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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.

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.

From time to time, severe or fatal injuries caused by small caliber air rifle projectiles are seen. In forensic sciences, the theoretical wounding potential of these weapons and projectiles is widely known. Usually, shots against the skull were reported and, in these cases, penetrating the eyes or thin bone layers of the temporal region. Amongst a huge number of different projectiles available for air guns, sub-caliber 4.4-mm (.173) caliber steel ball projectiles were used in an unusual suicide case. This case led to fundamental questions concerning wound ballistics. An 82-year-old man shot once against his right temporal region and twice into his mouth with a 4.5-mm (.177) caliber air rifle. Because of the exceptionally deep penetration of the base of the skull and the use of spherical-shaped sub-caliber air rifle projectiles, terminal ballistic features were analyzed and compared to results published in forensic literature. Test shots using the same weapon and similar projectiles were fired into ballistic gelatin to measure and calculate basic wound ballistic variables of cal. 4.4-mm (.173) steel balls. In comparison, further test shots with cal. 4.5-mm (.177) steel balls BB (ball bearing), flat-headed and pointed air rifle pellets ("diabolos") were carried out. The theoretical penetration depth in solid bone was calculated with 36.4 mm, and test shots in gelatin from hard contact produced an on-average wound track of 120 mm underlining the potential wounding effect. Furthermore, spherical projectiles could roll back and forth within the barrel, and an air cushion between projectile and breechblock can reduce muzzle velocity by more than half, explaining the retained missile in the temporal region.

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.

Two captive tiger attacks are presented that took place in Cologne and Münster zoos. Both attacks occurred when the handlers, intent on cleaning the enclosures, entered whilst the tigers accidently retained access to the location, and thus defended their territory against the perceived intruders. Both victims suffered fatal neck injuries from the bites. At Münster, colleagues managed to lure the tiger away from its victim to enable treatment, whilst the Cologne zoo tiger had to be shot in order to allow access to be gained. Whilst it was judged that human error led to the deaths of the experienced zookeepers, the investigation in Münster was closed as no third party was found to be at fault, whereas the Cologne zoo director was initially charged with being negligent. These charges were subsequently dismissed as safety regulations were found to be up to date.

In cooperation with the Crime Investigation Agency (Landeskriminalamt) of North Rhine-Westphalia, we carried out a study of 150 cases of (suspected) neonaticide dating from 1993 to 2007 from all over Germany. The autopsy reports and additional expert opinions (if performed) were evaluated for a minimum of 78 variables. Emphasis was placed on the application of special preparation techniques and other special questions arising during the examination of a deceased newborn child. Forty-five percent of the cases remained unsolved, which means that the mother could not be identified. Twenty-seven percent of the corpses were in a state of such severe putrefaction that forensic examination was limited. The main causes of death were all forms of suffocation. The signs of maturity (such as length, weight, and fingernails) were recorded in more than 95 % of the cases. Hydrostatic test of the lung was performed in 96 %, and that of the gastrointestinal tract in 84 %. Given the results of the study, standard protocols and checklists are recommended to facilitate comparability and to ensure the completeness of findings. Full-body X-rays or CT scans should be used to complete viability examinations.

If a case of physical child abuse is suspected in Germany, the general feeling is often that "it does not matter whether you make a report or not" because, generally, no conviction is made anyway. This study investigates the juridical analysis of complaint cases of physical child abuse [criminal complaint parag. 225 StGB (German penal code) with filial victim]. It focuses on the doctor's role and the impact of their practice in relation to a later conviction. It is based on the analysis of 302 files of the enquiry from 2004-2009 from the department of public prosecution in Cologne, Germany. Besides general epidemiological data on the reporting person, the affected child and the presumed offender, the documents were reassessed for the relevance of medical reports for successful convictions. Only 7% (n = 21) of 302 complaints led to a conviction. In 38.1% (n = 8) of those cases, a medical report was mentioned as a piece of evidence, and just in two cases a (legal) medical report was quoted and mentioned as relevant for the conviction. 50% of the complaint cases with legal medical expertise led to a trial. In contrast, only 30.2% with a common medical report and 7.3% without a report led to a trial. The results show how a medical report existed in only a few cases. In those cases, the rate of performed trials was higher than for those without a medical report, but the report played a minor part when reasoning a verdict.

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.

