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Standard radiographic positions for the lower extremity are required in order to match features on antemortem radiographs (68). Figures 89 through 96 provide information that can be used to determine how to position the body part and central beam of the X-ray for each standard position. Each positioning photo is accompanied by a sample of the image to be expected from it.

Forensic Radiography
Fig. 44. Old periosteal new bone around the distal femur from earlier trauma (arrows). Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.
Radiographic Appearance Greenstick
Fig. 45. Infantile ankle showing what Caffey called traumatic bowing, actually a green stick fracture of the metaphyses (arrows). Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Green Stem Fracture
Fig. 46. "Metaphyseal cupping" secondary to epiphyseal injury which blights the growth process. Reprinted from Brogdon BG, Vogel H, McDowell JD, eds. A radiologic atlas of abuse, torture, terrorism, and inflicted trauma (2003) with permission from CRC Press.
Ray Cupping Fraying Flaying

Fig. 47. Subluxation of the left femoral epiphysis due to intracapsular blood or effusion. This child had massive trauma elsewhere and was probably swung by this extremity. Compare with the right hip to see the widened joint. Reprinted from Brogdon BG, Vogel H, McDowell JD, eds. A radiologic atlas of abuse, torture, terrorism, and inflicted trauma (2003) with permission from CRC Press.

Fig. 47. Subluxation of the left femoral epiphysis due to intracapsular blood or effusion. This child had massive trauma elsewhere and was probably swung by this extremity. Compare with the right hip to see the widened joint. Reprinted from Brogdon BG, Vogel H, McDowell JD, eds. A radiologic atlas of abuse, torture, terrorism, and inflicted trauma (2003) with permission from CRC Press.

Fig. 48. Bilateral transverse fractures of the femora in a non-ambulatory child. Reprinted from Brogdon BG, Vogel H, McDowell JD, eds. A radiologic atlas of abuse, torture, terrorism, and inflicted trauma (2003) with permission from CRC Press.
Fig. 49. Transverse fracture of the tibial diaphysis with an associated plastic or bowing fracture of the fibula in an abused neonate.
Forensic Radiographs

Fig. 50. Evidence of serial injuries on a single radiograph. There is fairly mature periosteal new bone from a previous twisting injury to the femur (arrowheads) which now shows a new transverse fracture (arrows) through both the shaft of the femur and the pre-existing periosteal new bone. Reprinted from ref. 48 with permission from CC Thomas.

Fig. 50. Evidence of serial injuries on a single radiograph. There is fairly mature periosteal new bone from a previous twisting injury to the femur (arrowheads) which now shows a new transverse fracture (arrows) through both the shaft of the femur and the pre-existing periosteal new bone. Reprinted from ref. 48 with permission from CC Thomas.

Epiphyseal Injury

Fig. 51. Another example of multiple injuries. This 11-mo-old female from a communal house had 30% burns and multiple injuries. (A) The toes were completely destroyed by fire (arrow). (B) There was a healing fracture of the left distal femoral metaphysis (arrow). (C) An older healing fracture of the distal tibial metaphysis (arrow) with injury to the physis and metaphyseal cupping of the epiphyseal center. Reprinted from Brogdon BG, Vogel H, McDowell JD, eds. A radiologic atlas of abuse, torture, terrorism, and inflicted trauma (2003) with permission from CRC Press.

Fig. 51. Another example of multiple injuries. This 11-mo-old female from a communal house had 30% burns and multiple injuries. (A) The toes were completely destroyed by fire (arrow). (B) There was a healing fracture of the left distal femoral metaphysis (arrow). (C) An older healing fracture of the distal tibial metaphysis (arrow) with injury to the physis and metaphyseal cupping of the epiphyseal center. Reprinted from Brogdon BG, Vogel H, McDowell JD, eds. A radiologic atlas of abuse, torture, terrorism, and inflicted trauma (2003) with permission from CRC Press.

