Radiology in forensic expert team operations

Radiology in forensic expert team operations

Juha Rainio*, Kaisa Lalu, Helena Ranta, Antti PenttilaÈ

Department of Forensic Medicine, P.O. Box 40 (KytoÈsuontie 11), 00014 University of Helsinki, Helsinki, Finland

Received 28 December 2000; accepted 16 January 2001

Abstract

Radiological methods are widely used in forensic pathology. Their most common applications are in complementing human

identi®cation, particularly in investigations of mass disasters and decomposed bodies, and in searching for foreign material

inside corpses. A team of Finnish forensic experts investigated human skeletal remains in Bosnia and Herzegovina (1996) and

in Kosovo, the Federal Republic of Yugoslavia (1998). It also investigated more recently deceased victims in Kosovo (1999). In

these investigations, the bene®t of X-ray was in the detection of foreign material inside victims and their remains. For

identi®cation purposes, X-rays were mainly used to provide the best evidence possible of any pathological changes, physical

characteristics, and injuries present. q 2001 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Forensic pathology; Forensic radiology; Skeletal remains; Human identi®cation; Mass graves; Gunshot wounds

1. Introduction

Tasks of forensic scientists in investigation of mass

disasters and alleged mass graves include identi®ca-

tion of victims, determination of cause and manner of

death, and assembly of ®ndings that may help the

assertion of the causes of the incident and the

sequence of events [1±4]. For these purposes, multi-

disciplinary forensic teams collect data about the

victims using complementary methods [1,5±11].

Radiology is widely used to visualize and document

®ndings. It is recommended for use by the United

Nations in investigation of mass graves [12], by Inter-

pol in disaster victim identi®cation [13], and by the

American Board of Forensic Odontology in body

identi®cation [14].

Radiography is used in forensic pathology for

human identi®cation, especially in cases of decom-

posed, fragmented, or burned victims [5,15±20]. X-

rays can be used for anthropological determination of

sex, age, and stature [17±19,21,22]. For personal iden-

ti®cation, radiographs of nasal accessory or mastoid

sinuses [23±25], the thorax, or other areas typically

X-rayed [16,26±28] can be used to identify individual

anatomic features. Ante-mortem and post-mortem

radiographs can be compared concerning pathological

changes to bones, old traumas, prostheses, or other

orthopedic operations [5,8,15,16,21]. Radiology is

also used for assessment and documentation of dental

status [14,29,30]. Another application in forensic prac-

tice is in the determination and documentation of the

existence, number, localization, and identi®cation of

foreign material inside victims [17,22,27,31±33].

Legal Medicine 3 (2001) 34±43

1344-6223/01/$ - see front matter q 2001 Elsevier Science Ireland Ltd. All rights reserved.

PII: S1344-6223(01)00009-8

www.elsevier.nl/locate/legalmed

* Corresponding author. Tel.: 1358-9-19127473; fax: 1358-9-

19127518.

E-mail address: juha.rainio@helsinki.® (J. Rainio).

2. Materials and methods

2.1. Bosnia and Herzegovina 1996

Under the mandate of the United Nations, a team of

Finnish forensic experts (UN-FET) carried out an

investigation of human remains in Srebrenica, in

Bosnia and Herzegovina (BiH) in July 1996 [34].

The victims had allegedly been killed in July 1995.

In total, 64 samples of human remains were recovered

by the UN-FET on the battle®eld. The samples

included single bones and collections of bones and

soft tissue remnants from different parts of the

human body. Some of the human remains were joined

together by remnants of clothing.

X-ray examination for identi®cation purposes and

for indication and documentation of foreign material

was carried out for each bone or collection of bones in

52 of the 64 samples. The skull was X-rayed in lateral

and anterior-posterior views. Femora and tibias were

pictured for anthropological purposes. Other bones

were X-rayed when gunshot wounds, other injuries,

or pathological changes were noted. For tentative

identi®cation, including eventual age assessment,

dentition was X-rayed using periapical and occlusal

®lms. The objects of X-ray examination are presented

in Table 1.