In cases of suspected neonaticide, the results of a forensic autopsy might be important for conviction or acquittal. But autopsy findings in dead newborns are often unspecific and can rarely provide corroborative evidence of inflicted injury, as they are known to occur during normal birth as well. In our study, we examined 59 vaginally delivered, healthy newborns within the first 30 min after birth to know more about the prevalence and possible correlations of a caput succedaneum and facial petechiae. Caput succedaneum occurred in 33.9%, facial petechiae in 20.3%. As for the occurrence of caput succedaneum, statistically significant differences could be shown for the duration of delivery and the mother's parity. These correlations could not be shown for the occurrence of facial petechiae. Within the scope of our study, we could demonstrate that neither caput succedaneum nor facial petechiae are rare findings in healthy newborns. In the forensic investigation of suspected neonaticide, their potential significance can only be ascertained together with further investigations of the circumstances of death and a thorough forensic pathological autopsy.

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.

We report a case of a 19-year-old woman who developed a persistent uterine hemorrhage after spontaneous delivery of a healthy child. Emergency laparotomy was indicated and then begun under stable circulatory conditions. Cardiac arrest occurred during the course of massive manual compression and packing of the uterus. After successful resuscitation, a supracervical hysterectomy was performed. During the suturing of the remaining cervix, a second cardiac arrest followed. The procedure was completed under constant external heart massage. Resuscitation was terminated due to the persistence of widened pupils. An autopsy was ordered by the public prosecutor as the manner of death was declared to be unascertained. An X-ray and a CT scan prior to the autopsy showed extensive gas embolism in both arterial and venous vessels extending from the pelvic region to the head. During the autopsy, gas was collected by aspirometer from the right ventricle of the heart. The autopsy showed no additional relevant findings, and gas analysis confirmed the suspicion of air embolism. The histological examination of the excised uterus especially in the corpus/fundus revealed an edema of the local smooth muscle cells and dilated vessels showing no sign of thrombogenesis. Upon evaluation of the clinical records, it became evident that, in addition to uterine atony, there had been a complete uterine inversion. This inversion was manually repositioned. After this maneuver, manual compression was performed. The air embolism, thus, was a complication of the manual repositioning of the uterine inversion. There is no evidence for other possible entries of the detected gas. In order to perform an effective exploration, the availability of all clinical records should be mandatory for medico-legal investigations of unexpected postpartum deaths.

In cases of child abuse, usually, the parents are initial suspects. A common explanation of the parents is that the injuries were caused by a sibling. Child-on-child violence is reported to be very rare in children less than 5 years of age, and thorough investigation by the police, child protective services, and medicolegal examinations are needed to proof or disproof the parents' statement. We report two cases of physical abuse of infants by small children.

The use of stained histological sections as a source for DNA may be necessary in forensic case work if confusion of tissue is suspected, for identification or paternity cases. To elucidate the influence of different staining techniques on the PCR amplification of DNA, histological sections of liver tissue were prepared using eight different staining techniques and two histochemical methods. The DNA of the sections was extracted by a modified Chelex extraction and amplified using a commercial triplex kit. Staining with hematoxylin-eosin, hemalum-eosin, azan, periodic acid-schiff and prussian blue showed no adverse effect on the amplification of DNA while the extracts of tissue stained by Masson-Goldner, Ladewig and elastica-van Gieson methods had to be purified before amplification was possible. Staining with phosphoric tungsten acid hematoxylin and Gomori led to a degradation of DNA probably due to the use of potassium permanganate solution.

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.

Compared to the total number of deaths by heat (burning, scalding), homicides by the direct effect of thermal energy (setting the victim on fire, pouring hot liquids over them) are rare; accordingly this subject is seldom dealt with in forensic and criminological literature. From our own autopsy material three cases are presented describing some peculiarities of homicide by heat. Sometimes additional findings (e.g., residual traces of gagging or tying) primarily point in the direction of homicide.

A combination of 4 so-called markers of alcoholism, i.e. methanol, acetone + 2-propanol, gamma-glutamyltransferase and carbohydrate deficient transferrin, was investigated in 341 blood samples from alcoholics and non-alcoholics. From the history of alcohol consumption, four defined subgroups were formed: non-alcoholics divided into (A) 33 persons with no ethanol consumption during the past year and (B) 60 persons with daily consumption less than 40 g ethanol. Alcoholics were divided into (C) 177 persons with no ethanol at the time of admission/first blood sampling (withdrawal therapy) and (D) 71 persons with positive ethanol levels on admission/first blood sampling. All markers showed different extents of overlap between the collectives of alcoholics and non-alcoholics. By logistic regression, a formula was developed combining these markers with different mathematical weights. Thus an "Alc-Index" could be calculated for each individual. The ROC curve connecting all individual values gives an ideal form with 100% specificity and nearly 93% sensitivity. The threshold between the collectives of alcoholics and non-alcoholics was defined by the Alc-Index value 1.7. This was associated with no false positives among the non-alcoholics while nearly 93% of the alcoholics exceeded this index. The ROC-based calculation of the Alc-Index thus seems to be the most effective method for the diagnosis of alcoholism.

