Computed Tomography (CT Scan)-A superior Tool to Locate the Foreign Bodies and Tissue Injuries in Cases of Firearm

Injuries
Sachin S. Sonawane1, Shailesh C. Mohite2, Sushim A. Waghmare3, Rajesh Kharat4, Pawan Sabale 5
1 4,,5

Assistant Professor, Dept. of Forensic Medicine, 2Professor and Head, Dept. of Forensic Medicine, 3Resident, Dept. of Forensic Medicine, Assistant Professor, Dept. of Forensic Medicine, T.N. Medical College & B. Y. L. Nair Ch. Hospital, Mumbai

Abstract
The present study was conducted at Dept. of Forensic Medicine TNMC, Mumbai during the recent terror attack on Mumbai (26th Nov. 2008). 20 autopsies of firearm victims were conducted after whole body CT scan. Plain CT scan of all victims was imaged prior to autopsy by Siemens somatom spiral multidetector 4 slice CT- scanner. The coronal and saggital images of whole body were taken for detection of any hyperdense foreign bodies. Images were evaluated to determine the location of foreign bodies (bullet / pellet/any other metallic objects ) in the body along with defect (any fracture) in bone. Digital photographs were taken of the external appearances of the body, gunshot entry and exit wounds, dissected gunshot wound tracks,injuries to the internal organs and intact bullets / metal fragments recovered. The average time required for doing each CT scan was 10 minutes. Out of 20 autopsies , in 7 cases foreign bodies (bullet/pellets) were detected. In 13 cases foreign bodies were not detected.

Key Words
CT scan, gunshot injuries, bullets.

Introduction
One of the objectives of medico legal autopsy in fire arm cases is to collect evidence in order to identify the projectile causing death. Radiography is a valuable tool in the forensic investigation of gunshot wounds and is universally used for, 1. Localization of foreign bodies or metallic fragments particularly in head, face and neck region where it is difficult to retrive the projectile. 2. Identification of the type of ammunition. 3. To assist the retrieval of the bullet. 4. Documentation of fractures during autopsy. 5. Determining Bullet/Projectile Path [Track] and Direction. Moreover, recovery of the bullet jacket is important in forensic investigations because the jacket contains unique rifling characteristics that enable ballistics experts to identify the weapon from which the bullet was fired. Occasionally autopsy surgeon may face difficulty in locating and retrieving the objects present inside the body especially in cases of deaths due to firearm injuries. This is because, 1. Projectiles after piercing the skin may change their pathway due to internal ricocheting and may be lodged anywhere inside the body. 2. During medical intervention or while shifting the body to mortuary, the projectile may also shift their position inside the body. Knowing the exact location of the bullet will save valuable time of autopsy surgeon and also avoids tedious efforts in searching for bullets that are inaccessible. Traditional 2D radiography (X- rays) is taken in firearm injuries but sometimes the soft tissues having small density differences cannot be differentiated and also structures in 3-dimensional space tend to overlap.1 Our study assessed autopsy performed after whole body CT scan for the forensic evaluation of firearm wound victims. CT was discovered by a Sir Godfrey Hounsfield and Dr. Alan

Cormack, and for the first time was installed in 1970. It has become a mainstay for diagnosing medical diseases. Its advances based on computer technology, CT scanners have improved patient comfort. Nowadays they are much faster and have also possibility to produce higher-resolution images, which improve the diagnostic capabilities of the test. These images allow the radiologist to look at the inside of the human without slicing it mechanically.2 Computed tomography (CT) was, foregoing, used in medical application mainly as a method for diagnostic evaluation to retrench health condition of certain tissue. Assumption of higher leverage of CT images was generated recently, mainly in healing of patients in the way that CT data were used as a database for computational visualization and production of models and medical apparatus. One of application of CT scanned data is for determination of tissue destruction dimension, which is of high interest during the consideration of characteristics and mechanism of appearance of a gunshot wound. 3 The use of CT in Forensic Post-Mortem Diagnostic started about fifteen years ago. Many cases, for example gunshot injuries, head injuries, detection of foreign bodies as well as gas embolism have been published in this time. The first comprehensive studies of comparison between autopsy and Post-Mortem CT where made in 1994 by Donchin et al. 4, 5

