Forensic Science International 238 (2014) e11–e14
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Case Report
Human identification through the patella—Report of two cases Rhonan Ferreira Silva a,c,*, Ademir Franco b, Solon Diego Santos Carvalho Mendes a,c, Fernando Fortes Picoli a,c, De´cio Ernesto de Azevedo Marinho c,d a
Forensic Odontology, Federal University of Goias, Brazil Forensic Odontology, Katholieke Universiteit Leuven, Belgium c Forensic Anthropology and Legal Odontology, Scientific Police of Goias, Brazil d Forensic Medicine, Federal University of Goias, Brazil b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 November 2013 Received in revised form 14 January 2014 Accepted 21 February 2014 Available online 5 March 2014
The human identification process is often performed by the comparison between acquired post-mortem (PM) fingerprints, dental patterns, or DNA sample with ante-mortem (AM) databases. However, in some special situations alternative sources of human identifiers reveal valuable part as forensic tools. In this context, medical records of surgical interventions and morphological bone traits are useful in the anthropological environment, specifically for the PM examination of skeletal remains. The present study reports two cases of positive human identifications by the comparative analysis between AM and PM radiographic medical records of surgically treated human patella. The present outcome highlights the importance of storing and updating medical records in order to aid human identification processes in special forensic situations. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Human identification Forensic anthropology Forensic medicine Patella
1. Introduction
2. Case report
Human identifications are mostly performed by means of dental [1], medical [2], anthropological [3] and laboratorial approaches [4], in which fingerprints [5], dental patterns [6] and DNA tests [7] are the addressed scientific methods. In this context, the traditional identification process consists of comparing postmortem (PM) human identifiers, acquired both clinically and radiographically, to ante-mortem (AM) databases [8]. However, in special situations the lack of commonly used identifiers makes necessary targeting alternative sources. From an anthropological point of view, several skeletal traits can be considered unique for each person, such as the bone morphology [9], bone pathology [10] and human intervention [11] (e.g. placement of surgical plates on the bones), enabling the identification process. In this context, the present study aims to report two cases of human identification of decomposed and partially skeletonized bodies, which were identified by medical radiographic records of previous surgical intervention in the patella.
2.1. Case 1
* Corresponding author at: Forensic Odontology, Federal University of Goias, Av. Universitaria, Esquina com 1 Avenida s/n, Setor Universitario, Postal code: 74605220 Goiania, Goias, Brazil. Tel.: +55 62 3209 6051. E-mail address: [email protected] (R.F. Silva). http://dx.doi.org/10.1016/j.forsciint.2014.02.025 0379-0738/ß 2014 Elsevier Ireland Ltd. All rights reserved.
In 2008, an unknown body, compatible with a male adult, was found near to a Forest region in the state of Goias, Brazil. After the crime scene investigation the body was referred to the local medico-legal institute for the investigation of identity and cause of death. In this occasion, the fingerprint analysis was not possible due to advanced decomposition. Based on a police list of missing persons, a male individual, aging 45 years old and missing for 10 days, was pointed out. Relatives of the potential victim were contacted and asked to provide any kind of medical, dental or photographic records, contributing for an optimal investigation. The Police investigation led to three AM post-surgical radiographs of the left knee (Fig. 1). According to the medical report, the images were produced in order to treat a patient who accidentally fell on the ground. The first two images dated from January/2008, revealing the lateral and anteroposterior views of the knee, in which stainless steel wires and pins were crossing the patella for internal fixation. Yet, in the third image, which dated from April/ 2008, the fixation apparatus was removed. In this context, the right and left patella of the cadaver was dissected out for PM examination. The right patella was intact, while the left patella presented a transversal fracture. In addition,
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R.F. Silva et al. / Forensic Science International 238 (2014) e11–e14
Fig. 1. Lateral (A) and frontal (B) ante-mortem radiographs revealing the internal fixation of the fractured patella with metallic surgical wires, and frontal ante-mortem radiograph showing the post-surgical knee without the internal fixation (C).
