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American Journal of Forensic Medicine & Pathology:
doi: 10.1097/PAF.0b013e318273b606
Case Reports

Identification of Skeletal Fractures Before and After Removal of Soft Tissue: A Case Report

Kemp, Walter MD*†; McKeown, Ashley PhD; Symes, Steven PhD§; Skelton, Randall PhD

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Author Information

From the *Montana State Forensic Science Division, Missoula, MT; †University of Texas Southwestern Medical Center, Dallas, TX; ‡Department of Anthropology, University of Montana, Missoula, MT; and §Department of Anthropology and Applied Forensic Sciences, Mercyhurst College, Erie, PA.

Manuscript received May 27, 2011; accepted October 20, 2011.

The authors report no conflict of interest.

Reprints: Walter Kemp, MD, Forensic Science Division, PO Box 16010, Missoula, MT 59808. E-mail: wkemp@mt.gov.

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Abstract

Abstract: Evaluation of decomposed individuals by forensic pathologists is a common occurrence; however, complete removal of soft tissue to closely examine the skeletal elements of these individuals is not common. The decomposition process can mask injuries and impair examination of the skeleton. The case presented by the authors illustrates how complete removal of soft tissue from individuals who have undergone advanced decomposition is necessary to identify all fractures of the skeletal elements. Although removal of the soft tissue from all decomposed remains is not possible, this case shows how carefully the choice of whether to deflesh these remains should be made.

The identification of patterns of trauma is crucial to a forensic pathologist for the determination of the cause and manner of death. The process of decomposition can obscure traumatic findings; however, the skeleton may retain evidence of trauma, long after the skin and soft tissue have degraded to the point where the traumatic injuries can no longer be identified.

Performing autopsies on individuals in various states of decomposition is common practice for a forensic pathologist, but in only a few of these cases, depending on the circumstances, is the soft tissue entirely removed to allow for definitive examination of the skeletal elements. Blunt force injuries, gunshot wounds, and sharp force injuries are commonly found in forensic practice; however, advanced decomposition may impair or preclude their diagnosis at the time of autopsy.

In most cases, the evaluation of the skeletal system by a forensic pathologist is confined to palpation and radiologic examination, with limited direct visualization. Although the neurocranium, the anterior aspect of the middle and lower cervical, thoracic, and lumbar vertebral bodies, and the inner surface of the ribs can be closely or relatively closely examined after opening of the cavities and removal of the organs (as the ligaments of the neck and other soft tissue are still in place), the splanchnocranium, scapulae, bones of the upper and lower extremities, and pelvis are only amenable, in most cases, to examination via palpation and radiologic methods. In a fully preserved individual, hemorrhage can help direct a pathologist to the identification of even small, nondisplaced rib fractures; however, this guide is lost in decomposed individuals.

The decision to remove soft tissue from the skeletal elements to allow for direct examination of the bones must be undertaken carefully because it would delay release of the body to the funeral home and is only accomplished through extensive alteration of the body. In addition, given the number of cases examined by most forensic pathologists, the number of decomposed individuals within that caseload, and the time required to partially or fully remove soft tissue from a decomposed individual, routine removal of soft tissue from all decomposed bodies would overwhelm most if not all offices. Thus, the decision to remove soft tissue from decomposed remains must be made by balancing the added time required for the procedure and irreversible and extensive alterations of the body with the equal importance of the potential benefit to the investigation of the death. The choice to deflesh the body ultimately should be made by the pathologist performing the autopsy; however, consultation with an anthropologist may help. The case to be presented illustrates the importance of complete removal of soft tissue from the skeleton before definitive identification of fractures and offers strong evidence for how carefully that decision must be considered.

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CASE REPORT

The decedent, a 45-year-old man, was last known alive in June at approximately 1:00 or 2:00 PM and had reportedly been drinking alcohol with his brother-in-law and friends. At some point, the decedent and his brother-in-law walked together to the edge of a nearby cliff that overlooks the river, and shortly thereafter, the brother-in-law returned alone. He offered no explanation for the lack of the decedent’s return and later gave conflicting stories to the decedent’s family and law enforcement as to the events that occurred that day and the location of the decedent. One of the stories included that the decedent was swimming.

Searchers found the decedent 3 weeks later in July on his back, at the edge of the river at the base of the cliff where he had last been known alive. The edge of the cliff was approximately 50 to 100 yd slightly downhill from the parking lot where the decedent, his brother-in-law, and the friends were drinking. The ground between the parking lot and the edge of the cliff was flat and covered only with sparse vegetation and a few rocks. In addition, the edge of the cliff was approximately 50 to 100 yd slightly downhill from a frequently traveled road along the river. The distance from the top of the cliff to the base of the cliff was an estimated 300 ft and involved an initial very steep incline followed by a vertical drop (Fig. 1). The decedent was found on his back with his head between 2 large stones (each approximately the size of a human head), both with sharp projecting edges (Fig. 2).

