Different types of torture can lead to different clinical features which can vary with duration, frequency, intensity, underlying medical conditions etc. With each sign or symptom, the HCP should be able to assess the likelihood of having been caused because of torture. The disability and loss of function caused by the injury should be objectively assessed and the level of recovery should also be assessed. The terminology that should be used for documentation ranging from ‘not consistent with torture’ to ‘diagnostic of’

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Skin injuries

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The skin should be examined for generalized disease, including nutritional deficiencies. Skin changes due to torture can include abrasions, bruises, pigmentation changes, lacerations, puncture wounds, burns from cigarettes, chemicals, scalding liquids or heated instruments, electrical injuries, incised wounds, alopecia and nail removal.

 

Torture lesions should be described by their localization, symmetry, shape, size, colour and surface (e.g. scaly, crusty or ulcerating), as well as their demarcation and level in relation to the surrounding skin. Clinicians should note if normal hair growth is absent or there are any areas of numbness. Lesions may be described as fresh/acute or healed. Photography is recommended whenever possible. For injury interpretation it is useful to consider if the lesion is a pigmented or depigmented lesion, a scar or contains areas of scarring.

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The examination should include the entire body surface in order to detect signs of generalized skin disease, including signs of vitamin A, B and C deficiencies, pre-torture lesions or lesions inflicted by torture, such as abrasions, bruises, pigmentation changes, lacerations, puncture wounds, burns from cigarettes, chemicals, scalding liquids or heated instruments, electrical injuries, incised wounds, alopecia and nail removal.

 

Torture lesions should be described by their localization, symmetry, shape, size, colour and surface (e.g. scaly, crusty or ulcerating), as well as their demarcation and level in relation to the surrounding skin. Clinicians should note if normal hair growth is absent or there are any areas of numbness. Lesions may be described as fresh/acute or healed. Photography is recommended whenever possible. For injury interpretation it is useful to consider if the lesion is a pigmented or depigmented lesion, a scar or contains areas of scarring.

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Speculative judgements should be avoided in the evaluation of the nature and age of traumatic lesions since a lesion may vary according to the age, sex, condition, and health of the individual, the tissue characteristics, and the severity of the trauma. Fresh and old injuries can be seen together on people who have a long history of torture.

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Infection, irradiation, corticosteroids, scurvy (vitamin C deficiency), diabetes, hepatic cirrhosis, uraemia, blood loss, cold, and shock all inhibit wound healing. Wounds heal faster in young people. Bruises resolve over a variable period, ranging from days to weeks. Estimating the age of bruises is one of the most contentious areas of forensic medicine.

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When the skin is injured it can respond in different ways

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• Contusions (commonly known as bruises)

• Abrasions (or grazes)

• Incisions (including stab wounds)

• Lacerations (also, commonly but confusingly, known as cuts)

• Burns and scalds.

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The skin can present signs of torture in several ways. These should be documented in detail and accurately. Acute lesions may present with pain, secondary infection or poor healing (this could be due to the location or due to nutritional/metabolic diseases). 

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The examination of the skin should include the entire body surface to detect signs of skin diseases, non-torture-related lesions and/or torture-related lesions.

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With skin lesions, document the following

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1. Location, preferably using the body diagram and indicating if they are symmetrical or asymmetrical

2. Shape - whether round, oval, linear, irregular etc.

3. Size -using a ruler or measuring tape

4. Color - if it is uneven, this should be described

5. Surface - whether inflamed, scaly, crusty, ulcerated, necrotic

6. Smell - Some lesions, if infected, can have a smell. 

7. Edges - Whether regular or irregular, elevated, pigmented, inflamed

 

Bruises

A bruise occurs following a blow (blunt trauma) that does not break the skin, and  causes rupture of blood vessels and hemorrhage into soft tissues, making the area tender and boggy. The extent and severity of the bruise depends on the amount of force applied as well as the structure and vascularity of the bruised tissue.

 

If the skin and subcutaneous tissues are thin, the bruise becomes apparent relatively quickly and may take the shape of the inflicting instrument used, although this might not be obvious in darker skins. For example, a blow from a baton or heavy stick often leaves two parallel lines of bruising (tramline bruising) caused by the blood being pushed sideways by the contact. The shape of the object may be inferred from the shape of the bruise. The colour of a bruise does not assist in assessing age of injury.

 

The perception of bruise colour varies according to skin tone and cannot be determined accurately from images. In some skin types, bruising can lead to hyperpigmentation, which can last several years. Bruises that develop in deeper subcutaneous tissues may not appear until several days after injury, when the extravasated blood has reached the surface. Ideally bruises should be photographed as soon as possible, before they spread or fade. Some bruises may become better defined after some time in which case person may need to be examined again.

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When the bruise is deep the blood tracks slowly to the surface, and it may be several hours or even days before anything is visible. It is often helpful in such cases to re-examine the patient a day or two later. In such cases the extravasated blood (blood that has been lost from the vessels) follows tissue planes and may emerge some distance from the original injury, and is unlikely to be tender. For example, bruising of any part of the face may appear below the eye. Thus the site of the bruise is not the site of the injury, but the size of the bruise could be evidence of the force of the blow. This should be made clear in any report.

