Radiology Cases In Pediatric Emergency Medicine

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CASES



Case 1 - Toxic Infant With a Full Fontanelle
Case 2 - The Stomach Flu ? - The Target, Crescent, and Absent Liver Edge Signs
Case 3 - Abdominal Pain With a Negative Abdominal Examination
Case 4 - Persistent Abdominal Pain
Case 5 - Cervical Spine Malalignment - True or Pseudo Subluxation ?
Case 6 - Diminished Breath Sounds and Air in the Chest
Case 7 - Hamman's Sign
Case 8 - Foreign Body Aspiration in a Child
Case 9 - Respiratory Distress: That's a Tension Pneumothorax, Isn't It ?
Case 10 - Drooling, Stridor, and a Barking Cough: Croup ??
Case 11 - Elbow Ossification Centers in a Child
Case 12 - Radiographic Examination of the Elbow - The Hourglass Sign
Case 13 - Child With a Sprained Wrist
Case 14 - A Hand Contusion
Case 15 - Monteggia's Injury
Case 16 - Galeazzi's Injury
Case 17 - Elbow Sprain in a Child
Case 18 - Salter-Harris
Case 19 - Swollen Elbow with a Normal X-Ray
Case 20 - Sever's Disease
Volume 2 - March 1995 (Copyright 1995, L. Yamamoto)
Case 1 - Hemoptysis Identifies an Esophageal Coin
Case 2 - Seizure and VSD in a 2-Month Old Infant
Case 3 - Wheezing and Cyanosis in a 16-Month Old
Case 4 - Ignoring an E.D. Nurse's Assessment
Case 5 - Tachypnea and Abdominal Pain
Case 6 - Wheezing and Respiratory Distress in a 7-Week Old
Case 7 - Recurrent Pneumonia
Case 8 - Recurrent Abdominal Pain and Vomiting in a 7-Year Old
Case 9 - A Second Look at a Coin in the Stomach
Case 10 - Thigh and Knee Pain in an Obese 10-Year Old
Case 11 - Occult Hip Injury - 18-Month Old Won't Bear Weight
Case 12 - Hip Pain in a Hefty 13-Year Old
Case 13 - Vomiting Following Reduction of Intussusception
Case 14 - Hematemesis in a 6-Day Old Infant
Case 15 - Hematochezia and Cold Symptoms in an Infant
Case 16 - Sweeping the Airway for a Foreign Body
Case 17 - Sudden Thigh Swelling in a 6-Week Old Infant
Case 18 - Test Your Skill in Reading Pediatric Elbows
Case 19 - Rule Out Epiglottitis
Case 20 - Test Your Skill in Reading Pediatric Lateral Necks
Volume 3 - August 1995 (Copyright 1995, L. Yamamoto)
Case 1 - Myocardial Failure in a 2-Month Old
Case 2 - Severe Chronic Lung Disease and Respiratory Distress
Case 3 - Ankle Injuries: A Sprained Ankle ?
Case 4 - Foot Pain in Triage
Case 5 - Test Your Skill in Reading Pediatric Ankles
Case 6 - Aspirating the Ankle Joint
Case 7 - Hemoptysis and Anemia in a 12-Year Old
Case 8 - Dice Ingestion
Case 9 - Moyamoya Disease
Case 10 - Abdominal Pain with Faint Intra-Abdominal Calcifications
Case 11 - Respiratory Distress and Abdominal Distention
Case 12 - Severe Acute Chest Pain in an Adolescent
Case 13 - Acute Chest Pain in a Tall Slender Teenager
Case 14 - Severe Hypernatremia - Salt Poisoning
Case 15 - Severe Hyponatremia and Non-Reactive Pupils in a 3-Year Old
Case 16 - Failure to Thrive and Vomiting in a 1-Month Old
Case 17 - Bilious Vomiting in a 3-Month Old
Case 18 - Test Your Skill in Distinguishing Bowel Obstruction From Ileus
Case 19 - Abdominal Pain and the Peritoneal Fat Margins
Case 20 - Test Your Skill in Reading Pediatric Chest Radiographs
Volume 4 - January 1996 (Copyright 1996, L. Yamamoto)
Case 1 - Focal Seizure in a 5-Year Old
Case 2 - Bucket Handle and Corner Fractures
Case 3 - Tachypnea in a 2-Month Old
Case 4 - Pearl-Like Chest Calcifications
Case 5 - Test Your Skill In Reading More Pediatric Chest Radiographs
Case 6 - T.B. in the E.D.
Case 7 - Avoid This Airway Complication
Case 8 - Right Lower Quadrant Pain in an 13-Year Old Female
Case 9 - Periumbilical Abdominal Pain
Case 10 - Post-Surgical Febrile Seizure and Vomiting
Case 11 - Acute Knee Pain Following Trauma
Case 12 - Closed Reduction of a Dislocated Shoulder
Case 13 - Blunt Shoulder Trauma: Fracture, Dislocation, or AC Separation
Case 14 - Fractured Radius From a Fall, Rule-Out Foot Fracture
Case 15 - Osteoid Osteoma
Case 16 - A Limping 6-Year Old
Case 17 - Fever and Refusal to Walk In a 4-Year Old
Case 18 - The Toddler's Fracture: Accident or Child Abuse ?
Case 19 - Adolescent Female With Hip Pain
Case 20 - Acute Hip Pain in a Sprinting Teen

