Annie Vesterby Charles

Forensic medical examination of adolescent and adult victims of sexual violence

The acute care and examination of a victim of sexual violence must be carried out by a competent forensic examiner in a setting appropriate for crisis intervention, forensic evidence collection, and medical follow up. The aim of forensic evidence and biological material collection is to document an alleged physical or sexual contact between individuals and to corroborate the victims and the assailants history. This is why the forensic examiner is expected to be objective and in possession of specialised technical and scientific skills. These skills are addressed and recommendations are made on how to carry out a forensic examination. This includes medical and assault history, top-to-toe examination, biological material collection, and documenting injuries while obtaining the chain of custody. Yet, consensus on time limitations for forensic evidence collection is lacking. Available forensic evidence has been shown to benefit prosecution. To meet the legal systems needs, an interpretation of the findings in a written legal report is mandatory.

Pathoanatomy of the lower cervical spine facet joints in motor vehicle crash fatalities

Non-lethal injuries to the cervical spine facet joints have previously been described in decedents from motor vehicle crashes and in clinical settings these joints have been identified as potential culprits in chronic neck pain syndromes. The aim of this study was to conduct a detailed examination of the lower cervical spine facet joints in a forensic cohort of motor vehicle crash victims and controls using comparable data from medicolegal autopsy, stereomicroscopy and histological evaluations. Injuries to the cervical spine facet joints were common in the trauma cases and included facet fractures, haemarthrosis, and disruption and bleeding in the synovial folds. The injuries could not be reliably verified on stereomicroscopic evaluation, and routine autopsy procedures did not reveal any of the injuries to the facet joints. Despite the presence of these pathoanatomical lesions in road traffic crash fatalities their prevalence and potential clinical implications in survivors from motor vehicle crashes is unknown.

Medical examination of sexually abused children: medico-legal value.

UNLABELLED The Department of Forensic Medicine (forensic pathology and clinical forensic medicine), Aarhus, Jutland, Denmark, performs examinations of children suspected to have been sexually abused when reported to and requested by the police in Jutland, Denmark. Jutland covers an area of 210,000 km2 with about 300,000 inhabitants in Aarhus. A colposcope initially equipped with an Olympus camera, but now with a video camera attached has been used since 1994. Since 1994 the department has performed more than 100 examinations of children suspected of having been sexually abused. A preliminary study was taken to evaluate all cases from 1995 including the legal outcome. RESULTS The material included 34 cases with three boys, mean age 11 years, and 31 girls, mean age 8 years, at the time of the examination. The sexual abuse events were fondling including penetration of the vagina, vaginal (14), anal (7), and oral (5) intercourse as well as cunnilingus and nontouching abuses. The medical examination was most often performed more than a week after the abuse. The examination revealed normal findings in 23 cases, nonspecific findings including erytherma in 13 cases, and in only one child was a traumatic lesion with rupture of the hymen seen. The perpetrators were above 25 years of ane and were family members or someone known to the child. Nine perpetrators were convicted at court, of whom three admitted having abused the child. CONCLUSION A medical examination in cases of sexual child abuse seldom provides a legal proof of sexual abuse. The most important is the story told by the child. Therefore, the examination is a supplement which may support or remain neutral to the story told by the child.

Lethal esophageal rupture following treatment with Sengstaken-Blakemore tube in management of variceal bleeding: a 10-year autopsy study.

We report six cases of lethal esophageal rupture following treatment with Sengstaken-Blakemore (SB) tube in management of acute variceal bleeding. Esophageal rupture is a known complication to SB tube treatment which unfortunately often is a result of iatrogenic misplacement of the tube. Our report indicates that despite additional guidelines to verify correct placement and new promising treatment modalities, lethal esophageal rupture still occurs. For a proper evaluation of potential malpractice cases we find it important for forensic pathologists to have knowledge of procedures and complications to treatment with SB tube.

Hymenal lesions and legal outcome in sexually abused girls with a history of vaginal penetration

PURPOSE In many cultures, it is commonly accepted that the hymen remains unchanged throughout childhood, until it is torn at the first episode of sexual intercourse. Therefore, the definition of virginity is directly linked to a normal hymen. However, most girls referred for medical forensic colposcopic examination have normal or nonspecific findings, the prevalence of abnormal findings in girls with a history of genital penetration being only 4-6%. The aim of this study was to investigate the relation between hymenal findings seen at the colposcopic examination and the legal outcome: prosecution in court and conviction in court. RESULTS During the 80-month period of our study, 426 girls with a median age of 9 years (range 0-15 years) were included. A history of at least one vaginal penetration was given in 226 of the girls with a median age of 12 years (range 2-14 years). The hymenal findings were described as normal in 125 of the 226 cases (55%). In 50 cases (22%), hymenal clefts were found, 17 (34%) of which were complete and 33 (66%) incomplete. The finding of hymenal clefts increased with age. Of the 226 cases of girls being sexually assaulted with vaginal penetration, 119 cases (53%) were prosecuted in court, 102 of which (86%) resulted in conviction. Thirty-five (70%) of the cases with hymenal clefts and 100 (57%) of the cases without hymenal clefts were prosecuted in court, showing a correlation between hymenal clefts and conviction; however, the correlation was not significant (χ(2) test=2.1 and P=0.14). In total, 29 (58%) of the cases with hymenal clefts and 88 (50%) of the cases without hymenal clefts were convicted in court, which shows no significance (χ(2) test=1.0 and P=0.33). CONCLUSIONS The single most important feature for conviction in court is the childs testimony and not hymenal findings seen at the colposcopic examination. Especially the testimony of the older children leads to conviction, raising the question whether the videotaped testimonies are aimed at the court proceedings, or whether hearing the childs testimony directly in court has a more powerful effect. Overall, it is crucial that the videotaped police questioning of the younger children is performed by specialized personnel, with the aim of presenting the testimony in a detailed and credible manner in court, giving children of all ages a fair trial.

