In some cases, the use of diagnostic tests may aid in corroborating allegations of torture. Before obtaining such tests, however, clinicians should carefully consider the potential value of such tests and their inherent limitations in light of the level of “proof” needed in a particular case, the potential adverse consequences for the individual, and any resource limitations. Generally, diagnostic tests are not warranted unless they are likely to make a significant difference to a medico-legal case.
In the acute phase of injury, various imaging modalities may be quite useful in providing additional documentation of both skeletal and soft tissue injuries. Once the physical injuries of torture have healed, however, the residual sequelae generally are no longer detectable by these same imaging methods. This is often true even when the survivor continues to suffer significant pain or disability from his/her injuries.
References have already been made to various radiologic studies in the discussions of the examination of the patient and in the context of various forms of torture. What follows is a summary of the application of these methods, recognizing that the more sophisticated (and expensive) technology is not universally available.
Radiologic and imaging diagnostic examinations include routine radiographs (x-rays), radioisotopic scintigraphy, computerized tomography (CT), nuclear magnetic resonance imaging (MRI), and ultrasonography (USG). Each has its advantages and disadvantages. X-rays, scintigraphy, and CT scanning use ionizing radiation, which may be a concern for pregnant women and children. MRI uses a magnetic field; potential biologic effects on fetuses and children are theoretical, but thought to be minimal. Ultrasound uses sound waves; no biologic risk is known.
X-rays are readily available. They can be very useful when searching for fractures, fissures, deformity and foreign bodies in osseous structures. Excluding the skull, all injured areas should have routine radiographs as the initial examination. While routine radiographs will demonstrate facial fractures, CT is a superior examination as it demonstrates more fractures, fragment displacement and associated soft tissue injury and complications. When periosteal damage or minimal fractures are suspected, bone scintigraphy should be used in addition to x-rays.
The type of fracture can reveal important information on the force and its form of application. In this respect, soft tissue changes adjacent to the fracture or deformity as well as foreign bodies in the vicinity can also contribute information. The awareness of the forms of torture used can specify the cause of a lesion otherwise considered to be non-specific. Extension deformities can be followed up with these approaches during chronic stages.
A percentage of x-rays will be negative even when there is an acute fracture or early osteomyelitis. It is possible for a fracture to heal leaving no radiographic evidence of previous injury; this is especially true in children. Routine radiographs are not the ideal examination for evaluation of soft tissues.
Scintigraphy is an examination of high sensitivity but low specificity. Scintigraphy is an economic and effective examination to screen the entire skeleton for disease processes such as osteomyelitis or trauma. Testicular torsion can also be evaluated, but ultrasound is better suited to this task. Scintigraphy is not the appropriate examination to identify soft tissue trauma.
Scintigraphy can detect an acute fracture within twenty-four hours, but generally it takes two to three days and may occasionally take a week or more, particularly in the elderly. Generally the scan returns to normal after two years. However, it may remain positive in both fractures and cured osteomyelitis for years. The use of bone scintigraphy to detect fractures at the epiphysis or metadiaphysis (ends of long bones) in children is very difficult because of the normal uptake of the radiopharmaceutical at the epiphysis. Scintigraphy is often able to detect rib fractures that are not apparent on routine x-ray films.
Scintigraphy is more sensitive in the demonstration of bone tissue lesions than classical radiological techniques. It allows observation of the effects years later. It is more cost effective than MRI which can verify lesions in early stages. Fundamental events in revealing the pathology are osteoblastic activity and increased blood flow in tissues. In trauma not leading to fractures, bone metabolism and thus turnover is increased, and as trauma continues microfractures develop. The contribution of scintigraphy significantly increases in areas such as ribs, spinous processes and the scaphoid bone which are hard to evaluate by direct X-rays. Thus scintigraphy yields better results in trauma directed to thorax. Lesions such as epiphyseal separation or metaphyseal edge fractures which are easily missed can well be differentiated by the shape of epiphyseal plate and its visualisation. Scintigraphy also provides advantages as a screening procedure in multiple traumatic injuries.
Another contribution of scintigraphy is that activity of radioactive material changes in time. In acute stages, positive results are obtained in 80% of the lesions within the first 24 hours and 95% in 72 hours. Increased activity may be observed 1-2 years after the alleged injuries and may sometimes persist for 10-15 years.