Volume 5 - October 1996 (Copyright 1996, L. Yamamoto)
Case 1 - Fever With Neck Stiffness . . . Rule Out Meningitis?
Case 2 - Cervical Spine Radiographs
Case 3 - The Hangman's Fracture
Case 4 - The Jefferson Fracture
Case 5 - Other Cervical Spine Fractures
Case 6 - Intracranial Hypertension and Brain Herniation Syndromes
Case 7 - Intracranial Hemorrhages
Case 8 - Lethargy and Fever
Case 9 - Infant Skull Fractures
Case 10 - Lethargy and Vomiting Following Child Abuse
Case 11 - Hip Pain in an 11-Year Old
Case 12 - Abdominal/Hip Pain With Fever in a 2-Year Old
Case 13 - Hemoptysis in an 11-Year Old: Scimitar Syndrome
Case 14 - Pulmonary Sequestration
Case 15 - Near Drowning
Case 16 - CAST Syndrome
Case 17 - Gastric Dilatation in a 3-Week Old
Case 18 - Right-Sided Abdominal Pain in a 10-Year Old
Case 19 - Bowel Obstruction With Intraintestinal Sand
Case 20 - Membranous Croup

Volume 6 - July 1999
Case 1 - Shoulder Pain After Throwing a Football
Case 2 - Fussiness Following Minor Trauma in an Infant
Case 3 - Vomiting and Coughing in a 3-Month Old with Weak Bones
Case 4 - Wrist Swelling in a Neonate
Case 5 - Elbow Swelling in a 2-Year Old with Liver Disease
Case 6 - Knee Sprain in a Teenager
Case 7 - Acute Knee Deformity
Case 8 - Sunrise View of the Knee
Case 9 - Orbital Injury
Case 10 - Orbital Pseudotumor
Case 11 - Chronic Lower Extremity Pain
Case 12 - Chest Pain in a 6-Year Old
Case 13 - Backache in a 16-Year Old
Case 14 - Bloody Diarrhea and Dehydration in a 5-Month Old
Case 15 - Hip and Knee Pain in a 4-Year Old
Case 16 - Forearm Deformity in a 4-Year Old
Case 17 - Recurrent Wheezing in an Infant
Case 18 - Appendicoliths
Case 19 - Difficulty Breathing Throughout Infancy
Case 20 - Recurrent Coins and Recurrent Respiratory Infections

Volume 7 - Final Release Date Pending
Case 1 - Fever and Upper Back Tenderness
Case 2 - A Growing Skull Fracture
Case 3 - Prolonged Cough and Fever
Case 4 - Proteus Syndrome
Case 5 - Urolithiasis
Case 6 - A Large Calcified Kidney Stone
Case 7 - Forearm Swelling, Pain, and Numbness Following Trauma
Case 8 - Multiple Trauma in a 2-Year Old
Case 9 - Herpes Encephalitis
Case 10 - A Complication of a Retropharyngeal Abscess
Case 12 - Painless Scrotal Swelling
Case 18 - Find the Intussusception Target and Crescent Signs

