Two peculiar cases of cranial fractures running through craniotomy burr holes: may this be a kind of "exception" to the Puppe rule.

A correct assessment on the position, path, and direction of fracture lines is crucial when the sequence of different injuries on the skull has to be ascertained. In this context, the so-called Puppe's rule on intersecting fracture lines has always been considered a cornerstone of such an investigation. However, there is one factor that has never been previously considered: how do fracture lines behave when they reach the edges of an old and remodeled hole from a previous craniotomy? Two peculiar cases are presented of subjects undergoing cranial fractures due to blunt force trauma (case 1) and gunshot (case 2). Both previously underwent neurosurgical operations with persistence of the burr holes produced by the craniotomy drill (15 and 20 years before death). What was arguable, according to Puppe's rule, was that the fracture lines, when at the edge of the craniotomy hole, stopped. However, what has been detected was different than what expected: fracture lines continued exactly in the opposite direction, as though they were "skipping" the hole, following the same direction and the same axis and stopping a few centimeters over on the opposite side of the craniotomy hole. Puppe's rule has never been refuted, but these cases are the closest to an exception ever seen in forensic anthropology.

Analysis of interrater reliability in age assessment of minors: how does expertise influence the evaluation?

Nowadays, the clinical forensic medical management of migration flows comprises the age assessment of unaccompanied minors. The process of age estimation is a fundamental pillar for legally ensuring the minors' rights and their protection needs. The procedure is complex and involves different phases and actors, from medical doctors to law enforcement officers. The present study aimed to investigate the performance of Greulich and Pyle, Demirjian, and Mincer methods when performed by raters both trained and without training. Also, the interrater reliability within groups of raters from different areas of expertise was evaluated. A total of 36 participants were enrolled for this study, divided in two groups according to their level of experience with age estimation methods. Each rater was asked to allocate stages and standards for age assessment, evaluating ten orthopantomograms and ten hand-wrist roentgenograms. The interrater reliability expressed through the Fleiss Kappa coefficient and the agreement with the reference standard were calculated. The results showed that none of the categories analyzed could reach a good interrater reliability (ĸ > 0.8) for both methods. The study results highlighted variation and disagreement in the interpretation of the sample among raters and in the subsequent stages and standards allocation. In conclusion, the results of this study highlight that expertise does influence the reliability of the most utilized methods of age estimation of living individuals and stress the importance of proper training and practice, which could greatly increase the accuracy of age assessments.

Histological determination of the human origin from dry bone: a cautionary note for subadults.

Anthropologists are frequently required to confirm or exclude the human origin of skeletal remains; DNA and protein radioimmunoassays are useful in confirming the human origin of bone fragments but are not always successful. Histology may be the solution, but the young subadult structure could create misinterpretation. Histological tests were conducted on femur and skull of 31 human subjects. Each sample was observed focusing on presence or absence of fibrous bone, lamellar bone, radial lamellar bone, plexiform bone, reticular pattern, osteon banding, Haversian bone, primary osteons, secondary osteon and osteon fragments. Samples were divided into five age classes; 1 (<1 year), 2 (1-5 years), 3 (6-10 years), 4 (11-15 years) and 5 (16-20 years). Regarding femurs, class 1 presented the following: 87.5% fibrous bone, 37.5% plexiform bone, 12.5% reticular pattern and 12.5% lamellar bone radially oriented. Class 2 showed 37.5% of fibrous bone, 12.5% of reticular pattern and 37.5% of osteon banding. In the higher age classes, the classical human structures, lamellar bone and osteons were frequently visible, except for one case of reticular pattern, generally considered a distinctive non-human structure. The situation appeared different for the skull, where there was a lack of similar information, both in human and non-human. An analysis of the percentage of lamellar bone and osteons was conducted on femur and skull fragments. A trend of increase of primary osteon number and a decrease of the lamellar bone area has been detected in the femur. The present study has therefore shed some light on further pitfalls in species determination of subadult bone.

The importance of an anthropological scene of crime investigation in the case of burnt remains in vehicles: 3 case studies.

Inspection of a crime scene is a crucial step in forensic medicine, and even the methods taught by forensic anthropology are essential. Whereas a thorough inspection can provide crucial information, an approximate inspection can be useless or even harmful. This study reports 3 cases of burnt bodies found inside vehicles between 2006 and 2009 in the outskirts of Milan (Italy). In all 3 cases, the victim was killed by gunshot, and the body was burnt in the vehicle to destroy signs of skeletal injury and prevent identification. In every case, the assistance of forensic anthropologists was requested, but only after the inspection of the body at autopsy showed that the remains were incomplete, thus making it more difficult to determine the identity, cause, and manner of death. A second scene of crime inspection was therefore performed with strict anthropological and adapted archeological methods by forensic anthropologists to perform a more complete recovery, proving how much material had been left behind. These cases clearly show the importance of a proper recovery and of the application of forensic anthropology methods on badly charred bodies and the importance of recovering every fragment of bone: even the smallest fragment can provide essential information. Thus, a precise coordination, a correct and thorough recovery of bone fragments, and an anthropological approach are crucial for many issues: analysis of the scene of crime, reconstruction of the corpse, and reconstruction of the perimortem events.