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They occur more readily in areas of thin skin overlying bone or in fatty areas. Many medical conditions, including vitamin and other nutritional deficiencies, age and medication may be associated with easy bruising or purpura. Dietary deficiencies of, for example, vitamin C (scurvy), can cause spontaneous and widespread bruising. This may be evidence of neglect of detainees. Extensive bruising not explained by the history should, if possible, be investigated in case it is the consequence of a disease. 

 

In older people and those on certain types of medication, clotting is impaired and bruising is much larger than usual. This is particularly the case in those areas where the skin is loose. In these patients, for example, a minor injury on the neck can result in a large bruise. Bruises change colour and fade over a period of hours and days as the blood pigments are metabolised and absorbed, but this takes a different amount of time in different parts of the body following a single incident. However, if there are bruises at different stages of resolution in the same place, this could support allegations of repeated assaults over several days.

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The absence of a bruise or abrasion, however, does not indicate that there was no blunt force to that area. In cases of an allegation but an absence of a bruise, the victim should be re-examined after several days.vIt should be taken into consideration that the final position and shape of bruises may bear no relationship to the original trauma and that some lesions may have faded by the time of re-examination.

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Permanent changes in the skin due to blunt trauma are non-specific and usually without diagnostic significance. Prolonged application of tight ligatures may result in characteristic findings, including a linear zone extending circularly around the arm or leg, usually at the wrist or ankle, containing few hairs or hair follicles, a form of cicatricial alopecia.These findings are relatively rare, however; it is more common to see short, linear, narrow scars over the bony sides of the wrists from handcuff abrasions, especially in situations in which the person has been beaten while suspended by handcuffs. These findings may be diagnostic of the alleged torture or ill‑treatment as there are no other skin diseases or injuries that could account for such findings. Ligature injuries will depend on the tightness of the ligature, the nature of the ligature used, and the force applied, such as twisting of handcuffs or suspension and beating while handcuffed. 

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Abrasions

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Abrasions are caused either by a blow with a blunt object or a fall onto a rough surface. Parts of the epidermis are rubbed away, sometimes in lines showing the direction of the impact. They are more likely to occur if the superficial tissues are thin, for example, over a bone.Acute abrasions resulting from superficial scraping lesions of the skin may appear as scratches, brush burn type lesions or larger scraped lesions. At times, acute abrasions may show a pattern that reflects the contours of the instrument or surface that inflicted the injury. Repeated or deep abrasions may create areas of hypo or hyperpigmentation, depending on skin type. This occurs on the inside of the wrists if the hands have been tied together tightly.

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During the two or three days following the injury, abrasions produce fluid that crusts over. This makes them very susceptible to infection, which delays and distorts the healing process. Unless the abrasions are full-thickness, they will heal with few remaining signs, although they can leave hyperpigmentation or hypopigmentation.

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Abrasions may show a pattern that reflects the contours of the instrument or surface that inflicted the injury. For example, ropes can cause abrasions wider than the rope itself. When the blunt force is directed perpendicularly to the skin over the bony prominences, it will generally crush the skin at that point. Sometimes, if there is anything between the object and the skin, its imprint may be observed on the skin. In hanging and other asphyxiation by ligature, patterned abrasions can sometimes be found on the neck.

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Sometimes, survivors of torture may be thrown from moving vehicles so that they slide on the road, or they may be dragged along the ground during arrest or capture. In these cases, extensive abrasions may be seen, and particles of dirt, sand, etc. will predispose the abrasion to infection. The same particles may become embedded in the skin and leave a sort of ‘tattoo’ effect that can persist for years. Scratches are caused by sharp objects that produce superficial linear cuts. Identifiable patterns of scratches can be seen, for example, from fingernails.

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Incisions

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Incisions are caused by sharp objects like broken bottles, knives and blades that produce a more or less deep, sharp and well-demarcated skin wound. They must be differentiated from lacerations in which the skin is torn. The term ‘cut’ should never be used in a report, as colloquially the term usually means a laceration.

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Incisional wounds have clearly defined edges and, on close inspection, it may be possible to see that hairs have been cut. There are no tissue bridges. Sometimes the wound can be jagged, suggesting that it was not caused by a single stroke. However, because the skin stretches as it is cut, the size of the wound is not necessarily related to the size of the implement used.

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Small wounds and those that are supported by surrounding tissues heal at the surface, and they may be difficult to see after only a few days. If the wound is in a part of the skin that is not supported, it will gape. Unless it is sutured or otherwise closed, it will heal from inside.

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Stab wounds are incisions that are deeper than they are wide. They should be examined carefully because of the risk of damage to deeper structures.

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Lacerations

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Lacerations are caused by a tangential force such as a blow or a fall and produce tears of the skin. The wound edges tend to be irregular, and often any may be bruised or/and abraded. There might be tissue bridges (where the skin has not separated along the entire length of the wound).

 

Burns and scalds

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Burns are usually caused by dry heat, but the skin can also be scalded with very hot liquids or burnt with chemicals. Burning is the form of torture that most frequently leaves permanent changes in the skin.

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The shape of the lesion can sometimes, but not always, reveal the shape of the object that caused the burn. The damage caused by heat is proportional to the temperature and the duration of exposure.

 

Burns are classified into three degrees, according to severity.

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• In superficial (first degree) burns there is no permanent damage to the epidermis. They present as a reddening of the skin

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• In partial thickness (second degree) burns some of the epidermis is destroyed and there may also be damage to deeper tissues. They present as moist, red, blistered lesions and are normally very painful

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• In full thickness (third degree) burns there is complete destruction of the epidermis and significant damage to deeper tissues. They may not be as painful as partial thickness burns. If the burns are widespread, there is usually death from shock and fluid loss.