MENTAL HEALTH

Road Traffic Offences
Introduction
The forensic clinician enters a complex world in his/her dealings with the Road Traffic Acts (RTA)
where a knowledge of driver statute and case law may be more important than in any other field.
At first it seems simple, that the FME is called out, turns up, takes blood samples and fills in some
forms, and for the vast majority of cases that is the end of the matter.
It is for the few cases which are not simple that a wider knowledge is required.
RTA case law is full of examples where procedure rather than simple fact has been the lynch pin of
a defended case.
By the "RTA", in this text, reference is being made to the Road Traffic Act 1988, the last in a series
of Acts. The latter act is the source of virtually all the discussion in this chapter. Any other statute
will be cited and described with its full title, but otherwise RTA will mean the '88 Act.
Technical Matters
The current RTA kits involve the doctor transferring blood from a single syringe to two containers
with a "rubberised" membrane through which the blood can be injected. It is hard to conceive of any
other procedure in medical practice today which is designed to be as hazardous to the user from the
point of view of needle-stick injury or aerosol blood spray as this.
In 1994, a sub-committee of the Association of Police Surgeons met with representatives of the
Home Office Forensic Science Services to address this problem amongst others. There appeared to
be no problem in attitude from the scientists with regard to the re-organisation necessary for analysis
using a different and safer venesection process. However the legal advice sought suggested that any
other system available whereby two samples were obtained could not be deemed
to have satisfied the Road Traffic Offenders Act 1988 s15 (5)r until it had been through the courts. It
was not satisfactory therefore to change procedure without a change in statute.
The transfer of the blood to the container is best facilitated by allowing the syringe plunger to be
pushed back up the barrel by the pressure increase of the blood from the first container before filling
the second.
It is equally acceptable to insert another sterile needle into the membrane to allow pressure
equalisation. If this is done the FME should record the presence of two holes in the membrane.
One anecdotal case had the accused specimen container sporting 16 holes whilst the "police"
specimen had 1. Not all cases of interference would be as easy to spot as that, and it is good practice
to record multiple perforation of the membrane.
It is sensible to develop a routine with RTA cases.
As the consent for a blood specimen is requested in front of a police officer who witnesses the
response, there is no real requirement to have the consent to the simple transaction recorded in the
clinician's record. If, however, the case is a more complex one involving examination then written
consent should be obtained.
Many defences appear spurious and it helps to have developed a set notation for the record of the
sampling, so that it can be seen that a detailed procedure was followed.
Recording:
• From which arm the sample was obtained.
• How much blood was obtained (if the syringe was not full).
• Who packaged the specimen.
• Was it "selotaped" and by whom?
• Was the accused given information about approved laboratories?
• The name of the authorised operator or police officer running the procedure.
and such like can all help.
r "Where, at the time a specimen of blood or urine was provided by the accused, he asked to be provided with
such a specimen, evidence of the proportion of alcohol or any drug found in the specimen is not admissable on
behalf of the prosecution unless—
(a) the specimen in which the alcohol or drug was found is one of two parts into which the specimen provided
by the accused was divided at the time it was provided, and
(b) the other part was supplied to the accused."
to have satisfied the Road Traffic Offenders Act 1988 s15 (5)r until it had been through the courts. It
was not satisfactory therefore to change procedure without a change in statute.
The transfer of the blood to the container is best facilitated by allowing the syringe plunger to be
pushed back up the barrel by the pressure increase of the blood from the first container before filling
the second.
It is equally acceptable to insert another sterile needle into the membrane to allow pressure
equalisation. If this is done the FME should record the presence of two holes in the membrane.
One anecdotal case had the accused specimen container sporting 16 holes whilst the "police"
specimen had 1. Not all cases of interference would be as easy to spot as that, and it is good practice
to record multiple perforation of the membrane.
It is sensible to develop a routine with RTA cases.
As the consent for a blood specimen is requested in front of a police officer who witnesses the
response, there is no real requirement to have the consent to the simple transaction recorded in the
clinician's record. If, however, the case is a more complex one involving examination then written
consent should be obtained.
Many defences appear spurious and it helps to have developed a set notation for the record of the
sampling, so that it can be seen that a detailed procedure was followed.
Recording:
• From which arm the sample was obtained.
• How much blood was obtained (if the syringe was not full).
• Who packaged the specimen.
• Was it "selotaped" and by whom?
• Was the accused given information about approved laboratories?
• The name of the authorised operator or police officer running the procedure.
and such like can all help.
r "Where, at the time a specimen of blood or urine was provided by the accused, he asked to be provided with
such a specimen, evidence of the proportion of alcohol or any drug found in the specimen is not admissable on
behalf of the prosecution unless—
(a) the specimen in which the alcohol or drug was found is one of two parts into which the specimen provided
by the accused was divided at the time it was provided, and
(b) the other part was supplied to the accused."
ulation, could be due to a drug and therefore would seem to satisfy the requirements of the act.
What has been tested in the court is that the doctor must give an oral indication to the constable concerning the presence may cause the specimen to be inadmissable.
There appears to be no requirement in the RTA for an accused to consent to a full examination, but there is also nothing practitioner to do a full consensual examination before advising the police officer. It seems perfectly acceptable for accused, record as much as possible of his/her observations and if there is a demonstrable condition satisfying the The police surgeon must record accurately all the findings

