diagnosing be declared dead. medical negligence, and in establishing biological aging In cases in which foul play is suspected, the detective’s in disputed cases. Additionally, in forensic anthropology job is more difficult when the victim remains unidenti- and odontology, the comparison of antemortem and post- fied. In addition, when the remains are decomposed or mortem radiographs is one of the cornerstones of positive severely marred by fire, a cause of death may be impossible identification of human remains. This outline summa- to determine. In these cases, once the victim’s identity is rizes forensic radiology’s main services: known, sometimes the cause of death can be established from the medical history. The Scope of Forensic Radiology15 I. Service Methods A. Determination of Identity B. Evaluation of Injury and Death In general, several factors, including the condition of 1. Accidental the body, how well the person was known in the com- 2. Nonaccidental munity in which the death occurred, the number of vic- a. Osseous injury tims, and the capabilities of the forensic team, dictate the b. Missiles and foreign bodies methods of identification used.17 Identification methods c. Other trauma fall under two main categories: The first, and least repro- d. Other causes ducible, method involves visual identification; that is, C. Criminal Litigation family or friends may be asked to examine the remains, 1. Fatal a photograph or video of the remains, details such as 2. Nonfatal tattoos on the remains, or personal effects found either D. Civil Litigation on or about the victim. The second and most reliable 1. Fatal method involves the physical comparison of postmortem 2. Nonfatal to antemortem characteristics. These anatomic markers, E. Administrative Proceedings including fingerprints, dental restorations, healed fea- II. Education tures, or surgical sutures, can often be compared with III. Research similar antemortem documentation (such as fingerprints, IV. Administration radiographs, or dental records). Regardless of the method used, two general prin- DETERMINATION OF IDENTITY ciples apply: first, all techniques from visual observa- tion of the remains to sophisticated DNA profiling rely on pattern recognition. If the pattern is not disrupted Radiology plays a major role in the determination of (whether it is fingerprints or teeth), a positive, reliable identity. The personal identification of human remains identification is much more likely. Pattern recognition constitutes about 10% of the normal caseload of any also relies on the skill and experience of the examiner; forensic medicine practice.16 that is, the more familiar the examiner is with the anal- forensic radiology CEWebSource.com PAGE  OF 20 expirES August 15, 2013 ysis of the patterns, the higher the likelihood of a suc- older ages.19 The use of radiographs to establish age is cessful outcome. possible because of the complex, but dependable, system The second overarching principle is that the pro- by which the osseous framework of the body develops, cess of identification requires a team approach. Even grows, and matures. in the simplest of cases in which visual inspection of The determination of the sex of a skeleton may also the body is all that is required, a police officer most aid in identification. The skeletal maturation in females often notifies the family or friends, and the medical is accelerated over that of males after the third or fourth examiner witnesses the observation and confirms the year of life. However, the use of skeletal radiography identity. In complex cases, such as that following the as a means of sex differentiation is reliable only after tragedy of the World Trade Center after September 11, puberty.20 At this time, sexual characteristics discernible 2001, the team can be quite large. In such difficult by radiography begin to appear. cases, forensic professionals include the entire range of In general, the male skeleton is more robust and heavier, forensic experts, from fingerprint examiners, to anthro- with more prominent attachment for muscles and ten- pologists, to radiologists. dons. Male skeletons tend to exhibit more degenera- The forensic odontologist examines and character- tive changes and exhibit more signs of abnormal osseous izes the teeth of unidentified bodies and necessarily tissue growth (hyperostosis). The long bones of males are works extensively with radiographs. The dental charts about 10% longer than those of females. The male fem- of missing individuals can then be compared with the oral head is larger in all dimensions. All of the general forensic odontologist’s report to identify the body. findings are helpful, but not definitive, in establishing Forensic anthropologists must also be conversant in the sex of unidentified human remains. The pelvis offers radiologic methods. They are trained to determine the the most definitive traits in establishing the sex of a skel- sex, height, weight, and ethnic group of the deceased eton. Krogman states that the chance of correctly deter- person from an incomplete body. Marks on the bones mining the sex of bones is 100% if the entire skeleton is often indicate past injuries, disease, and occupational available, 95% with the pelvis and skull or with the pelvis stresses suffered by the individual. Investigators may be and a long bone, and 90% with the skull alone or with able to identify a body by comparing old x-rays and the the long bones and skull.20 medical history of a missing person with the findings of a forensic anthropologist. Mass Casualty Situations When a body has decomposed or has been mutilated by fire or excessive forces that preclude visual identifi- In mass disasters such as plane crashes or other trans- cation, investigators know from the start that scientific portation-related tragedies, all the forensic tools men- methods must be used. Therefore, the inquiry can start tioned may be needed. In addition, manifest lists, seating by collecting items such as dental and medical records, charts, and other documentation is invaluable in identi- antemortem radiographs, and fingerprints. Dental fying the bodies. In these situations, it is preferred, when records and radiographs are the most productive tool possible, that all remains be identified scientifically with for identifying such mutilated remains. Radiographs of methods such as dental records or radiographs rather a variety of anatomic regions and body parts, ranging than visual identification because relatives and friends from those of extremities with healed fractures to scout may not have seen the victim for years, making visual films of the abdomen with distinctive phleboliths, may identification less reliable. Additionally, comparison of prove invaluable.17 radiographs, dental records, and fingerprints by profes- The determination of age at time of death is an sionals reduces the involvement of loved ones during an important step toward the identification of unknown extremely stressful time.21 remains. In addition, the question of biological age can Mass disasters often necessitate temporary morgues be raised in courts of law in a variety of other situations. and improvised field x-ray operations. How resources For example, age determination may help establish if a are configured depends on the nature of the casualty defendant should be tried in juvenile courts, to verify and upon the number and condition of the victims. legal age for marriage, or to determine cases of statutory Generally, it is more efficient to use preexisting, per- rape. Through radiography, age can be established with manent radiology facilities in a nearby hospital or in a considerable accuracy from the time of skeletal devel- medical examiner’s offices. In some instances, outpatient opment at about the 20th week of gestation until early clinical radiology departments can be used by working adulthood.18 However, biological age of living per- in the evenings when the clinic is normally closed. In sons cannot be accurately estimated in adult individuals the past decade, a philosophy concerning the use of pre- older than 25 years.14 The most common radiographs existing clinical facilities has shifted somewhat due to used for establishing age of up to 16 years are dental concerns over public health and environmental issues. radiographs and hand radiographs. Postcranial radio- Apprehensions over blood-borne pathogens have led to graphs of specific ossification centers, depending on the stringent regulations restricting access to disaster sites reputed age of the individual, are useful for estimating and to material potentially containing human remains. forensic radiology CEWebSource.com PAGE  OF 20 expirES August 15, 2013