Figure 1
Figure 1
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Figure 2
Figure 2
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At the time of initial viewing in the morgue, the body was in a state of advanced decomposition, with generalized brown-yellow discoloration and mummification of the skin. The body was clothed in pants, but no shirt. At several points on the body, including the head, chest, and lower extremities, large patches of skin were absent or partially avulsed, revealing the skull and ribs. The abdominal cavity was collapsed. The internal organs were present as a homogeneous red-black mass loosely adherent to the inner surface of the body cavities in several areas.

Preliminary examination of the head revealed multiple fractures of the skull (including calvarium and splanchnocranium; Fig. 3). Initial palpation of the extremities revealed no fractures. Because of the skin’s mummified nature and difficulty in removal and to avoid the production of artificial injuries, the skull and cervical vertebrae 1 to 5 were removed from the body, radiographed, defleshed, and submitted to forensic anthropologists for evaluation of the injuries and, most importantly, for identification of any injuries that may indicate a specific mechanism of production (eg, tool marks or characteristic fracture patterns) to help determine the manner of death.

Figure 3
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Before the release of the initial autopsy report, radiographs of the lower neck, chest, pelvis, and upper extremities were obtained. The soft tissue of the back and upper and lower extremities was incised, and the bones were cut down to for direct visualization and less hindered palpation of the skeletal elements. This examination revealed fractures of upper ribs (fracture of the vertebral end of right ribs 1 and 2, and the vertebral end of left rib 1); however, no other definitive fractures of the trunk or extremities were identified via x-ray or physical examination. The autopsy report was released, with the cause of death determined to be blunt force injuries of the head and neck and the manner of death to be undetermined.

After the release of the autopsy report, at the request of the Public Defender’s Office, the body was retained at the Forensic Science Division until the time when another forensic anthropologist could perform a second examination. The second forensic anthropologist subsequently viewed the body and examined the defleshed skull and cervical vertebrae. During his examination, an additional rib fracture was identified, and he subsequently requested to have the soft tissue removed from the trunk. This procedure revealed additional fractures, and the decision was made to deflesh the remainder of the skeleton, a process that also revealed additional fractures (Fig. 4, A–D). Even with the identification of additional fractures, the cause of death remained as blunt force injuries of the head and neck, and the manner, as undetermined; however, the brother-in-law was ultimately tried and convicted in court.

Figure 4
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The additional skeletal elements with fractures identified upon removal of the soft tissue from the trunk and extremities are listed in Table 1. Figures 5 and 6 are a diagrammatic illustration of the fracture distribution before and after removal of soft tissue. The dots are meant to identify the bone fractured for comparison purposes and not necessarily to show the extent of the fracture.

Table 1
Table 1
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Figure 5
Figure 5
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Figure 6
Figure 6
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DISCUSSION

The insensitivity of conventional radiography in completely assessing fractures is not a new concept1; however, the scenario that occurred in the case presented, that is, the identification of fractures in an autopsied individual both before and after removal of soft tissue, has not, to our knowledge, been described in the medical or anthropological literature. Several articles1–4 do address the comparison of radiologic studies to autopsy studies in the evaluation of the presence of fractures.

Cattaneo et al2 performed a study using piglets to assess the detection of fractures via autopsy, traditional radiography, and computed tomography (CT), with removal of soft tissue after the infliction of skeletal injuries as the gold standard for fracture identification to assess the other 3 methods. The authors addressed the need for such a study to determine the ability of each method to identify fractures and also stated that no study has verified the actual sensitivity of radiology, CT scan, and autopsy on control cases. Their study used four 3-kg newborn piglets, severely compressed anteroposterior and lateral-to-lateral to inflict fractures, combined with beating of the cranium and limbs. The authors used traditional radiography, helical CT scan, autopsy, and direct examination of the bones after cleaning of soft tissue to assess fractures. There were 110 total fractures: 26 on the crania, 62 on ribs, 11 on anterior limbs, and 11 on posterior limbs. On crania, traditional radiology showed 35% of the fractures; autopsy, 31%; and CT, 126% (more fractures were recorded via CT scan with respect to actual single linear fractures present at osteologic control). With an autopsy, many fractures of the facial skeleton obviously go undetected, and traditional radiology may have problems in interpreting superimposed bone structures, which can cause one to underestimate the number of actual fracture lines present. Computed tomographic scans may overcall fractures, being unable to distinguish a single long fracture and several shorter linear fractures that follow each other. For ribs, traditional radiology detected 47%, CT scans detected 34%, and autopsy detected 65%. For the posterior limbs, all 3 methods detected all fractures, and for the anterior limbs, 73% was detected by traditional radiology and CT scan, and 91% was detected by autopsy.

