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CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 4  |  Page : 261-263  

A rare long-term complication of physical torture


Department of Forensic Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka

Date of Submission12-Jan-2017
Date of Acceptance27-Sep-2017
Date of Web Publication11-Dec-2017

Correspondence Address:
Prof. Muditha Vidanapathirana
Department of Forensic Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijabmr.IJABMR_14_17

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   Abstract 


The allegations made against custodians regarding ill treatments have been increased in Sri Lanka. However, their attention is grabbed by the immediate complications of torture, but not by late or delayed complications. A 35-year-old male was arrested for alleged housebreaking and kept under police custody. He alleged that he was hanged with his hands on several occasions. Six weeks after the incident, he presented to a tertiary care hospital with the weakness of his right shoulder. Examination revealed hyperpigmented scars over the left wrist and back of the left forearm with the right-sided medial winging of the scapula. He alleged that it had affected his day-to-day life. The presence of hyperpigmented scars over the left wrist and the long-term complications such as winged scapula of the right shoulder corroborated with the alleged history of torture by suspension from the wrists.

Keywords: Long-term complications, medial winged scapula, suspension from wrists, torture


How to cite this article:
Ranil Sanjeewa H K, Vidanapathirana M. A rare long-term complication of physical torture. Int J App Basic Med Res 2017;7:261-3

How to cite this URL:
Ranil Sanjeewa H K, Vidanapathirana M. A rare long-term complication of physical torture. Int J App Basic Med Res [serial online] 2017 [cited 2021 Jul 31];7:261-3. Available from: https://www.ijabmr.org/text.asp?2017/7/4/261/220359




   Introduction Top


The World Medical Association in its Tokyo Declaration in 1975 defined torture as “deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting along, or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.”[1]

When considered public media, it is thought that the public interest and the allegations made against custodians regarding ill treatments have been increased in Sri Lanka. Their attention is grabbed by the immediate complications of torture, but do not pay much attention to the late or delayed complications. However, perpetrators seldom kill or leave permanent physical marks on their victims, as corpse and scars are powerful evidence during a criminal investigation.[2]

The techniques of torture can be classified into 3 main groups; physical, psychological, and sexual.[3] Hanging is a type of physical torture and survivors can be suspended from upper limbs or lower limbs. When hands are used for hanging, the wrists or thumbs are tied in front of the body and then hang. Whereas, in Palestinian (reversed) hanging, the custodians tie the wrists behind the body of the person.[4] Both methods can cause damage to upper limb joints, nerves, muscles, and bones and produce short- and long-term complications. The present victim presented with a rare, long-term complication of such physical torture.


   Case Report Top


A 35-year-old male was arrested for alleged housebreaking. Custodians kept him under police custody and repeatedly tortured him physically and mentally. Alleged to have hanged with his hands for a number of hours for several occasions, on several days and had been beaten with clubs of numerous times. They applied coconut oil on his body before beating him and used soft ligature materials around the wrists to hang.

He presented to a tertiary care hospital 6 weeks after torture with the weakness of the right shoulder. He complained of poor concentration, lack of sleep, and fear. He also complained that he could not perform many movements of his right shoulder including the inability to raise the right hand above his head. He also alleged that he finds it difficult in combing his hair and changing clothes etc., Further, these have affected in his day to day life.

Examination revealed hyperpigmented scars; transverse, 1 cm × 5 cm scar over the left wrist and longitudinal, 2 cm × 9 cm scar, on back of the left forearm [Figure 1]. Further, the right-sided medical winging of the scapula was evident with resistance [Figure 2]. X-ray of the right shoulder excluded dislocation.
Figure 1: Hyperpigmented scars over left wrist and back of left forearm

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Figure 2: Right-sided medial winging of the scapula

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   Discussion Top


In winged scapula, the shoulder blade protrudes back with a wing-like resemblance. It is particularly be seen when the affected person pushes against a wall. The person may also have limited ability to lift his arm above the head.

Although the most common cause of winged scapula is serratus anterior palsy, there are still other circumstances that present the same ailment less commonly[5] such as trapezius and rhomboid palsy, and dislocation of scapula.[6] In this case, the dislocation of scapula was excluded by the X-ray studies. The differentiation of serratus anterior palsy and trapezium and rhomboid palsy is easy and is made on the position of the scapula. The serratus anterior paralysis results in medial winging of the scapula, and the trapezius and rhomboid paralysis causes lateral winging of the scapula.[7] In this case, the presence of medical winging confidently excluded the trapezius and rhomboid paralysis. However, scapular winging due to serratus anterior palsy is a rare lesion.[8] Further, the serratus anterior paralysis is typically caused by damage to the long thoracic nerve[6] due to several reasons; nontraumatic, iatrogenic, or traumatic injury.[7]

The causes of nontraumatic injury to the long thoracic nerve includes viral illness (e.g., influenza, tonsillitis-bronchitis, and polio), allergic-drug reactions, drug overdose, toxic exposure (e.g., herbicides, tetanus), C7 radiculopathy, and coarctation of the aorta.[7] Evidence suggestive of such nontraumatic injuries were not found in this case.