Requirements, including the use of isolation garments was initiated.24 Forensic radiology was a key component in or decontamination suits, make it logistically difficult to the system of casualty identification. Forensic investiga- bring remains into working clinical facilities. Such regu- tion of the deaths that occurred at the Pentagon was car- lations may force a return to the use of field facilities and ried out at the port mortuary of Dover Air Force Base in temporary morgues. Delaware. Here, the Office of the Armed Forces Medical In March 1997, 582 people were killed when a KLM Examiner was assisted by a support group of more than Boeing 747, attempting to take off, collided with a Pan 200 military and federal personnel representing all ser- Am 747 on the Canary Island of Tenerife.22 The emer- vices and many agencies.25 Unlike past experience in war gency investigative facility set up in a warehouse provided and peacetime accidents, the military faced a unique sce- a prototype for such operations. The facility was main- nario: a mass-casualty situation with the involvement of tained for three weeks, during which all remains were both military personnel and civilians, with the addition radiographed. Radiologic technologists and radiologists of terrorists among the remains. The US Department of were part of the multidisciplinary team of more than 130 Radiologic Pathology at the Armed Forces Institute of military and federal civilian workers that included experts Pathology (AFIP) performed the radiographic analysis of in fingerprinting, dental analysis, anthropology, blood the remains with support from the Diagnostic Imaging chemistry, toxicology, medical photography, personal Department of the Dover Air Force Base Medical Clinic. effects investigation, and forensic pathology. A system The enormity of the situation required the help of an was established so that each group gathered data available additional radiologist and military radiologic technolo- in their discipline for each victim’s body. Whenever pos- gist from two reserve components. The volume of the sible, identifications were confirmed by multiple modali- recovered remains necessitated that this staff operate up ties. For example, if the FBI fingerprint team made an to 12 hours per day, 7 days per week.24 apparent identification, all other modalities were cross- Disaster sites uncover human remains that are highly checked for consistency. Radiological examination of all variable in form and condition. Recovered remains are remains was an early step, so that films could be pro- likely to have been subjected to extreme physical and cessed and reported prior to the pathologic examination thermal trauma. Death may have resulted from a wide that was performed near the end of the process. Thus, variety of causes, such as crash impact, building col- details that might be hidden on gross external exami- lapse, fire, and smoke. In aircraft crashes, the fuel from nation, but which were revealed radiologically, could be jet engines burns at high temperatures and can severely sought and confirmed at autopsy.22,23 burn tissue, clothing, and furnishings. Furthermore, the Sadly, not long ago a precedent was set for a mas- process of recovery from beneath fallen rubble can also sive identification project. This occurred in the former alter remains.25 Yugoslavia following the war of the 1990s. Because of All these factors played a role in the Pentagon site that conflict, some 40,000 citizens had disappeared and recovery, where specimens ranged from relatively intact were presumed dead. Families had been separated; thou- bodies to small body-part fragments. Whole-body radi- sands of spouses, children, and parents had no idea what ography was an important step in processing the remains. had happened to their loved ones. In response, the world Unfortunately, many specimens were received as body community, through the G-7 economic powers, orga- parts, often unrecognizable by visual inspection, and nized an enormous team of forensic scientists whose sole mixed with debris from the site. The Federal Bureau of job was to deliver closure by identifying remains. During Investigation assigned identification numbers to each the war, many bodies had been dumped in shallow mass specimen prior to processing. This number linked the graves, burned, and dismembered. Clothing, jewelry, specimen to its recovery location at the scene. and other standard means of identification were often Whole-body radiography was employed to uncover body missing. In spite of the nearly overwhelming obstacles, parts, personal effects, or other material present in the however, the commission persevered, resulting in thou- specimen. The forensic radiologist reported on all iden- sands of identifications.23 tifiable human structures, but also on any other objects Later, members of the team from the former that were recognized, such as jewelry or other personal Yugoslavia flew to New York following the World effects. They also noted any distinguishing features that Trade Center disaster to offer their expertise. They could potentially help in identifying the victim. These also offered the software package that helped match included characteristics that could aid in establishing the thousands of Yugoslavian victims with their families. age of the victim, such as the appearance of an epiphysis Edwin Huffine, PhD, a former US Army forensic at the end of a long bone or of osteoarthritis in a knee. chemist who headed the team, said, “We brought Because the event was known to be the result of ter- advice and let them [the New York City team] take rorist action, the radiologist also searched for clues such whatever they needed.”23 as weapons or aircraft parts that might lead to a better Following the attacks of September 11, 2001, even understanding of the attack.24 while search and rescue efforts continued, the process of Radiologic services were a crucial part of the team at recovery and identification of those who did not survive the Pentagon site. For the final identification step, dental forensic radiology CEWebSource.com PAGE  OF 20 expirES August 15, 2013 records and DNA reference samples may often be suffi- The arrangement and direction of skull fractures can cient. Radiography of victims is still essential, however, indicate the impact point and the direction of impact. particularly when reliable dental information is not avail- Occasionally, the radiograph can suggest a sequence of able or when attempts to collect DNA from victims are repetitive blows and sometimes even the shape of the hampered. Although DNA analysis is a powerful tool, object or weapon that inflicted the injury.28 Certain it has limitations. The DNA sources from victims sub- types of skeletal injuries are known to be defensive in jected to intense fire may not be recoverable.26 The mass- nature. Evidence of multiple injuries in various stages of casualty operation resulting from the Pentagon attack healing is an obvious indicator of chronic physical abuse. confirms the value of forensic radiology as part of the Strangulation is indicated by fractures of the hyoid bone recovery and identification process that follows mass- or thyroid cornua.29 In motor vehicle accidents, certain casualty situations. bone injuries can suggest the velocity of the impact or Similarly, international forensic teams have been orga- deceleration.15 nized and sent to other areas in the world where large- Many diseases such as infections, infestation, metabolic scale violence has occurred, such as Afghanistan, Rwanda, abnormalities, and dietary anomalies can leave telltale Guatemala, and Nigeria.27 signs on the skeleton that can be seen radiographically. Once spotted on the film, these indicators can be com- EVALUATION OF INJURY AND DEATH pared to medical histories for help in identification.