Physical assessment of tortures: Interobserver analysis of medico-legal degrees of consistency based on the Istanbul protocol.

The Istanbul Protocol section on medicolegal evaluation delineates the guidelines for the correct management of the physical examination and the methods of assigning the degrees of consistency. Considering that most cases exhibit highly heterogeneous lesions, the examiner is forced to rely on his own experience, and their evaluation may be very subjective. The purpose of this work is to understand how subjective such an evaluation may be and whether the "experience" factor, interpreted as years dedicated to this profession and the number of cases evaluated, is statistically significant. To this end, a survey containing eleven cases of pre-evaluated asylum seekers was sent to thirty Italian clinical forensic practitioners. The participants were invited to assign a degree of consistency to each case according to the Istanbul Protocol guidelines, besides answering a few questions regarding their professional record. The doctors were divided into groups based on the number of cases evaluated and the experience collected expressed in years, and then interobserver analysis was performed. Results showed that the Fleiss' Kappa coefficient acquired significant values when attention was turned to the sub-samples composed of more experienced participants. Therefore, the introduction of appropriately trained health professionals - "experts in migrations and torture" - could lower the risks of misinterpretation and make the assessment as reproducible as possible.

Case study: Lesions due to forced ritual scarification in Cameroon - A warning from cultural anthropology to forensic medicine.

Asylum seekers and refugees are constantly increasing worldwide because of human rights' violations and political-related abuses. As a result, some of them show scars due to torture and other forms of maltreatments. In addition, they may also present scars due to ethnical practices, namely ritual scarifications. This case study presents a victim who did not give consent to perform such ethnical practices on her body. The authors aim to enlighten the difficulty to understand the origin and the purpose of these specific injuries and the importance to know how to distinguish them from other forms of abuse. Indeed, it appears that such lesions follow a cultural path, meaning that the lesions are performed methodically and may show macroscopic differences compared to others. The story narrated by the victim can be helpful for the experts' assessment, regardless, they may present memory-loss issues. This represents the value of a correct injuries' diagnosis and the importance of cultural anthropology-related analyses. The cultural and social background are relevant since the injuries have their own signification because of their symbolism. Therefore, a multidisciplinary approach with a cultural anthropologist may have the possibility to help the forensic experts in understanding and interpreting such stories fostering their ability to better assess asylum seekers stories and their reliability.

Age estimation in the living: A scoping review of population data for skeletal and dental methods.

Age estimation of living individuals has become a crucial part of the forensic practice, especially due to the global increase in cross-border migration. The low rate of birth registration in many countries, hence of identification documents of migrants, especially in Africa and Asia, highlights the importance of reliable methods for age estimation of living individuals. Despite the fact that a number of skeletal and dental methods for age estimation have been developed, their main limitation is that they are based on specific reference samples and there is still no consensus among researchers on whether these methods can be applied to all populations. Though this issue remains still unsolved, population information at a glance could be useful for forensic practitioners dealing with such issues. This study aims at presenting a scoping review and mapping of the current situation concerning population data for skeletal (hand-wrist and clavicle) and dental methods (teeth eruption and third molar formation) for age estimation in the living. Two hundred studies on the rate of skeletal maturation and four hundred thirty-nine on the rate of dental maturation were found, covering the period from 1952 and 2020 for a total of ninety-eight countries. For most of the western and central African countries there are currently no data on the rate of skeletal and dental maturation. The same applies to the countries of the Middle East, as well as the eastern European countries, especially as regard the skeletal development.

Are cranial peri-mortem fractures identifiable in cremated remains? A study on 38 known cases.

Accurate identification and analysis of signs of trauma on human bone is one of the mainstays of forensic pathology. However, when a forensic pathologist has to deal with charred remains, the task become extremely difficult, because tissues are subjected to severe morphological alterations and their assessment can be critically distorted. We analyzed 38 individuals with peri-mortem skull fractures due to falls from height (17 cases), traffic accidents (16 cases), gunshots wounds (5 cases), of which we had the demographic and clinical data and the autopsy report with the description and photographic records of the fracture lines. After autopsy, the bodies were cremated in gas furnaces and the analysis of cremated cranial remains was conducted in order to verify if it was possible to reconstruct the original peri-mortem fractures and verify differences between known peri-mortem and post-mortem fractures. After 90 min and exposure to temperatures up to 1280 °C, in less than a third of cases (11-29%) the original peri-mortem fracture pattern could be found and reconstructed. The edges and the surface of the fractures can preserve their proper morphology, or they can be affected by post-mortem heat-induced fractures and deformations. Interestingly whenever peri-mortem fracture margins showed the evidence of yellow/brownish colouration, a matte appearance was observed, much different from post-mortem fractures, which may provide further food for thought for the identification of peri-mortem fractures after the cremation process.

