Case Report Samples
The following examples of reports are presented to clarify the kind of information best supplied by the forensic anthropologist. The format was developed by the author, Robert Pickering, from more than 20 years of consultation. His format works, but so do others. The first page of the report is a listing of the major biological characteristics and other observations, such as timing of trauma observed on the remains. The information in each category is purposefully brief and, one hopes, clear. The second part of the format provides a more detailed explanation of how each variable was determined.
This report format provides accurate and pertinent information in a manner that is understandable and useful to medical and police investigators. The first page, with its brief biological profile, can be used to start a missing person search and can be released to a wide circle of people who might need to know some of the general aspects of the case. The second part of the form, with its explanations, is useful for the investigators and patholo-gists who may need more detail. Experience has shown that one format does not serve the purposes of all people involved in death investigations. The format presented here attempts to resolve that problem.
These examples present different kinds of cases. The first is a complete adult skeleton. The forensic anthropologist was brought into the case when the skeleton was already at the medical examiner's office. The second case was a body drastically altered by fire. The forensic anthropologist was called to the site and conducted the recovery with the assistance of coroner's and sheriff's personnel. The third case involved a nearly complete remains. Again, the anthropologist saw it in the lab and did not take part in the recovery. Soft tissue and most organs were generally intact. As you review these examples you will note that although many of the basic procedures of examination did not change, the condition of the remains and amount of data are different. These examples clearly show that the number of characteristics that can be determined does vary with the completeness of the remains.
Summary of Physical Characteristics Case XXX—Sept. 1986
Sex: Age: Race: Height: Handedness: Antemortem trauma:
Perimortem trauma:
Pathology:
Build:
Male
55-70 years
Caucasoid
Right
Numerous facial fractures; three ribs (left); two ribs (right); first metacarpal (right).
Extensive fracture across the face and extending to the left temporal.
Extensive degenerative joint disease; antemortem tooth loss; caries; periosti-tis at left ankle.
Short and robust
Explanation of Physical Characteristics Case XXX—Sept. 1986
Sex — All pertinent morphological characteristics of the pelvis and skull indicate that the remains are male. Characteristics on the pelvis include a narrow sciatic notch, narrow subpubic angle, and the alae are high and relatively narrow. Cranial characteristics include a very prominent supraorbital ridge, large mastoid process, and robust nuchal crest. There are no morphological characteristics that would indicate the female sex.
Age — All of the epiphyses of long bones and the basi-occipital suture are fused. Therefore, the individual is definitely an adult. All the major endocra-nial sutures are closed, thus indicating an age of 45+ years. Morphological features of the pubic symphyses also indicate advanced age, at least 55+ years of age. Lack of accepted morphological features make it very difficult to assign an upper age limit to people in the older adult category. The best estimate, however, is 55 to 70 years of age.
Race — Characteristics of the facial portion of the skull were used to determine race. In general ,the skull has a long narrow shape. It lacks prognathism and robust malar elements. It should be noted, however, that both zygomatics present healed fractures. The nasal elements are particularly important. The nasals are narrow throughout their length and are ridged. The nasal aperture is relatively long and narrow and presents a sharp nasal sill. All of these features are compatible with caucasoid features and are not compatible with negroid or mongoloid features.
Height — Determining an accurate height estimate was difficult because of destruction of the ends of long bones by rodents. In almost all cases, the superior and inferior articular surfaces were totally eaten away. Only the right fibula was complete enough to get a precise measurement on its total length. Although the humeri were damaged, they were complete enough to provide a usable estimate of their length. In addition, Steele's formula for reconstructing the length of long bones from their specified segments was used to estimate the length of the tibia. That estimated length was then used to estimate stature of the individual. The following figures show that all of the elements provided similar estimates.
Height estimate 66.1"-67.4"-68.73"
B. Left humerus (32.3cm) Right humerus (32.2 cm)
Height estimate 66.23"-67.9"-69.47"
Height estimate 66.29"-67.64"-68.98"
In this case, height estimates were calculated on three different bones. For each bone, the low and high end of the range as well as the central height estimate are provided. Note that all three estimates are similar but not identical. The anthropologist uses all of these measurements to refine the final height estimate. Because of the person's age, it is appropriate to reduce the stature estimate. Although regression formulas result in the estimates listed above, approximately 1 inch should be subtracted from those figures. I suggest the best estimate as being 65" to 67".
Handedness — From the size of the glenoid fossa on the scapula, morphology of the scapula and size of the humeri, it is probable that the individual was right handed.