For X-ray examination, the portable Atomscope

803 machine (Fig. 1) and Kodak TML1, TME1,

and ENB1 ®lms were used. The developing machine

was the Flat Level 365. For forensic odontological

examination, the Philips Oralix 65S machine, Kodak

DF50 and DF58 ®lms, and the Periomat 1304 devel-

oping machine were used. In addition to the afore-

mentioned, all other equipment was brought from

Finland. The same equipment for medical and dental

X-ray examinations was used in the subsequent

operation in Kosovo. The radiological examination

was carried out by two specially trained autopsy

technicians, both of whom also participated in the

Kosovo operation. The X-rays were analyzed by

the presiding forensic pathologists and forensic odon-

tologist, and the ®ndings were recorded in the

autopsy protocols.

2.2. Kosovo 1998

In December 1998, the Finnish forensic expert team

under the mandate of the European Union (EU-FET)

investigated human skeletal remains from two alleged

mass graves in Volujak and Klecka, in Kosovo, the

Federal Republic of Yugoslavia [35]. The victims had

reportedly been killed some months earlier.

The investigated material from Volujak comprised

three almost complete human skeletons, along with

individual bones and bone fragments. The three skele-

tons were X-rayed selectively, and all of the individual

bones were X-rayed. The total number of medical X-

rays was 70. Dental X-rays were taken in four cases.

The objects X-rayed are presented in Table 1.

The Klecka material consisted of 90 human bone

samples. Most samples included one to ten bones,

which were partly burned and fragmented, with one

sample containing 108 small, burned bone fragments.

An X-ray examination was carried out for all bones,

except the sample with 108 fragments (see Table 1).

The number of medical X-rays was 95. Dental X-rays

were taken in six cases.

J. Rainio et al. / Legal Medicine 3 (2001) 34±43 35

Table 1

X-ray examination in investigations of human skeletal remains

Srebrenica Volujak Klecka

(n� 64)a (n� 6)b (n� 4)c

Skull 16 5 4

Maxilla 1 ± 1

Mandible 4 2 3

Cervical vertebrae 4 1 2

Thoracic vertebrae 9 2 3

Lumbar vertebrae 10 2 2

Scapula 6 3 2

Clavicle 2 2 2

Sternum 2 1 1

Ribs 8 3 3

Humerus 14 4 3

Ulna 7 3 4

Radius 4 4 4

Bones of hand 2 1 1

Pelvis 9 2 3

Femur 21 5 3

Tibia 20 3 2

Fibula 3 3 2

Bones of foot ± 4 1

a Remains of 30 to 35 victims.b Five adult male victims and nine bone samples which could not

be connected with the ®ve victims by DNA analysis.c Three adult male victims and nine mostly burned bone samples

which could not be connected with the three victims by DNA analy-

sis.

J. Rainio et al. / Legal Medicine 3 (2001) 34±4336

Fig. 1. The portable X-ray machine Atomscope 803 used in the investigations.

2.3. Kosovo 1999

In January 1999, the EU-FET participated in foren-

sic investigation of 40 victims who were killed during

an incident at the village of Racak, Kosovo [36],

approximately ten days before the investigation. The

EU-FET performed an autopsy in ten cases, moni-

tored 14 autopsies performed by Yugoslavian forensic

experts, and carried out an external examination of 16

corpses, which had been autopsied before the arrival

of the EU-FET.

The purpose of the X-ray examination was to loca-

lize X-ray-positive foreign material, with objects of

the examination speci®ed after the external examina-

tion of victims. The head was X-rayed in 21 autopsies,

the thorax in 25, the abdomen in 14, the pelvis in nine,

the neck in six, the upper limb or part thereof in ®ve,

and the lower limb or part thereof in ten cases. The

total number of medical X-rays taken in all 40 autop-

sies was 157; in the ten autopsies performed by

Finnish experts, the number was 73, in 14 of the

autopsies performed by the Yugoslavian experts 60.