EXAMINATION OF SUSPECT IN SEXUAL ASSAULT

Examination of Suspect in Sexual Assault
This chapter is short.
The brevity with which this particular aspect of FME work has been treated is inversely proportional
to its importance.
The two previous Chapters (7 & 8) need to be read.
The standard of detail with which a specific suspect needs to be examined is no less than in the
examination of an alleged victim.
The forensic clinician owes a duty to accused, victim and the courts to perform a thoroughly
professional appraisal.
If the alleged offence is remote from the examination of the suspect, such that weeks have passed, it
may not be worthwhile looking for forensic material other than blood for identification.
It should be remembered that bruises may be visible for 14 days. 70 They may be visualised with
specialist UV photography (mainly of benefit in bite-marks) for up to 4 months.75
If a particular scar, skin lesion or other distinguishing mark has been mentioned by the complainant,
it may be appropriate to perform an inspection whatever the delay.
Repeated here is the opinion emphasised in the previous chapter.
It is not improper for the clinician examining the suspect, to discuss, by telephone, any
peculiar findings with the police surgeon examining a complainant.
Discussions have, apocryphally, attracted a condemnation of this practice as collusion. Such is not
the case. There is no difference between giving the forensic scientist as much information as
possible to enable him/her to carry out a professional analysis and extending the same courtesy to
ones clinical colleagues. In all cases the clinician's role is to gather evidence which will help any
court make a balanced decision.
Procedure
Discuss with the Senior Investigating Officer (SIO) the purposes of the examination. No forensic
clinician should be satisfied with a request to simply ''get blood and hair samples please". Full
discussion should take place about the complexities of the case and then the police surgeon should
inform the SIO about the extent and restrictions of any examination. The FME should also ensure
that the appropriate requirements for the obtaining of intimate samples (v.i.) have been fulfilled.
The suspect should have the right to be seen without the presence of a police officer. Though as has
been mentioned previously in the guidelines, the custody officer may object to this if there is a
safety consideration.
If the suspect wishes the solicitor to be present, then this should pose no problem. However undue
delay should not be contemplated at the risk of losing forensic evidence. Fibre evidence, for
example, may degrade within a few hours.
Written consent should be obtained. This should include in the dialogue a mention of why the
examination is being performed. An example would be "in the case of an alleged rape". The
examination structure and sample procedure should be outlined. The disclosure pathways should be
mentioned (see Chapters 2 & 3).
If consent is refused, then the police surgeon can still make observations and record those findings.
Intimate Samples
If intimate samples are required then consent under PACE requirements which includes the written
consent of the examinee will already have been obtained. 76 This should not deter the clinician from
obtaining his/her own consent. A simple explanation that such consent is a medical ethic rather than
a legal requirement usually produces amicable compliance.
Intimate samples are defined under Police and Criminal Evidence Act 1984 s65 as amended by the
Criminal Justice and Public Order Act 1994 s58
Intimate samples are:-
• Dental impression
• Sample of blood
• Sample of semen
• Any other tissue fluid
• Urine
• Pubic hair
• Swab from a body orifice other than the mouth.
With the exception of urine, none can be taken by anyone other than a registered dental or medical
practitioner.
Having obtained consent, a history of the alleged incident should be requested. As many allegations
relate to the question of consent or what actually occurred rather than the identification of who the
perpetrator was this is not as fruitless as it may at first seem.
Sometimes, however, no event related history is forthcoming.
The examination should proceed.
A sexual offences kit should be used and, unless the clothes have already been obtained by the
police, the examinee undressed on a paper sheet as with a victim. The clothes should be carefully
packaged and the same courtesy of dignity extended to the patient as is given to the victim.
Clinical findings and the sample harvest should be performed meticulously and recorded accurately.
If injuries are discovered duing the examination, the examinee can be asked to account for them,
even if no history was obtained, and even if legal advice, or the patient himself results in no
response. The police surgeon should record "no response" without expression or comment and carry
on with the procedure. Though "comments" should not be made, it is good clinical practice to
maintain a discourse with the examinee throughout the contact, even if only in so far as explaining
exactly what is entailed in the examination process. However the doctor should not embark on an
interrogation that should properly be conducted by the investigating officer.
The genital examination should be as gentle as possible but thorough. The area, as with the rest of
the body should be viewed under UV light for fluoresence, and any stain swabbed. Even in the
absence of fluorescence a swab should be taken of the coronal sulcus.
The anal and peri-anal area should be inspected and examined in more detail depending on the
allegations and findings. Though it must be remembered that consent may be witheld for any
individual part of the examination process, and such a decision must be respected.
At the end of the examination it could be advantageous to ask the suspect and particularly the
solicitor, if present, if they have any comment or criticism to voice. Record any answer.
The samples should be labelled in the same manner as described in Chapter 8 and also disposed of
similarly.
The Doctor at the Scene of Death
Introduction
Police surgeons get called to many scenes of death.
The majority will not become the scene of a major crime investigation.
It is imperative that the clinician brings his/her skills and knowledge to the scene, alert from the
beginning. It is likely that the police surgeon is the only one present with the medical and scientific
training to perceive some anomalies which may give rise to suspicion.
FMEs are usually called to a death, because it is "suspicious", sudden or the General Practitioner of
the deceased is unknown or not contactable. Suspicious deaths, in this context, are likely to include
homicide, suicide or accidents, as well as some cases of natural death.
This chapter is not intended to be a panorama of death and its forensic aspects but to draw attention
to the main areas of consideration.
These are:-
1. Approach to the scene
2. Communication
3. FMEs actions at the scene
4. Safety
All police surgeons should be familiar with the Scenes of Crime Directive produced by their Police
or by the Home Office Forensic Science Laboratories (or the Metropolitan Service).
Approach to the Scene
Contamination of the scene should be avoided.
The only exception to a slow measured and controlled approach to a body is the possibility
that the life may be preserved in which case the primary responsibilty is the patient. Such
preservation should not be under
taken without first making sure the scene is without danger to the doctor or others (see "Safety"
below).
Approaching the scene of death, the doctor should alight from his/her transport no closer than the
nearest police vehicle, unless directed to a particular area by a uniformed police officer or other
official. It may appear that some vehicle is closer to the scene, but that may be one that is connected
with the death.
If the FME is only the second or third person to arrive, he should discuss with the reporting officer
the circumstances of the case before inspecting the body, and determine life to be extinct with as
little disturbance to the scene as possible. If it is early in the case, or there may need to be an
investigation, the police surgeon should not hesitate to inform his police colleagues about protection
of the scene and the prevention of intrusion by unwanted observers.
If an investigation team is already there, it is likely that one officer will be keeping the log. The
doctor should report his/her arrival to that log-keeper. Discussion with the Senior Investigating
Officer (SIO) or equivalent should occur to determine the path of entry to the body and the known
circumstances. The FME should keep to this path, which should be marked, with tape or stepping
plates, where necessary.
The metaphor that it is best to keep ones hands in ones pocket should be taken literally. If without
pockets, thinking about this adage should be enough to keep ones hands away from anything other
than the body.
Having determined that life is extinct, no further interference with the body should take place
without clearance from the SIO, and until after the Scenes of Crime Officers (SOCO) have
completed their evidence gathering from the undisturbed body and environs. If the case is one
without suspicion and no investigation is taking place it is still good practice for the professionals
there to be informed before the doctor moves the body. In these latter circumstances, if the doctor is
intending to take photographs for his/her clinical records, they should also be started before moving
the body.
It is good practice, even in the most obvious and benign cases, for the body to be inspected on all
sides, just in case a suspicious lesion or object lurks beneath.
The doctor should exit by the agreed pathway.
In the case of suspicious deaths, the doctor should remain, whenever possible, to offer to the
investigating team his/her expertise, until the Home Office Pathologist arrives, or the body is
removed. It is educational, if ever case load permits, for the clinician to attend the autopsy if
possible

