I had the opportunity to be part of the presenting team for Bakeng se Afrika a bone trauma workshop at the University of Coimbra, Portugal, in 2019. Here are a few musings about our collaboration and the importance of education in bone trauma.
My first experience with evaluating bone trauma on skeletal remains was nearly 20 years ago in South Africa. I was working at the University of Pretoria as a lecturer and completing my PhD in Anatomy (biological anthropology), when investigating officers from the South African Police Service (SAPS) requested my assistance in evaluating the incomplete, fragmented and decomposed remains of a young male, who had, allegedly, been strangled with a telephone cord. Up until that point, my experience was in constructing biological profiles for (what we would call) straight-forward forensic cases, teaching gross anatomy, osteology, histology and human evolution and writing research papers on bioarchaeology and forensic anthropology. I had also spent some time excavating graves for both University contracts as well as my PhD research.
I could interpret the effects of various environmental factors on bones (the taphonomy), such as the damage done by carnivore teeth, or by a veldt fire burning a set of skeletonised remains. I could also analyse certain types of pathology, such as osteomyelitis and leprosy. But bone trauma was uncharted territory.
I examined the bones at length and described them in my report. I recall observing smooth cut marks along the vertebral body of the 2nd cervical vertebra and intuitively thinking that telephone cords were not that sharp…
To this day I think of this young victim as my first mentor in bone trauma analysis.
I don’t know if my analysis ever made much of a contribution to the overall medico-legal process for the case - the outcome was never communicated to me - but pouring over these chop marks associated with a homicide did expose foundational cracks in my knowledge. To this day I think of this young victim as my first mentor in bone trauma analysis. Since then, I have built an amazing network of colleagues and have benefitted a great deal from their mentorship. I have also immersed myself in research and have come to realise the value of education in trauma analysis. From my current position as the director of the Forensic Anthropology Research Centre (FARC) at the University of Pretoria, I want to develop a large, inclusive community of practice around bone trauma analysis as a means to improve education, research, and interpretations of trauma from skeletal remains.
An early practitioner’s first experience with bone trauma is likely to be quite similar to my own, and for this reason I would like to use bone trauma short courses/workshops to create an educational platform for these practitioners to be able to share their ideas in a safe environment with other experts in the field and to be able to receive useful feedback from their experiences. A supportive community of practice will ultimately lead to improving bone trauma analysis in forensic anthropology but might also be of use in research with inter-disciplinary collaborations in orthopeadic surgery, forensic pathology and biomechanics, to name a few.
The first inter-disciplinary workshop (forensic anthropology and orthopaedic surgery) in bone trauma education was arranged within our CBHE Erasmus+ funded grant (Erasmus + Capacity Building in Higher Education: 597924-EPP-1-2018-1-ZA-EPPKA2-CBHE-JP) from 02 to 06 September, 2019 at the University of Coimbra. We are grateful to the University of Coimbra’s Laboratory of Forensic Anthropology (LFA), who hosted us for the week, and arranged the catering, travel and stay of all the workshop participants.
Bakeng se Afrika (translated: For Africa) involves partnerships with three South Africans Universities (Stellenbosch University, Sefako Magatho University, and the University of Pretoria) and three European institutions (University of Coimbra, University of Bordeaux and the Katholieke Universiteit Leuven) as well as the National Energy Corporation of South Africa (Necsa). The project aims to develop a comprehensive digital repository of skeletal remains of South Africans, develop quality assurance guidelines via standard operating procedures (SOP’s) for the access and ethical use of the digital images in this database, and to use this database for advancement in both research and education. For example, the ability to 3D print bone trauma specimens from microCT scanned images enhances our ability to offer teaching specimens to both the national and international community.