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Cigarettes are commonly used by torturers to inflict pain. Most cigarette burns are superficial and fade over a few hours to a few days. They tend to be circular, and have a diameter  from 5-10 mm up to 1 cm. They cause an erythematous (reddening of the skin) and an oedematous circle that can blister.

 

Deeper burns are caused when the lit cigarette is pressed against the skin for a long time. When this happens the lesion is deeper and there might be a full thickness burn in the centre surrounded by blisters. If the cigarette is rubbed in, it leaves a larger and more irregular lesion.

 

Burns from hot objects tend to take the shape of the surface that caused the burn. The wound contracts as it heals, so the lesion may be smaller than the object. Liquids flow on contact with the skin, and this can leave a distinctive pattern reflecting the survivor’s posture at the time of the incident. Scalds lose heat rapidly so the resulting lesion diminishes away from the point of first contact, whereas chemical burns are often more extensive. A number of lesions from scalding in different parts of the body are suggestive of torture. A single burn might be caused by torture but could also be due to an accident either at work or otherwise. A good occupational history is paramount.

 

Burning with cigarettes, hot instruments or hot fluids leaves acute burns of varying degrees. Burning is the form of torture that most frequently leaves scars, often of diagnostic value. Cigarette burns often leave 5-10 mm large, circular and macular scars with a depigmented centre and a hyperpigmented, relatively indistinct periphery.1 Burning via the transfer of larger amounts of energy to the skin than those transferred when stubbing a cigarette on the skin often produces markedly atrophic scars. They present a narrow, regular, hyperpigmented or hypertrophic periphery, originating from the inflammatory zone, which surrounds the necrotic tissue in the acute phase. While their shape reflects the shape of the instrument used, their size relates to the amount of energy transferred to the skin. Following alleged torture from burning on several areas of the skin with a heated, circular metal rod the size of a cigarette, mostly circular scars with an atrophic centre and a regular, narrow, hyperpigmented or hypertrophic zone in the periphery can be observed. Burns on the nails leads to striped, thin, deformed nails which can also be broken. 

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Bites 

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They tend to be a mixture of laceration and crush injury. Human bites, especially those that are sexual in nature, can show petechiae from sucking. Petechiae are obvious in the twenty-four hours following the assault. The marks from human bites have a semicircular shape and appear blunt. Animal bites cause deeper and sharper wounds. It is important to look for lacerations caused by the claws

 

Blunt trauma

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Blunt trauma may leave contusions or lacerations with extravasation of blood into the skin and subcutaneous tissue, and leave ecchymoses, contusions or lacerations, in some cases reflecting the shape of the instrument used, e.g. from beating with a stick.

 

Blunt trauma often leaves no or uncharacteristic scars. Flogging or beating with canes or truncheons may, however, leave characteristic scars, e.g. asymmetric, linear, straight or curved or “tramline”-shaped scars, showing a pattern of external infliction. The hemorrhagic areas can move down over the next few days.

 

Deep tissue bruises may not be visible on surface and only tenderness may be present. blunt injuries can change colour from dark red, to purple to brown or green or yellow followed by hyperpigmentation or disappearance.  The scars may be hypertrophic with a narrow, regular, hyperpigmented area in the periphery, representing the inflammatory zone appear- ing around necrotic tissue in the acute phase.

 

Prolonged application of tight ligatures may leave a linear zone extending circularly around the arm or leg. Blunt trauma on feet (falanga) (described later in Section……)can leave contusions in the arch of the feet and swelling.

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Scars

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Various forms of physical torture like electric shock, burns (with cigarettes, instruments, scalding liquids, caustic substances), crush or penetrating injuries, stab wounds, amputations, surgical removal of organs etc. can cause scarring. Physical torture can leave scars which can become more difficult to interpret with time. They should be examined in good light and scar area measured. Scars should be documented in terms of size, shape, location (in relation to the closest anatomical landmark), color, contours, associated infection or tenderness, whether raised or flat, pigmentation, 

 

Scars can be a form of medico-legal evidence even months or years after the incidents. The nature of scar can be affected by whether it had been infected or not, if there was repeated trauma in the same area, association with malnutrition etc. A detailed history can corroborate allegations of torture. It can also give an idea of whether healthcare services were adequate and quality of nutrition during the time of healing of the wound. Comparing photos of wounds when they occur with later scar formation can give clues to the nature of the injury.

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Full thickness wounds (those that go through the epidermis) heal in one of two ways. When the wound is small and the edges are opposed, it heals from the top down (by primary intention). This tends to leave a small, tidy scar. Pockets of infection inside can become abscesses.

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If this process cannot occur, especially if the wound gapes, it heals from below (by secondary intention). This is a slow process and prone to infection, and will leave a wide scar. When the original wound was straight, and especially if it was an incision, the scar tends to be symmetrical, with curved edges, and is widest at the middle (a biconvex scar). Pain and secondary infection can occur if lesions are located in areas of venous or arterial insufficiency. If close to a joint, they can induce contracture, decreased mobility of joint and pain.

