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Scientific Working Group for Forensic Anthropology (SWGANTH)

Identifying and Describing Pathological Conditions, Lesions, and Anomalies

Issue Date: 08/01/2012

Revision: 0

Identifying and Describing Pathological Conditions, Lesions, and Anomalies

1.0 Principle, Spirit, and Intent 

Skeletal material and documentation should be examined in a systematic manner for the purpose 

of identifying, describing, and documenting pathological conditions, lesions, and anomalies that 

may be relevant to the identification of unknown individuals, life history, and/or the 

circumstances surrounding death. The examination should be performed in a manner that 

facilitates the development of a differential diagnosis as well as the independent replication and 

verification of the work performed and the conclusions drawn. 

2.0 Purpose and Scope 

These guidelines outline acceptable practices for describing, documenting, evaluating and 

reporting pathological conditions, lesions and anomalies in bones and teeth. Practitioners of 

forensic anthropology should implement these guidelines to the fullest extent as applicable, 

practical, and appropriate. In the absence of specific guidelines, or in the case of conflicting 

procedures, the principle, spirit and intent should be met. 

3.0 General Principles 

The pathological conditions, lesions, and anomalies detailed in these guidelines are the result of 

antemortem processes. The description and documentation of these conditions in the human 

skeleton can be extremely useful in helping to develop a presumptive identification and/or 

confirm the identity of unknown remains. The interpretation of observations of this type merits a 

cautious approach as the degree and type of bone response to various pathological conditions and 

lesions often overlap, particularly in infectious, metabolic, and neoplastic disease. 

Identification of pathological conditions, lesions, and anomalies should only be as specific as can 

reasonably be determined by a careful differential diagnosis. Evaluation of some conditions, such 

as biomechanically related changes to bone originating from degenerative joint disease might 

only require macroscopic observations. Other cases such as infectious, metabolic, neoplastic, and 

other complex designations may need to meet more specific criteria that can be better assessed 

through other modalities, such as imaging, histology, and microscopy. 

A detailed description (to include a graphic representation of the patterning and distribution) of 

observed conditions and their distribution throughout the skeleton may be sufficient when a 

differential diagnosis cannot be made. 
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Because the subject of pathological conditions, lesions, and anomalies is diverse and complex, a 

comprehensive and specific discussion of methods and literature is beyond the scope of these 

guidelines. Rather, the anthropologist working within this area is expected to consult the relevant 

literature, much of it clinically based, in accordance with the observations at hand. 

3.1 Pathological Conditions and Lesions

As often used in anthropology and medicine, a pathological condition represents an abnormal 

change in the normal anatomy, often the result of a disease, as recognized grossly, 

radiographically, or histologically. Common types of pathological conditions and lesions that 

may be diagnosed include: 

Chronic infectious disease (e.g., tuberculosis, osteomyelitis). 

Metabolic disorders (e.g., porotic hyperostosis, osteoporosis). 

Neoplastic diseases (e.g., tumors). 

Congenital anomalies (e.g., spina bifida). 

Vascular/circulatory (e.g., aneurysm). 

Degenerative joint disease (e.g., osteoarthritis). 

Calcified arterial plaque, cartilage, or other soft tissue. 

Autoimmune diseases (e.g., rheumatoid or psoriatic arthritis). 

Trauma (e.g., healed or healing fracture).

3.2 Anomalies 

Anomalies are recognized skeletal variants and are usually congenital or epigenetic in origin. 

They may or may not have clinical significance. 

Examples include: 

Accessory bones (e.g., wormian bones, Os japonicum). 

Bipartite bones (e.g., bipartite patella). 

Sternal, septal, and other apertures. 

Bifid and/or supernumerary ribs. 

Vertebral shifts and other axial anomalies. 

Prominent features (e.g., everted gonia, bilobed chin, unusually large or small facial 

features). 

Cranial asymmetry not attributed to cultural modification (e.g., scaphocephaly). 

Dental anomalies (e.g., supernumerary teeth, extra roots, dental agenesis).

Polydactyly.

4.0 Best Practices 

Where possible, pathological conditions, lesions, and anomalies should be assessed in 

comparison with standard examplars and models derived from documented clinical and research 
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cases with comparable diagnostic criteria. Exemplars may consist of anatomical sets, individual 

specimens, casts, reproductions, and medical/clinical or anthropological literature.

Interpretations of pathological conditions and lesions should be supported by documented 

clinical and forensic case studies and literature that provide sufficiently detailed observations. 

Forensic anthropologists should: 

Record, document, and describe all observations of pathological conditions, lesions and 

anomalies in osseous and dental remains. Bench notes, supplemented with written 

diagrams, sketches, photographs (and other imaging modalities, when appropriate), are 

best used to describe and evaluate pathological conditions, lesions and anomalies. 

Terminology should be consistent throughout.

Report only supportable conclusions based on a reasonable interpretation of all available

data. 

Present all reasonable interpretations (e.g., “... given the remains present, the advanced 

nasal destruction could be a manifestation of tertiary yaws, advanced syphilis, or 

leprosy”).

4.1 Description and Differential Diagnosis

The following section offers guidance and methodology for developing a differential diagnosis 

from osseous and dental remains. 