Another important aspect of forensic radiology is to Gunshot Wounds evaluate injuries sustained by the deceased or the factors that resulted in death. This evaluation leads to a determi- Violence is an unfortunate reality in the United States. nation of whether the death was accidental or intentional. Guns, particularly handguns, make a major contribution In these cases, information about the previous medical to this ongoing national crisis. Gunshot wounds severely history of the deceased can be of enormous benefit. Such affect the criminal justice and healthcare systems. In fact, evaluation frequently requires elements of detection, pat- gunshot wounds (missiles) accounted for 31,224 deaths in tern recognition, interpretation, and comparison. These the year 2007.30 fundamentals are each based on radiologic training The Centers for Disease Control (CDC) reports that and experience with normal and abnormal findings in the rate of firearm death among children under the age patients of both sexes and all age groups. Although radi- of 15 is almost 12 times higher in the United States than ology most often focuses on the bony skeleton, in many in 25 other industrialized countries combined. American situations the soft tissues of the musculoskeletal frame- youths are 16 times more likely to be murdered with work and the abdominal and thoracic viscera can provide a gun, 11 times more likely to commit suicide with a essential information.15 gun, and 9 times more likely to die from a firearm acci- dent than children in 25 other industrialized countries Osseous Injuries combined.30,31 The forensic evaluation of gunshot wounds and weapon In determining whether a death was intentional, ballistics is complex and wide ranging. Radiographs are the forensic team looks for a variety of indicators. To used in several ways: look for osseous injuries, the body parts are manipu- * lated to replicate standard radiographic positions. Just Localize the bullet as in clinical radiography, body parts are examined in * Determine if bullets of different calibers are present at least two positions. Again, just as in clinical radi- ography, common views such as AP, lateral, oblique, * Determine the number of bullets and customary positioning methods such as adduction, * abduction, flexion, and extension are employed. The Provide information concerning the angle and imaging techniques employed in forensic radiology are direction of fire nearly identical to those of standard radiography; the * Indicate the type of weapon major exceptions are the lack of concern for motion or radiation exposure.13 * Reveal clues that a crime has been committed A fracture can often point to whether the injury was acci- dental or inflicted. The radiologist looks at the location Principally, the forensic pathologist is interested in the and type of fracture and considers the age and expected location of the bullet. Although the entrance wound is level of activity of the individual. Certain common types typically visible upon visual examination, bullets often of fractures, dislocations, and epiphyseal separations are travel to a site far distant from their entrance points, par- known to be the result of accidents, while others types ticularly if they have been deflected by an impact with of injuries are nearly impossible to sustain in the normal bone. The curved nature of the ribs and skull can cause course of activities.13 a significant alteration in a bullet’s trajectory. The avail- forensic radiology CEWebSource.com PAGE  OF 20 expirES August 15, 2013 ability of fluoroscopy in the autopsy suite is especially in soft tissues or the gut. Foreign bodies in the vagina, valuable for allowing the pathologist to scan the body for rectum, bladder, or other tissues can indicate sexual unsuspected bullets.32 abuse, autoeroticism, or psychosis.15 X-ray also reveals whether bullets of a variety of cali- bers are present. Radiographs determine the number of Other Trauma bullets, and these are then correlated to the entrance and exit wounds. A discrepancy may lead to a search for bul- A huge variety of physical trauma can leave behind lets at the crime scene. radiographic signs. Shaken babies may have intracranial The angle and direction of fire is often indicated by the hemorrhage, fractures of the laryngeal soft tissues have x-ray. Additionally, radiographs may offer clues about the been seen in hangings, and massive soft-tissue contusions type of weapon used. For example, high-velocity hunting can indicate beatings.28 ammunition wounds leave a characteristic appear- ance of many tiny lead fragments referred to as a “lead Other Causes snowstorm.”32 When a decomposed body is discovered, x-ray may present Radiography can be used to help determine the cause the first indication that a crime has been committed. In of death in many other situations. Radiography is the the normal process of decay, tissues bloat, deform the body, best and earliest method of demonstrating air embolism and thereby easily mask an entrance wound. Radiographs to the heart, brain, or vascular tree.15 Conditions such should always be done on bodies that have been partially as pneumothorax, pneumopericardium, pneumomedi- destroyed by fire or on skeletonized remains to determine astinum, pneumo-peritoneum, or abnormal air collec- the likelihood of criminal activity. tions associated with abscess, obstruction, or paralytic dysfunction can be diagnosed after death using radio- Suicides logic techniques in much the same way they are used in clinical settings. Firearms are involved in up to two-thirds of suicides.33 It is also important to note that criminals often set fires to In most cases, careful forensic examination can distin- hide their crime. For this reason, all bodies burned beyond guish suicide from an accidental injury or a homicide. recognition must be investigated radiographically. In the determination of suicide, the forensic patholo- gist looks for a number of findings. The majority of sui- CRIMINAL LITIGATION cide gunshot wounds are contact wounds, usually to the right of the head since most people are right-handed. The value of radiologic imaging in violent crimes, such Subsequently, in suicides it is common to find wounds to as murder, assault, abuse, or terrorism, is easily apparent the right temple with a posterior and superior trajectory. and well known to the public, thanks, in part, to a mul- However, the nondominant hand is sometimes used, and titude of detective novels and forensic science television its use cannot, in itself, rule out suicide. Likewise, suicide programs. The contribution radiology can make in non- wounds to the top or back of the head are also possible, violent crimes, such as smuggling, larceny, forgery, mail although infrequent. Conversely, suicide gunshot wounds fraud, the adulteration of foodstuff, and counterfeiting, is in or near the eye are uncommon and such cases are sus- much less recognized. picious for homicide.34,35 Similarly, suicide wounds that involve the mouth do not generally involve the tongue. Smuggling When the tongue is involved, homicide must be consid- ered. In this case, the rationale is that in the case of a For more than one hundred years, radiology has been homicide, the victim attempts to push the weapon from used to seize forbidden goods. As early as 1897, the French the mouth with the tongue.35 customs service employed fluoroscopic x-ray equipment to apprehend smugglers of contraband.36 The 1970s Other Foreign Bodies brought forth a new breed of smuggler, one that could be identified and apprehended with the use of the radiologic Many other materials are radiographically opaque method. In forensic circles, this type of smuggler is called and may be important forensically. Radiographs can be a “body packer” and transports illegal drugs across bor- used to detect the snapped-off point of a knife, frag- ders in specially devised packages hidden in the carrier’s ments of broken glass, bomb fragments or shrapnel, rectum, vagina, or alimentary canal. Because packages parts of the automobile or aircraft in which the victim of drugs stored in the vagina or rectum can be discov- was riding, as well as animal, mineral, or vegetable ered by manual examination in a body search, the prac- matter embedded, aspirated, or injected.15 A cave-in or tice of swallowing the packages became more common. drowning in surf can result in aspirated dirt, which is Cocaine, heroin, amphetamines, hashish, and marijuana seen on the film as an opacity in the victim’s trachea. have all been transported in the alimentary tract. The Some poisons are also radio-opaque and can be seen packaging is most often latex, which can be accomplished forensic radiology CEWebSource.com PAGE 10 OF 20 expirES August 15, 2013 by wrapping the drug in condoms, the fingers of surgical were forgeries.41 gloves, or even small balloons. The ends of the packages A scientist, however, can use many tools to uncover are securely tied and then swallowed. Up to 214 packages forgeries. A few of them are scanning electron micros- have been found in a single smuggler.37 copy, carbon dating, ultraviolet light, infrared tech- Body packers have caught the attention of the authori- niques, and a variety of radiographic techniques. In ties following complications such as obstruction of the fact, x-ray and art have a long history together. A con- alimentary canal or overdose resulting from the leaking nection can be found as far back as 1896 in Frankfurt, of drugs from the packaging. The radiographic appear- Germany, although x-ray did not come into regular use ance is of regularly shaped round or oval foreign bodies to analyze art until it was used at Harvard’s Fogg Art outlined by thin, bow-shaped air shadows, sometimes in Museum in 1925.42 multiple layers.38 Occasionally, the entire package is out- The types of radiographic methods that have proved lined by gas in the gastrointestinal tract. The density of helpful in detecting forgeries include x-ray fluores- the bag on the radiograph may vary. That is, bags can be cence (XRF), autoradiography, and stereoradiography. hyperdense, hypodense, or isodense. In XRF, a material is exposed to x-rays with a relatively CT is useful in cases in which a flat plate of the high energy. These photons are capable of exciting the abdomen is equivocal. Water-soluble iodinated contrast electrons in the core levels of the material under inves- material (such as Hypaque™, [diatrizoate sodium] GE tigation. The induced excited state relaxes under emis- Healthcare) is usually given orally to confirm or exclude sion of an x-ray photon with a smaller energy. This body packages.39 emitted light is analyzed in a spectrometer. Because the core levels have different energies for different ele- Larceny ments, the XRF spectrum contains information on the elemental composition of the sample under investiga- Radiography is not an effective tool in revealing swal- tion. Autoradiography refers to the technique in which lowed precious stones. Diamonds and other precious film exposure is accomplished using beta particles or stones are not sufficiently opaque to be visible inside gamma rays. Most clinical radiographers are familiar the water-density structures of the human body by con- with the concept of stereoradiography, which operates ventional radiography (unless the gems are mounted in in the same wavelength range as medical x-rays and metallic jewelry settings). Interestingly, false gems are offers a three-dimensional effect. radiopaque, and, therefore, radiography can be used to To understand how x-ray may be useful in detecting forg- determine fraud.40 eries, some background in art is necessary. Throughout Although radiography has not been useful in catching the centuries, the canvas and wood panels artists have jewel thieves, it has been effective in uncovering other painted on have been expensive. Rarely could an artist types of larceny. The Israeli National Police have imple- afford to make poor use of a canvas or wood panel. mented a radiographic technique to uncover auto theft.40 Therefore, artists often used them repeatedly. Oil paint- Using an industrial x-ray machine, they have found that ings may contain as many as seven layers, each having properly positioned radiographs readily display the tell- their own characteristic appearance during the aging pro- tale welding seams of the forged vehicle identification cess. These are called underpaintings, and they occur both number (VIN) on a stolen auto. legitimately and in forgeries. Much can be learned from the radiographic evaluations of these paint layers. It is in Art Forgeries seeing through the layers of paint that the radiograph has proven effective in authenticating art. For example, a work Shortly after Roentgen’s discovery, radiographic tech- of art titled Absinthe Drinker was alleged to have been niques were used to detect fraud and forgeries in the art done by Pablo Picasso and appeared to be from his Blue world. The advances in digital imaging and other tech- Period. The x-ray revealed an abstract painting under- nologies have enhanced opportunities to document both neath, which was a historical impossibility. In another authenticity and fakery. More than 500 years ago, the instance, a painting called Holy Antony Eremita was Dutch painter Johannes Vermeer was quoted as saying, alleged to have been created by Bernhard Strigel around “As long as there is art there will be forgeries.” The 1460. When radiographed, it was learned that an artist truth is that art forgeries started well before Vermeer’s who lived 250 years after Strigel’s death produced the times and will likely continue past our own. More than painting underneath. 2,000 years ago, Roman sculptors produced copies of Another example of the use of x-ray in art authentica- Greek sculptures. However, today art forgery is more tion is evident in the case of a painting titled Madonna common than ever before. Art dealers claim that 15% of and Child, attributed to Robert Campin. The detail all art pieces sold at auctions are fake.41 A past curator shows that the right portion of the painting at one point at the Metropolitan Museum of Art in New York, was destroyed and subsequently replaced with a piece of Thomas Hoving, stated that approximately 40% of all wood of inferior quality. This was determined because art pieces proposed to him for purchase by the museum the x-ray revealed that under the painting the wood had forensic radiology CEWebSource.com PAGE 11 OF 20 expirES August 15, 2013 wormholes that were filled by lead paint. Of course, to those with no experience in those matters. To do this the reason that the filled wormholes were revealed was effectively, the expert must collect, test, and evaluate evi- because of the radio-opacity of the dense lead pigment in dence, form an opinion about the evidence, and then the paint. The painting was suspected of being a forgery effectively communicate that opinion to others present because it is known in the art world that no right-minded in the courtroom. Renaissance artist would have worked with such a poor- quality panel.42 EDUCATION Radiography played an important role in the investiga- tion and apprehension of John Myatt, a master faker who Another role of the forensic scientist is to alert the public fooled international art experts by creating supposedly lost to situations that may be dangerous to public health or works by modern masters such as Marc Chagall, Graham safety. This information can become known from com- Sutherland, Ben Nicholson, and Alberto Giacometti.43 piling and analyzing data gathered from a medical exam- Myatt created his forgeries using a variety of unorthodox iner’s office. Examples are statistical reports leading to materials and methods. For example, he used a mixture bicycle helmet laws, warnings of the danger of large of a household emulsion and KY® lubricating jelly to get water-filled buckets to infants and young children (who the paint to move like the oil paint used in the original, have a high center of gravity and cannot extricate them- and salt water to distress the nails in the frames. He also selves after tumbling in), or publicity alerting citizens to aged the works with the contents of a vacuum cleaner the dangers of hyperthermia and hypothermia during bag. Although his techniques created replicas that were spells of severe weather. The early awareness campaigns visually convincing, they could not hold up under scien- regarding child abuse may be one of the best examples of tific scrutiny. public education by radiologists. COURTROOM TESTIMONY RESEARCH AND TECHNICAL ADVANCES A radiologist, and less commonly a radiologic technol- ogist, may be called as a defendant, plaintiff, ordinary witness, or expert witness in court cases. Proceedings Diagnostic imaging methods are also used in forensic could be centered on professional liability or malpractice, biomedical practice and research. Studies in the field personal liability, property liability, or product liability. have resulted in the establishment of forensic stan- Expert testimony may be required in civil actions in cases dards, as in the fields of skeletal development and of wrongful death or birth, civil rights violation or, quite maturation. For example, because the laryngeal car- commonly, personal injury.15 tilages undergo age changes, including mineralization A professional in radiology, like any other person, may and ossification, a recent study analyzed the degree be involved in a legal process as a party (a plaintiff or of laryngeal radiopacity to determine whether radiog- a defendant) to a lawsuit, or as a witness (by virtue of raphy of the larynx can be used routinely in forensic what he or she has observed through the five senses) to pathology to estimate age at death.45 The study found events relevant to proof of the facts at issue. In either a positive correlation between the total score of laryn- instance, he or she may be required to give testimony, geal radiopacity and age. It was concluded that this under oath, as an ordinary lay or fact witness (except method is simple, fast, nondestructive, and has a good when Fifth Amendment protection against self-incrimi- reproducibility among observers. nation is relevant).44 Rapid technical advances have occurred in radiology The term fact witness must be differentiated from expert in recent years. Many of these new techniques and witness. A fact witness can testify based on personal modalities have also been embraced and modified by knowledge of matters perceived through the five senses. the forensic science community. Examples include con- The only opinions or inferences admissible in court are trast techniques for the study of cadaver arterial systems, those rationally based on the perception of the witness the use of solidifying rubber with lead oxide in autopsy and helpful in clarifying the testimony or the determina- studies of vascular structures, and similar contrast tech- tion of a fact at issue. Therefore, a fact witness could tes- niques for demonstration of esophageal, tracheal, and tify that a film in question, properly identified with the aortic fistulae.46-48 accused person’s name, was actually taken of that person, As in clinical medicine, the usefulness of MRI and and not the mislabeled result of another exam. CT in forensic radiology has been demonstrated. For Conversely, an expert witness differs from a fact wit- example, one study looked at the feasibility of circum- ness in that an expert witness can testify, not only on venting the classic forensic autopsy by replacing it with the basis of personal knowledge, but also in the form of a full-body CT scan. The March 2003 study involved opinion. This duty is expected of the expert witness in the full-body documentation of a gunshot wound victim keeping with the ability to translate complex scientific with multislice helical CT for subsequent comparison or technical issues into language readily understandable with the findings of the standard forensic autopsy.49 forensic radiology CEWebSource.com PAGE 12 OF 20 expirES August 15, 2013

