Current Practice in Forensic Medicine

Although forensic medicine has been in existence for centuries in one guise or another, it is only with the recent growth in international research that it has begun to be acknowledged as a specific discipline in its own right. Many areas of progress are being made and this text aims to provide a unique, in-depth and critical update on selected topics that are of direct relevance to those practicing in the field including lawyers, police, medical and dental practitioners, forensic scientists and postgraduate/undergraduate medical students and undergraduate law students preparing for forensic medicine examinations. This volume is designed to cover the wider aspects of forensic medicine, including the law, science, medicine (forensic pathology, clinical forensic medicine and forensic psychiatry) and dentistry. Topics covered include subjects of debate and/or uncertainty in areas where significant advances have been made and in those of current relevance to the forensic profession, Chapters provide a variety of approaches to the areas under discussion with reviews of current knowledge, information on significant changes and pointers to the future that the reader should be aware of. Features: An authoritative review, for forensic medicine practitioners throughout the world, from leading international experts in the field. Provides critical commentary and updates on current practice. Topics include: a guide to the presentation of forensic medical evidence, bioterrorism, the paediatric hymen, assessment and interpretation of bone trauma in children, adult sexual assault, genital photography, forensic photography, common errors in injury interpretation, self-inflicted injuries and associated psychological profiles, bite marks and the role of the pathologist in aviation disasters. Includes a wealth of four colour figures to illustrate key points discussed within the text.

List of Contributors ix Foreword xvii Preface xix Chapter One: Expert evidence and healthcare professionals 1 Introduction 1 The adversarial system of justice 2 Expert reports 3 Evidentiary exclusionary rules 3 Pre-trial preparation for expert witnesses 5 Appearance 6 Timeliness 7 Giving of evidence 7 Managing cross-examination 10 Summary 14 References 14 Chapter Two: Forensic investigation of biological weapon use 17 Introduction 17 A choice of words 17 Threat assessments 18 Presenting features 22 Forensic microbiology or microbial forensics? 25 Assembling evidence from emerging infectious disease biology 26 Current constraints 34 References 34 Appendix 37 Chapter Three: The paediatric hymen 43 Introduction 43 Studies of normal anatomy 44 Studies of genital findings in sexually abused girls 49 Studies of acute injuries as they heal 54 A consideration of test reliability 56 Putting it all together 58 References 59 Chapter Four: Assessment and interpretation of bone trauma in children 63 Introduction 63 How should I evaluate suspected bone trauma in children? 64 What radiological investigations identify bone trauma? 68 How do X-rays detect fractures? 69 How does ultrasound detect bone injury? 73 How do nuclear medicine scans detect bone injury? 74 How does MRI detect bone injury? 75 How are medical images presented and shared? 78 What forces cause bones to fracture? 79 Are some bone injuries diagnostic of child abuse? 80 What do we know about bone healing in children? 82 What tests detect fragile bones? 83 Neonates with fractures: what are the special considerations? 85 Can the time of bone injury be determined? 87 Why might an X-ray be reported as normal when bone trauma exists? 87 Why might an ultrasound appear normal when bone trauma exists? 87 Why might a nuclear medicine scan appear normal when bone trauma exists? 88 Why might an X-ray appear abnormal when no bone trauma exists? 88 Why might a nuclear medicine scan appear abnormal when no bone trauma exists? 89 How do I deal with correctly interpreted but discordant imaging findings? 90 A. Why might an X-ray appear normal and bone scan ‘hot’ when bone trauma exists? 90 B. Why might a fracture seem obvious on plain X-ray but bone scan is ‘cold’ when bone trauma exists? 90 When and why should I repeat X-rays? 91 How does the process of forming a forensic medical opinion differ from the process of diagnosis in clinical medicine? 91 Why do I need to be aware of my level of confidence in my medical diagnosis? 91 What factors should I consider when forming a diagnostic opinion about the cause of a child’s fracture? 92 References 93 Chapter Five: Adult sexual assault 95 Introduction 95 Sexual assault settings and characteristics 96 Findings after sexual assault 101 Toxicology and sexual assault 116 Forensic science and sexual assault 116 Treatment after sexual assault 117 Summary 118 References 118 Chapter Six: The ethical and medical aspects of photodocumenting genital injury 123 Introduction 123 Sexual assault 126 Imaging the body in the history of medicine 126 Photography 128 The evolution of the photography of genital injury 129 A particular Australian’s experience 132 Ethics of care 140 Why no ethical objection to children being photographed? 141 The difference that being a child makes and its relevance 142 Advancing the question of best ethical practice 143 Clinical forensic medicine and sexual assault 150 Conclusion 152 References 153 Appendix 157 Chapter Seven: The photography of injuries 159 Introduction 159 The image 160 Equipment 161 Illumination 163 Polarizing filters 164 Forensic scales 164 The photography of an injury 164 The colour control or reference 166 Cross-polarized photography 167 Reflected ultraviolet 172 Infrared 181 Long wave ultraviolet-induced fluorescence 184 Imaging file format 188 The audit trail 189 Conclusion 190 Acknowledgements 191 References 191 Further reading 191 Chapter Eight: DNA analysis: Current practice and problems 193 Introduction 193 DNA collection and storage 194 DNA extraction 196 DNA quantification 196 DNA amplification 199 DNA separation and detection 200 DNA genotyping 201 Standard loci sets and commercial STR kits 202 Statistical evaluation of a DNA match 203 Assessing STR profiles 208 Mixtures of DNA 213 Degraded DNA 217 Low-template DNA 217 Other genetic markers 221 Tissue identification 228 Use of DNA in the criminal justice system 229 References 231 Chapter Nine: Injury interpretation: Possible errors and fallacies 239 Injury visualization 241 Nomenclature 244 Photography 245 Aging of injuries 248 Force of injury 253 Medical limitations and considerations 255 Genito-anal injuries in the adult 255 Child abuse 258 Self-inflicted injury 262 Other specialist opinions 263 Opinions 266 How to avoid errors 267 References 268 Chapter Ten: Self-inflicted injuries and associated psychological profiles 273 Introduction 273 Forensic aspects of self-harm 273 Psychiatric aspects of self-harm 280 Epidemiology 281 Classification of self-harm 282 The clinical dilemma 284 Management 285 Long-term outcome 286 Conclusion 286 References 288 Chapter Eleven: Bite marks 291 Introduction and cautionary remarks 291 Animal bites 291 Other injuries mimicking bites 294 Bites in foodstuffs 295 Examination of injuries in the dead 296 Examination of the living 300 Examination of the suspect 301 Trends in bite-mark analysis 303 Acknowledgement 306 References 306 Further reading 307 Chapter Twelve: Aviation disasters: The role of the forensic pathologist 309 Introduction 309 The scene 309 The autopsy 311 Establishing the cause of death 314 Circumstances surrounding death 317 Forensic pathology report 320 References 321 Index 323