Forensic Radiology ImagesForensic RadiologyRadiology And Child Abuse
Fig. 52. "Toddler's fracture." A common result of normal activity in young children as they first learn to walk. The same fracture in a nonambulatory infant or child indicates probable child abuse.
Forensic Radiography
Fig. 53. Physiologic periosteal elevation and calcification in a 4-mo-old male. The bilateral symmetry and the single thin lamina of subperiosteal calcification is typical of this normal process. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Forensic Radiographs
Fig. 54. Thin, gracile, osteoporotic bone with healed fractures typical of osteogensis imperfecta.
Celery Stalk Rubella

Fig. 55. Intrauterine infection with rubella (German measles) produced these linear radi-olucencies in the metaphyses. This is sometimes called a "celery stalk" appearance. It is not specific for rubella; other intrauterine infections may produce a similar appearance. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 55. Intrauterine infection with rubella (German measles) produced these linear radi-olucencies in the metaphyses. This is sometimes called a "celery stalk" appearance. It is not specific for rubella; other intrauterine infections may produce a similar appearance. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fracture Zone Scurvy
Fig. 56. Typical rachetic appearance with softened osteomalacic bone with periosteal reaction, bending fractures, and widened, frayed metaphyses with absence of the zone of provisional calcification.
Periosteal Reaction Fracture

Fig. 57. Scurvy. A dense ringlike band surrounds the epiphyses (Winberger's sign). There are beak-like projections at the corners of the metaphyses (Pelken's sign). The zone of provisional calcification is dense and wide. On the shaft side of that is a zone of increased radiolucency (the scurvy zone) and another white line of trabecular fragmentation. The overall quality of the bone indicates osteoporosis. A subperiosteal hemorrhage may eventually form periosteal calcification (not shown).

Fig. 57. Scurvy. A dense ringlike band surrounds the epiphyses (Winberger's sign). There are beak-like projections at the corners of the metaphyses (Pelken's sign). The zone of provisional calcification is dense and wide. On the shaft side of that is a zone of increased radiolucency (the scurvy zone) and another white line of trabecular fragmentation. The overall quality of the bone indicates osteoporosis. A subperiosteal hemorrhage may eventually form periosteal calcification (not shown).

Menkes Radiologic Changes

Fig. 58. Menkes disease (kinky hair syndrome). Rachetic-like bone changes are related to copper deficiency in this degenerative disease, which is also characterized by mental and motor retardation, clonic seizures, and peculiarly kinky hair. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 58. Menkes disease (kinky hair syndrome). Rachetic-like bone changes are related to copper deficiency in this degenerative disease, which is also characterized by mental and motor retardation, clonic seizures, and peculiarly kinky hair. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Forensic Radiography
Fig. 59. Osteomyelitis. Involucrum (arrowheads) encloses the deformed and partially destroyed bone. Those particularly bright white areas of the bone are necrotic and represent sequestra. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Involucrum Radiology
Fig. 60. Tibial periostitis in a case of Caffey's disease. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Forensic Radiographs
Fig. 61. Leukemic bone changes in a child, characterized by rarifaction just beneath the zone of provisional calcification, as well as periostitis. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Congenital Syphilis Baby
Fig. 62. Congenital syphilis with periostitis and focal destructive lesions in the metaphysis.
Forensic Radiography
Fig. 63. Fracture of the talar neck in a young woman who had a head-on collision while driving an automobile. She believed she jammed her foot against the brake pedal.
Forensic Radiographs

Fig. 64. Extrusion of the talus in a man who was driving a beverage truck that became involved in a collision. The X-ray technologist noted a peculiar bulge in his sock and took the radiograph without removing it. It shows a nearly complete talus with perhaps a minor fragment remaining in situ. This was reported informally as a posterior extrusion. We have not been able to confirm this but believe it likely, because the Achilles tendon shadow is not observed on the radiograph. If so, this is the rarest form of talar extrusion. Reprinted from ref. 48 with permission from CC Thomas.

Fig. 64. Extrusion of the talus in a man who was driving a beverage truck that became involved in a collision. The X-ray technologist noted a peculiar bulge in his sock and took the radiograph without removing it. It shows a nearly complete talus with perhaps a minor fragment remaining in situ. This was reported informally as a posterior extrusion. We have not been able to confirm this but believe it likely, because the Achilles tendon shadow is not observed on the radiograph. If so, this is the rarest form of talar extrusion. Reprinted from ref. 48 with permission from CC Thomas.

