ANNEX II Diagnostic tests Scintigraphy is an examination of high sensitivity, but low specificity. It is an inexpensive and effective examination used to screen the entire skeleton for disease processes such as osteomyelitis or trauma. Testicular torsion can also be evaluated, but ultrasound is better suited to this task. Scintigraphy is not a method to identify soft tissue trauma. Scintigraphy can detect an acute fracture within 24 hours, but it generally takes two to three days and may occasionally take a week or more, particularly in the case of the elderly. The scan generally returns to normal after two years. However, it may remain positive for years in cases of fractures and cured osteomyelitis. The use of bone scintigraphy to detect fractures at the epiphysis or metadiaphysis (ends of long bones) in children is very difficult because of the normal uptake of the radiopharmaceutical at the epiphysis. Scintigraphy is often able to detect rib fractures that are not apparent on routine X-ray films. Diagnostic tests are being developed and evaluated all the time. The following tests were considered to be of value at the time of writing of this manual. However, when additional supporting evidence is required, investigators should attempt to find up-to-date sources of information, for example by approaching one of the specialized centres for the documentation of torture (see chapter V, sect. E). 1. Radiological imaging In the acute phase of injury, various imaging modalities may be quite useful in providing additional documentation of skeletal and soft tissue injury. Once the physical injuries of torture have healed, however, the residual sequelae are generally no longer detectable by the same imaging methods. This is often true even when the survivor continues to suffer significant pain or disability from his or her injuries. Reference has already been made to various radiological studies in the discussion of the examination of the patient or in the context of various forms of torture. The following is a summary of the application of these methods. However, the more sophisticated and expensive technology is not universally available or at least not to a person in custody. (a) Application of bone scintigraphy to the diagnosis of falanga Bone scans can be performed either with delayed images at about three hours or as a three-phase examination. The three phases are the radionucleide angiogram (arterial phase), blood pool images (venous phase, which is soft tissue) and delayed phase (bone phase). Patients examined soon after falanga should have two bone scans performed at one-week intervals. A negative first delayed scan and positive second scan indicate exposure to falanga within days before the first scan. In acute cases, two negative bone scans at an interval of one week do not necessarily mean that falanga did not occur, but that the severity of the falanga applied was below the sensitivity level of the scintigraphy. Initially, if three-phase scanning is done, increased uptake in the radionucleide angiogram phase and the blood pool images and no increase uptake in the bone phase would indicate hyperaemia compatible with soft tissue injury. Trauma in the foot bones and soft tissue can also be detected with MRI.a Radiological and imaging diagnostic examinations include routine radiographs (X-rays), radioisotopic scintigraphy, computerized tomography (CT), nuclear magnetic resonance imaging (MRI) and ultrasonography (USG). Each has advantages and disadvantages. X-rays, scintigraphy and CT use ionizing radiation, which may be a concern in cases of pregnant women and children. MRI uses a magnetic field. Potential biologic effects on foetuses and children are theoretical, but thought to be minimal. Ultrasound uses sound waves, and no biologic risk is known. X-rays are readily available. Excluding the skull, all injured areas should have routine radiographs as the initial examination. While routine radiographs will demonstrate facial fractures, CT is a superior examination as it demonstrates more fractures, fragment displacement and associated soft tissue injury and complications. When periosteal damage or minimal fractures are suspected, bone scintigraphy should be used in addition to X-rays. A percentage of X-rays will be negative even when there is an acute fracture or early osteomyelitis. It is possible for a fracture to heal, leaving no radiographic evidence of previous injury. This is especially true in children. Routine radiographs are not the ideal examination for evaluation of soft tissue. (b) Ultrasound Ultrasound is inexpensive and without biological hazard. The quality of an examination depends on the skill of the operator. Where CT is not available, ultrasound is used to evaluate acute abdominal trauma. Tendonopathy can also be evaluated by ultrasound, and it is a method of choice for testicular abnormalities. Shoulder ultrasound is carried out in the acute and chronic periods following a See chapter V, footnotes 76 and 83; also refer to standard radiology and nuclear medicine texts for further information. 61