Complete volume data of the head, neck, and trunk were Appendix A includes images from the Virtopsy Web acquired using two acquisitions with less than one minute site, which demonstrate the usefulness of these new tech- of total scanning time. Sophisticated reformation tech- niques in modern forensics.50 niques helped document the gunshot-created skull frac- Obstacles in the way of widespread use of newer tures and brain injuries, including the wound track, and imaging modalities include their cost and the difficulty the intracerebral bone fragments. CT also demonstrated of gaining access to equipment. Although the Swiss intracardiac air embolism and pulmonary aspiration of project is a notable exception, much of the other research blood resulting from wound-related trauma. The study that employs radiologic methods and modalities is per- concluded that, the so-called digital autopsy, even when formed by nonradiologists without the benefit of regis- postprocessing time was added, was more rapid than the tered radiologic technologists. These researchers often classic forensic autopsy and, based on the nondestructive struggle because of unfamiliarity with well-known radio- approach, offered certain advantages in comparison with logic tenets.51 the forensic autopsy. In Switzerland, virtual autopsy has already become ADMINISTRATION a reality. The University of Bern’s Institute of Forensic Medicine, in collaboration with its Institute of Radiographs can also be used as evidence in an admin- Diagnostic Radiology, has combined the latest in radio- istrative legal proceeding that is not, strictly speaking, in logic imaging technology with forensic science to pro- a court of law. Such action would include a worker’s com- vide a bloodless, minimally invasive method to examine pensation hearing or a military board to determine line victims for causes of accidental deaths and murders.50 of duty status of an injury or illness as well as the extent From the start of the Virtopsy project in 2000, over 100 of any resultant disability and eligibility for a pension or forensic cases were examined using postmortem whole award.15 body multislice computed tomography (MSCT) and MRI. The cases represented a wide spectrum in cause of CONCLUSION death, including gunshot wound, blunt trauma resulting from motor vehicle accidents, falls from heights, blunt Forensic medicine has humble and ancient origins. injuries caused by a third party, hanging or manual Ancient writings have provided evidence that medical strangulation, electrical or chemical accidents, injuries principles have been applied to legal issues for thousands from sharp objects, as well as cases of sudden cardiac of years. It was not long after Roentgen discovered “a new death and medical malpractice. All age groups were kind of ray” that innovative forensic scientists established included in the study. its value in forensic science. Professor Roentgen furnished The Swiss project has five stated goals: the tool; the imagination and diligence of many scientists to follow resulted in x-ray’s myriad uses. 1. The implementation of radiological digital imaging Contrary to popular belief, modern forensic medicine methods (MSCT and MRI) as main diagnostic is not limited to grisly anatomic pathology, or even to tools in forensic pathology, ultimately leading to minimally invasive autopsy analogous to keyhole criminal cases. It is better defined as the practice that lies surgery in clinical medicine. at the many interfaces of medicine and law. Radiologic imaging plays a vital role at many of those intersections, 2. With the use of imaging techniques (CT and from the identification of the dead to the authentication MRI), photogrammetry, and three-dimensional of priceless art. optical measuring techniques, a reliable, accurate geometric presentation of forensic findings (the body surface as well as the interior) should be achieved. With this technology, exact forensic medical reconstructions can be performed. 3. The application of photogrammetry and 3-D surface scanning reconstruction, in addition to radiological imaging techniques as development of biomechanical models. 4. Producing and validating a postmortem biochemical profile by means of MR spectroscopy to estimate, for example, the time of death. 5. The implementation of an imaging database as a technical basis of a center for competence in virtual autopsy. forensic radiology CEWebSource.com PAGE 13 OF 20 expirES August 15, 2013

