ORIGINAL ARTICLE The synergy between radiographic and macroscopic observation of skeletal lesions on dry bone Lucie Biehler-Gomez 1 & Stefania Tritella 2 & Federica Martino 3 & Carlo Pietro Campobasso 3 & Angélique Franchi 4 & Riccardo Spairani 5 & Francesco Sardanelli 2,6 & Cristina Cattaneo 1 Received: 14 May 2019 /Accepted: 4 July 2019 # Springer-Verlag GmbH Germany, part of Springer Nature 2019 Abstract The diagnosis of bone lesions is a fundamental part of the study of skeletal remains, both in the archeological and forensic context. On the one side, the literature proved the relevance of radiography for the detection of bone lesions; on the other side, the careful macroscopic observation of the morphology of bone lesions is often underestimated. For this study, we examined and performed plain radiography on 14 skeletons of the CAL Milano Cemetery Skeletal Collection diagnosed with rheumatoid arthritis, diabetes, multiple myeloma, metastatic cancer, and osteomalacia to compare the macroscopic morphology and radio- graphic visualization of bone lesions. At least 200 osteolytic lesions and 65 areas of proliferative bone reaction (either spongiosclerotic or periosteal) were studied. We realized “comparative sets” of macroscopic pictures and radiographic imaging of the same skeletal elements to allow comparisons of detection and recognition of bone lesions. As a result, while trabecular lesions may be lost through naked eye observation, many lesions can also be unperceived on radiographs due to contrast, including periosteal reactions, osteolytic lesions, and spongiosclerosis. The aim of this research was to investigate the strengths and pitfalls of digital radiography and macroscopic analysis and to demonstrate the synergy of a complementary approach between the two methods for lesion analysis in dry bone. Keywords Forensic anthropology . Bone pathology . Radiographic imaging . Rheumatoid arthritis . Diabetes . Metastatic carcinoma Introduction The study and recognition of bone pathologies is an important, although often underestimated, part of the forensic anthropol- ogy practice. When confronted with a skeletonized individual, the forensic anthropologist must construct an identikit or “bi- ological profile” to help narrow down the potential pool of candidates for identification among a list of missing persons. This biological profile includes the estimation of sex, age, ancestry, and stature, the recording of anatomical variants as well as the analysis of pathological and/or traumatic lesions. In addition, as skeletal features that distinguish one individual from another, bone pathology can act as factors of individual- ization [1]. Despite their potential, the main issue with bone pathology is their recognition. As bones can only react in two ways to injuries (with either bone proliferation—osteoblastic activity—or bone remodeling—osteoclastic activity), bone re- actions to different pathological conditions overlap. Complicating diagnosis even further are the non-specificity * Lucie Biehler-Gomez lucie.biehler@unimi.it 1 Laboratorio Di Antropologia E Odontologia Forense (LABANOF), Sezione Di Medicina Legale, Dipartimento Di Scienze Biomediche per La Salute, Università Degli Studi Di Milano, Via Mangiagalli 37, 20133 Milan, Italy 2 Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy 3 Dipartimento di Medicina Sperimentale, Università degli Studi della Campania “Luigi Vanvitelli”, via Santa Maria di Costantinopoli 16, 80138 Naples, Italy 4 Forensic Medicine Department, University Hospital of Lyon, Lyon 69003, France 5 Post-Graduate School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy 6 Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy International Journal of Legal Medicine https://doi.org/10.1007/s00414-019-02122-0