Fig. 2. Right (intact) and left (fractured) patella (A); close view of the bone channels present after the removal of the surgical metallic wires and pins (B); illustration of the bone channels direction by placing metallic wires (C).
two bone channels were detected vertically crossing the fractured patella, which diameter and position were compatible with the post-surgical metallic pins radiographically detected AM (Fig. 2). The confrontation between the AM radiographic data and the PM autopsy findings allowed for a positive identification of the victim, which cause of death remained unknown.
3. Discussion The human identification of carbonized and decomposed bodies, as well as skeletal remains, consists of a complex procedure which often demands a multidisciplinary approach. The present case report illustrates two situations in which medical, anthropological and radiographic information were addressed multidisciplinarilly,
2.2. Case 2 In 2013, unknown skeletal remains were found near to a highway in the state of Goias, Brazil. After the crime scene investigation, the skeleton was referred to the local medico-legal institute, in which an anthropological examination was performed. Cranial and pelvic traits were confirmative for the male gender. Additionally, osteophytes on the thoracic and lumbar vertebrae, and partially erased cranial sutures pointed out that the victim was aged over 40 years old. Further on, it was observed that the right patella was intact, while the left one was transversally fractured presenting a metallic apparatus composed by stainless steel surgical wires and pins for internal fracture fixation (Fig. 3). The police investigation led to a 50-years-old man who was missing for 2 months. The potential victim had a history of fractured left patella, in which the surgical approach was performed in 2011 with a anterior tension band wiring. A lateral radiograph of the reported surgical approach was obtained out of the medical records of the missing man (Fig. 4). Considering the compatibility between the AM radiographic data and the autopsy findings of the left patella, a PM radiographic registration of the left patella was performed for imaging comparison (Fig. 5). The AM/PM radiographic comparison resulted in a positive identification.
Fig. 3. Post-mortem view of the skeletal region of the left knee, and left patella presenting a metallic surgical apparatus.
R.F. Silva et al. / Forensic Science International 238 (2014) e11–e14
Fig. 4. Ante-mortem lateral radiograph of the victim’s knee.
focusing in the analysis of the human patella for a positive human identification. The comparison between AM and PM forensic identifiers, such as unique morphological traits or pathologies, is the most performed methods aiming human identifications. Specifically in the presented case reports, the detection of post-surgical apparatus in the patella allowed for an optimal forensic investigation regarding the victim’s identity. Despite often being described as rare, the PM detection of post-surgical interventions is in fact more common nowadays [12], even considering the patella, which accounts for 1% of all the fractures of the human skeleton [13]. However, only 50% of these fractures involve displacement of the patella. Additionally, only displacements over 2 mm, and unstable
Fig. 5. Comparison between the ante-mortem (A) and the post-mortem (B) lateral radiographs of the left patella.
e13
extensor mechanism, justify surgical approaches [13]. The potential uniqueness of patellar fractures is increased if considering its classification, which comprehends the displaced fractures into the following possibilities: (1) transversal fractures; (2) fracture in the apex; (3) comminuted fracture; (4) vertical fracture; (5) and osteochondral fracture [14]. Specifically, in the presented cases the modified anterior tension band (MATB) technique was performed for the stabilization of transversal patellar fractures. This technique is performed through the fixation of the fractured patella with stainless steel wires bended in an ‘‘8-shaped’’ design. However, due to the limitations of performing MATB, such as difficulties in manipulating stainless steel, alternative techniques and materials, such as polyester sutures, are becoming more common, making the MATB more unique over the time [15]. In a study performed in the largest city of Brazil, one hundred and three cases of patellar fractures were detected in the period between the years of 1988–1999. Only 36% out of the 103 cases corresponded to transversal fractures, and only 20% of the cases were treated with tension banding techniques [14]. It reveals that the amount of transversal fractures of the patella treated with surgical tension banding in Brazil is discrete, reinforcing its uniqueness for forensic identification purposes. Mostly, the medical literature relates the patella to the forensic sciences exclusively based on its morphological traits. Ying et al. [16] reported three cases in which bifid human patellae were detected, highlighting its forensic relevance as a PM identifier. Similarly, Fierro et al. [17] presented a case of congenital double patella, which is a rare genetic alteration that