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The number, position and size of lesions may indicate other aspects of the conditions in which the individual was detained. For example, if the floor of a cell is flooded for any reason, and there is no access to a toilet so that the person has to urinate and defecate in the cell, the detainees will have to sit or stand in dilute sewage. In these circumstances, minor wounds, whether caused by assault or accident, may well become infected and can leave many small scars around the lower legs or buttocks. These must be differentiated from lesions left by childhood skin infections. All scars should be documented, including those that the individual is clear were caused in incidents other than torture. If those detained in certain centres have far more such lesions than other individuals from the same social background, this should be documented.

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If a scar has suture marks around it, this should be documented, as this demonstrates that medical care was given. Equally it should also be noted if there are scars from wounds that have clearly not received medical attention, or have been seriously infected. Scars from surgery should also be noted, especially if it is alleged to be associated with torture, for example the removal of a ruptured spleen. Self inflicted scars are superficial and within easy reach of the dominant hand.

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Keloids are scars that exceed the boundaries of the original wound. They are much more common in some skin types than others. The exact pathogenesis is unclear, but the tendency to them is probably inherited. Those who have a tendency to keloid will probably have several thickened scars on their bodies. Thus such scars are more difficult to attribute to specific allegations of torture.Sharp trauma, caused by the use of razor blades, knives etc. leave recognizable scars. 

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Cigarette burns often leave 5-10 mm large, circular and macular scars with a depigmented centre and a hyperpigmented, relatively indistinct periphery. Burning with heated metal rods can leave circular scars with atrophic centres and hyperpigmented or hypertrophic zone in the periphery. 

Corrosive injuries by acid can cause linear scars with depigmented centre and hyperpigmented periphery. The path of the liquid running down the body can also show features of corrosive injury.

Scars seldom inconvenience the patient but can cause distress for cosmetic or psychological reasons because they can be a constant reminder of the torture. 

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Post-inflammatory hyperpigmentation

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Hyperpigmentation can follow inflammation. The hyperpigmentation retains the shape of the original inflammation, which can be important forensically. For example, classic tramline bruising (e.g. parallel lines of bruising following a blow from a baton or similar object) or inflammation from burns can leave distinctive patterns of hyperpigmentation. The increased pigmentation can last for between five and ten years.

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Whipping can sometimes leave lines of hyperpigmentation, especially in darker skin. These lesions are rarely confused with stria which are caused by sudden gain or loss of weight, so are also seen in some former detainees. They tend to be irregular rather than linear, and have a well-recognised distribution.

Less regular patterns of hyperpigmentation are seen following abrasions, again particularly in darker skins. Tight ropes or handcuffs may leave marks around the wrists, and marks following rope burns can be seen elsewhere on the body where the individual has been tied up or suspended. These are rarely pathognomonic individually, but the locations and distribution of the marks can support the history of torture.

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As hyperpigmentation can follow any inflammation, any other cause of inflammation can cause a similar pattern. For example, lines of increased pigmentation that follow an irritant dermatitis from contact with plant stems can be mistaken for similar lines following whipping (although it is not unknown for victims to be whipped with irritant plant stems as a form of ill-treatment).

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Hematoma

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This can occur following blunt trauma. Blows with rods or sticks or lathis can leave two parallel lines (tramline bruises) or asymmetric, linear, straight or curved scars. The scars may be hypertrophic with a nar- row, regular, hyperpigmented area in the periphery, representing “arrowline”  bruises or an inflammatory zone appearing around necrotic tissue in the acute phase. Hemorrhagic areas often move down the body during the following days. The color can change from dark red to dusky purple, to brown to green etc. Deep tissue bruises may not be visible on the surface of the skin particularly in dark skinned individuals. Prolonged application of tight ligatures may leave a linear zone extending circularly around the arm or leg. 

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Electrical shock 

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Electric shocks are commonly used because they cause severe pain but may not leave identifiable physical signs. The equipment can be basic or high tech. In electric torture, the current travels along nerves and blood vessels as they offer lower resistance. When the current travels, it causes contractions of the muscles and severe pain. Genitals and breasts are often targeted and the victim could be threatened with loss of reproductive function. The mouth is extra sensitive and can be targeted. 

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There can be complaints of severe pain due to muscle contraction. It can cause dislocation of joints and if chest muscles are involved, difficulty in breathing. If it passes through the heart, it can cause arrhythmia leading to sudden death. It can also lead to loss of control of urine and defecation if the muscles of the bladder and rectum are affected.

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One examination, areas of reddening can be present for weeks. The electrodes can sometimes leave small burns, possibly from sparking. These tend to be circular and less than 0.5 mm in diameter. They can also create hyperpigmentation. They can corroborate allegations of electric shock torture if they are in the parts of body alleged to have been targeted. 

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In cases of electric shock, 3-4 mm punch biopsy under local anesthesia can show deposition of calcium salts on dermal fibers in viable tissue around necrotic areas and on collagen fibers deep in the dermis.

Biopsy one month after alleged electric torture shows a conical scar with increased number of fibroblasts and tightly packed thick collagen fibres parallel to the surface. Biopsy five days after torture via battery driven electric instrument shows non-specific alterations with sub-epidermal bullae consistent with thermal injuries. 

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Even if an examination does not reveal any abnormal findings, the possible use of electrical torture  cannot  be  excluded. The use of high-frequency ultrasound may be helpful to discover the location of calcium deposits in order to select an area for biopsy.