APPENDIX A

MSCT and MRI Images reprinted with permission from the Virtopsy Project,50 Bern, Switzerland.

FIGURE 3. Suicidal hanging. Note the 3-D reconstructed MSCT showing the strangulation mark around the neck. FIGURE 1. Axial MSCT scan displaying intracerebral wound track (white arrows) in a case of suicidal gunshot injury. Note the intracranial air and the bullet fragments (red arrows) along the wound track.

FIGURE 4A. Note the varying density values in a 3-D MSCT reconstruction in a case of blunt trauma to the head. FIGURE 2. This is a 3-D reconstruction of a skull fracture system from the MSCT data in a case of a motor vehicle acident in which the victim was run over by a car. forensic radiology CEWebSource.com PAGE 14 OF 20 expirES August 15, 2013

FIGURE 4B. Note the varying density values in a FIGURE 5. This is a 3-D MSCT reconstruction 3-D MSCT reconstruction in a case of blunt trauma of the pelvis and upper femoral bones, which show to the head. multiple fractures due to a motor vehicle accident.

FIGURE 4C. Note the varying density values in a FIGURE 6. This is an axial MSCT revealing 3-D MSCT reconstruction in a case of blunt trauma massive air embolism in the heart cavities as well as to the head. air in the soft tissues in a fatal diving incident. forensic radiology CEWebSource.com PAGE 15 OF 20 expirES August 15, 2013

FIGURE 9. This coronal T2 fat-saturated MR FIGURE 7. This coronal T2-weighted MR image image shows contusion of the fatty tissue on the shows wound tract (arrows) through the brain in a left side. The deceased had been struck by a car as a suicidal gunshot case. pedestrian.