Talus Fracture Radiology
Fig. 65. Anterolateral fracture/extrusion of the talus in a driver involved in a roll-over automobile accident. Anterolateral extrusion indicates supination and extension of the foot. Courtesy Jeremy Rich, DPM.
Anterior Extrusion The Talus
Fig. 66. Total absence of the talus, which was extruded anteromedially during a motorcycle accident. Courtesy Christopher Cenac, MD.
Forensic Radiography
Fig. 67. "Aviator's foot." Plantar invagination of the foot, with multiple fracture dislocations of the midfoot and hindfoot caused by impact with the rudder bar at the time of a crash that was the result of an inverted spin. Reprinted from ref. 54 with permission.
Forensic Radiographs
Fig. 68. This heavy flying boot was deformed by the rudder pedal at the time of a crash but protected the flyer from "aviator's foot."
Divergent Lisfrancs
Fig. 69. Divergent Lisfranc fracture/dislocation, with fractures and subluxation of the lateral rays away from the first metatarsal.
Complete Lisfranc Disruption Divergent
Fig. 70. "Bumper fracture." This pedestrian was struck from the right side by an automobile. The impact produced angulated fractures pointing away from the point of impact. The level of the fractures is consistent with the height of the bumper.
Bumper Fracture

Fig. 71. Close-up of the midshafts of the tibia and fibula of a victim of palmatoria. The anterior cortex of the tibia is thickened by periostitis and there are peculiar endosteal and intramedullary changes. Reprinted from Brogdon BG, Vogel H, McDowell JD, eds. A radiologic atlas of abuse, torture, terrorism, and inflicted trauma (2003) with permission from CRC Press.

Fig. 71. Close-up of the midshafts of the tibia and fibula of a victim of palmatoria. The anterior cortex of the tibia is thickened by periostitis and there are peculiar endosteal and intramedullary changes. Reprinted from Brogdon BG, Vogel H, McDowell JD, eds. A radiologic atlas of abuse, torture, terrorism, and inflicted trauma (2003) with permission from CRC Press.

Fig. 72. A young man was struck on the shin with a metal rod. He sustained a laceration that was irrigated and sutured. (A) A worrisome finding on the radiograph prompted his being recalled to the hospital, where the wound was reopened and explored to reveal an intact periosteum. (B) A CT scan revealed a cone-shaped endosteal fracture fragment beneath an intact, slightly dimpled outer cortex. Reprinted from ref. 58 with permission from the American Roentgen Ray Association.

Forensic Radiology
Fig. 72. Continued.

Fig. 73. Another young man struck on the shin with a metal rod. This presents findings identical to those in Fig. 72. A. Internal endosteal fracture fragment (arrow). B. Longitudinal reconstruction demonstrating the endosteal fragment (arrow). Courtesy of Daniel Vanel, MD. Reprinted from ref. 57 with permission from the American Roentgen Ray Society.

Forensic RaySindrome Canal Guyon Terapia

Fig. 74. Bilateral plantar edema and hematomas of the feet after falaca, as demonstrated by CT. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.

Forensic Radiology
Fig. 75. CT demonstrates chronic changes after falaca: splay- and flat-foot deformities due to relaxed ligaments and aponeurosis. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.
Calcaneous Fractures
Fig. 76. Multiple fractures of the calcaneous, sustained during falaca, now healed with residual deformity. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.
Forensic Ray

Fig. 77. "Knee capping." A. Photograph of a shotgun exit wound from a knee capping in Northern Ireland. B. Lateral radiograph of knee-capping wound just above the knee. Notice how the elastic skin contains many of the small shots. There is massive soft tissue and bony injury. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 77. "Knee capping." A. Photograph of a shotgun exit wound from a knee capping in Northern Ireland. B. Lateral radiograph of knee-capping wound just above the knee. Notice how the elastic skin contains many of the small shots. There is massive soft tissue and bony injury. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Forensic Radiology
Fig. 78. A lateral radiograph shows total destruction of the subtalar joint. The anterior half of the talus is missing. Bullet fragments remain in the area. "Knee capping" in another major joint. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.
Forensic Radiography

Fig. 79. APview of an ankle shot with a low-velocity bullet as a punitive injury. Bullet fragments remain near the medial and lateral malleoli. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.

Fig. 79. APview of an ankle shot with a low-velocity bullet as a punitive injury. Bullet fragments remain near the medial and lateral malleoli. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.