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Electrical torture via electrodes shaped like a knitting needle, “Picana”,   leaves   clus- ters and linear arrangements of 1-5 mm wide lesions, covered by red-brown crusts, sometimes surrounded by a 1-2 mm broad, erythematous zone with irregular and in- distinct edges.   

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Face injuries

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Injuries, scars, lesions etc. on the face can be particularly distressing because they are constant reminders of the torture. Injuries are common over bony points especially the eyebrows and cheekbones. They could be associated with fracture of the malar (cheek) bone.

 

The face should be palpated for evidence of fracture, crepitation, swelling or pain. All cranial nerves should be examined. Appropriate radiological techniques should be used when possible to confirm facial fractures, determine alignment and diagnose associated soft tissue injuries and complications. Intracranial and cervical spinal injuries are often associated with facial trauma.

 

Mandibular fractures or dislocations may result from beatings. Temporomandibular joint syndrome is a frequent consequence of beatings, including forceful slaps about the lower face and jaw. The alleged victim should be examined for evidence of crepitation of the hyoid bone or laryngeal cartilage resulting from blows to the neck. Findings concerning the oropharynx should be noted in detail, including lesions consistent with burns from electric shock or other trauma. The maxillary labial frenum may be torn. Gingival hemorrhage and the condition of the gums should also be noted.

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Eye injuries

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Look for sub-conjunctival hemorrhages (bleeding in the white of the eye). Some victims/survivors may complain of soreness in the eye after being in detention over prolonged periods of time; on examination, there is redness of the eye and often no other finding. Retinal hemorrhages in children are very suggestive of violent shaking. 

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Direct trauma to the eyes can present in many ways, including conjunctival hemorrhage, lens dislocation, subhyaloid hemorrhage, retrobulbar hemorrhage, retinal hemorrhage, traumatic optic neuropathy, ruptured globe , choroidal hemorrhage, irregular pupils and visual field loss. Ophthalmologic consultation should be obtained whenever there is a suspicion of ocular trauma or disease. Radiological techniques must be used to confirm orbital fractures and soft tissue injuries to the bulbar and retrobulbar structures. Forced solar gazing can cause eye damage, including burns to the retina. Retinal examination should also be conducted to rule out retinal bleeding, which may be associated with whiplash/impact head trauma.

 

Acute eye symptoms  in  torture  survivors are conjunctivitis, probably caused by dirty cloth used for blindfolding, which the victims often have to wear for many days and nights on end. Very few long-lasting eye symptoms that are possibly related to torture have been described. Perron-Buscail, Lesueur, Chollet, and Arne (1995) observed opacities in the cornea 10 years after electric torture in the eyes, influencing the vision.

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Nasal injuries

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The nose should be evaluated for alignment, crepitation and deviation of the nasal septum. For simple nasal fractures, standard nasal radiographs should be sufficient. Radiological techniques should be used to confirm fractures and identify soft tissue injury.

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Head and neck injuries

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Bruises and scars on the scalp may be difficult to find, especially if the hair is thick. Bruises will usually be tender to touch. Head trauma a very common  outcome of torture and even repetitive minor head trauma can cause permanent damage to the brain. This in turn can lead to neurological deficits. Some survivors of torture may report losing consciousness during periods of time, in which case, the presence of a reliable witness would help in documentation. Loss of consciousness can occur because of direct blows to the head, post-traumatic epilepsy, asphyxiation, pain and exhaustion, excessive loss of blood internally or externally or any combination of this. After having been hit on the head, many complain of persistent or recurrent headaches. There could be areas of hyperaesthesia on the scalp (extreme sensitivity of the nerves) and thickening of the scalp due to scar tissue. This can be palpated by running the fingers along the scalp. 

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Violent shaking of the upper body, as can happen with a child or a small made person, can leave severe headaches and cognitive changes. Even though no external injuries may be identifiable, internally, it can manifest as cerebral edema or sub-dural bleeding. After severe head injury, there may be concussive convulsions but may not necessarily lead to epilepsy. Convulsions in the first week after severe head injury tend to be tonic-clonic, can recur for a year or more, but are not generally lifelong. If the injuries, specifically in the temporal area, do cause brain damage, then they are likely to develop complex partial seizures, months or years after the incident, making history very important in proper management and for documentation. More than 90% cases of complex partial seizures start with an aura, with concurrent automatic movements (like lip smacking) and followed by absence that can last for up to 2 minutes, followed by a few minutes of disorientation. This has to be differentiated from Post Traumatic Stress Disorder (PTSD) symptoms where the person can be roused and doesn’t completely lose consciousness. 

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Survivors of torture rarely have an accurate account of their head injuries, and unless they have an external reference, they cannot know for how long they were unconscious. One problem with attributing epilepsy to head trauma is that there is rarely any information about the individual’s neurological state prior to the incident.

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 It is essential in possible cases of neck compression or strangulation that all areas of the eyes, skin and mucosa (including inside the mouth, the eyelids, the palate and the uvula, and the skin of the scalp) above the level of compression are examined with a good light to identify any localized areas of petechiae. It is important to identify petechiae at an early stage as they fade and disappear within 24 hours or so. In cases of manual strangulation or neck compression petechiae may be florid and may coalesce to form larger bruises. There may also be difficulty breathing, ptosis or facial nerve palsy. Late complications include aspiration pneumonia, pulmonary oedema and seizures.