Application of Bone Scintigraphy to the Diagnosis of Falanga
Bone scans may be performed either with delayed images at about three hours or as a three-phase examination. The three phases are: 1) radionucleide angiogram (arterial phase); 2) blood pool images (venous phase, which is soft tissue); and 3) delayed phase (bone phase). Patients examined soon after falanga should have two bone scans performed at one-week intervals. A negative first delayed scan and positive second scan indicates exposure to falanga within days before the first scan. In acute cases, two negative bone scans at an interval of one week do not necessarily mean that falanga did not occur, but that the severity of the falanga applied was under the sensitivity level of the scintigraphy. Initially, if three-phase scanning is done, increased uptake in the radionucleide angiogram phase and in blood pool images and no increased uptake in the bone phase indicate hyperemia compatible with soft tissue injury. Trauma in the foot bones and soft tissue can also be detected with MRI.
Ultrasound is inexpensive and without biologic hazard. The quality of the examination depends on the skill of the operator. In parts of the world where CT is not available, USG is used to evaluate acute abdominal trauma. Tendonopathy can also be evaluated by USG, and it is a method of choice for testicular abnormalities.
Shoulder USG is carried out in acute and chronic periods following suspension torture. In the acute period, edema, fluid collection on and around the shoulder joint, lacerations and hematomas of the rotator cuffs can be observed by USG. The reapplication of USG and subsequent observation that findings from the acute period disappear in time strengthens the diagnosis. In such cases, EMG, scintigraphy and other radiological examinations should be carried out together and their correlation examined. Even lacking positive results from other examinations, USG findings alone are adequate to prove suspension torture.
Although ultrasound is primarily used for evaluation of muscles and joints, especially the shoulder joint, its contributions can be much wider depending on the skill of the applicator administering it. Insufficient documentation increases the possibility of mis-diagnosis as results may appear conclusive. However, results by less experienced operators can well serve as a document for more experienced specialists who evaluate the event later.
Contribution of conventional ultrasound varies according to its capacity for morphological evaluation. At present, high channel probes with multifrequencies between 8 and 15 MHz can be more sensitive than CT and MRI in showing changes in cutaneous, subcutaneous, osseous and soft tissues as well as in muscles and joints. Ultrasound sensitivity to pathology related to shoulder, knee and ankle joints and related lesions of joints, tendons and adjacent soft tissues is usually is higher than MRI. It is possible to demonstrate correctly muscle contusion and haematomas, subcutaneous contusion and haemorrhages, loss of uniformity of subcutaneous fat tissue, soft tissue micro and macro-calcifications and foreign bodies with ultrasound. Traumatic changes and contusions of soft tissue in genitals, breast and perineum can be identified in detail with high resolution probes.
A second contribution is information on the perfusion of tissues identified by Doppler studies. Focal deficits of tissue perfusion and areas of reactive hyperaemia can be identified in injuries especially caused by cold (cold water, cold air). Findings of testicular torsion or of early detorsion can also be successfully demonstrated. It is also possible to demonstrate fracture, fissure, small osseous cortical discontinuities, neovascularisation due to wound healing, or reactive periosteal callus formation in osteochondral injuries earlier and more precisely in comparison to direct X-rays or CT and MRI. However, in cases when there are no cortical injuries, verification of medullary and trabecular osseous changes is possible neither by classic nor by Doppler sonographic studies.
CT is excellent for imaging both soft tissue and bone. MRI is better for soft tissue than bone. However, MRI may detect an occult fracture before it can be imaged by either routine radiographs or scintigraphy. Use of open scanners and/or sedation may alleviate anxiety and claustrophobia that are especially prevalent among torture survivors.
CT is also excellent for diagnosing and evaluating fractures, especially temporal bone and facial bones. Other advantages include determining alignment and displacement of fragments, especially spinal, pelvic, shoulder and acetabular fractures. CT cannot identify bone bruising.
CT with and without intravenous infusion of a contrast agent should be the initial examination for acute, subacute and chronic central nervous system (CNS) lesions. If the CT examination is negative, equivocal or does not explain the survivor’s CNS complaints or symptoms, proceed to an MRI.
CT with bone windows and a pre- and post-contrast examination should be the initial examination for temporal bone fractures. Bone windows may demonstrate fractures and ossicular disruption. The pre-contrast examination may demonstrate fluid and cholesteatoma. Contrast is recommended because of the common vascular anomalies that occur in this area. For rhinorrhea, injection of contrast into the spinal canal should follow a temporal bone. MRI may also demonstrate the tear responsible for the leakage of fluid.
When rhinorrhea is suspected, a CT of the face with soft tissue and bone windows should be performed. Then, a CT should be obtained after contrast is injected into the spinal canal.