Rather than being an outcome or a result, differential diagnosis is a process of elimination that 

narrows the field of possible conditions. When a diagnosis cannot be made, a description of the 

observed features and pattern of distribution is sufficient. 

Depending on the nature of the remains (e.g., completeness, preservation) not all steps in the 

differential diagnosis process may be feasible and/or they may only progress to a certain stage in 

the process. If a definitive conclusion or diagnosis is not forthcoming, equivocal results should 

be reported as such. 

Upon recognition of a pathological condition, lesion, or anomaly, the anthropologist should 

describe, document, and attempt to identify what is observed using the process of differential 

diagnosis. The process of differential diagnosis may not result in a single diagnosis but a list of 

likely conditions. Regardless, description and documentation are the most important steps in the 

differential diagnosis. The observations should be completely described and documented using a 

combination of text, photographs, diagrams, radiographs (or other imaging modalities), and 

sketches. Other anthropologists should be able to visualize the condition on the bone based on 

the written description from the notes. 

4.2 Guide to Differential Diagnosis 
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Clearly describe skeletal conditions in case documentation using accepted anatomical 

terminology. For example, lesions may be described or classified as lytic, proliferative, a 

combination of both, or deformative. Other considerations in descriptions of conditions include: 

Overall shape and size. 

Extent of the bone involved (describe anatomically, e.g., distal third of shaft). 

Distribution on the bone (discrete, multifocal, diffuse, circumferential, etc.). 

Characteristics of the edges, walls, and floor (blunt, sharp, regular, irregular, etc.). 

Type of proliferative bone (compact, pitted, porous, loosely woven), if present. 

Remodeling of bone. 

Extent and progress of healing, if present. 

Presence of accompanying features (cloacae, sequestrae, periostitis). 

If the bone is damaged, where possible, describe the condition of the bone layers in cross section. 

Describe the condition of the remainder of the bone including the articular surface (e.g., 

eburnation on an adjacent articular surface).

Describe the adjacent bones (e.g., infection spread from the radial shaft to the interosseous crest 

of the ulna), to include articular surfaces. 

If paired, compare the altered bone to its antimere, and note atrophy, deformation, rarification, 

thickening, etc. 

Describe other related pathological conditions and lesions in the remainder of the skeleton. Some 

conditions (e.g., treponemal) are diagnosed based on overall lesion distribution patterns in the 

skeleton. 

If possible, describe the distribution of similar conditions, lesions, or anomalies in the 

population. Clinical literature can be consulted as to frequencies in various populations. If two 

or more conditions are suspected, list all possibilities and state which of them is more probable. 

This probability should be based on the literature and knowledge of the presumptive population. 

Consider that an individual may exhibit more than one condition concurrently. If there are 

ambiguous or conflicting criteria, they may represent two or more diseases. 

Conduct appropriate research using the clinical and anthropological literature, since many 

alternative diagnoses may not be obvious. 

When available, consider previously diagnosed conditions documented in the medical record.

5.0 Additional Considerations

5.1 Pseudopathology 
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Pseudopathology is a skeletal change or artifact that may mimic and be mistaken for a 

pathological condition or lesion during the process of differential diagnosis; it should be 

described and photographed and clearly distinguished from a bona fide condition. For example, 

taphonomic alterations like rodent gnawing or insect damage are sometimes mistaken for 

pathological conditions and lesions on bones. Cultural modifications may also be similarly 

misinterpreted. 

5.2 Secular, Temporal, and Geographical Considerations 

Given changes in the standard of living, access to and advances in medical care, and improved 

nutrition over the past 100 years, many chronic and acute conditions that once affected the 

human skeleton are now less common. Consequently, the presence of some conditions (e.g., 

chronic osteomyelitis) may be of value in differentiating more modern forensic cases from 

ancient or historic remains, or distinguishing remains of individuals with limited, or no, access to 

medical treatment.

Some pathological conditions, lesions and anomalies may suggest a regional origin for the 

remains, or reinforce previous population-based determinations (e.g., gout in adolescent Pacific 

Islanders). 

5.3 Occupational Markers 

Stresses and strain on an area of the skeleton over time may cause the skeleton to respond or 

adapt to these forces. The most common indicators of these types of changes are occupational 

markers. Occupational markers represent the cumulative effects on bone from repetitive activity 

over time (e.g., from occupational or recreational activity) that may alter the skeleton in the form 

of hyper-developed tubercles, crests, processes, and fossae; bowing or other changes in the 

diaphyses; facets; degenerative changes; or lesions. Often, in paired bones, asymmetry in 

robusticity, length, shape, and density may be indicative of such activity. Exposure to certain 

chemicals may alter bone response and quality. Facets, grooves, notches, fractures with worn 

surfaces, premature wear, and lesions may be apparent in the dentition.

6.0 Unacceptable Practices 

The following practices are considered unacceptable and should be avoided when identifying and 

describing pathological conditions, lesions, and anomalies: 

Reporting unsupportable results, over-reaching in interpretation, or too narrowly 

interpreting observations. 

Reaching a differential diagnosis with inadequate descriptions or documentation. 

Reaching an immediate conclusion without undertaking a differential diagnosis. 

Failing to employ imaging modalities when appropriate.