FIGURE 8. This T2-weighted MR image reveals massive intrcranial hemorrhage and subdural hemorrhage above teh left hemisphere. FIGURE 10. This T2-weighted axial shows hyperintensity of the submandibular glands in a case of manual strangulation. forensic radiology CEWebSource.com PAGE 16 OF 20 expirES August 15, 2013

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41. Atkins D. My Studios Web site. Art forgeries and the x-ray. The Artists Mind [serial online]. Available at: http://www. mystudios.com/artists-mind/volume-04-2002.html. Accessed August 16, 2011. 42. Fleming SJ. Authenticity in Art: The Scientific Detection of Forgery. New York, NY: Taylor & Francis; 1976:50. 43. Wikipedia Web site. John Myatt. Available at: http:// en.wikipedia.org/wiki/John_Myatt. Accessed August 16, 2011. 44. Kuzmack NT. Legal aspects of forensic science. In: Saferstein RE, ed. Forensic Science Handbook. Englewood Cliffs, NJ: Pren- tice-Hall; 1982:chap 2. 45. de la Grandmaison GL, Banasr A, Durigon M. Age estimation using radiographic analysis of laryngeal cartilage. Am J Forensic Med Pathol. 2003;24:96-9. 46. Karhunen PJ, Mannikko A, Penttila A, Liesto K. Diagnostic angiography in postoperative autopsies. Am J Forensic Med Pathol. 1989;10:303-9. 47. Karhunen PJ. Neurosurgical vascular complications associated with aneurysm clips evaluated by postmortem angiography. Forensic Sci Int. 1991;51:13-22. 48. Karhunen PJ, Lalu K. Radiographic demonstration of esoph- ageal and tracheal fistulas at an autopsy using a contrasting medium that vulcanizes at room temperature. J Forensic Sci. 1991;36:1129-33. 49. Thali MJ, Schweitzer W, Yen K, et al. New horizons in forensic radiology: the 60-second digital autopsy-full-body examination of a gunshot victim by multislice computed tomography. Am J Forensic Med Pathol. 2003;24:22-7. 50. Virtopsy Web site. Available at: http://www.virtopsy.com/ index.php?option=com_content&view=article&id=1&Itemid= 6. Accessed August 16, 2011. 51. Brogdon BG. Chapter 18: Research and Applications of the New Modalities. In: Brogdon BG. Forensic Radiology. Boca Raton, Fla: CRC Press; 1998:333-338. forensic radiology CEWebSource.com PAGE 18 OF 20 expirES August 15, 2013 forensic radiology POST TEST c. There is no formal training program for either a radiologist or technologist that wishes to work Expires: August 15, 2013 Approved for 2 ARRT Category A Credits in forensic radiology. d. Nationwide regulations forbid unregistered tech- 1. The word forensic is derived from the Latin word nologists from working in the field of forensic that means medicine. a. courtroom. 7. At what stage in a postmortem examination is it b. death. most common to take radiographs? c. public. a. Radiographs are most often done at the crime d. conversation. scene, before the victim is moved. 2. Which terms are often used synonymously with b. Obtaining radiographs is the first step in the forensic medicine? autopsy process and done as soon as the victim a. Anthropology and odontology is brought to the morgue. b. Paleontology and postmortem evaluation c. Radiographs are usually done after the external c. Coroner and medical examiner examination and before the dissection. d. Legal medicine and medical jurisprudence d. Radiographs are the final step in the process; 3. In fifth century Western Europe, what was the they are taken after the dissection is complete. Wergeld? 8. Barotraumas are injuries a. The judicial system of the time a. sustained from the failure of the body to b. A fee that must be paid to the victim by the equalize the pressure of an air-containing space. criminal, or in the case of murder, to the vic- b. resulting from the excessive wear and tear the tim’s family and relatives body endures from chronic, long-term morbid c. The practice of denying a funeral to the obesity. deceased when death resulted from suicide c. to a group of nerves located in blood vessels in d. The term used to describe family vendettas that the intrathoracic and cervical areas and in the often remained in force for many generations heart and its great vessels that mediate reflexes. 4. A method that uses x-ray in the recovery of finger- d. that result from a disease caused by infection prints from difficult surfaces is called with Bartonella bacilliformis, transmitted by a. x-ray fluorescence radiography. female sandflies. b. cyanoacrylate fuming. 9. In situations in which a traumatic subarachnoid c. mass spectrometry. hemorrhage is suspected, what postmortem d. phenolphthalein. radiology exam is recommended to confirm the 5. Disadvantages of the method of fingerprinting diagnosis? that is also called backscatter radiography include a. CT which of the following? b. MRI 1. It requires special equipment. c. Vertebral angiography 2. The lead dust used can pose a health risk to d. Ultrasonography forensic workers. 10. The identification of human remains constitutes 3. It only recovers fingerprints on smooth surfaces about ______of the normal caseload of any such as glass or plastic. forensic medicine practice. 4. It is very technically complex and requires a. 2% extensive training. b. 10% a. 1 and 2 c. 50% b. 1 and 3 d. 70% c. 2 and 4 11. Age can be established with considerable accuracy d. 1, 2, 3, and 4 through radiography up until 6. Which of the following is a TRUE statement a. age 8. regarding the specialty of forensic radiology? b. puberty. a. An additional year of residency is required to c. early adulthood. perform the coursework that allows a radiologist d. about age 60. to work in forensic radiology. 12. Which bone is the most useful in determining the b. In the United States, there are many board-certified sex of a skeleton? forensic radiologists who work full-time in the field. a. The pelvis b. Any long bone c. The mandible d. The sternum forensic radiology CEWebSource.com PAGE 19 OF 20 expirES August 15, 2013