Genital Examination in Girls

A small child is often most easily examined on her mother's knee, particularly if only a visual
inspection is needed. The mother can hold the child's legs apart. Alternatively a similar inspection
can be done with the child lying prone over the mother's knee with the clinician examining from
behind.
With older children, the usual technique is for the child to be examined lying supine on the medical
couch with her knees flexed and hips externally rotated. Whilst in this position the labia may be
gently separated (labial separation) by the examiner's fingers or traction exerted in a forward and
downward direction with the examiner holding the labia gently between thumb and forefinger
(labial traction).
The genital area can also be examined thoroughly with the child in the kneechest position.p In this
position the important posterior edge of the hymen can often be seen more clearly than when the
child is lying supine on the couch.
Ideally the child should be examined in both positions. The child should however be given control
over the choice. Many children appear to prefer the knee chest position.
Ideally a colposcope should be used, but in the absence of this a magnifying glass or optical loups
are an alternative. The colposcope should include optical measurement and recording.
In many cases when the genitalia are examined in different positions, the edge of the hymen will
have been clearly visualised without the need for any kind of intrusive examination, but in some
cases it is helpful to use a glass probe (Glaister's globe).
Glaister's globes are glass rods with a diameter of 0.6 mm with one end of the rod being expanded
into a globe from 1-2.5 cm in diameter. They can be inserted gently behind the hymen to display its
edges over the glass. In this way apparent folds and indentations often smooth out and small nicks
and tears can be more easily identified. Glass rods used in this way, with explanation and
demonstration to the child, are much less traumatic than using a moistened cotton wool swab which
often causes pain in a delicate area.
If swabs have been taken for forensic purposes, or to carry out tests for STD, then it is helpful to
show the child an unused swab. In some cases it helps to allow the child to use the swab herself and
keep control. Again the child should be allowed to halt the proceedings if distressed.
In most cases where indecent acts are alleged it is not necessary, after the above procedures, to
insert any object into the vagina. However, where there is an allegation of full sexual intercourse or
findings such as a completely torn hymen,
p Crouched on the examination couch with the small of the back arched downwards, knees flexed under the
chest and bottom in the air.
then in some cases it is appropriate to carry out a gentle digital examination of the vagina to
establish whether:
—The hymenal ring is completely torn
—Whether the vagina can admit an object the size of an erect penis and
—Whether its walls are rugose or smooth and the canal enlarged
In older girls it may be appropriate to carry out a full gynaecological examination, including the
insertion of a speculum, to inspect the cervix. Bimanual palpation may indicate pregnancy and a
pregnancy test may be advisable.
Genital Examination in Boys
There is rarely any genital injury in boys who have been indecently assaulted. The penis and
testicles should be thoroughly inspected for signs of bruising, tears of the frenulum, or "love-bites"
and signs of sucking. The root of the penis may show bruising or other lesions. It is important to
consider that the penis may have been sucked and to swab for saliva, in the knowledge that saliva,
on the unwashed penis, may survive for up to one week.
The testicles should be examined for signs of bruising or biting.
The Anal Area
The anus should be inspected in every case. This may be done in the left lateral or knee-chest
position.
The buttocks should be gently separated, without applying traction, and the anal orifice observed for
about 30 seconds to see if there is any dilatation. Slight twitchiness or dilatation of the external
sphincter is probably of no significance. Anal dilatation in the presence of a stool in the rectum is
regarded by most experienced examiners as being unlikely to be a sign of abuse. If observed,
however, it should be recorded.
The anal folds should be regular and symmetrical around the anal opening but there is often a
redundant fold, particularly in boys, anteriorly which can be confused with a skin tag or healed
fissure. A midline raphe extending backwards from the scrotum is normal and should not be
confused with signs of injury.
Prominent veins have sometimes been claimed to be significant pointers to abuse. However, they
often come up during the examination as the child tenses and relaxes his muscles, and no great
significance can be attached to them, though they must, of course, be noted.
If no abnormality is seen on careful inspection of the anus then it is appropriate to do no more.
However if there is an allegation of anal abuse then a finger gently can be placed against the anal
orifice to test its tone. A very good estimate
of anal tone can be obtained in this way without doing a full digital examination. In some cases a
digital examination should be done, the subject asked to squeeze the examining finger to test the
anal tone. It is important to remember, however, that this procedure relies on a subjective
assessment of the examiner based on experience and can be unreliable.