2016 coroner's crematorial inquests of the Bonn Institute of Legal Medicine over a 3 years' period were evaluated and the statements in the death certificates were compared to those ones of the Statistical Country Office of Northrhine-Westphalia. No significant differences were found with respect to age, gender and reason of death. However, the number of insufficiently classified deaths with respect to the reason of death were overrepresented especially in cases of older women, while the number of unnatural deaths was generally underrepresented. According to legal medical criteria 2 1/4 per cent of the deaths were falsely classified as natural. Only in 2 cases an autopsy was accomplished. Other author's statements on the validity of death certificates were confirmed.

If the order to carry out an autopsy has been neglected, exhumation is the only possibility to obtain findings which allow conclusions on the manner of death, cause of death and chain of events. The quality of findings will however be influenced by advanced states of putrifaction. In spite of identical legislature the number of exhumations carried out at the institutes of legal medicine in München and Münster differs considerably, as demonstrated by a comparison of the data from the years 1993-1996. As previously described by other authors, there is a reciprocal correlation between the number of autopsies and the exhumation rate. The frequency of autopsies which are ordered can be explained by the varying application of the statutory framework by the investigation procedure. In some cases where an exhumation has been carried out, it was difficult to comprehend why an autopsy was not originally ordered.

The use of saliva samples is an alternative to blood samples when a large number of control samples are to be compared by DNA investigations. The most convenient and safe method is by using cotton wool swabs. In this investigation the average DNA content of saliva samples taken by three different sampling techniques (i. e. cotton wool swab, filter paper, liquid saliva) was compared. In addition the possibility of a DNA mixture of saliva samples after intensive kissing was investigated by taking samples from voluntary pairs. Mixed STR patterns were found in five samples but restricted to the first sampling after kissing within max. 60 s.

When there is a possibility that tissue samples have been interchanged, DNA analysis of the histological specimens can be carried out to correctly assign the specimens to a patient. The use of polymerase chain reaction enables results to be obtained even from degraded DNA in formalin-fixed and paraffin-embedded samples.

A case of physical activity following a suicidal gunshot to the head including perforation of the left frontal lobe from a .22 rimfire rifle is reported. Subsequently, the man was able to walk a distance of more than 100 m and to reload manually. The special wound ballistic features of the head leading to increased intracranial projectile effects are discussed and the morphological changes such as cortical contusion zones, intracerebral hemorrhages or indirect skull fractures are explained. The analysis of 38 cases of head shots followed by physical activity reveals that injury to certain CNS-areas or the use of centre fire rifles and large handguns usually excludes a potential for subsequent physical activity. But physical activity is possible if the trajectory is restricted to the frontal brain or one temporal lobe only and if a projectile of low wounding potential has been used for this gunshot.

A case of extended suicide resulted in two fatalities due to craniocerebral gunshots from a 12-gauge shotgun firing Brenneke shotgun slugs. In each case, the gunshot shattered the skull and the brain and in one case, large parts of the brain including a complete hemisphere were ejected similar to a “Kronlein shot”. The location of the trajectory close to the base of the skull, the muzzle gases and the ballistic characteristics of the missile contributed to this rare form of head injury. The high mass and the large diameter of the lead missile do not necessitate a high muzzle velocity to crush large amounts of tissue or to produce an explosive type of head injury. The wadding material and the metal screw attached to the Brenneke slug can be of forensic significance.

In addition to metastases, the differential diagnosis of pulmonary nodules also includes tuberculosis, sarcoidosis, and silicosis. Rarer diseases such as amyloid tumors, rheumatic nodules, and plasma-cell granulomas can, depending on the clinical situation, be the cause of this finding. For the example of the clinical picture of pulmonary hyalinizing granuloma, the differential diagnosis of multiple pulmonary nodules is illustrated under consideration of the pathognomonic, morphologic observations.