 

Where strangulation by ligature or hand has been attempted, potential findings include:

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(a) No injury seen;

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(b) Pain or tenderness – at site of application of force with no visible injury on swallowing or on neck movement;

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(c) Reddening (erythema), which may resolve after a few hours;

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(d) Skin bruising, abrasions or swelling at the point of compression – for example, at sites of finger/thumb/ligature application – this may appear early or later and persist for days;

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(e) Pinpoint bruising (petechiae) above the site of compression;

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(f) Damage to the larynx – thyroid cartilage (voicebox) – causing hoarseness and/or hyoid bone (bone at base of neck);

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(g) Scratches to neck

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(h) Damage to mucosa of the mouth and tongue due to direct pressure on teeth internally and swelling of the tongue;

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(i) Bleeding from mucosa where the intravenous pressure has been raised – for example, from the nose and ears;

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(j) Additional non-specific features that may rarely be present include frank hemorrhage from orifices such as the nose and ear and spontaneous evacuation of feces and urine. These may appear alone or in combination.

 

Oral cavity

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Broken or missing teeth can be evidence of assault, but if the oral hygiene is generally poor, conclusively connecting broken teeth to torture may be difficult. Petechiae on the palate can be evidence of forced oral intercourse. 

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There can be untreated caries, tooth or gum pain, gingival inflammation due to poor oral health facilities. Poor oral health can affect a person's physical, psychological and social well being. People may have discomfort due to bleeding gums, bad odor or broken/missing teeth. Individuals who have been tortured are often fearful, anxious, and panicked when placed in a prone position, and sharp dental objects may trigger recollection of torture experiences; clinicians need to exercise patience in allowing patients to maintain control of their environment. However, dentists rarely have the background, education, time, or experience needed to provide appropriate and sensitive care to this population.

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Oral cavity examination to look for untreated caries, gingivitis or tooth abscesses. Tooth avulsion, fractured teeth dislocated fillings and broken prostheses could arise from direct trauma or electric shock torture. The tongue, gums or lips can be bitten. Lesions can occur by forcing objects or materials into the mouth as well as by applying electric shocks. There can be bruises or abrasions on the buccal aspect of the cheek, the frenulum may be inflamed or torn. Radiological techniques should be used to assess the extent of soft tissue, mandibular and dental trauma.

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Ears

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Repeated or hard slaps to the ear can damage the eardrum. However, the presence of scars in the tympanic membrane (ear drum) could also be attributed to childhood infections.

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Trauma to the ears, especially rupture of the tympanic membrane, is a frequent consequence of harsh beatings. The ear canals and tympanic membranes should be examined with an otoscope and injuries described. A common form of torture, known in Latin America as teléfono, is a hard slap of the palm to one or both ears, rapidly increasing pressure in the ear canal, thus rupturing the tympanic membrane. This type of impact may also cause ipsilateral subdural bleeding, which may need to be explored by CT scan. Prompt examination is necessary to detect tympanic membrane ruptures, which may heal within 10 days, although healing may be delayed. Fluid may be observed in the middle or external ear. The presence of hearing loss should be investigated. Beating is the type of torture that carries a high risk of damaging the hearing functions, particularly in the form of “teléfono”, in which both ears are beaten simultaneously with the flat of the hand.

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Upper limbs and hands

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Small wounds to the backs of the hands can be caused by punching or being hit. Wounds on the backs of the forearm could be defense injuries. The inside of the non-dominant forearm is the usual location of self-inflicted wounds. Superficial abrasions or reddening around the wrists could have been caused by tight handcuffs or cords. At a later stage there is often hair loss and there may be hyperpigmentation.

Finger and toe nails can be extracted or crushed during torture, but the late appearance is normally indistinguishable from infection or innocent trauma. Vaccination scars should be noted to ensure they are not attributed to ill-treatment. if the nail has been pulled off, an overgrowth of tissue may occur from the proximal nail fold.

 

Chest, Back, Abdomen

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Partial asphyxiation is very frightening for the victim and torturers have used many methods of causing it. These include putting plastic bags or other sealed objects over the head, holding the head under water, and forcing objects into the mouth, such as a wet cloth. Sometimes chilli pepper, petrol or sewage are added. Victims can be exposed in a confined space to smoke or tear gas. Many survivors will give an account of a persistent dry cough for a few days or weeks afterwards, probably as a result of inhalation pneumonitis (inflammation of the lungs). Some survivors say that they have been asthmatic since such an incident, but it would be very difficult to demonstrate causation. Examination of the lungs, and respiratory function tests are usually normal.

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Lesions on the trunk, as in all parts of the body, can be accidental or self-inflicted, or a consequence of torture. The late effects of whipping and beating with sticks can include lines of hyperpigmentation as well as scarring. Sometimes torturers embed small pieces of metal in whips, or hammer nails through sticks, and these can leave a distinctive appearance.

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Striae distensae (stretch marks) are most common on the abdomen (especially after pregnancy), the lower back, the upper thighs, and around the axillae. They are hypopigmented lines in which the skin might be folded. They must not be confused with scars from whipping. In striae, the skin is intact. They can be evidence of significant weight loss, for example in detention.

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Survivors of torture frequently complain of non-specific pains, and the chest is a regular site for them. On examination there is rarely anything significant to find, except perhaps some tenderness of the chosto-chondral joints (joint between the rib and the sternum (breastbone)). The pain is often helped by sympathetic physiotherapy. Patients with acute rib fractures should be examined thoroughly to ensure that there is no damage to underlying tissues.