Antemortem Trauma — There is evidence of numerous healed fractures on the facial portion of the skull. Both nasal bones and adjacent portions of the maxillae have been broken and healed. The nasals are deviated to the left. Both zygomatic bones have been broken and healed. In both cases, the fractures were at or near the zygotemporal symphysis. There is a noticeable thinning in these areas and a slight displacement at this junction of the zygo-matics and temporals. Three ribs on the left side of the body have been broken and are now healed. Left ribs 10, 11, and 12 appear to have healed without serious complication. On the right side, ribs 9 and 10 also indicate healed fractures. The right first metacarpal has been badly damaged by rodent gnawing. However, it is obvious that the bone has been fractured near its proximal end and later healed. The fracture appears to have been complicated by possible infection. There is hyperostosis and ankylosis with an adjacent carpal element.
Perimortem Trauma — There is a major unhealed trauma that diagonally crosses the face of the skull and the left temporal bone. A small portion of bone along the nasal sill of the right maxilla has been fractured away. The contiguous portion of the left maxilla is bent rather than completely fractured. A fracture line is visible running from the nasal margin of the left maxilla and extends diagonally down to the area above the upper molars on the left side. Another fracture line extends from the nasal margin of the right maxilla to the maxillozygomatic symphysis. The fracture then bifurcates: one side extending up to the lower portion of the right orbit, and the second branch extending down along the symphysis line between the maxilla and zygoma. A fracture line also crosses the base of the left sphenoid, extends across, and bisects the left temporal.
There is no evidence of healing on any of these fractures. There is no discoloration which might indicate that they are recent; that is, they do not appear to be the result of improper recovery or care. The fracture pattern would indicate that all of these fractures could have resulted from the same traumatic event.
Pathology — The dentition shows poor dental health. There is only one cavity, although it is a large one. Most of the dentin has been destroyed and only the hollow enamel shell of the upper right canine remains. There is a probable abscess at the alveolus of the upper right first molar. At least 10 teeth have been lost before death. Their sockets are in various stages of resorption. The remaining teeth show calculus deposits along the gum line. Another 10 teeth have been lost after death. There is no resorption at their sockets.
On virtually all long bone joints that are observable, there is evidence of degenerative joint disease. Vertebrae also present considerable degenerative change. The second and third cervical vertebrae show partial ankylosis on the left side. The lower cervicals and upper thoracics all have marked lipping on the body of the vertebrae. The sixth thoracic vertebra is wedged as a result of compression stress and degeneration. There is a probable Schmorl's nodule affecting the 10th and 11th thoracic vertebrae.
There is initial ligament ossification on the superior surfaces of the sacrum and adjacent areas of the ilia, just above the sacroiliac junction. There is no ankylosis. However, the ossification would be visible on radiographs of the area.
There is degeneration and periostitis on the distal portion of the left fibula. Examination of the adjacent tarsals revealed evidence of some initial ligament ossification and erosion of the articular surface between calcaneus and cuboid. It is probable that the extent of this degeneration would cause some disability, possibly a limp.
Build — Although the long bones are relatively short, they have rugged areas of muscle attachment. The humeri and ulnae are particularly rugous.
Summary — A generalized description of the remains would include the following characteristics. The individual was a short, stocky white male in his late 50s or 60s. He led a life that was physically stressful as indicated by muscularity and degenerative change. Numerous examples of healed trauma also may indicate a physically stressful life. Trauma to the face might have resulted in some disfigurement. Certainly, the formerly broken nose would be obvious. The man may have walked with a limp which favored the left leg. The thumb of the right hand probably did not have a full range of motion.
Summary of Physical Characteristics Case YYY—1994
Age:
Sex:
Race:
Height:
Stature:
Handedness:
Distinguishing dental traits:
Pathology: Antemortem trauma: Perimortem trauma: Postmortem trauma:
Adult Male?
Indeterminate Indeterminate Indeterminate Indeterminate
The left lower lateral incisor was lost antemortem and the socket has totally resorbed. A three-tooth ceramic bridge was found in the area of the head. It appears to correspond with the lost incisor.
None observed None observed None observed
Extreme discoloration, fragmentation, and destruction of bone because of exposure to intense long-term burning.
Postmortem disturbance:
Some scattering of the bones occurred during and after incineration. An additional thin (1 to 3 inch) layer of dirt was then thrown on the remains. A second smaller burning episode occurred on top of the dirt layer. The body was lying on the left side with arms and legs flexed; a wristwatch band and metal studs from clothing were found among the bones indicating that they were with the body at the time of incineration.
Less than 2 years.
Disposition of the body:
Time since death:
Explanation of Physical Characteristics Case YYY—1994
Age — Adult. All epiphyses of long bones that were present are fused. The third molar was erupted and the root tip was closed.
Sex — Male? The size and robusticity of the long bones suggests that the individual was male.
Race — Indeterminate. No diagnostic criteria.
Height — Indeterminate. Long bones were too fragmentary to be used as a basis for height estimation.
