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Diagnostic imaging plays a key role in the evaluation of non-accidental consequences of injuries in childhood. Fractures are the second most common consequence of child abuse, after skin lesions such as abrasions or bleeding. With the evidence of radiological criteria, non-accidental fractures can be differentiated from accidental fractures. Special types of fractures such as the classic metaphyseal lesion can only be differentiated if the image quality is high.The goal of this prospective study was to assess adherence to guidelines and quality assurance of radiological diagnostics in the event of suspected abuse in Germany. For this purpose, the quantity and diagnostic quality in university and non-university hospitals as well as the existence of a pediatric radiology department were analyzed.In all, 958 X‑ray examinations of 114 suspected abuse cases (46 girls, 68 boys) were evaluated; 42 cases from university, 42 from maximum care and 30 from regular care clinics with a median age of 6 months (3 weeks-3 years of age) were assessed as DICOM data by 3 pediatric radiologists in a consensus procedure with regard to adherence to guidelines and various quality parameters. An accompanying questionnaire was used to compare the theoretical knowledge with the respective practical implementation.A mean of 8.4 X‑rays (range 1-22) were made per case. In 12 of 114 assessed cases (10%) there was a complete skeletal status according to the S1 guideline. A babygram was performed in 13 cases (10.5%). Departments with focus on pediatric radiology produced significantly more X‑rays per skeletal status than facilities without this specialization (p 0.04). Significantly higher qualitative implementation was recorded in university hospitals (p 0.001). Regardless of the type of institution, there was only marginal agreement between the questionnaire response and the available image material.In Germany, a guideline-compliant procedure in the event of suspected child abuse is largely lacking. It remains to be seen whether this will change in the future with the broader implementation of child protection groups and the S3+ child protection guideline adopted in 2019 (AWMF register 027-069). The establishment of reference centers for a second diagnosis and recommendations for imaging technology can also improve the quality of care over the long term.HINTERGRUND: Die bildgebende Diagnostik nimmt in der Evaluation nichtakzidentieller Verletzungsfolgen im Kindesalter eine Schlüsselrolle ein. Frakturen sind nach Hautläsionen wie Abschürfungen oder Hämatomen die zweithäufigste Folge körperlicher Kindesmisshandlung. Mit Hilfe radiologischer Kriterien können nichtakzidentielle von akzidentiellen Frakturen differenziert werden. Spezielle Frakturtypen wie die klassische metaphysäre Läsion können nur bei hoher Bildqualität differenziert werden.In einer prospektiven Analyse sollten Leitlinientreue und Qualitätssicherung der radiologischen Diagnostik bei Misshandlungsverdacht in Deutschland erfasst werden. Dazu wurden Quantität und diagnostische Qualität in der universitären und nichtuniversitären Versorgung sowie in Abhängigkeit einer vorhandenen kinderradiologischen Fachabteilung analysiert.Es wurden 958 Röntgenuntersuchungen von 114 vermuteten Misshandlungsfällen (46 Mädchen, 68 Jungen) bewertet. Insgesamt 42 Fälle aus universitären, 42 aus maximalversorgenden und 30 aus regelversorgenden Kliniken mit einem medianen Alter von 6 Monaten (3 Wochen – 3. Lebensjahr) wurden als DICOM-Daten von 3 Kinderradiologen im Konsensverfahren hinsichtlich Leitlinientreue und verschiedener Qualitätsparameter beurteilt. Ein Begleitfragebogen sollte die theoretischen Kenntnisse mit der jeweiligen praktischen Umsetzung vergleichen.Je Fall wurden im Mittel 8,4 Röntgenaufnahmen (1–22) angefertigt. In 12 von 114 beurteilten Fällen (10 %) lag ein vollständiger Skelettstatus nach S1-Leitlinie GPR vor. In 13 Fällen (10,5 %) wurde ein Babygramm durchgeführt. Abteilungen mit kinderradiologischem Schwerpunkt fertigten signifikant mehr Röntgenaufnahmen je Skelettstatus an als Einrichtungen ohne Schwerpunkt (p 0,05). Eine signifikant höhere qualitative Umsetzung wurde in Universitätskliniken verzeichnet (p 0,001). Eine Übereinstimmung von Fragebogenantwort und vorliegendem Bildmaterial zeigte sich unabhängig der Institutionsart nur marginal.In Deutschland fehlt bislang mehrheitlich ein leitliniengerechtes Vorgehen bei Misshandlungsverdacht. Es bleibt abzuwarten, ob sich dies mit der breiteren Implementierung von Kinderschutzgruppen und der 2019 verabschiedeten S3-Kinderschutzleitlinie (AWMF-Registrierungsnummer: 027-069) zukünftig ändern wird. Die Etablierung von Referenzzentren für Zweitbefundung und Empfehlungen zur Aufnahmetechnik können zusätzlich die Versorgungsqualität nachhaltig verbessern.