contributes for specific cases of identification. Further on, Riddick et al. [18] reported a case of human identification of a carbonized body through the analysis of the patella, which presented a unique dorsal defect. However, despite the morphological relevance, Brogdon [19] and Murphy [20] state that, in specific situations, the comparison of post-surgical findings is more significant than matching morphological traits, and even a single post-surgical identifier is enough for a positive identification if its uniqueness is unmistakable. In accordance, the present study reports the assessment of the human patella based on the medical interventions performed AM. Human identifications through the registration of medical intervention was also reported by Matoso et al. [11], Wilson et al. [21] and Bennett [22] examining implanted orthopedic plates and internal fixation devices, which described the additional advantage of having identification numbers of the manufacturer on the surgical plates. In the present study, only the type of used materials (stainless steel surgical wires and pins) was described in the AM medical files. The absence of AM measurements and manufacturing codes of the materials lacked the possibility of metrical analyses and manufacturing code tracking. However, the time and place registered in the police files of missing persons were compatible with the time elapsed and the place near from which the bodies were found, restricting the number of potential victims. Dental identification was not performed in forehand because the victims’ relatives did not provide information regarding the name or addresses of the related dentists. Besides, random searches executed by police officers did not result positively, justifying the creation of PM profiles of the victims. In case 1, despite of the decomposition, there were remains of the external genitalia, enabling sex differentiation. Yet in case 2, the nuchal crest; the mastoid process; the supra orbital ridge; and the mental eminence were addressed for sex differentiation according to Buikstra and Ubelaker [23]. Both victims were considered adults due to the presence of fully erupted third molars and partially closed cranial sutures [23]. The stature was not estimated in case 1 due to the stage of decomposition. In case 2, the analysis of the long
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R.F. Silva et al. / Forensic Science International 238 (2014) e11–e14
bones indicated the range between 164 cm and 172 cm according to Trotter and Gleser [24]. However, in both cases there were no reliable AM data concerning the stature of the victims. The ethnicity was not assessed due to the unreliability within the Brazilian miscegenation. Moreover, the post-surgical apparatus detected in the patella of both victims allowed the search for more specific AM medical data, making feasible further PM comparisons. Despite the standardization of the post-surgical apparatus, especially in MATB, there are variations such as the type of material, the optional association with intramedullary pins, the number of contortions for pressure fixation, and the entire morphological display. These variables were only correctly investigated through radiographic exams. Imaginological records are one the most addressed means for the registration and detection of AM and PM findings, revealing high accuracy and practicality [8]. Due to these aspects and to the feasibility for being less invasive, forensic radiology is an emerging branch in the forensic sciences [8,12]. Its relevance is observed under the large demand of human identification cases based on conventional radiographs [20], Cone-Beam Computed Tomography [9], and Multi-Slice Computed Tomography [8]. Specifically into these imaging modalities, hard tissue structures are clearly observed, even small bones such as the patella. In this context, the present study aims to highlight the importance of correctly processing and executing radiographic techniques, as well as recording surgical procedures, especially for therapeutics related to the patella. Its relevance is observed when necessary the search for accurate and low costing AM records in forehand, specifically in cases of human identifications into the mass disaster environment.
4. Final considerations In the forensic sciences, clues of possible identity are mostly obtained out of discrete details. The present case report indicates that even small bones, such as the patella, must be carefully examined PM. Thus, the presumed uniqueness that makes feasible the human identification process can be found both on morphological altered and surgically treated bones. In the AM context, clinicians must be aware of the needing for a proper data recording system, enabling for an optimal AM forensic search. Yet in the PM context, forensic experts must consider the possibility of finding identifiers, such as post-surgical apparatus, in vulnerable anatomical sites, such as the knees. Based on that, the human identification process would not be exclusively limited to the AM/PM comparison of conventional sites, such as the dentomaxillofacial region, and alternative sources of comparative data would be feasible.