Forensic pathologists can identify very small fractures at the time of autopsy because hemorrhage within the soft tissue serves as a marker of the fracture. In a decomposed body, although hemorrhage is easily masked, it can still be detected. Tabata and Morita5 tested 91 specimens (skin and muscle) each with various degrees of decomposition (12-hour to 2- to 3-month interval after death) for glycophorin A (GPA). Glycophorin A is a glycoprotein of human erythrocyte membranes and is very resistant to putrefaction. Hemoglobin can diffuse outside of blood vessels, but GPA will not; therefore, it can only be detected outside the blood vessel if bleeding has occurred. In 31 of their specimens deemed via gross examination to be without bleeding, GPA was found only in vessels. In 15 specimens with bleeding based on gross examination, GPA was found outside the vessels. These results indicate that GPA positivity outside a vessel identifies hemorrhage. Based on the GPA testing done with those samples in which bleeding was or was not identified grossly, the authors felt confident in the determination of hemorrhage or no hemorrhage in an additional 45 samples. So, in small suspicious samples where a definitive determination of hemorrhage outside the vessels must be determined, immunohistochemical staining may be appropriate; however, using this technique to evaluate an entire body would be too time consuming and far too expensive for routine use. Other authors2 have also indicated that hemorrhage into the surrounding soft tissue from fracture sites may be slight and barely detectable upon autopsy, particularly in the paravertebral and posterior vertebral regions, and if present, can be hidden by decomposition processes.

In addition to the loss of hemorrhage as a marker for fractures in a decomposed body, the decomposition process, and especially mummification, will physically hinder the identification of fractures. Mummification involves desiccation and hardening of skin, which will constrict the underlying soft tissue and skeleton. Palpation of fractures is more difficult when movement of the skeleton is impaired (such as when it is constricted). With movement of the skeleton, it is easier to palpate the fracture as it moves abnormally (ie, the displaced ends of the fracture may be felt, or the bone will bend in an abnormal location, not normally associated with a joint).

Another consideration in the case presented is that the additional fractures identified were nondisplaced. Displaced fractures are much easier to palpate on physical examination and easier for a nonradiologist to visualize on radiograph, and the case presented illustrates how nondisplaced fractures can easily be missed by a nonradiologist on postmortem radiography or physical examination of a decomposed individual. After the identification of the fractures after complete removal of the soft tissue from the body, the radiographs of the extremities were re-examined. In retrospect, the fracture of the ulna was present; however, without already knowing that the fracture was present, it was not easily identified by the author (a nonradiologist).

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CONCLUSIONS

Rhine and Curran6 address the challenge that decomposed bodies present to forensic pathologists because of loss of and changes in the soft tissue. In this case, some of the skull fractures were quite obvious upon initial examination of the body; however, as was presented previously, radiographs and extensive physical examination of the body did not reveal the multiple additional fractures of the trunk and extremities. Only complete removal of the soft tissue from the skeleton revealed the fractures that were not appreciated on radiologic or physical examination.

The case presented illustrates the importance of strong consideration of complete removal of the soft tissue from human remains when the cause and/or manner of death are not apparent through the normal examination or simply when the specifics of a case indicate the need for thorough documentation of all injuries, including minor fractures of the skeletal system, because the identification of these minor fractures may yield information of vital importance in understanding the circumstances of the death. In probably no other general situation is this added information as vital as in a homicide; therefore, the removal of soft tissue from the decomposed remains of all homicide victims is recommended.

Although it is known that removal of the soft tissue from a skeleton is crucial to proper identification of fractures,2 this case serves as an illustrative example of just how vital it is. In forensic practice, decomposed bodies are commonly encountered; however, the complete removal of all soft tissue from the skeleton is only undertaken in some cases, and not even all victims of a homicide who are decomposed are completely defleshed. This report serves as an indication that complete removal of soft tissue from a skeleton should be more commonly considered in cases with moderate to advanced decomposition to allow for the best possible identification of skeletal injuries and other skeletal abnormalities.

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ACKNOWLEDGMENTS

Dr Kemp would like to thank the Cascade County Sheriff-Coroner’s office for their investigative efforts regarding the death; Bill Unger and the Montana State Forensic Science Division, for use of the morgue facilities to process the skeletal remains; Dr Gary Dale, for his contribution of experience and expertise in evaluation of the case; Drs Ashley McKeown and Steven Symes, for analyzing the skeletal remains and educating me on the various fracture patterns; and the National Association of Medical Examiners, for accepting my abstract for presentation of this case at the 2008 annual meeting in Louisville, KY.

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REFERENCES

1. Lederer W, Mair D, Rabl W, et al.. Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest x-ray. Resuscitation. 2004; 60 (2): 157–162.

2. Cattaneo C, Marinelli E, Di Giancamillo A, et al.. Sensitivity of autopsy and radiological examination in detecting bone fractures in an animal model: implications for the assessment of fatal child physical abuse. Forensic Sci Int. 2006; 164 (2–3): 131–137.

3. Thomsen TK, Elle B, Thomsen JL. Post-mortem radiological examination in infants: evidence of child abuse? Forensic Sci Int. 1997; 90 (3): 223–230.

4. Williamson SL, Perrot LL. The significance of postmortem radiographs in infants. J Forensic Sci. 1990; 35 (2): 365–367.

5. Tabata N, Morita M. Immunohistochemical demonstration of bleeding in decomposed bodies by using anti-glycophorin A monoclonal antibody. Forensic Sci Int. 1997; 87 (1): 1–8.

6. Rhine JS, Curran BK. Multiple gunshot wounds of the head: an anthropological view. J Forensic Sci. 1990; 35 (5): 1236–1245.

Keywords:

skeleton; decomposition; fractures

© 2013 Lippincott Williams & Wilkins, Inc.

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