13. In mass casualty situations, identification _____ 20. When a bullet is deflected by impact with a bone, it is recommended. a. most often travels in a straight line and then a. by scientific methods such as dental records or exits the body. radiographs, b. can often travel to a site distant from the b. by visual identification of the remains by family entrance point. members c. may fracture the bone, but seldom changes in c. through the use of seating charts trajectory. d. through the victim’s personal effects such as d. seldom can be located. jewelry or a wallet, 21. The availability of fluoroscopy in the autopsy suite 14. What concerns have affected the practice of using is especially valuable for allowing a pathologist to existing medical facilities for forensic medicine in a. find unsuspected bullets. the cases of disaster? b. identify the victim. a. Financial concerns c. determine the time of death. b. Labor union disputes d. localize an area on the body where tissue sam- c. Apprehensions over blood-borne pathogens ples can be taken. d. The lack of the highly-specialized x-ray equip- 22. A lead snowstorm is caused by ment necessary for forensic examinations a. severe hypothermia. 15. International teams of forensic experts offer assis- b. a small handgun. tance when c. high-velocity hunting ammunition. a. the death involves a high-ranking government d. an assault weapon, such as an AK-47. official. 23. Firearms are involved in up to ______of suicides. b. there are Americans among the victims. a. 5% c. situations involving large-scale violence have b. 14% occurred. c. 66% d. approved by the United Nations. d. 90% 16. Which is a TRUE statement regarding radiologic 24. Which of the following factors would lead a forensic studies performed forensically? examiner to suspect homicide rather than suicide? a. Only one view, most often an AP, is needed. a. Gunshot wound in or near the eye b. Body parts are examined in at least two positions. b. Contact gunshot wounds c. The position of the body part is unimportant. c. Gunshot wound to the right temporal bone d. Views are limited because of concern over the d. Gunshot with a posterior and superior trajectory damaging effects of radiation exposure on the 25. The term body packer refers to remains. a. a person who dies of metastatic disease. 17. The arrangement and direction of skull fractures b. the way a murderer disposes of a body. can indicate the c. a homicide from poisoning. a. time of death. d. a smuggler who transports illegal drugs within b. age of the victim. his or her body. c. identity of the victim. 26. What is the radiographic appearance of smuggled d. impact point and the direction of impact. drugs? 18. Fractures of the hyoid bone or thyroid cornua suggest a. Ill-defined, hypodense areas, most often in the a. strangulation. thorax b. arson. b. Regularly shaped round or oval foreign bodies c. blunt trauma. outlined by thin, bow-shaped air shadows d. motor vehicle accident. c. Square-shaped bundles, roughly the size of 19. Compared with all other industrialized countries, postage stamps the rate of firearm death among children under d. Drugs cannot be seen on the radiograph; there- the age of 15 is ______in the United States. fore, radiography is not an effective tool in a. much lower revealing smuggled drugs. b. about the same 27. X-ray has been used to uncover auto theft by radio- c. nearly twice as high graphs that reveal d. nearly 12 times higher a. tampered VINs on stolen vehicles. b. hidden objects on the thief’s body. c. tampered ignitions. d. federal identification tags on stolen auto parts. forensic radiology CEWebSource.com PAGE 20 OF 20 expirES August 15, 2013

28. Radiography can be valuable in discovering an art forgery by a. uncovering materials used by the forger that are historically inconsistent with the purported age of the painting. b. carbon dating the artwork. c. detecting the actual artist’s fingerprints on the canvas beneath the painting. d. analyzing the brush strokes on the painting and correlating them to the purported artist’s style. 29. Research has shown that radiography of the ____ can be useful to estimate the age of the individual at death. a. tarsal bones b. larynx c. shoulder girdle d. sternum 30. Which is an advantage of virtual autopsy over the classic forensic autopsy? a. It is less expensive. b. Equipment is readily available at most coroners’ offices. c. It is more rapid and less destructive to the body. d. The technique is simple; therefore, trained technologists are not required. Enterprises for Continuing Education, Inc. CEwebsource.com answer key PO Box 300 forensic radiology Brighton, MI 48116-0300 Phone: 810-229-3354 Fax: 810-229-3235 expires august 15, 2013 E-mail: [email protected] CEWEBSOURCE.COM ANSWER SHEET Approved by the AHRA for 2 Category A CE Credits Please Note: Approved for ARRT and NMTCB Direct Credit • Circle the letter corresponding to the correct answer for each question. • Mail or fax this completed answer sheet along with payment to the address or fax number on the top of this page. If faxing, credit card information must be included. • You must receive a score of 75% or better to receive credit in any section. Allow up to 4 weeks to process. A Record of Continuing Education will be sent to you. • Include payment. Answer keys must be accompanied by a $18 processing fee. • In a hurry? RUSH SERVICE is available for an additional $10 for CREDIT CARD ORDERS. Fax this answer key along with your credit card information to (810) 229-3235 for a 48-hour (M-F) turn-around! Whether faxing one answer key or several, only one $10 charge is added to the total of your order when faxing multiple sheets at once!

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Article Title: Forensic Radiology Office Use: GR69/2.0 1. a b c d 7. a b c d 13. a b c d 19. a b c d 25. a b c d 2. a b c d 8. a b c d 14. a b c d 20. a b c d 26. a b c d 3. a b c d 9. a b c d 15. a b c d 21. a b c d 27. a b c d 4. a b c d 10. a b c d 16. a b c d 22. a b c d 28. a b c d 5. a b c d 10. a b c d 17. a b c d 23. a b c d 29. a b c d 6. a b c d 12. a b c d 18. a b c d 24. a b c d 30. a b c d