MRI is more sensitive than CT in detecting central nervous system (CNS) abnormalities. The time course of CNS hemorrhage is divided into immediate, hyperacute, acute, subacute and chronic phases. The time course of CNS hemorrhage has ranges that correlate with imaging characteristics of the hemorrhage. Thus, the imaging findings may allow estimation of the timing of head injury and correlation to alleged incidents. CNS hemorrhage may completely resolve or produce sufficient hemosiderin deposits that the CT scan will be positive even years later. Hemorrhage in soft tissue, especially in muscle, usually completely resolves leaving no trace, but rarely can ossify. This is called heterotrophic bone formation or myositis ossificans and is detectable on CT scan.
Recently there have been significant advances in demonstration of acute and chronic lesions using MRI. MRI with Turbo STIR sequences, directed to the whole body can demonstrate general body trauma and identify lesions and areas needing detailed evaluation. Unidentified lesions and those not causing any clinical complaints can also be visualized. Early stage cortical and medullary oedema and trabecular destructions can be much more readily demonstrated than CT. Minimal changes identified as bone bruise in pre-oedema stages can also be identified in osseous tissues. New special sequences which can verify these changes within hours are being developed and administered. Small millimetric cortical destructions, minimal oedematous changes of soft tissue, especially in series with fat suppression, and muscle contusion or strain injuries can also be identified.
Biopsy of Electric Shock Injury
Electric shock injuries may, but do not necessarily, exhibit microscopic changes that are highly diagnostic and specific for electric current trauma. The absence of these specific changes in a biopsy specimen does not mitigate against a diagnosis of electric shock torture, and judicial authorities must not be permitted to make such an assumption. Unfortunately, if a court requests that a petitioner alleging electric shock torture submit to a biopsy for confirmation of the allegations, refusal to consent to the procedure or a “negative” result is bound to have a prejudicial impact upon the court. Furthermore, clinical experience with biopsy diagnosis of torture-related electrical injury is limited, and the diagnosis can usually be made with confidence from the history and physical examination alone.
This procedure is therefore one that should currently be done in a clinical research setting, and not promoted as a diagnostic standard. In giving informed consent for biopsy, the individual must be informed of the uncertainty of the results and permitted to weigh the potential benefit against the impact upon an already traumatised psyche.
Rationale for biopsy
There has been extensive laboratory research measuring the effects of electric shocks on the skin of anaesthetized pigs. This work has shown that there are histologic findings specific for electrical injury that can be established by microscopic examination of punch biopsies of the lesions. However, further discussion of this research, which may have significant clinical application, is beyond the scope of this publication. The reader is referred to the above cited references for further information.
Few cases of electric shock torture of humans have been studied histologically. Only in one case, where lesions were excised probably 7 days after the injury, were alterations in the skin believed to be diagnostic of electrical injuries observed (deposition of calcium salts on dermal fibers in viable tissue located around necrotic tissue). Lesions excised a few days after alleged electrical torture in other cases have shown segmental changes and deposits of calcium salts on cellular structures highly consistent with influence of an electrical current, but not diagnostic since deposits of calcium salts on dermal fibers were not observed. A biopsy taken one month after alleged electrical torture showed a conical scar, 1-2 mm broad, with increased number of fibroblasts and tightly packed, thin collagen fibers, arranged parallel to the surface, consistent with, but not diagnostic of, electrical injury.
After receiving informed consent from the patient, and before biopsy, the lesion must be photographed according to accepted forensic methods. Under local anesthesia, a 3-4 mm punch biopsy is obtained, and placed in buffered formalin or similar fixative. Skin biopsy should be performed as soon as possible after injury. Since electrical trauma is usually confined to the epidermis and superficial dermis, the lesions may quickly disappear. Biopsies can be taken from more than one lesion, but the potential distress to the patient must be considered.
Biopsy material should be examined by a pathologist experienced in dermatopathology.
Diagnostic findings for electrical injury
- Vesicular nuclei in epidermis, sweat glands and vessel walls (only one differential diagnosis: injuries via basic solutions)
- Deposits of calcium salts distinctly located on collagen and elastic fibers (the differential diagnosis, calcinosis cutis, is a rare disorder only found in 75 of 220,000 consecutive human skin biopsies, and the calcium deposits are usually massive without distinct location on collagen and elastic fibers.
Typical, but not diagnostic, findings for electrical injury
- Lesions appearing in conical segments, often 1-2 mm large
- Deposits of iron or copper on epidermis (from the electrode)
- Homogenous cytoplasm in epidermis, sweat glands and vessel walls
- Deposits of calcium salts on cellular structures in segmental lesions
- No abnormal histologic observations