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GAZETTE
JULY 1989
fracture, may aggravate the
changes of normal ageing. Experi-
ence is required in the assessment
of such areas, in order that what
are natural ageing features are not
misinterpreted as being directly due
to injury. The radiologist can often
ascertain this with a good degree
of certainty.
Head injuries are a particularly
important medico-legal area. In the
majority of cases radiographs are
not of significant help in diagnosis.
They will show fractures of the
skull, but wi ll not give any
indication of the extent of damage
to the structures within the skull,
principally the brain. Clinical
examination of the patient is much
more important in assessing brain
injury, although sophisticated
exami na t i on
by
compu t ed
tomography, (a "brain scan") is
helpful in the appropriate clinical
setting. Many serious cases of
brain injury show no skull fracture
on x-ray, and the radiograph can be
misleading as to the extent of
injury. Conversely, many fractures
which do show on x-ray are
relatively innocuous. The important
factor in head injury is whether or
not the brain is damaged and skull
x-rays may not tell this.
A less common situation where
x-rays may be useful is when
strangulation is suspected. Views
of the neck may show fractures of
the hyoid bone or thyroid cartilage.
These are small and are not
commonly damaged in accidents.
They can be damaged during post-
mortem examination, making their
assessment difficult, other than by
radiography beforehand.
Non-accidental injury
In recent years the problem of non-
accidental injury, or "battered
baby" has become all to prevalent.
The radiologist may be the first
person to raise a suspicion of this
as the child's injuries are often
given a very plausible explanation.
There are certain types of bony
injury which are unlikely to occur
accidentally.
These
include
posterior fractures of ribs, fractures
close to the growing ends of bones,
vertebral fractures and spiral
fractures of long bones. There are
often injuries at different stages of
healing, indicating several episodes
of trauma. Minor bony injuries may
not show immediately and follow-
up examinations may be helpful.
There are, however, some rare
abnormalities which may mimic
non-accidental injury but these can
be excluded by a careful study of
the whole skeleton.
Foreign bodies
The localisation of foreign material
within the body is a situation
uniquely suited to radiology. Many
foreign bodies are encountered,
some innocently, some through
violence. Figure 4 shows the
remains of the head of a nail which
was fired into the skull by a nail
gun, by a young man who
committed suicide after killing his
fiancee in a similar fashion. Some
foreign bodies are swallowed by
patients and others are inserted
into body cavities (Fig. 5). In the
case of gunshot wounds, x-rays are
necessary to find the bullet
fragments as they may travel a long
way from the site of entry.
Radiographs of an assassinated
foreign diplomat in London a few
years ago showed a tiny metallic
sphere which had been injected
into him. This had contained a
potent poison, but might never
have been found without the x-ray
study.
Non-metallic foreign bodies may
also be identified and x-rays have
been used to catch drug smugglers,
who swa l l ow the drugs in
condoms. Generally it is more
difficult to see non-metallic foreign
bodies, however. Diamonds do not
show on x-rays because of their
carbon content. In America, a lady
was detained on suspicion of
swa l l ow i ng a d i amond in a
jeweller's. She was mistakenly x-
rayed to find the missing gem and
a radiograph of her abdomen
showed a diamond shaped opacity!
When the jeweller was told that
true diamonds do not show up, the
charges were quickly dropped.
X-rays, which have the fascinat-
ing property of being able to pass
through the body, essentially un-
noticed, have a useful role to play
in many medico-legal situations.
Their accurate i n t e r p r e t a t i on
requires some expertise and a
rigorous course of training. Newer
modalities are now available for
imaging various parts of the body.
These involve the use of more
sophisticated computer linked radio-
graphy (computed tomography, CT
or CAT scan), high frequency sound
waves (ultrasound), radio-isotopes
(nuclear medicine) and magnetic
fields
(magnetic
resonance
imaging). These modalities are all
available in Ireland, although not
easily accessible in some instances,
due to their high cost and limited
numbers. X-rays, however, still
remain the basis of many of the
investigations performed, and are
readily available.
Figure legends
Figure 1. Frontal sinuses of two
people are outlined, showing quite
different shapes.
Figure 2. Three views of an animal
foot showing different bone con-
figuration from man. Small bones in
the toes (arrow) are more
numerous.
Figure 3. Left side shows fracture
of the radius (arrow) in a child's
wrist. Middle shows healing one
month later. Right shows healed
fracture at four months.
Figure 4. Nail fragments (arrow-
head) and skull fracture and air in
the skull (arrow) are seen following
suicide.
Figure 5. This disturbed young girl
had inserted a plastic doll into her
vagina.
•
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