X-ray examination of the bodies, which had been

autopsied before the arrival of the EU-FET, was

performed after the external examination carried out

by the EU-FET. Totally 24 X-rays were taken in seven

cases of the 16. In nine cases, X-ray examination

could not be performed after breakage of the X-ray

machine. For identi®cation purposes, dental X-rays

were carried out in 37 cases. A summary of X-ray

examination during the Racak investigation is

presented in Table 2.

3. Results

3.1. Bosnia and Herzegovina 1996

During the investigation in BiH, the 64 samples of

human skeletal remains, part of which had remnants

of soft tissue attached, yielded a minimum number of

30±35 individuals, estimated morphologically.

In seven cases, skeletal anomalies useful in identi-

®cation were noted: one skull was asymmetrical and

another had no frontal sinuses but did have a metopic

suture, in another case, the clavicles were unusually

straight and the right clavicle was also unusually

short, two tibias presented with a radiologically brigh-

tened area, one scapula presented with a small defor-

mation on the inner edge, and one lumbar vertebra had

a groove-like defect. In eight cases, degenerative

changes were present. Furthermore, in one case,

signs of a maxillary operation, and in another case,

an old fracture were noted. Prostheses were not

observed.

Dental radiographs were included in the autopsy

reports together with the Interpol post-mortem forms

of dental ®ndings. Unfortunately, this information


Table 2

X-ray examination in the Racak investigation

Autopsy Monitoring Veri®cation Total

(n� 10) (n� 14) (n� 16) (n� 40)

Medical X-ray examination performed 10 14 7a 31

Number of medical X-rays 73 60 24 157

Object of X-ray examination

Head 10 7 4 21

Thorax 9 10 6 25

Abdomen 8 6 0 14

Pelvis 5 3 1 9

Neck 3 2 1 6

Upper limb or part thereof 4 1 0 5

Lower limb or part thereof 4 4 2 10

Dental X-ray examination performed 10 13b 14c 37

Number of dental X-rays 80 104 112 296

a In nine cases, examination could not be performed after breakage of the X-ray machine.b In one case, the victim had no teeth.c In one case, the victim had no teeth and in another case, the head was fragmented.

could not be used at the time of investigations due to

the lack of reliable ante-mortem information. The

®ndings including severe periodontal destruction and

periapical translucencies indicate deteriorating dental

health among the population of the enclave.

Gunshot injuries to bones were noted in 21 cases

and other injuries to bones in 12 cases. In 15 cases,

pellets (Fig. 2), and in one case, the remains of a small

caliber bullet were identi®ed. X-ray-positive material,

which could not be identi®ed, was seen in ®ve cases.

The X-ray-positive foreign material ®ndings are

presented in Table 3.


Fig. 2. X-ray of a right femur with pellets (Bosnia and Herzegovina).

Table 3

X-ray-positive foreign material found in human remains

BiH 1996 Kosovo 1998 Kosovo 1999

(n� 64)a (n� 8)b (n� 40)c

Bullets 1 1 16

Pellets 15 0 0

Other X-ray-positive materiald 5 5 4

a Number of samples. X-ray examination performed for 52.b Number of victims from Volujak and Klecka.c Number of victims from Racak. X-ray examination performed for 31.d Fragmented material which could not be identi®ed, possibly including remains of bullets or pellets.

3.2. Kosovo 1998

During the investigations of Volujak and Klecka in

1998, the skeletal remains of most likely eight adult

males, ®ve in the Volujak material and three in the

Klecka material, were examined.

Skeletal anomalies which could be used for identi-

®cation were noted in three cases: in the ®rst, there

was a sutural bone of the skull and lumbar vertebra V

was fused to the sacrum, in the second, the xiphoid

process of the sternum was crescent-shaped (Fig. 3),

and in the third, the angle of the upper edge of the left

scapula was unusually sharp. Five of the victims had

degenerative changes to their bones. No prostheses

were present.