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Back pain is also common in survivors of torture, and there may be some local tenderness in the lumbar spine. However, these findings are non-specific and common in the general population. Fractures of the vertebral pedicles (the parts of the vertebra going away from the main body) may result from direct blunt force and in some instances radiography of the vertebrae may indicate recent or healed fractures.

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Incision wounds to the abdomen can be mistaken for surgical wounds, including those from surgical drains, and vice versa. If the wound was not sutured properly, this increases the likelihood of it not having been made surgically. The location of the wound is always helpful. Renal failure due to crush syndrome may be seen acutely following severe beatings, severe burns and electrical torture.

 

Musculo-skeletal system

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Complaints of musculoskeletal aches and pains are very common in torture survivors, immediately as well as later. They may be the result of repeated beatings, suspension, other positional torture or the general physical environment of detention. They may also be psychosomatic or somatic in nature, but should still be documented. Pain may be specific to the torture mechanism or non-specific and generalized.

 

Physical examination should include testing for mobility of the joints, spine and extremities.

Clinicians should note: pain on palpation or with motion, muscle strength, contracture, evidence of compartment syndrome, fractures with or without deformity and dislocations. In the case of severe beatings, muscle tissue breakdown may lead to myoglobin release into the blood circulation in large amounts, potentially leading to acute kidney failure. The urine myoglobin level may be tested when and if available in severely beaten survivors during the acute phase.

 

Suspected dislocations, fractures and osteomyelitis should be evaluated radiologically. Injuries to tendons, ligaments and muscles are best evaluated with MRI, although arthrography can also be performed. In the acute stage, this can detect hemorrhage and possible muscle tears. Muscles usually heal completely without scarring; thus, later imaging studies will be negative. MRI and CT images of denervated muscles and chronic compartment syndrome may demonstrate muscle fibrosis. Bone bruises can be detected by MRI or scintigraphy Bone bruises usually heal without leaving traces. Vitamin D deficiency due to lack of sunlight and poor diet can also be a cause of musculoskeletal pain and responds to replacement therapy.

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Symptoms related to the musculo-skeletal system are the most frequently reported physical complaints at the time of torture, as well as at later stages. The associated signs and symptoms in the acute phase are similar to those following other types of acute trau- mas causing lesions in soft tissues (muscles, joint capsules, tendons, ligaments,  nerves and vessels) and distortion/dislocation of joints and fractures.

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Pain is the dominant symptom in relation to the musculo-skeletal system in the chronic phase. The clinical picture is one of localised or diffuse pain in muscles, joint pain, pain related to the spine and pelvic girdle, and neurological complaints mainly in the form of sensory disturbances and  radiating pain.

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Examination of the torso, in addition to noting lesions of the skin, should be directed towards detecting regions of pain, tenderness or discomfort that would reflect underlying injuries of the thoracic muscles and skeleton or abdominal organs. The examiner must consider the possibility of intramuscular, retroperitoneal and intra-abdominal haematomas, as well as laceration or rupture of an internal organ. Radiological techniques are required to confirm such injuries. Blood tests and urinalysis may be useful screens for such injuries. Routine examination of the cardiovascular system, lungs and abdomen should be performed in the usual manner. Pre-existing respiratory disorders are likely to be aggravated in custody and new respiratory disorders frequently develop.

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Acute stretching of the muscle can cause partial or complete tear of the muscle tendon unit 

Typical findings in the musculo-skeletal system in the chronic phase are:

• Increased muscle tone

• Tender and trigger points, especially in the muscles of the neck and shoulder girdle, muscles in the low back and pelvic girdle, and muscles of the lower ex- tremities; tendinitis around the shoulder joint, elbow, knee and ankle joint

• Tenderness and restricted range of move- ment in peripheral joints, cervical and lumbar spine

• Tenderness in the soles and a compensatory altered gait 

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Assessment of the musculo-skeletal system should in general include:

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• Examination of muscles and tendons: in- spection, palpation (tone, stretch range, tenderness, changes in  tissue  texture) and assessment of function (strength, endurance)

• Examination of peripheral joints and bones: inspection, palpation and assess- ment of joint function (range of movement and stability)

• Examination of the spine and pelvic girdle: inspection, palpation and range of movement in the cervical, thoracic and lumbar spine

• Neurological examination: muscle strength, tendon reflexes, and  sensibility.

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Acute stretch of a muscle may cause a partial or even complete tear of the mus- cle-tendon unit. These injuries are usually designated as stretch-induced injuries or muscle strains. A direct, non-penetrating blow to the muscle belly is another common mechanism for muscle injuries. Such muscle contusions may cause significant damage to the structure and function of the muscle.

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Immediately following the injury, there is disruption of the architecture due to ruptured muscle fibres, as well as injury to the connective tissue framework and haematoma formation. Within  two-three  days,  an  intense  inflammatory  response  develops.   Pain and disability in the acute phase are, at least in part, due to this inflammation, and biomechanically the muscle is most impaired at this point.

Within the first week, evidence of muscle regeneration may be found. The combined regenerative and scar response results in a healed muscle that has fewer and smaller muscle fibres in the injured area, as well as an increased amount of collagenous tissue between the fibres.

