Amputations and Large Resections

Relevant clinical history

In addition to age and gender, relevant clinical history is often necessary or helpful for interpretation ( Table 9.1 ).

GENERAL GROSS DESCRIPTION

The description of all amputations includes the following:

Traumatic Amputations

Traumatic amputations may contain forensic evidence. Careful documentation of the examination by description and photography, when relevant, is important. Bullets or other metal objects may become legal evidence.

After the Boston Marathon bombing, recommendations for the evaluation of pathology specimens with forensic evidence were developed by pathologists, the Office of the Chief Medical Examiner of Massachusetts, and representatives of the Boston, Massachusetts Division of the US Federal Bureau of Investigation.

Guidelines for Evaluation of Specimens With Known or Suspected Forensic Evidence

• 1.

  Designate a person or a team of people who will handle all specimens from a single event. An unbroken “chain of custody” should be established for each specimen to ensure the correct identification from the time of arrival to the time of possible release to law enforcement personnel. Each person responsible for the specimen must be documented.

• 2.

  Specimens consisting of only a foreign body should remain in the sealed container in which they are received. They can be weighed (with the weight of the container subtracted), photographed, and radiographed in the container.

• 3.

  Tissue specimens should be radiographed in anteroposterior and lateral views including a specimen label. The location and types of foreign bodies are identified, as well as bone fractures. The location of foreign bodies can help avoid injuries when examining the specimen.

• 4.

  Tissue specimens are photographed with a specimen label. A diagram can be made for complex specimens.

• 5.

  Superficial objects are removed and placed in a sealed container with three patient identifiers for possible release to law enforcement (e.g., clothing, tourniquets).

  If clothing needs to be cut, it is preferable to cut along seams to preserve areas damaged by the trauma.

• 6.

  The tissue is described including lacerations, fractures, burns, and foreign bodies. The viability of the tissue at the margin can be assessed.

• 7.

  The specimen may be cleaned and any additional findings are described. The type of injury may be more evident after blood and other material is removed.

• 8.

  Tissue blocks may be taken of lesions, as appropriate. If the identity of the person is unclear, frozen tissue for possible DNA analysis may be considered.

• 9.

  Foreign bodies may be removed from tissue, photographed, weighed, measured, and placed in a sealed container with three patient identifiers. If there are numerous foreign bodies, a representative sample may be removed and a notation made that additional foreign material remains in the specimen.

• If bullets are present, they should not be touched with a metal instrument as this can scratch the surface and interfere with evidence markings. Plastic vascular sheaths can be used over instruments, if available (see also “Bullets” in Chapter 24 on “Medical Devices and Foreign Material”).

• 10.

  All foreign body specimens and all tissue specimens with foreign bodies should be kept in a locked, secure, area with limited access. Photographs and radiographs should be accessible only within a password protected system. The chain of custody must be kept intact with responsible personnel identified at each step of specimen transfer.

• 11.

  If specimens are requested by law enforcement or the medical examiner’s office (in the case of a patient death), the person releasing the specimens and the person receiving the specimen must be documented.

Digits—Nontumor

Fingers and toes are usually removed due to vascular insufficiency (toes) or trauma (usually fingers).

• 1.

  Describe including the features listed above.

• 2.

  Submit one section of soft tissue margin and an additional section of any skin lesions. A marrow margin should only be taken if there is concern for marrow disease.

• 3.

  Fix entire specimen overnight.

• 4.

  Decalcify the following day.

• 5.

  When the bone is sufficiently decalcified, take one section of bone at the resection margin and one additional section of bone if there is a question of osteomyelitis (e.g., bone below a deep ulcer bed).

If specific areas need to be sampled (e.g., an area of possible osteomyelitis), the sections should be submitted after decalcification.