18 A practical guide to the Istanbul Protocol – for medical doctors II. POSSIBLE LESIONS AND ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM FOLLOWING SPECIFIC FORMS OF PHYSICAL TORTURE The following is not meant to be an exhaustive description of the numerous specific physical torture methods that carries a risk of injury to the musculo-skeletal system. Suspension by the arms and falanga have been selected since they are widely used torture methods that cause chronic disability, and may serve as examples of the variety of lesions that may occur, all of which require special attention at clinical examination. 1. SUSPENSION BY THE ARMS There are many types of positional torture, all of which are directed towards the musculo-skeletal system, producing injuries mainly in the soft tissues. Examples include suspension by the limbs, prolonged forced squatting or standing, prolonged back loading positions (the spine being hyperextended or maximally flexed) and restriction of movement during confinement in small cells or cages. Characteristically, these types of torture 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 separately 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 period 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. The shoulder is a joint complex comprising four joints: the glenohumeral joint, the sterno-clavicular joint, the acromio-clavicular joint and the “scapula-thoracic” joint. Normal shoulder function requires an optimal coordination between these four joints. The bony anatomy of the glenohumeral joint allows for the greatest possible range of movement found in any joint in the body, sacrificing joint stability for mobility (Fig. 5). Additional stabilisation is therefore provided by: 1. Static stabilisers: the glenoid labrum, joint capsule and ligaments (Fig. 6) 2. Dynamic stabilisers: the muscles – in particular the rotator cuff – the deltoid and the long head of the biceps; the “scapula-thoracic” joint; and neuromuscular control ensuring a constant awareness of joint position and joint movement (proprioception). During suspension with the arms in forward flexion (Fig. 7), the shoulder joint is maximally flexed and slightly outward rotated. This “closed packed” position provides maximum bony contact between the articular head and the articular socket assisting joint stability. In Palestinian hanging (Fig. 8) 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 (Fig. 9), 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 (Allden et al., 2001).