Material and Methods

The present study was conducted at Dept. of Forensic Medicine TNMC, Mumbai after the recent terror attack on Mumbai (26th Nov. 2008) 20 autopsies of firearm victims were done after whole body CT scan. Plain CT scan of all victims was imaged prior to autopsy by Siemens somatom spiral multidetector 4 slice CT- scanner. The coronal and saggital images of whole body were taken for any detection of hyperdense foreign bodies. All victims were scanned with one mm section thickness (32 x 5 mm) with rotation speed of 0.5 second. Images were evaluated to determine the location of foreign bodies (bullet or pellet) in the body along with defect (any fracture) in bone. Digital photographs were taken of the external appearances of the body, gunshot entry and exit wounds, dissected gunshot wound tracks, internal organ injuries, and intact bullets, metal fragments recovered. Complete dissection of the intracranial contents, neck, chest, abdomen, and pelvis was performed in each case. All metallic fragments (bullet and metal pieces) associated with major wounds were documented and removed for evidence collection.

Observations & Results

The scan time was short and ranged from 4 to 10 minutes. The time required for locating bullets was short and ranged from 2 to 4 minutes. The determination of entrance and exit wounds is possible based on the characteristic fracture pattern with inward or outward beveling of the bone respectively. In 7 victims, foreign bodies were detected. In 13 victims foreign bodies were not detected. CT Plate No 1. Showing bullet present above patella of left knee joint

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Discussion
The study was prospective and performed under realistic routine conditions. This study provides an overview of the experience gained during whole body CT- scan of 20 victims before a traditional forensic autopsy. CT- scan is a quick method-a whole body scan takes 10 minutes while X- rays requires at least 1hour. It provides documentation in digital form. Advantages of ct scan over traditional radiography 1. CT scan completely eliminates the superimposition of images of structures outside the area of interest. 2. It detects small density differences in the various soft tissues.2 3. It provides multiple views with higher resolution than plain film radiography. 4. The time required for obtaining images of CT scan is much lesser than traditional radiograph. 5. The time required for retrieving bullet is also less as compared to traditional radiograph. 6. CT scan gives clear idea about exact location of bullets in relation to soft tissue and organs. 7. There is no need to change position of body for different views. 8. Artefacts like breakage of rigor mortis can be prevented.5 9. There is no need of repeating the scan 10. Digital view is obtained directly. 11. It is very useful in instances of mass disasters where large numbers of bodies are to be handed over rapidly. 12. Limited human resources are required. 13. Multiple films of X- ray need not to be preserved.

1. Saggital plane image

2. coronal plane image

Conclusions
In the present prospective study, the CT scans were done before the PM which was found to be very useful in firearm cases. CT scans determined defects in bones in the areas which were not easily approachable on direct examination. CT scan provides documentation in digital form, permits review by others and provides pictures that were more suitable for presentation in court than conventional X ray photos. In cases of multiple firearm injuries it requires multiple radiographs/plates (at least 15-20), however there is no need to take multiple CT scan images only single CT scan image /plate is sufficient. We can take two plane images (coronal and saggital) in single CT plate and no need to change the position of body during scan. So, now Computed tomography should be considered as an integral part of the postmortem examination process wherever such resources are available.

CT Plate No.2. Showing a bullet was present in between 2th and 3th right side intercostals space.

1. Coronal plane image

2. Saggital plane image

References
1. Peter Mygind Leth. Computerized Tomography used as a routine procedure at postmortem investigation. Am J Forensic Med Pathol. 2009; 30 (3):219-222. uro ari , Antun Stoi , Mirjana Luci Application of computed tomography in human body Injuries 10th international scientific conference on production engineering Lumbarda, Korula, 2005 Poulsen K, Simonsen J. Computed tomography as routine in connection with medico-legal autopsies. Forensic Sci. Int. 2007;171:190-197. Thali M. J.,Yen K, Schweitzer W, Virtopsy, a new imaging horizon in forensic pathology:virtual autopsy by postmortem multislice computed tomography(MSCT) and magnetic resonance imaging (MRI)- a feasibility study. Journal of Forensic Sci. 2003;48:386403. Michael J. Thali , Christian Jackowski, Lars Oesterhelweg VIRTOPSY The Swiss virtual autopsy approach. Legal Medicine 9 , (2007) , 100104

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CT plate No 3. Showing a bullet was present in right inguinal region

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