The causes of iatrogenic winged scapula due to long thoracic nerve damage are forceful manipulation, mastectomies with axillary node dissection, and usually occur in females.[5] Such findings were not available in this case.

The trauma-induced long thoracic nerve injury includes repetitive movements of shoulder (e.g., weight lifting or sports that involve throwing), excessive compression of the shoulder area by straps (e.g., backpack palsy), various household activities (e.g., gardening, prolonged abduction of the arms when sleeping, etc.), and blunt trauma (e.g., blow to the neck or shoulder, etc.).[9] In this case, the presence of hyperpigmented scars over the left wrist and the medial winged scapula of the right shoulder corroborated with the history of physical torture by suspension from wrists by the custodians. The Istanbul protocol also has identified the winged scapula as a recognized complication of hanging from wrists.[10]

A winged scapula is considered normal in young children, but not in older children and adults. Since this victim presented after 6 weeks of the incident, it is a long-term complication. Scapular winging has contributed to decrease flexion and abduction of the upper limbs, as well as a loss in power and a source of considerable pain. Patients who developed winged scapula have more limitation of shoulder flexion, adduction, and abduction.[9] Therefore, it can affect a person's ability to lift, pull or push weighty objects, and other day-to-day work.[7] In serious cases, the ability to perform activities of daily living such as changing clothes and combing hair may be hindered.[7] In this case, he complained that he could not raise his right hand above the head and also has affected his day-to-day life including difficulty in combing hair and changing clothes. Therefore, the complications observed in the current case should also be considered as serious long-term consequences of the winged scapula.

Other bodily injuries may have been healed due to delayed presentation. Further, the custodians had applied coconut oil on his body before beating him and used soft ligature materials for hanging to avoid injuries, scars, or marks being produced. The victim further complained of poor concentration, lack of sleep, and fear. Therefore, in addition to physical consequences, consultant psychiatrist was in the opinion that he suffers with psychological consequences as well.


   Conclusion Top


The cause for the right-sided medial winging of the scapula was serratus anterior palsy following suspension from wrists. Finally, the medicolegal examination form issued to police included that he had suffered grievous injury following blunt force trauma. In addition to the above facts, the full medicolegal report sent to the courts included that the injury pattern is consistent with the given history of suspension from wrists by the custodians. Further, it was noted that these injuries have caused long-term physical and psychological consequences and has affected his day-to-day life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
The Declaration of Tokyo Adopted by the 29th World Medical Assembly. Tokyo Japan: World Medical Association; 10th October, 1975.  Back to cited text no. 1
    
2.
Galano GJ, Bigliani LU, Ahmad CS, Levine WN. Surgical treatment of winged scapula. Clin Orthop Relat Res 2000;8466:652-60.  Back to cited text no. 2
    
3.
Shrestha NM, Sharma B. Torture and Torture Victims. 1st ed. Published by Centre for Victims of Torture, Nepal (CVICT); 1995.  Back to cited text no. 3
    
4.
Pollanen MS. Fatal rhabdomyolysis after torture by reverse hanging. Forensic Sci Med Pathol 2016;12:170-3.  Back to cited text no. 4
    
5.
Nevola Teixeira LF, Lohsiriwat V, Schorr MC, Luini A, Galimberti V, Rietjens M, et al. Incidence, predictive factors, and prognosis for winged scapula in breast cancer patients after axillary dissection. Support Care Cancer 2014;22:1611-7.  Back to cited text no. 5
[PUBMED]    
6.
Istanbul Protocol, Manual of Effective Investigations and Documentation of Torture and other Cruel, Inhuman and Degrading Treatment or Punishment. New York, Geneva: Officer of the United Nations High Commissioner for Human Rights; 2004. p. 40.  Back to cited text no. 6
    
7.
Martin RM, Fish DE. Scapular winging: Anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med 2008;1:1-1.  Back to cited text no. 7
[PUBMED]    
8.
Fardin P, Negrin P, Dainese R. The isolated paralysis of the serratus anterior muscle: Clinical and electromyographical follow-up of 10 cases. Electromyogr Clin Neurophysiol 1978;18:379-86.  Back to cited text no. 8
[PUBMED]    
9.
Winged Scapula. Available from: http://www.med.nyu.edu/neurosurgery/pns/conditions/injuries/scapular.html. [Last retrieved on 2016 Jan 24].  Back to cited text no. 9
    
10.
Nath RK, Lyons AB, Bietz G. Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: Long-term results in 50 cases. BMC Musculoskelet Disord 2007;8:25.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]


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1 Suspension torture and its physical sequelae
Sara Woldu,Marie Brasholt
Journal of Forensic and Legal Medicine. 2021; 80: 102155
[Pubmed] | [DOI]



 

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