EXAMINATION OF VICTIM OF ALLEGED SEXUAL ASSAULT

Examination in the Case of Alleged Sexual Assault
Introduction
There is no doubt that examinations of adults in this arena, along with those involving children, can
be the most demanding of circumstances.
The first part of this chapter will deal with the adult. The second with the child where this differs.
This is not to say that other areas of clinical forensic medicine can be approached with less skill and
more superficial knowledge; they cannot. In these areas however, the FME will be faced with
establishing an ambience which will allow the necessary comprehensive examination to take place.
• Whilst preserving the dignity of the examinee as well as the forensic specimens
• By coaxing the patient to be compliant whilst allowing them to regain a control which may have
been severely damaged during any assault
• Whilst accepting the patient's communications with total belief and compassion yet maintaining a
scientific objectivity so that any evidence can be presented without bias or prejudice
"Examination" is a euphemism for the whole doctor/patient interface, involving as it does in good
forensic practice, skills, knowledge and attitudes which go a long way beyond the ability to record
genital findings.
Ideally the "processing" of a complainant, should take place within an organised structure involving
not only appropriately trained and experienced forensic clinicians but also:
1. Trained police officers
2. Trained counsellors
 3. Sexually Transmitted Disease (STD) screening facilities and specialist adviser.
4. Obstetric and Gynaecology/Urology/Paediatric specialist back up services
5. Specialist suites.
It is important that where possible the patient has a choice of gender of those who are going to have
intimate contact with them.
In this chapter the use of the term "victim" must be read as "alleged victim". There is no intent that
any forensic clinician should have a prejudicial bias. It is the court that will decide guilt or
innocence, whatever the initial percieved truth of the matter.
Appendix 8a shows a schematic outline of Greater Manchester Services in this field.
General Issues
Medical records are important. Chapter 1 should be read.
Some centres (eg St Mary's Sexual Assault Centre (SMSAC) in Manchester) have developed their
own proformata. If there are confidential notes or common notes which are important for continuing
care such as counselling or STD treatment, it may be a policy that those notes are not removed from
the centre. Otherwise the advice about record responsibility is as discussed in Chapter 1.
Consent has been covered in Chapter 2. Examination of a victim may present forensic and
therapeutic aspects and the doctor must ensure that the appropriate informed consent is obtained.
The police surgeon must be clear in his/her own mind before explaining the features of each to the
examinee.
Though this chapter describes the situation with regard to females, the procedure apart from the
obvious exception of the genital examination applies equally to male complainants. For examination
of the penis, the section in the following chapter should be read.
It is extremely important that the patient understands that any relevant detail of the exchange
between him/herself and the doctor may be discussed in public court.
The Examination
Introduction
The FME should introduce him/herself, explaining what must be done.
The complainant should be asked how they would like to be addressed. It should not be assumed
that they wish to be called by their first name.Sympathy to their plight is important (remembering, but in no way expressing, that this predicament
is only alleged at this stage), it can be expressed whilst the details of the thoroughness of the
examination and sample taking procedure are explained. Attention should be drawn to the way the
evidence can help in court, but additionally the examinee informed that no promises can be given as
regards the outcome of any court case.
The benefit of being able to reassure as to the lack of anatomical damage can be comforting.
Explaining to the patient that they are in control, and even though the examination may be long and
tedious, it should never be more than uncomfortable at the most and that they can call a halt at any
time, may help to dispel some of the feeling of vulnerability which can be left after an assault.
Continuing to converse with or talk to the patient throughout the examination can be reassuring.
Specific medical problems can also be addressed such as STD. It is worth reminding the patient that
this information is not recognised generally as being of value as forensic evidence, and that the
disclosure is covered by law (see Chapter 3). If AIDS is mentioned as a specific concern, then it
must be addressed in superficial general terms and specialist counselling arranged with pre and post
HIV testing counselling sessions provided, otherwise it is best left for any counsellors to deal with
it, if necessary, at a later date.
History of Event
This should be obtained from the sources available. This usually means the reporting police officer
and then the complainant. Detailed notes should be made and checked with the patient with
particular reference to any discrepancies that exist between any versions received (see page 10