Non-fatal injuries to the cervical spine facet joints after a fatal motor vehicle crash: a case report

Injuries to the lower cervical spine facet joints may be identified in people killed in road traffic crashes. However, many of these injuries are not identified on diagnostic imaging procedures despite histological evidence of injury. This case report illustrates possible non-lethal pathological conditions in the facet joints following fatal road traffic trauma. The cervical spine segments C4 to C7 were removed en bloc and examined with magnetic resonance imaging, computed tomography and conventional radiology. The specimen was fixated in alcohol, embedded in methylmethacrylate, and divided into 3 mm thick parasaggital slices from where 10μm thick sections were produced and evaluated with light microscopy. Injuries identified on microscopy included haemarthrosis, capsular avulsion, synovial fold contusions and subchondral fractures. None of the injuries were detected on diagnostic imaging or at routine autopsy. Discrete injuries to the cervical spine facet joints were identified using supplemental histological procedures in this case report. Post-mortem diagnostic imaging did not reveal these injuries and future studies should investigate the nature, prevalence and clinical relevance of such lesions.

An Unusual Case of Sudden Unexpected Death: Postmortem Investigation and Biomechanical Analysis of the Cervical Spine

ABSTRACT: A naked man died under peculiar circumstances and the postmortem examination revealed unexpected lesions in the cervical spine. Investigations of the cervical spine (computed tomography, magnetic resonance imaging, and histological examination) showed that a piece of bone was torn of the anterior part of vertebra C6 and that there was fresh bleeding in the surrounding tissue. The cause of death remained unclear but was most likely cardiac arrhythmia initiated by β‐2 agonist inhalation due to an acute asthmatic attack. Data from biomechanical investigation using finite element analysis supported the conclusion that the cervical spine injury was secondary to impact during falling as a consequence of the cardiac arrhythmia.

Histological Osteoarthritic Changes in the Human Cervical Spine Facet Joints Related to Age and Gender

Study Design. Cross-sectional autopsy study. Objective. Quantify histological changes in the lower cervical spine facet joints with regard to age and sex using systematic random sampling of entire joints. Summary of Background Data. Neck pain is a common debilitating musculoskeletal condition and one of the highest ranked causes of years lived with disability. The cause of neck pain is multifactorial and osteoarthritis is one potential cause. The cervical spine facet joints have been implicated in the etiology of chronic neck pain. Hence, a detailed description of their anatomy and age- and sex-related changes is needed. Methods. The lower four cervical spine segments (C4-C7 included) were obtained from 72 subjects during autopsy; 29 women (median age 53 years [22–77]) and 43 men (median age 38 years [20–78]). A total of 1132 articular facets were embedded in toto in hard plastic and sliced into 3-mm thick sections from where 10 &mgr;m thick histological sections were produced. Morphological variables were evaluated microscopically and histomorphometric variables were retrieved using random sampling methods. Data were analyzed with a linear regression model. Results. Significant associations were found between increasing age and in particular splitting, fissures, osteophytes, thickness of the calcified cartilage, and subchondral bone plate. The thickness of the calcified cartilage and subchondral bone plate increased with increasing age, whereas the hyaline cartilage thickness decreased. Males had more extensive degenerative changes in the cartilage. Conclusion. Using semiquantitative histological methods, degenerative findings were observed at all spinal levels involving the articular cartilage and the osseous structures of the cervical spine facet joints similar to those observed in larger weight-bearing joints. In particular, the thickening of the calcified cartilage and the subchondral bone identified the osteocartilaginous junction as an important area in osteoarthritis. These findings may be relevant for the pathogenesis of osteoarthritis. Level of Evidence: 3

Families coping with the forensic anogenital colposcopic examination

Abstract Background: The anogenital colposcopic examination is not a routine procedure in the ordinary examination of children, and knowledge is sparse regarding child and parental anticipation and coping. Methodology: The study included 60 children aged 4 - 15 years of age, examined on grounds of alleged sexual abuse, during a two year period. The physician rated the child using the Procedure Behavioral Rating Scale (PBRS). In addition, the child and parent completed a questionnaire concerning their experience. Principal findings: Mean PBRS score was 1.3. Significant positive correlations were found between the parental expectations to the child’s anxiety regarding the examination, and the children’s anxiety, the experience of the examination being bad/ugly and the experience of pain during the examination. Significantly higher PBRS scores were found in the group with no perpetrator conviction. Conclusions: High levels of parental and child distress emphasizes the need for better preparatory and stress reducing procedures, to avoid possible re-victimization and negative influence of parental anticipatory anxiety on the child. The finding of significantly higher PBRS scores in the group with no conviction could indicate, that lack of behavioral distress might be related to the possibility of sexual abuse.