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V. PHYSICAL EVIDENCE OF TORTURE AND ILL-TREATMENT ISTANBUL PROTOCOL

(g) Painful peripheral neuropathy. This may be a disoriented or lose consciousness. Careful examination
late complication of falanga. Other causes, such as should be made for ligature marks, which may vary
diabetes, should be ruled out. depending on the type of ligature (e.g. metal handcuffs,
plastic ties or rope). Reverse suspension may produce
443. Routine radiographs are recommended as permanent brachial plexus injury in a short period.
the initial examination. MRI is the preferred The “parrot perch” may produce tears in the cruciate
radiological examination for detecting soft tissue ligaments of the knees. Victims will often be beaten
injury. MRI or scintigraphy can detect bone while suspended or otherwise tortured or ill-treated. In
injury in the form of a bruise, which may not the chronic phase, it is usual for pain and tenderness
be detected by routine radiographs or CT. 434 around the shoulder joints to persist, as the lifting of
weight and rotation, especially internal, will cause
3. Suspension severe pain many years later. Complications in the
acute period following suspension include weakness of
444. Suspension is a common form of torture that can the arms or hands, pain and paraesthesia, numbness,
produce extreme pain, but which leaves little, if insensitivity to touch, superficial pain and tendon reflex
any, visible evidence of injury. Oedema of the loss. Intense deep pain may mask muscle weakness.
dependent or constricted limbs may be found with In the chronic phase, weakness may continue and
the risk of deep vein thrombosis with prolonged progress to muscle wasting. Numbness and, more
restraint in a single position, including forced frequently, paraesthesia are present. Raising the
standing. The finding of peripheral neurological arms or lifting weight may cause pain, numbness
deficits, diagnostic of brachial plexopathy, virtually or weakness. In addition to neurologic injury, there
proves the diagnosis of suspension torture. may be tears of the ligaments of the shoulder joints,
Suspension can be applied in various forms: dislocation of the scapula and muscle injury in the
shoulder region. On visual inspection of the back,
(a) Cross suspension, which is applied by spreading the a “winged scapula” (prominent vertebral border
arms and tying them to a horizontal bar; of the scapula) may be observed with injury to the
long thoracic nerve or dislocation of the scapula.
(b) Butchery suspension, which is applied by fixation of
the hands upwards, either together or one by one; 446. Neurologic injury is usually asymmetrical in the
arms. Brachial plexus injury manifests itself in
(c) Reverse butchery suspension, which is applied by many different ways, including motor, sensory and
fixation of the feet upward and the head downward; reflex dysfunction. Subtle changes may be difficult
for a non-specialist to detect or diagnose. By the
(d) Reverse suspension, which is applied by suspending time of evaluation, the injury may have resolved,
the victim with the forearms bound together behind the but a careful history of the symptoms suffered is
back, the elbows flexed at 90 degrees and the forearms of value in the assessment and there should be a
tied to a horizontal bar. Alternatively, the prisoner is low threshold for specialist referral. Assessments
suspended from a ligature tied around the elbows or of possible neurologic injury should include:
wrists with the arms behind the back. A similar effect
can be produced when a victim is forced to lie prone (a) Motor examination. Asymmetrical muscle
with handcuffs behind their back, then pulled upwards weakness, more prominent distally, is the most
by the handcuffs; expected finding. Acute pain may make the
examination for muscle strength difficult to interpret. If
(e) “Parrot perch” suspension, which is applied by the injury is severe, muscle atrophy may be seen in the
suspending a victim by the flexed knees from a bar chronic phase;
passed behind the knees, usually while the wrists are
tied to the ankles. (b) Sensory examination. Complete loss of sensation
or paraesthesia along the sensory nerve pathways
445. Suspension may last from minutes to several hours is common. Positional perception, two-point
or even longer. The amount of time described as discrimination, pinprick evaluation and perception
spent suspended is often inaccurate as victims are of heat and cold should all be tested. If, at least three

434 Ozkalipci and others, “A significant diagnostic method in torture investigation: bone scintigraphy”.

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