"WHAT").
A complainant may not mention all that has happened, and careful probing may be needed to elicit
the full history of events (for example a female may be reluctant to admit buggery). Leading
questions, as always, should be used as a last resort.
The history should also include recent sexual intercourse before and after the event.
General Medical History
Current medical problems, and past medical, surgical, injury (not considered by some to be a
medical problem) and obstetric & gynaecological history should be obtained.
Gynaecological history is important as is history of recent intercourse.Sympathy to their plight is important (remembering, but in no way expressing, that this predicament
is only alleged at this stage), it can be expressed whilst the details of the thoroughness of the
examination and sample taking procedure are explained. Attention should be drawn to the way the
evidence can help in court, but additionally the examinee informed that no promises can be given as
regards the outcome of any court case.
The benefit of being able to reassure as to the lack of anatomical damage can be comforting.
Explaining to the patient that they are in control, and even though the examination may be long and
tedious, it should never be more than uncomfortable at the most and that they can call a halt at any
time, may help to dispel some of the feeling of vulnerability which can be left after an assault.
Continuing to converse with or talk to the patient throughout the examination can be reassuring.
Specific medical problems can also be addressed such as STD. It is worth reminding the patient that
this information is not recognised generally as being of value as forensic evidence, and that the
disclosure is covered by law (see Chapter 3). If AIDS is mentioned as a specific concern, then it
must be addressed in superficial general terms and specialist counselling arranged with pre and post
HIV testing counselling sessions provided, otherwise it is best left for any counsellors to deal with
it, if necessary, at a later date.
History of Event
This should be obtained from the sources available. This usually means the reporting police officer
and then the complainant. Detailed notes should be made and checked with the patient with
particular reference to any discrepancies that exist between any versions received (see page 10
"WHAT").
A complainant may not mention all that has happened, and careful probing may be needed to elicit
the full history of events (for example a female may be reluctant to admit buggery). Leading
questions, as always, should be used as a last resort.
The history should also include recent sexual intercourse before and after the event.
General Medical History
Current medical problems, and past medical, surgical, injury (not considered by some to be a
medical problem) and obstetric & gynaecological history should be obtained.
Gynaecological history is important as is history of recent intercourse.Clinical features should all be recorded. Height, weight, general appearance and demeanour, as well
as any fetor or other stigmata may all be important.
A thorough inspection of the body is necessary. The general body inspection can be done in sections
to preserve the dignity of the patient as much as possible.
Any injury or significant lesion should be notated. See page 92 on examination in cases of assault.
Photography can be useful as an adjunct to the handwritten records and/or sketches and are
extremely useful as a teaching accessory later. Whenever possible a photograph of a lesion, as
opposed to a scene, should contain a scale. If photography is considered necessary for evidential
purposes then the FME should contact the Senior Investigating Officer with regard to use of
the professionally trained police photographer. It helps if female Scenes of Crime Officers
(SOCOs) trained in evidential photography are available.
As well as the general injuries mentioned in the previous chapter there are further specific findings
which may be of evidential value:-
Bite-marks, as well as photography and the referral to a forensic odontologist, should be swabbed.
The swab should be moistened with water from a sterile ampoule, and twisted around on the bite
area. If photography is performed without the presence of the odontologist the views should be
ideally 1:1, with two scales at right angles, and three views perpendicular and either side at 45 ° in
the same plane.
The eyes should be inspected for redness or petechiae.
The scalp may show petechiae, purpura or pin-point haemorrhage at the hair roots when the hair has
been pulled. Hair loss may also be noted. The scalp should be palpated for soft tissue swelling.
The mouth should be inspected as should the auditory meatus and behind the pinnae.
It is possible that fellatio occurred causing petechiae on the palate. 72
As well as soft tissue damage, the nails should be inspected for breaks or possible fibres or skin
from the "assailant".
Genital Examination
The vulva should be inspected, under illuminated magnification, for redness, grazes, splits in the
fourchette and bruising.
External swabs should be taken, including the peri-anal area.
Low vaginal swabs should be taken after gentle separation of the labia. Care must be taken not to
introduce any external contaminant into the vagina.