Gunshot Wound Elbow
Fig. 80. High-velocity gunshot wound just above the elbow, producing massive destruction of the distal humerus. This is another punishment gunshot of the "knee-capping" variety. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.

Fig. 81. Radiograph of several low-velocity bullets in profile shows a group of 9-mm bullets on the left; .45 caliber in the middle, and .38 caliber on the right. There is little difference in their size, and even with slight variation in magnification, the difference is very difficult, or impossible, to detect Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.

Barium Swallow Images Abnormal

Fig. 82. This person sustained a gunshot wound in the left flank, but radiography of the area disclosed no bullet. A. The bullet was found after it obstructed blood flow to the lower extremity by lodging in the superficial femoral artery. B. Lateral aortogram shows a pseudoaneurysm (arrows) on the posterior wall of the aorta where the bullet entered the arterial flow. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 82. This person sustained a gunshot wound in the left flank, but radiography of the area disclosed no bullet. A. The bullet was found after it obstructed blood flow to the lower extremity by lodging in the superficial femoral artery. B. Lateral aortogram shows a pseudoaneurysm (arrows) on the posterior wall of the aorta where the bullet entered the arterial flow. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Forensic Radiography

Fig. 83. A. A chest radiograph had revealed no bullet, but the autopsy showed a gunshot wound to the anterior surface of the heart (arrowheads). B. Radiographic search displayed the bullet in the left groin where dissection showed it to lie within the left femoral artery. Reprinted from ref. 65 with permission from the Radiological Society of North America.

Fig. 83. A. A chest radiograph had revealed no bullet, but the autopsy showed a gunshot wound to the anterior surface of the heart (arrowheads). B. Radiographic search displayed the bullet in the left groin where dissection showed it to lie within the left femoral artery. Reprinted from ref. 65 with permission from the Radiological Society of North America.

Forensic Radiology

Fig. 84. Radiograph of the shoulder shows a shattered upper humerus with scattered bone and lead fragments along the path of the bullet before it came to rest in the chest. Of interest is the less dense large piece of jacketing (arrowheads) lying next to the largest bullet fragment. This jacket fragment will contain valuable ballistic information. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 84. Radiograph of the shoulder shows a shattered upper humerus with scattered bone and lead fragments along the path of the bullet before it came to rest in the chest. Of interest is the less dense large piece of jacketing (arrowheads) lying next to the largest bullet fragment. This jacket fragment will contain valuable ballistic information. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Forensic Radiographs

Fig. 85. (A) A low-velocity gunshot wound through the femur shows a circular entry wound (arrowhead) with surrounding radial fractures. (B) The frontal view, somewhat enlarged, shows a small cloud of bone splinters extending into the soft tissues from the exit point of this fully jacketed bullet. Note that there are no metallic fragments. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.

Fig. 85. (A) A low-velocity gunshot wound through the femur shows a circular entry wound (arrowhead) with surrounding radial fractures. (B) The frontal view, somewhat enlarged, shows a small cloud of bone splinters extending into the soft tissues from the exit point of this fully jacketed bullet. Note that there are no metallic fragments. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.

Forensic RadiologyForensic Radiography
Fig. 86. A high-velocity jacketed bullet, fired from a military weapon, carried away almost the entire talus and a portion of the distal tibia, leaving no small bone or bullet fragments. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.
Forensic Radiology
Fig. 87. A lateral view of the thigh shows two "rubber" bullets embedded in the soft tissues. One can differentiate the halo of the rubber coating surrounding the metallic core of the projectile. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.
Fig. 88. This totally shattered femoral shaft was hit with a ceramic bullet, which disintegrated into the tiny bright fragments seen among the less dense bone fragments. Reprinted from ref. 42 with permission from ecomed verlagsgesellschaft mbH.
Table 3 Technique Chart

Region

Projection

Thickness, cm

mAs

kVp

Grid

Distance,

Hip

Frontal

15-20

40

76

Yes

40

21-25

60

76

26-31

100

80

Femur

Frontal

15-18

25

72

Yes

40

Lateral

14-17

25

70

Yes

40

Knee

Frontal

10-13

20

60-70

Yes

40

Lateral

9-12

20

62-66

Yes

40

Leg

Frontal

9-13

3

66-70

Yes

40

Lateral

8-12

3

62-66

Yes

40

Foot/Ankle

Frontal

5/8

3

60-62

No

40

Lateral

6-9

3

64-66

No

40

Note: For tissues filled with gas, or incinerated or dehydrated tissue decrease mAs by 30% or decrease kVp by 6-8 cm. Defleshed bones require mAs to be reduced by half and kVp to be reduced to 50 (non-grid). Modified from ref. 67, with permission from CRC Press.