ZusammenfassungIn der Notaufnahme wurde ein 14 Monate alter Säugling mit einer lividen Schwellung des Penis vorgestellt, die wie ein Hämatom imponierte. Da die anamnestischen Angaben keine plausible Erklärung für einen möglichen Unfallhergang lieferten, bestand zunächst der Verdacht auf eine nichtakzidentelle Verletzung. Auch die Sozialanamnese bot Hinweise in diese Richtung.Als Ursache der Schwellung und Verfärbung stellte sich dann eine Penisphlegmone heraus, die mittels i.v.-antibiotischer Therapie rasch erfolgreich behandelt werden konnte.

Rechtsmedizin : Organ der Deutschen Gesellschaft für Rechtsmedizin 31(5), 457-462 (2021). doi:10.1007/s00194-021-00460-1 special issue: "COVID-19", Published by Springer, Berlin ; Heidelberg

This paper describes the variety of information that a tool mark analysis on human tissue can provide based on a case of multiple sharp violence. The perpetrator attacked the victim with a sharp-edged weapon against the head, leaving several deep wounds on the back of the skull bone. Three of those marks on the skull bone could be used for a forensic tool mark examination. Silicone casts of the marks were compared by light microscopy with casts of test marks of Japanese katana swords found at the crime scene. One of the swords could be identified as the one responsible for the marks. In addition, the marks and the test marks were scanned in 3D and examined in a visual on-screen comparison confirming the results from the light microscopic examination. Furthermore, a mathematical approach in which the signatures of the marks from the skull bone and the test marks from the sword were compared by cross correlation confirms those findings. In addition, the aforementioned results were used to determine the orientation of the sword in relation to the cranial bone at the time of the respective impact.

Various parameters can be used for the estimation of gestational age and maturity with arising challenges in the assessment of decomposed bodies. In order to assess gestational age and thus maturity, the study measured the femoral length, the diameter of the distal femoral epiphysis and the presence of the proximal tibial epiphysis compared to a known clavicle length. The resulting gestational ages were compared and statistically evaluated. As a result, discrepancies between the estimated gestational ages became apparent in some cases when comparing the individual structures to be measured. However, there was a clear tendency towards a lower gestational age calculated based on clavicle length and a higher gestational age calculated based on femoral length and distal femoral epiphysis. With regard to the assessment of maturity, it has been concluded that, if the proximal tibial epiphysis is present, maturity can also be assumed based on the diameter of the distal femoral epiphysis and the length of the femur.

Signs of maturity such as weight, length and head circumference are still a measure used to investigate cases of suspected neonaticides as they help to differentiate between newborns born dead or alive. However, limit values for these signs have not changed for a long time. Our study considers whether limit values should have changed and which validity the current ones have. We investigated the cases of 3162 newborns, dividing them into a mature and an immature collective on the basis of the gestational week. Application of these signs of maturity (2500 g, 48 cm, 34 cm) had a high predictive value concerning maturity (>99%), and even applying only one sign of maturity gave a predictive value over 97%. Clinically the mature collective showed a slightly lower rate of ventilation (2% compared to 2.4% for the non-mature collective). Coherences between maternal age/weight and postnatal ventilation could be shown. Coherences with reanimation could not be investigated since the case number was too low. Our results show that, for valid forensic investigation, these numeric signs of maturity have to be supplemented by further investigations and other influencing factors have to be considered. Therefore, clinical instruments such as the Petrussa-Index, clavicule length measuring and foot length measuring must be considered.