The facilitators for the course included Prof Steve Symes, Dr Rudolph Venter and me (Prof Ericka L’Abbé). Prof Symes currently works at the Office of the State Medical Examiner in Jackson, Mississippi, USA. He is the world expert in the analysis and interpretation of bone trauma for medico-legal investigations. He is also the leading authority on saw and knife mark analysis. He is a sought-after consultant in criminal cases with a particular specialty in criminal dismemberment and mutilation and has provided cut mark analyses in at least 200 dismemberment and 400 knife wound cases. Both Prof Symes and I are Board Certified Forensic Anthropologists in the USA (D-ABFA 57 and 84, respectively). Dr Venter is a consultant orthopaedic surgeon at Tygerberg Hospital in Cape Town, South Africa. He has fellowship training in limb lengthening and treatment of chronic osteomyelitis. Currently, he is a part time lecturer in the Division Clinical Anatomy at Stellenbosch University and also coordinates multidisciplinary research projects, between the Institute of Biomedical Engineering (IBE), Division Clinical Anatomy and Division Orthopaedic Surgery.
During the course, Prof Symes and Dr Venter each discussed characteristics of blunt and ballistic injuries as well as healed injuries (suspected child abuse) from their respective practices. Prof Symes and I discussed burned bone along with other colleagues from the University of Coimbra. I focused on conveying to our audience the big picture of trauma analysis, the limitation of our interpretations and how forensic anthropologists fit (and collaborate) within the larger medico-legal system. As a team, we all worked with the course attendees on interpreting bone fractures from a variety of bone trauma cases. After the course, Dr Venter was also asked to evaluate healed fractures and possible osteomyelitis infections from the Neolithic period.
Our aims were to present a course that would assist our colleagues in improving their knowledge of bone trauma and the application of bone trauma analysis in their case work within a medico-legal environment.
A total of 32 practitioners attended the course from around the world, including Brazil, Sweden, France, Portugal, Italy and South Africa. During the week, the facilitators provided lectures and hands-on practicals in blunt, ballistic, burned and healed traumatic injuries to bone. The hands-on approach to teaching in all areas of bone trauma were definite highlights of the course. We had the opportunity to physically break foam casts of tibia and fibula to simulate bone trauma and assess fracture patterns in blunt force trauma. We also discussed pre- and post-operative radiographs of long bone fixation in South African gunshot victims.
Opportunity to work with real and simulated bone was enhanced by the peer to peer interdisciplinary collaboration of course attendees. The class was structured around a particular topic each day but the execution of these topics were informal with some participants sharing information about their own cases and/or research throughout the week. We also made a Google Drive available to participants with articles, lectures, as well as redacted case reports and methods on how to compile a biological profile and to describe traumatic injuries to bone. The inter-disciplinary perspectives on bone injuries from a both forensic anthropology and orthopaedic surgery provided practitioners with a more in-depth understanding of the limitations in interpreting fractured bone from skeletal remains.
For example, an orthopaedic surgeon is able to obtain a history from a patient as to how an injury occurred, but a forensic anthropologist or pathologist will often work without any information on the person they are working with. This is particularly true in South Africa where bones are often haphazardly discovered in the veldt. Limiting one’s interpretations based on prior knowledge, or the lack of it, is a critical skill in bone trauma analysis, and, as we learned during this course, this concept is best represented with an inter-disciplinary approach.
Our greatest obstacle during the course was that the week was too short to disseminate all the information on all our cases. We did manage to initiate a community of practice in bone trauma analysis and we invited our colleagues to share their experiences and provide feedback and suggestions for improving the course. The feedback was overwhelmingly positive and for future courses, we will: narrow-down our bone trauma case list, provide a short synopsis for each case with its associated photograph, increase theoretical concepts through required reading and synthesis of ideas prior to the course, limit class sizes for better group interactions (particularly with the use of bones), as well as include extra time for sharp trauma (knives and dismemberments) and blast trauma.
"Post-university education is not something done to us or for us, but it comes from within us.."
Guided learning experiences are instrumental for professional development expertise in any discipline and is particularly needed in forensic anthropology. We need to build a community of practice as a means to mentor each other and to become more confident as experts, researchers and teachers in our discipline. Post-university education is not something done to us or for us, but it comes from within us - our internal dialogues, our feelings, our interactions with our colleagues and or our changing view of the world. A strong community of practice in bone trauma analysis is way forward for strengthening the discipline and improving our contributions towards those who no longer have a voice in our world.
Prof Ericka L'Abbé
Director of the Forensic Anthropology Research Centre (FARC)
Head: Physical Anthropology Section
Department of Anatomy
University of Pretoria
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