Note: For tissues filled with gas, or incinerated or dehydrated tissue decrease mAs by 30% or decrease kVp by 6-8 cm. Defleshed bones require mAs to be reduced by half and kVp to be reduced to 50 (non-grid). Modified from ref. 67, with permission from CRC Press.

Forensic Radiology

Fig. 89. (A) Position for frontal radiograph of the hip. The central ray should be directed at the midpoint (X) of the line drawn from the pubic symphysis to the anterior superior iliac spine. (B) Resultant radiograph. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 89. (A) Position for frontal radiograph of the hip. The central ray should be directed at the midpoint (X) of the line drawn from the pubic symphysis to the anterior superior iliac spine. (B) Resultant radiograph. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Mri PositioningForensic Radiography
Fig. 90. (A) Position of the thigh, central beam, and cassette for a frontal view of the femur. (B) Resultant radiograph. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Pubic Symphysis RadiographForensic Radiography

Fig. 91. (A) Positioning for a lateral view of the thigh or knee. For the thigh, the central beam should enter at the X and the cassette, standing upright, should be moved farther toward the patient's head than shown here. The cassette is in the proper position for a lateral knee view, with the central beam entering at the site of the arrow. (B) Lateral radiograph of the femur. (C) Lateral radiograph of the knee. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 91. (A) Positioning for a lateral view of the thigh or knee. For the thigh, the central beam should enter at the X and the cassette, standing upright, should be moved farther toward the patient's head than shown here. The cassette is in the proper position for a lateral knee view, with the central beam entering at the site of the arrow. (B) Lateral radiograph of the femur. (C) Lateral radiograph of the knee. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Forensic Radiology
Fig. 92. (A) Positioning for frontal view of the knee. (B) Resultant radiograph. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Forensic Ray

Fig. 93. Position for a frontal view of the leg with the central beam entering at point X. (A) Frontal view of the ankle could be obtained by moving the central beam to the arrow and the cassette downward appropriately. (B) Frontal radiograph of the leg. Frontal view of the ankle (arrow) would be better demonstrated if the central beam were directly over it, as shown by the position of the arrow in (A). Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 93. Position for a frontal view of the leg with the central beam entering at point X. (A) Frontal view of the ankle could be obtained by moving the central beam to the arrow and the cassette downward appropriately. (B) Frontal radiograph of the leg. Frontal view of the ankle (arrow) would be better demonstrated if the central beam were directly over it, as shown by the position of the arrow in (A). Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Forensic RadiographsCross Table Lateral View
Fig. 94. (A) Positioning for a cross-table lateral view of the leg against an upright cassette with the central beam entering at point X. (B) Resultant radiograph shows a comminuted fracture of the proximal tibia. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Forensic Radiography
Fig. 95. (A) Positioning for frontal view of the foot. (B) Resultant radiograph. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.
Radiology And Forensic Science PicsCross Table Lateral

Fig. 96. (A) Positioning for cross-table lateral view of the foot or ankle with the cassette held vertically. The central ray is directed at the mid-tarsal area (X) for optimal visualization of the foot. For optimal visualization of the lateral ankle, the central ray should be directed at the lateral malleolus (arrow). (B). Lateral radiograph of the foot, showing a tarsal navicular fracture/dislocation. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Fig. 96. (A) Positioning for cross-table lateral view of the foot or ankle with the cassette held vertically. The central ray is directed at the mid-tarsal area (X) for optimal visualization of the foot. For optimal visualization of the lateral ankle, the central ray should be directed at the lateral malleolus (arrow). (B). Lateral radiograph of the foot, showing a tarsal navicular fracture/dislocation. Reprinted from Brogdon, BG, Forensic radiology (1998) with permission from CRC Press.

Forensic Radiology
Fig. 96. Continued.

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