Accidents constitute one of the greatest risks to children, yet there are few medical reports that discuss the subject of accidental asphyxia. However, a systematic analysis of all documented cases in Germany over the years 2000-2008 has now been conducted, aiming at identifying patterns of accidental asphyxia, deducing findings, defining avoidance measures and recommending ways of increasing product safety and taking possible precautions. The analysis is based on a detailed retrospective analysis of all 91 relevant autopsy reports from 24 different German forensic institutes. A variety of demographic and morphological data was systematically collected and analysed. In 84 of the 91 cases, the sex of the victim was reported, resulting in a total of 57 boys (68 %) and 27 girls (32 %). The age spread ranged between 1 day and 14 years, with an average of 5.9 years. Most accidents occurred in the first year of life (20 %) or between the ages of 1 and 2 years (13 %). In 46 % of cases, the cause of death was strangulation, with the majority occurring in the home environment. In 31 % of all cases, the cause of death was positional asphyxia, the majority resulting from chest compression. In 23 % of cases, the cause of death was aspiration, mainly of foreign bodies. Today, accidental asphyxiation is a rare cause of death in children in Germany. Nevertheless, the majority of cases could have been avoided. Future incidence can be reduced by implementing two major precautions: increasing product safety and educating parents of potentially fatal risks. Specific recommendations relate to children's beds, toys and food.

Background: Female genital mutilation (FGM) occurs mainly in Africa, parts of the Arabian Peninsula and parts of Asia. It is commonly associated with acute complications as well as diverse late/delayed complications. One of the most common of these late complications is progressively enlarging painless cysts of the vulva. Case Report: An 8-year-old girl from Eritrea presented to our paediatric emergency department with a progressively enlarging mass of the vulva. She had undergone a clitoridectomy and partial removal of the labia minora as an infant in Eritrea. We performed surgical excision of the cyst and reconstruction of the labia. Histology showed a traumatic squamous epithelial inclusion cyst of the vulva. Conclusion: Epithelial or dermoid cysts of the vulva following FGM are extremely rare. Symptoms often require surgical intervention. Through increasing migration, more girls and female youths with FGM are likely to present to practices and hospitals in Germany. Thus increased knowledge and awareness of the medical complications of FGM and their treatment will be necessary in years to come.

Due to the suspicion of a gynaecologist, a pathologist was suspected of incorrect diagnoses in cases of breast cancer and the interchanging of tissue samples. Many women applied to the attorney’s bureau to clarify the reproaches. The privately owned laboratory for pathology was searched and 926 histological slides, roughly the same number of paraffin blocks and about 20 formalin fixed tissue samples were confiscated. Together with other confiscated material, at least 1236 histological slides and additional 249 paraffin blocks had to be sorted. Histological slides and paraffin blocks were matched with patients as far as possible following the laboratory book. Many of the warranted samples which were diagnosed as containing the carcinoma by the pathologist were missing. A total of 160 samples were chosen and rediagnosed by two independent pathologists. The formalin fixed tissue was negative for DNA most likely due to storage in formalin for years. Most of the histological slides were positive for DNA. On the whole, 18 expertises about histological findings and the DNA results were given. In some cases only DNA results could be presented, as previous experts had only performed DNA examinations without controlling the histological diagnosis. In six cases a carcinoma could be confirmed and the DNA profile matched with patient’s DNA; in seven cases a carcinoma was confirmed without match with the patient; in two cases the carcinoma could not be confirmed in the presented samples. A jurisdictional solution was impossible because the accused pathologist died during the investigation. In conclusion, it must be stated that a DNA examination of histological slides should never be performed without a rediagnosis of an independent pathologist and photographic documentation of the findings. Whenever possible, material should be left on the slide.

The work of specialists in forensic medicine in those cases of child abuse that result in the killing of a child is defined and well known. It is less well defined in cases of (suspected) sexual abuse. The cases presented show the difficulties that arise if medical doctors and prosecutors are uncertain about the procedures that have to be followed or do not appreciate the value of objective findings. It is concluded that knowledge about necessary examinations by physicians, police officers and prosecutors has to be promoted in order to improve handling and (legal) outcome of these cases.

A homicide by smothering may leave unobtrusive or even no injuries if the victim is not able to struggle. This is especially true for infants up to 12 months of age. The differentiation between the sudden infant death syndrome and smothering, by an autopsy alone may be impossible. To establish whether this is different in older children because of their rising capacity for defence six cases of smothering in children >1 year of age were re-examined. The age of the children ranged between 1.5 and 7 years (surviving child). The smothering was inflicted with hands in three cases (including the surviving child), with a pillow in two cases, and the way of smothering remained unknown in one case (no confession of the perpetrator). Depending on the tool used for smothering, abrasions on the facial skin (hands, lesser in cases of smothering by a pillow) and petechiae (pillow/hands) could be seen by external examination. The older the children were, the more injuries could be found. Together with circumstantial evidence all cases could have been established by a thorough autopsy. This is important to prevent further offences against (surviving) siblings.