References [1] P. Pittayapat, R. Jacobs, E. De Valck, D. Vandermeulen, G. Willems, Forensic Odontology in the disaster victim identification process, J. Forensic Odontostomatol. 30 (2012) 1–12. [2] F. Dedouit, N. Telmon, C. Guilbeau-Frugier, D. Gainza, P. Otal, F. Joffre, D. Rouge, Virtual autopsy and forensic identification–practical application: a report of one case, J. Forensic Sci. 52 (2007) 960–964. [3] F. Dedouit, N. Telmon, R. Costagliola, P. Otal, F. Joffre, D. Rouge, Virtual anthropology and forensic identification: report of one case, Forensic Sci. Int. 173 (2007) 182–187. [4] S.B. Seo, J.L. King, D.H. Warshauer, C.P. Davis, J. Ge, B. Budowle, Single nucleotide polymorphism typing with massively parallel sequencing for human identification, Int. J. Legal Med. 127 (2013) 1079–1086. [5] M.B. Thompson, J.M. Tangen, D.J. McCarthy, Expertise in fingerprint identification, J. Forensic Sci. 58 (2013) 1519–1530. [6] H.D. Sheets, P.J. Bush, M.A. Bush, Patterns of variation and match rates of the anterior biting dentition: characteristics of a database of 3D-scanned dentitions, J. Forensic Sci. 58 (2013) 60–69. [7] J. Cemper-Kiesslich, E. Tutsch-Bauer, F. Neuhuber, Forensic Sci. Int. Genet. 7 (2013) 405–407. [8] A. Franco, P. Thevissen, W. Coudyzer, W. Develter, W. Van de Voorde, R. Oyen, D. Vandermeulen, R. Jacobs, G. Willems, Feasibility and validation of virtual autopsy for dental identification using the Interpol dental codes, J. Forensic Leg. Med. 20 (2013) 248–254. [9] R.F. Silva, T.L. Botelho, F.B. Prado, J.T. Kawagushi, E. Daruge Junior, F. Berzin, Human identification based on cranial computed tomography scan: a case report, Dentomaxillofacial Radiol. 40 (2011) 257–261. [10] K. Rubin, The manifestation of cocaine-induced midline destructive lesion in bone tissue and its identification in skeletal remains, Forensic Sci. Int. 231 (2013), 408.e1-11. [11] R.I. Matoso, N. Benedicto Ede, S.H. De Lima, F.B. Prado, E. Daruge, E. Daruge Junior, Positive identification of a burned body using an implanted orthopedic plate, Forensic Sci. Int. 229 (2013) 168e1–1685e. [12] R. Ciaffi, D. Gibelli, C. Cattaneo, Forensic radiology and personal identification of unidentified bodies: a review, Radiol. Med. 116 (2011) 960–968. [13] H.P. Springorum, J. Siewe, J. Dargel, G. Schiffer, J.W. Michael, P. Eysel, Classification and treatment of patella fractures, Orthopade. 40 (2011) 877–880, 882. [14] A.S. Pailo, E.A. Malavolta, A.L.G. Santos, M.T.R. Mendes, M.U. Rezende, A.J. Hernandez, G.L. Camanho, Patellar fractures: a decade of treatment at IOT-HCFMUSP. Part I. Functional analysis, Acta Ortop. Bras. 13 (2005) 221–224. [15] J.S. Melvin, S. Mehta, Patellar fractures in adults, J. Am. Acad. Orthop. Surg. 19 (2011) 198–207. [16] C.L. Ying, Y.H. Wang, L. Wan, Imaging manifestation and medicolegal significance of bipartite patella, Fa Yi Xue Za Zhi 26 (2010) 43–46. [17] G.M. Fierro, G. Calvino, F.S. Sasso, Congenital double patella – presentation of a case, Radiol. Med. 73 (1987) 113–115. [18] L. Riddick, B.G. Brogdon, J. Lasswell-Hoff, B. Delmas, Radiographic identification of charred human remains through use of the dorsal defect of the patella, J. Forensic Sci. 28 (1983) 263–267. [19] B.G. Brogdon, The scope of forensic radiology, Clin. Lab. Med. 18 (1998) 203–240. [20] W.A. Murphy, F.G. Spruill, G.E. Gantner, Radiologic identification of unknown human remains, J. Forensic Sci. 25 (1980) 727–735. [21] R.J. Wilson, J.D. Bethard, E.A. DiGangi, The use orthopedic surgical devices for forensic identification, J. Forensic Sci. 56 (2011) 460–469. [22] J.I. Bennett, D.C. Benedix, Positive identification of cremains recovered from an automobile based on presence of an internal fixation device, J. Forensic Sci. 44 (1999) 1296–1298. [23] J.E. Buikstra, D.H. Ubelaker, Standards for Data Collection of Human Skeletal Remains: Proceedings of a Seminar at the Field Museum of Natural Story, 1st ed., Arkansas Archeological Survey, Arkansas, 1994. [24] M. Trotter, G.C. Gleser, Estimation of stature from long bones of American Whites and Negroes, Am. J. Phys. Anthropol. 10 (1952) 463–514.