In the Volujak material, gunshot injuries were

noted in three cases and suspected in one. These inju-

ries were found in four skulls, one lumbar vertebra,

one left elbow, and one right scapula and humerus.

One victim from Klecka had sustained a gunshot

injury to the lumbar and sacral vertebrae.

Inside one skull, an almost intact bullet of an assault

ri¯e was located. Other X-ray-positive material was

seen in ®ve cases (Fig. 4). This was excised and

analyzed by using a scanning electron microscope

and performing an energy dispersive X-ray analysis.

The material was shown to be of soil origin. The X-

ray-positive foreign material ®ndings are presented in

Table 3.

3.3. Kosovo 1999

In 1999, 40 victims, presumably killed one week

earlier in Racak, comprising 38 adult men, one adult

female, and one adolescent boy, were investigated.

All of the victims had sustained from one to twenty

gunshot injuries, which were declared to be their

cause of death.

X-ray-positive material was detected in 20 cases.

During the autopsy, bullets or their fragments were

found in 16 victims. In four cases, minor X-ray-posi-

tive material could not be detected in autopsy due to

its fragmentation. No other X-ray-positive material


Fig. 3. X-ray of a sternum with a crescent-shaped xiphoid process

(Kosovo).Fig. 4. X-ray of vertebrae with X-ray-positive material, shown to be

of soil origin (Kosovo).

was noted. X-ray-positive foreign material ®ndings

are presented in Table 3.

The victims had skeletal injuries that were most

likely in¯icted by assault ri¯e projectiles. In the ten

autopsies performed by the EU-FET, skull fracture

was present in seven cases, fractures of the ribs in

eight, fracture of the vertebral column in seven, pelvic

fractures in two, scapular fractures in two, and frac-

tures of the long bones in four cases (Fig. 5).

4. Discussion

Radiological methods have a ®rmly established

position in forensic pathology. Forensic investigation

of unknown persons and cases with suspicion of

foreign material inside the victim may be insuf®cient

and complicated if X-ray equipment is not available.

The UN, Interpol, and the American Board of Foren-

sic Odontology recommend the inclusion of X-ray

examination in forensic investigation of victims of

mass disasters and alleged mass graves.

In our investigations, radiography complemented

the forensic examination of both skeletal remains

and more recently deceased victims. Methods of

physical anthropology, forensic pathology, forensic

odontology, DNA analysis, and morphological

inspection of material belongings and appearance of

victims proved to be suf®cient for human identi®ca-

tion. In addition, since previous radiographs and other

ante-mortem information were unavailable, the

complementing of age, sex, and stature estimation

was the limit of the X-ray examination [17].

In September 1994, the liner M/S Estonia with 803

passengers and 186 staff members sank. In all, 137

people were rescued and 756 victims remain missing.

Finnish forensic experts had investigated and identi-

®ed 95 victims, and a further victim was examined in

Stockholm, Sweden. Most of the victims were well

preserved and had only minor injuries. A medical

X-ray examination was carried out in only four

cases to con®rm the macroscopic diagnosis of skeletal

or articular pathology. Orthopantomography was

performed in all cases as part of the forensic odonto-

logical examination. Dental examination con®rmed

identity of 56 victims and was combined with other

methods for identi®cation of 14 [37].

In the Tenerife air disaster investigation in 1977,

the number of victims was 570. The Dutch disaster

victim identi®cation (DVI) team examined 248 of

these. Of the 204 victims identi®ed, X-ray examina-

tion assisted identi®cation in three cases [6]. In New

Zealand, during the investigation of more than 200

victims of the aircrash on Mount Erebus in 1979,

medical X-rays were not taken on a routine basis. At

a later stage, however, medical X-ray examinations

and comparisons proved invaluable, and in seven

cases, provided major identifying features [38]. In

investigation of the Gander airliner accident (1985)

with 256 victims, radiological data con®rmed identi-

®cation in 12.5%, was part of presumptive identi®ca-

tion in 23.5%, and was critical in 25% of cases of

identi®cation with an exclusion matrix [8]. In inves-

tigation of 87 victims of the 1992 Airbus A320

aircrash upon Mount Ste-Odile, France, X-ray exam-

inations were involved only to con®rm information

reported by the family [39].