EXAMINATION IN CASES OF ASSAULT

Examination in Cases of Assault
The examination of a patient in the case of an alleged assault should follow the same pattern
whether the examinee is the complainant or accused.
Standard medical history taking techniques should be involved
• Introduction
• Consent
• History
• Examination
• Investigation
• Diagnosis
The "Diagnosis" in the forensic context, of course, as has been alluded to in other chapters, is a
formulation of opinion about causation.
Introduction
The FME should introduce him/herself to the patient explaining
1. The purpose of the examination
2. The procedure to be adopted
3. The investigations needed to be done (if any)
Consent
Consent should then be taken, including explicit parameters regarding disclosure, investigation and
photography etc. Chapter 2 on Consent should be read.
History
The history of the alleged events insofar as that history has a direct bearing on the clinical appraisal
should be taken.
Account must also be taken of factors which may affect such an appraisal. This would include any
intoxicants, or other drugs, past medical and surgical history, any medication being taken, and any
social history which may reflect on the condition of the patient, such as homelessness and having
lived "rough". Any other recent physical confrontation, of any form, which may have produced
stigmata must also be obtained.
Examination
A full body examination should be performed. It is classically known that in the stress of a physical
confrontation, symptoms of trauma, and memory of causation may be absent. This dictum is also
true in the examination of a police officer in the case of alleged "police assault". The oft related
habit of examining a constable's hands does a disservice to the profession and creates a two tier
standard with a reduced level of competency for the police. To the police officer in such a situation
should be extended the full facilities of a complete, competent and consensual examination.
The examination should be performed carefully. The order of the facets of the complete examination
is completely at the discretion of the individual doctor, though developing a standard format and
using proformata (see Chapter 4) can be helpful. It is important however, that any samples that
should be obtained are taken at a time when they are not going to have been contaminated by
previous procedures. This is particularly true in, but not exclusive to, sexual offences, and is covered
in Chapters 8 & 9.
Injuries
The recording of injuries accurately is absolutely vital.
The use of body charts (see Appendix 1c) is of great aid.
Any injury or lesion which can be measured, should be measured.
There are six objective parameters to any such traumatic lesion:
• Type of lesion
• Position
• Size
• Appearance
• Orientation
• Direction of causation
In addition to these there are the subjective symptoms of:
• Pain
• Tenderness
• Stiffness

Clinical Assessment of Interviewee

The previous chapter on Fitness to be Detained should be read.
Physical Illness
Any detainee who is suffering from a specific physical illness should be stable before interview
takes place. It is difficult to be specific. For example the hypertensive does not have to be
normotensive, only preferably so. Some hypertensive patients are stable at a theoretically
hypertensive level. It behoves the clinician to establish, if possible, the "normal" state for that
patient, if a higher blood pressure reading than expected is obtained. This, of course, can be a
difficult or even impossible task in the middle of the night, in which case the clinical judgement of
the FME must be exercised. A similar approach can also be taken towards other conditions such as
diabetes mellitus. In the latter case no clinical appraisal should be considered complete without a
blood sugar estimation.
If a patient is on medication then the treatment protocol should be ratified and
written up on whatever is the accepted format for care instructions for detainees (see Appendix 3c
for the example of the Greater Manchester Police form).
The detainee who is injured or suffering from a musculoskeletal disorder needs assessing and any
appropriate analgesia given. If serious injury is considered they should have that condition assessed
and treated before interview. The British National Formulary (BNF) describes both Aspirin and
Paracetamol as particularly useful for musculoskeletal pain and pyrexia. The former can be used (if
not contra-indicated in the individual) where anti-inflammatory action is required. The BNF points
out that any combined analgesic, containing an opioid, has no substantiated benefit over the simple
drug, if the dose is low, and carries all the side effects of the opioid if containing a higher dose.
Visceral pain is however more responsive to opioid analgesics.
Care must be taken not to give an opioid analgesia in a dose which may cause drowsiness, during
the interview, in a patient unused to strong drugs.
In police surgeon practice the above example infrequently presents. The specific case of drug
addicts is dealt with below.
Examination
The examination should include:-
1. A full medical history including family, social, and past medical/surgery/ (obstetric) histories.
2. Medication details including any alcohol or illicit drugs used.
2.1 For illicit drugs it is of help to use the regional data base forms as part of the medical
record (see Chapter 3 Section and Appendices 3a & b).
2.2 It is worthwhile remembering the availability of legal "herbal" highs.
2.3 The history should include habitual use as well as intake in the last 24 hours.
3. Nutrition
3.1 General condition, and
3.2 Food intake—when and what?
4. Full clinical examination with particular reference to stigmata of drug abuse and/or withdrawal.
4.1 Does the patient normally wear spectacles (or contact lenses)?, or
4.2 Have a hearing deficit? (important if going to be interviewed or asked to sign anything).
5. The CNS examination should include.
5.1 Locomotor function.
5.2 Co-ordination.
5.3 Temporo-spatial orientation.