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Case Report
Human identification through the patella—Report of two cases Rhonan Ferreira Silva a,c,*, Ademir Franco b, Solon Diego Santos Carvalho Mendes a,c, Fernando Fortes Picoli a,c, De´cio Ernesto de Azevedo Marinho c,d a
Forensic Odontology, Federal University of Goias, Brazil Forensic Odontology, Katholieke Universiteit Leuven, Belgium c Forensic Anthropology and Legal Odontology, Scientific Police of Goias, Brazil d Forensic Medicine, Federal University of Goias, Brazil b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 November 2013 Received in revised form 14 January 2014 Accepted 21 February 2014 Available online 5 March 2014
The human identification process is often performed by the comparison between acquired post-mortem (PM) fingerprints, dental patterns, or DNA sample with ante-mortem (AM) databases. However, in some special situations alternative sources of human identifiers reveal valuable part as forensic tools. In this context, medical records of surgical interventions and morphological bone traits are useful in the anthropological environment, specifically for the PM examination of skeletal remains. The present study reports two cases of positive human identifications by the comparative analysis between AM and PM radiographic medical records of surgically treated human patella. The present outcome highlights the importance of storing and updating medical records in order to aid human identification processes in special forensic situations. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Human identification Forensic anthropology Forensic medicine Patella
1. Introduction
2. Case report
Human identifications are mostly performed by means of dental [1], medical [2], anthropological [3] and laboratorial approaches [4], in which fingerprints [5], dental patterns [6] and DNA tests [7] are the addressed scientific methods. In this context, the traditional identification process consists of comparing postmortem (PM) human identifiers, acquired both clinically and radiographically, to ante-mortem (AM) databases [8]. However, in special situations the lack of commonly used identifiers makes necessary targeting alternative sources. From an anthropological point of view, several skeletal traits can be considered unique for each person, such as the bone morphology [9], bone pathology [10] and human intervention [11] (e.g. placement of surgical plates on the bones), enabling the identification process. In this context, the present study aims to report two cases of human identification of decomposed and partially skeletonized bodies, which were identified by medical radiographic records of previous surgical intervention in the patella.
2.1. Case 1
* Corresponding author at: Forensic Odontology, Federal University of Goias, Av. Universitaria, Esquina com 1 Avenida s/n, Setor Universitario, Postal code: 74605220 Goiania, Goias, Brazil. Tel.: +55 62 3209 6051. E-mail address: [email protected] (R.F. Silva). http://dx.doi.org/10.1016/j.forsciint.2014.02.025 0379-0738/ß 2014 Elsevier Ireland Ltd. All rights reserved.
In 2008, an unknown body, compatible with a male adult, was found near to a Forest region in the state of Goias, Brazil. After the crime scene investigation the body was referred to the local medico-legal institute for the investigation of identity and cause of death. In this occasion, the fingerprint analysis was not possible due to advanced decomposition. Based on a police list of missing persons, a male individual, aging 45 years old and missing for 10 days, was pointed out. Relatives of the potential victim were contacted and asked to provide any kind of medical, dental or photographic records, contributing for an optimal investigation. The Police investigation led to three AM post-surgical radiographs of the left knee (Fig. 1). According to the medical report, the images were produced in order to treat a patient who accidentally fell on the ground. The first two images dated from January/2008, revealing the lateral and anteroposterior views of the knee, in which stainless steel wires and pins were crossing the patella for internal fixation. Yet, in the third image, which dated from April/ 2008, the fixation apparatus was removed. In this context, the right and left patella of the cadaver was dissected out for PM examination. The right patella was intact, while the left patella presented a transversal fracture. In addition,
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R.F. Silva et al. / Forensic Science International 238 (2014) e11–e14
Fig. 1. Lateral (A) and frontal (B) ante-mortem radiographs revealing the internal fixation of the fractured patella with metallic surgical wires, and frontal ante-mortem radiograph showing the post-surgical knee without the internal fixation (C).