In investigation of victims burned during or after


Fig. 5. X-ray of a fractured humerus with fragments of a bullet

(Kosovo).

death, in varying states of decomposition, or when

routine identi®cation methods are otherwise ineffec-

tive, radiology may prove essential. Radiographs

supplement documentation together with drawings,

photography, and video techniques.

Radiological methods for identi®cation do present

certain problems even in conventional forensic prac-

tice. To identify unknown deceased persons, ante-

mortem and post-mortem data are compared, and

thus, the ante-mortem data must be completely reli-

able. In addition, its availability can be complicated.

Medical or dental records do not always exist. Similar

situation exists in more substantial number in mass

disasters, when fast and reliable identi®cation of the

victims is one of the main tasks of the forensic

experts. In incidents involving political or ethnic

hostilities, medical or dental data may be withheld

from mass grave investigators or data may be

destroyed [40,41]. The availability of adequate post-

mortem material for radiological identi®cation may

also be restricted due to the fragmentation of victims

during or after death.

In searching for foreign material an X-ray exami-

nation should be conducted even in the case of skele-

tal remains, since the localization of bullets or bullet

fragments inside the victims can be very challenging

[17,21,22,31±33]. Estimation of retained bullets and,

consequently, determination of exact entrance and

exit wounds can be dif®cult without radiology in

cases of multiple gunshot wounds.

The X-ray examination can be carried out at differ-

ent stages of the investigation. This decision depends

on the number and condition of victims, the size and

number of both X-ray and body investigation units, the

radiological equipment, and the space available for the

X-ray examination. When it is possible to organize a

constant X-ray examination process, the optimal order

is to ®rst perform an external examination and an X-ray

examination before proceeding to an internal examina-

tion of the body [1,2,16,31]. The X-ray ®ndings can

guide the autopsy. In this way, also the objects of the X-

ray examination can be determined restrictively and

the examination directed exactly, thus limiting the

number of the X-rays required. The time needed for

the X-ray examination can, however, become a bottle-

neck in the investigative procedure.

Physically, the medical and dental radiography unit

should be located where it is easily accessible to all

members of the team. Forensic pathologists, odontol-

ogists, and anthropologists may need to look at X-rays

immediately. In addition, unnecessary re®lming can

be avoided, although during autopsies, some situa-

tions may require X-rays to be retaken. For radiation

protection, however, the X-ray unit must be separated

from other activities and a lead shield used [16,28].

In mass casualty situations, such as mass disasters

or investigations of mass graves, forensic scientists

usually work in circumstances which differ from

routine ones. The large number and varying state of

the victims, and the need for fast reliable results guide

the work. The investigation is often performed under

®eld conditions [10,42] in temporary morgues [4,5]

using simple X-ray facilities [8,16,20,43]. Electricity

and water may be absent or irregular [8,10,43]. The

equipment should have suf®cient image productivity

and quality. It should be easy to move and suitable for

use in narrow spaces. The application of ¯uoroscopy

in screening foreign objects and gross bone injuries

should be considered in mass disasters and investiga-

tions of atrocities with high numbers of casualties.

Transmission of ante-mortem X-rays by telephoto

to the identi®cation unit can hasten data collection

[44], but the quality of information should not be

allowed to diminish [13]. This technique was success-

fully used between Sweden and Finland during the

investigation of the Estonia disaster [37]. A digital

technique provides new possibilities for performing

the X-ray examination as well as for improving the

quality and transmission of X-ray documentation.

When the number of victims is very high, computer

assistance greatly enhances data management.

Acknowledgements

The authors wish to thank all members of the UN-

FET and the EU-FET. We are especially grateful to

autopsy technicians Petri Holopainen, Seppo TyynelaÈ,

and Kari Suomela whose work made possible the

®gures used in this article.

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Radiology in forensic expert team operations