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The majority of muscle lesions heal leaving no specific gross findings, but very often torture victims present with muscular dysfunction in the chronic phases. Typical, but unspecific, findings are: increased muscle tone, restricted stretch range of movement, tender and trigger points, and musculo-tendinous inflammation. The range of muscle movement may be restricted because of painful trigger points or reduced elasticity due to muscle contracture/fibrosis. A tender point is a hyperirritable spot that is painful on compression. A trigger point is painful on compression and also gives rise to a characteristic pattern of referred pain. Inflammatory reactions in musculo-skeletal system can occur in joints, tendons, muscle, bursae and periosteum. Inflammation of muscle-tendon attachment to bone (teno-periostitis) is characterised by localised tenderness as well as when the connected muscle group is contracted against resistance (isometric testing). With tendinitis and bursitis, there can be tenderness, swelling and crepitus. 

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Exceeding normal range of movement or adding excess weight on a joint as happens with some forms of torture, can lead to pain, swelling and joint dysfunction. Full recovery may take months. Clinically, reduced range of movement of joints, joint laxity and instability can be found. 

 

Suspension by the limbs, prolonged squatting or standing, prolonged back loading positions, restricted movement due to confinement etc.  leave relatively few and unspecific findings, despite subsequent frequently severe, chronic physical disability.

 

Suspension by the arms, an often-applied torture method, is practised either separate- ly or in combination with other forms of torture, such as beatings and electrical torture. The torture victim is most often tied at the wrists and left hanging for a prolonged pe- riod of time by one or both arms. This form of torture is extremely painful and causes an immense overload of the shoulder joint and surrounding soft tissues.

 

In Palestinian hanging, the shoulder joint is maximally extended, inward rotated and the entire body weight loading the weak anterior aspect of the shoulder joint placing traction on the brachial  plexus.  Typically, the lower plexus, and thereafter the middle and the upper plexus fibres if the traction force is severe enough, will be damaged.

 

If the suspension is of the “crucifixion” type, the shoulder joints being in abduction, the traction force will primarily be placed on  the  middle  plexus  fibres,  which are likely to be the first ones damaged.

 

Symptoms in the acute phase are severe pain in the neck and shoulder girdle and in the shoulder joints, and loss of function in the upper extremity. Occasionally, one or both shoulder joints may dislocate during the torture.

 

Neurological complaints indicative of plexus lesion are frequent: radiating pain and re- duced muscle strength in the upper extremities, accompanied by sensory disturbances, typically in the form of paraesthesia and reduced sensibility. At neurological examination, common findings are reduced muscle strength, most prominent distally, loss/reduction of tendon reflexes and sensory disturbances along the sensory nerve pathways).

 

In the chronic phase, many torture victims who have been exposed to suspension by the arms, in particular Palestinian hanging, develop chronic disability with pain, reduced shoulder function and permanent  neurological  deficit,  indicative of partial lesion of the brachial plexus, most often involving sensory modalities. In the late stages, typical  complaints  are pain in the neck and shoulder girdle, deep pain in  the  shoulder  joints  during  activity, especially in connection with overhead movements  (abduction,  inward  rotation) and lifting, reduced range of movements in  the shoulder joints, feeling of instability in the shoulder joints or popping, locking sen- sations on movement.

 

Neurological symptoms are likewise frequent: radiating pain, muscle  weakness with a feeling of heaviness in the upper extremities and various sensory disturbances, including vasomotor and sudomotor changes.

 

At clinical examination, most of the findings are unspecific and confined to the soft tis- sues: typical findings are tender and trigger points in the neck and shoulder girdle, muscular imbalance with musculo-tendinous inflammation. At joint examination, a reduced range of active movement in the shoulder joint is common. Signs of habitual luxation/subluxation are rare, but upon specific testing, various degrees of instability may be present.

 

At neurological examination, brachial plexus injury will manifest itself as sensory and motor deficit, depending on the severity of the nerve lesion. Reduced muscle strength, which often is asymmetrical and most pronounced distally as well as reduction/loss of tendon reflexes are signs of motor involvement. Sensory disturbances, which might involve different sensory modalities,  are signs of sensory involvement.

Ligaments

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Exceeding the normal  range  of  movement in a joint or loading the joint by traction, as in suspension and other types of positional torture, the ligaments may be sprained. An inflammatory response with swelling, pain and joint dysfunction will be present in the acute phase. In a first-degree distortion, the ligaments are sprained without macroscopic rup- ture, and there will be no mechanical instability in the joint. In a second-degree distortion, there will be a partial macroscopic rupture of the ligaments, leading to a slight mechanical instability in the joint. In a third-degree distortion, the liga- ments will be completely ruptured  and the joint clearly mechanically unstable. The healing process in ligaments and tendons is considerably slower than that of muscles. A full recovery with normalization of strength and function takes months. Pain and joint dysfunction are very frequent complaints in the chronic phase. At clinical examination, reduced range of movement in peripheral joints, as well as in the spine, is the most typical finding, but various degrees of joint laxity/instability may also be found . Specific clinical tests may be applied for diagnosing the instability and direction of instability in joints.

 

Lower limbs

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Scars on the knees and shins are common in many people, especially those who have played contact sports. Thus lesions in this part of the body can rarely be significant, though they might be consistent with allegations of torture (see section 4.6). Additionally, tropical ulcers in childhood can leave large, irregular scars primarily around the lower legs. Lesions on the upper thighs and particularly those inside the thighs are much more important, as they are less likely to be the result of disease or accidental causes.

 

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