Fig. 2. Right (intact) and left (fractured) patella (A); close view of the bone channels present after the removal of the surgical metallic wires and pins (B); illustration of the bone channels direction by placing metallic wires (C).
two bone channels were detected vertically crossing the fractured patella, which diameter and position were compatible with the post-surgical metallic pins radiographically detected AM (Fig. 2). The confrontation between the AM radiographic data and the PM autopsy findings allowed for a positive identification of the victim, which cause of death remained unknown.
3. Discussion The human identification of carbonized and decomposed bodies, as well as skeletal remains, consists of a complex procedure which often demands a multidisciplinary approach. The present case report illustrates two situations in which medical, anthropological and radiographic information were addressed multidisciplinarilly,
2.2. Case 2 In 2013, unknown skeletal remains were found near to a highway in the state of Goias, Brazil. After the crime scene investigation, the skeleton was referred to the local medico-legal institute, in which an anthropological examination was performed. Cranial and pelvic traits were confirmative for the male gender. Additionally, osteophytes on the thoracic and lumbar vertebrae, and partially erased cranial sutures pointed out that the victim was aged over 40 years old. Further on, it was observed that the right patella was intact, while the left one was transversally fractured presenting a metallic apparatus composed by stainless steel surgical wires and pins for internal fracture fixation (Fig. 3). The police investigation led to a 50-years-old man who was missing for 2 months. The potential victim had a history of fractured left patella, in which the surgical approach was performed in 2011 with a anterior tension band wiring. A lateral radiograph of the reported surgical approach was obtained out of the medical records of the missing man (Fig. 4). Considering the compatibility between the AM radiographic data and the autopsy findings of the left patella, a PM radiographic registration of the left patella was performed for imaging comparison (Fig. 5). The AM/PM radiographic comparison resulted in a positive identification.
Fig. 3. Post-mortem view of the skeletal region of the left knee, and left patella presenting a metallic surgical apparatus.
R.F. Silva et al. / Forensic Science International 238 (2014) e11–e14
Fig. 4. Ante-mortem lateral radiograph of the victim’s knee.
focusing in the analysis of the human patella for a positive human identification. The comparison between AM and PM forensic identifiers, such as unique morphological traits or pathologies, is the most performed methods aiming human identifications. Specifically in the presented case reports, the detection of post-surgical apparatus in the patella allowed for an optimal forensic investigation regarding the victim’s identity. Despite often being described as rare, the PM detection of post-surgical interventions is in fact more common nowadays [12], even considering the patella, which accounts for 1% of all the fractures of the human skeleton [13]. However, only 50% of these fractures involve displacement of the patella. Additionally, only displacements over 2 mm, and unstable
Fig. 5. Comparison between the ante-mortem (A) and the post-mortem (B) lateral radiographs of the left patella.