The medico-legal assessment of asylum seeker victims in Italy.

INTRODUCTION: Changing patterns of migration has required states and governments to respond to the specific medical and legal needs of asylum seekers. Based on medical assessments undertaken at the University Institute of Legal Medicine, the present study aims to describe the cases of asylum applicants who have suffered from physical violence, including torture, and the variables involved. METHODS: Over a 10-year period, 225 survivors were examined by clinical forensic professionals from the University Institute of Legal Medicine. RESULTS: 85% of asylum applicants came from Africa, 87% were male, and the most common age group was 26-40 years old. 46% of applicants fled their country for political reasons. Blunt force injuries were reported in 45% of cases, the trunk was the most affected area of the body (40%), and applicants presented with an average of two different mechanisms of lesions and an average of four lesions each. DISCUSSION/CONCLUSION: Assessment of physical violence on asylum seekers requires the cooperation of professionals with different skillsets and training.

Effects of Cremation on Fetal Bones.

The charring process is a weak point of anthropological analysis as it changes bone morphology and reduces information obtainable, specially in fetuses. This experiment aims at verifying the conservation of fetal bones after cremation. A total of 3138 fetuses of unknown sex and age were used, deriving from legal and therapeutic abortions from different hospitals of Milan. Cremations took place in modern crematoria. Nine cremation events were analyzed, each ranging from 57 to 915 simultaneously cremated fetuses. During the cremations, 4356 skeletal remains were recovered, 3756 of which (86.2%) were morphologically distinguishable. All types of fetal skeletal elements were found, with the exception of some cranial bones. Only 3.4% of individuals could be detected after the cremation process, because of the prevalence of abortions under 12 lunar weeks. All fire alterations were observed and the results were statistically analyzed. This pilot study confirmed the possibility of preservation of fetal skeletal elements after cremation.

Dismemberment and disarticulation: A forensic anthropological approach.

The dismemberment of a corpse is fairly rare in forensic medicine. It is usually performed with different types of sharp tools and used as a method of concealing the body and thus erasing proof of murder. In this context, the disarticulation of body parts is an even rarer event. The authors present the analysis of six dismemberment cases (well-preserved corpses or skeletonized remains with clear signs of dismemberment), arising from different contexts and in which different types of sharp tools were used. Two cases in particular showed peculiar features where separation of the forearms and limbs from the rest of the body was performed not by cutting through bones but through a meticulous disarticulation. The importance of a thorough anthropological investigation is thus highlighted, since it provides crucial information on the manner of dismemberment/disarticulation, the types of tools used and the general context in which the crime was perpetrated.

Thermal modifications of root transparency and implications for aging: a pilot study.

Root transparency has proven to be related to age and has been considered by different odontological methods for age estimation. Very little is known concerning possible variations of root transparency with heat, although the applicability of the method to burnt remains depends on the possible modifications of this specific variable. This pilot study presents the results of an experiment performed on 105 teeth obtained from dental patients and autopsy material, heated in an industrial oven at 50°C, 100°C, 150°C and 200°C. Root transparency was measured before and after the charring experiment. The heating process proved to radically modify root transparency, which decreased in 20% of samples at 50°C, in 34.6% at 100°C, in 50% at 150°C, in 77% at 200°C. The overall correlation index (CI) between decrease in root transparency and increase in temperature amounted to 0.96. These results show that heat may modify root transparency and suggest caution in using methods based on root transparency for age estimation.

Applicability of cranial models in urethane resin and foam as a substitute for bone: are synthetic materials reliable?

As literature is poor in functional synthetic cranial models, in this study, synthetic handmade models of cranial vaults were produced in two different materials (a urethane resin and a self-hardening foam), from multiple bone specimens (eight original cranial vaults: four human and four swine), in order to test their resemblance to bone structure in behavior, during fracture formation. All the vaults were mechanically tested with a 2-kg impact weight and filmed with a high-speed camera. Fracture patterns were homogeneous in all swine vaults and heterogeneous in human vaults, with resin fractures more similar to bone fractures. Mean fracture latency time extrapolated by videos were of 0.75 msec (bone), 1.5 msec (resin), 5.12 msec (foam) for human vaults and of 0.625 msec (bone), 1.87 msec (resin), 3.75 msec (foam) for swine vaults. These data showed that resin models are more similar to bone than foam reproductions, but that synthetic material may behave quite differently from bone as concerns fracture latency times.