Stature — Indeterminate. Remains were too incomplete to determine this trait.
Handedness — Indeterminate. No comparable left and right arm elements are measurable.
Distinguishing Dental Traits — The left lower lateral incisor was lost antemortem and the socket has totally resorbed. A three-tooth ceramic bridge was found in the area of the head. It appears to correspond with the lost incisor. A forensic odontologist should examine these remains.
Pathology — None observed.
Antemortem Trauma — None observed.
Perimortem Trauma — None observed.
Postmortem Trauma — Extreme discoloration, fragmentation, and destruction of bone because of exposure to intense long-term burning. Much of the bone is calcined, that is, burned gray to white, cracked, and warped.
Postmortem Disturbance — Some scattering of the bones occurred during and after incineration as evidenced by finding bone fragments in different parts of the burning area. An additional thin (1 to 3 inch) layer of dirt was then thrown on the remains after the fire had subsided. No discoloration of the dirt on top was evident. Thus, it had been deposited after the fire cooled. A second smaller burning episode occurred on top of the dirt layer. It was not an intense fire in that it did not discolor the underlying layer.
Disposition of the Body — The body was lying on the left side with arms and legs flexed. The head lay toward the northeast and the feet to the southwest. Bones of the forearms and hands, and the wristwatch band, were found together and indicate that the bones were in anatomical position. The two forearms were together or slightly crossed. They were positioned in front of the upper chest. The back was adjacent to the left side of the interior of the fire pit as evidenced by the vertebral elements recovered. Bones of the leg and feet were found on the right side of the fire pit. A wristwatch band and metal studs from clothing were found among the bones indicating that they were with the body at the time of incineration.
Time since Death — Less than 2 years. Moisture in the bone layer was frozen and there was snow on top of the bone layer. Ash from the second (most recent) fire was adhering to the underside of the snow. Much of the bone was exposed directly under the snow. The dirt layer between the two burning episodes was soft. Under the bone an ash layer was evidence of previous fires. The twig and bark residues were different in texture, content, and compactness from the ash and charcoal residue in the incineration layer.
Summary of Physical Characteristics
Case ZZZ—1992
20-24 years Male
Caucasian?
Tattoos were visible on both sides of the thorax.
Tattoos:
Pathology: Antemortem trauma: Perimortem trauma:
Many episodes of dental intervention.
Healed fracture of right nasal bone.
Two blunt instrument strikes to right supraorbital ridge and related fracture to right orbital roof; incomplete fracture of right wing of hyoid, fractured enamel of right upper canine tooth.
None
Postmortem trauma:
Postmortem disturbance: No animal, insect, or mechanical disturbance.
Explanation of Physical Characteristics Case ZZZ—1992
Identiacation — Antemortem dental records and radiographs for John Doe were compared with the dentition and postmortem dental radiographs. The records were compatible. There were no unexplainable incompatibilities. Other major physical characteristics were compatible with this identity. There were no incompatible characteristics.
Age — 20-24 years. The medial clavicles are fusing. The basi-occipital suture was fused. Examination of the pubic symphyses indicates the age range of 20 to 24 years.
Sex — Male. The remains were complete enough for a visual examination of external genitalia and determination of sex as male.
Race — Caucasian? The face is relatively long and narrow. Face is not broad. The nasal aperture has a sharp lower rim and is relatively high and broad. The nasal bones are ridged at their common suture and are narrow.
Tattoos — A tattoo was visible on each side of the chest. The anthropologist did not examine them in detail.
Pathology — Many episodes of dental intervention. The dentition evidences one well-healed extraction and one that was in the process of healing at time of death. There are many filings and one probable pulp extraction at the lower left first molar. All fillings appear to be amalgam except the filling on the upper left first incisor, which is a material that approximates the color of enamel. See attached dental chart.
Antemortem Trauma — Healed fracture of right nasal bone. The right anterior portion of the nasal bone was fractured but has healed.
Perimortem Trauma — Two blunt instrument strikes to right supraorbital ridge and related fracture to right orbital roof. One strike was to medial portion of the supraorbital ridge. There is a fracture approximately 10 mm in length that runs superior and perpendicular from the medial ridge. The second strike hit the frontozygomatic suture. Both strikes resulted in a detachment of a piece of bone. Viewed from inside the cranium, a fracture to the right orbital roof is clearly visible. It is related to the strike to the supraorbital. There is an incomplete fracture of the right wing of the hyoid. Morphology of the hyoid fracture indicates that pressure was applied from lateral to medial. The occlusal portion of the right upper canine tooth enamel has been fractured away.
Postmortem Trauma — None.
Postmortem Disturbance — No animal, insect, or mechanical disturbance. The remains was recovered in a heavy plastic bag that had been buried.
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