e13
extensor mechanism, justify surgical approaches [13]. The potential uniqueness of patellar fractures is increased if considering its classification, which comprehends the displaced fractures into the following possibilities: (1) transversal fractures; (2) fracture in the apex; (3) comminuted fracture; (4) vertical fracture; (5) and osteochondral fracture [14]. Specifically, in the presented cases the modified anterior tension band (MATB) technique was performed for the stabilization of transversal patellar fractures. This technique is performed through the fixation of the fractured patella with stainless steel wires bended in an ‘‘8-shaped’’ design. However, due to the limitations of performing MATB, such as difficulties in manipulating stainless steel, alternative techniques and materials, such as polyester sutures, are becoming more common, making the MATB more unique over the time [15]. In a study performed in the largest city of Brazil, one hundred and three cases of patellar fractures were detected in the period between the years of 1988–1999. Only 36% out of the 103 cases corresponded to transversal fractures, and only 20% of the cases were treated with tension banding techniques [14]. It reveals that the amount of transversal fractures of the patella treated with surgical tension banding in Brazil is discrete, reinforcing its uniqueness for forensic identification purposes. Mostly, the medical literature relates the patella to the forensic sciences exclusively based on its morphological traits. Ying et al. [16] reported three cases in which bifid human patellae were detected, highlighting its forensic relevance as a PM identifier. Similarly, Fierro et al. [17] presented a case of congenital double patella, which is a rare genetic alteration that contributes for specific cases of identification. Further on, Riddick et al. [18] reported a case of human identification of a carbonized body through the analysis of the patella, which presented a unique dorsal defect. However, despite the morphological relevance, Brogdon [19] and Murphy [20] state that, in specific situations, the comparison of post-surgical findings is more significant than matching morphological traits, and even a single post-surgical identifier is enough for a positive identification if its uniqueness is unmistakable. In accordance, the present study reports the assessment of the human patella based on the medical interventions performed AM. Human identifications through the registration of medical intervention was also reported by Matoso et al. [11], Wilson et al. [21] and Bennett [22] examining implanted orthopedic plates and internal fixation devices, which described the additional advantage of having identification numbers of the manufacturer on the surgical plates. In the present study, only the type of used materials (stainless steel surgical wires and pins) was described in the AM medical files. The absence of AM measurements and manufacturing codes of the materials lacked the possibility of metrical analyses and manufacturing code tracking. However, the time and place registered in the police files of missing persons were compatible with the time elapsed and the place near from which the bodies were found, restricting the number of potential victims. Dental identification was not performed in forehand because the victims’ relatives did not provide information regarding the name or addresses of the related dentists. Besides, random searches executed by police officers did not result positively, justifying the creation of PM profiles of the victims. In case 1, despite of the decomposition, there were remains of the external genitalia, enabling sex differentiation. Yet in case 2, the nuchal crest; the mastoid process; the supra orbital ridge; and the mental eminence were addressed for sex differentiation according to Buikstra and Ubelaker [23]. Both victims were considered adults due to the presence of fully erupted third molars and partially closed cranial sutures [23]. The stature was not estimated in case 1 due to the stage of decomposition. In case 2, the analysis of the long
e14
R.F. Silva et al. / Forensic Science International 238 (2014) e11–e14
bones indicated the range between 164 cm and 172 cm according to Trotter and Gleser [24]. However, in both cases there were no reliable AM data concerning the stature of the victims. The ethnicity was not assessed due to the unreliability within the Brazilian miscegenation. Moreover, the post-surgical apparatus detected in the patella of both victims allowed the search for more specific AM medical data, making feasible further PM comparisons. Despite the standardization of the post-surgical apparatus, especially in MATB, there are variations such as the type of material, the optional association with intramedullary pins, the number of contortions for pressure fixation, and the entire morphological display. These variables were only correctly investigated through radiographic exams. Imaginological records are one the most addressed means for the registration and detection of AM and PM findings, revealing high accuracy and practicality [8]. Due to these aspects and to the feasibility for being less invasive, forensic radiology is an emerging branch in the forensic sciences [8,12]. Its relevance is observed under the large demand of human identification cases based on conventional radiographs [20], Cone-Beam Computed Tomography [9], and Multi-Slice Computed Tomography [8]. Specifically into these imaging modalities, hard tissue structures are clearly observed, even small bones such as the patella. In this context, the present study aims to highlight the importance of correctly processing and executing radiographic techniques, as well as recording surgical procedures, especially for therapeutics related to the patella. Its relevance is observed when necessary the search for accurate and low costing AM records in forehand, specifically in cases of human identifications into the mass disaster environment.
4. Final considerations In the forensic sciences, clues of possible identity are mostly obtained out of discrete details. The present case report indicates that even small bones, such as the patella, must be carefully examined PM. Thus, the presumed uniqueness that makes feasible the human identification process can be found both on morphological altered and surgically treated bones. In the AM context, clinicians must be aware of the needing for a proper data recording system, enabling for an optimal AM forensic search. Yet in the PM context, forensic experts must consider the possibility of finding identifiers, such as post-surgical apparatus, in vulnerable anatomical sites, such as the knees. Based on that, the human identification process would not be exclusively limited to the AM/PM comparison of conventional sites, such as the dentomaxillofacial region, and alternative sources of comparative data would be feasible.
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