Force Injuries Research Articles

Observational Case Series: An Algorithm Incorporating Multidetector Computed Tomography in the Medicolegal Investigation of Human Remains after a Natural Disaster

An algorithm incorporating multidetector computed tomography (MDCT), digital radiographs, and external examination was used to triage cases for noninvasive or complete autopsy after a natural disaster. The algorithm was applied to 27 individuals who died during or soon after the earthquake that struck the Republic of Haiti on January 12, 2010. Of the 27 cases reviewed, 7 (26%) required a complete autopsy to determine cause and manner of death. In the remaining 20 (74%), cause and manner of death were determined with a reasonable degree of medical certainty after review of circumstances, an external examination, and postmortem imaging by MDCT and digital radiography (noninvasive autopsy). MDCT was particularly useful in detecting skeletal fractures caused by blunt force injury which were not evident on digital radiographs. The algorithm incorporating postmortem MDCT can be useful in the triage of human remains for autopsy after a natural disaster.

An unusual mechanism for patterned bruising in a fatal fall from a building

A 90-year-old man was found dead lying on the ground in front of a building. He had committed suicide by jumping from the 5th floor (approximately 15 m height) of the building where he had lived in his apartment. His medical records revealed that the man had suffered from dementia with a history of psychiatric disorders and suicidal tendencies. A suicide note was found in his apartment. External examination of the body revealed blunt force injuries on the skin (abrasions and hematomas) of the thorax and on the limbs. Of note, an unusual finding was that of patterned bruising of the right forearm with parallel linear stripes along the posterior surface of the arm overlying the right radius and ulna (Fig. 1). At autopsy, multiple fractures of the thoracic cage including the sternum, the ribs and the thoracic spine, were found. Complete transmural tears of the heart were also observed together with extensive contusions and tears of both lungs and the liver. In addition, there were comminuted fractures of the lower limbs. Toxicological examination was negative. Death was attributed to multiple trauma. The manner of death was ruled as a suicide. Discussion

Prison Suicides in South Australia: 1996–2010

Forty-eight deaths occurring in prisons in South Australia were identified between January 1996 and December 2010, including 25 cases of suicide (mean age=37years; median age=34years; age range=24-70years). Most suicides were due to hanging (23/25; 92.0%) with victims using bedding, belts, or shoelaces attached to cell shelves, air vents, doors, or other accessible projections. There were no suicides attributed to drug overdose or sharp force injury. Over a third of all suicides (39.1%) occurred during the first month of confinement, with 26.1% of cases occurring within the first week. There was one suicide reported after 2years of imprisonment. Given that suicide in state prisons currently occurs at a rate approximately eight times that of the general South Australian community, it appears that the subset of incarcerated individuals represents a group in need of effective preventive strategies to enable more appropriate provisions of existing prisoner resources.

Homicide by Blunt Trauma in Brescia County (Northern Italy) Between 1982 and 2012

Blunt force injuries are produced by a variety of objects, including hands and feet (which is human strength) and many different weapons. Some of these objects produce distinctive patterns of injury of potential evidentiary value. This article presents a series of 53 homicides by blunt trauma along the period from 1982 to 2012, representing 16% of all homicides treated by the University Institute of Forensic Medicine in Brescia (northern Italy). Fifty-seven percent (30 cases) of the victims were male. The mean age of the victims was 47.9 years. The weapon most frequently involved was human strength. Not surprisingly, head trauma was the most common cause of death (66%). Forty-seven percent (25 cases) of the victims survived their assaults for varying periods. Homicides due to blunt trauma are still a relevant challenge for the forensic pathologist, who must obtain a complete and accurate history of the crime (including details regarding the crime scene), interpret patterns of injury and other findings at autopsy, and correlate all of the findings to make an accurate ruling of the cause and manner of death.

Headhunting and amphitheatre combat in Roman London, England: new evidence from the Walbrook Valley

In 1988, the disarticulated human remains of forty Roman individuals were discovered at 52-63 London Wall, London. Examination of the sample using techniques employed by forensic anthropology and entomology found that some of the material had been deposited in open waterlogged pits. The majority of the sample were adult males who had evidence for multiple peri-mortem blunt- and sharp- force injuries; many also had healed injuries, suggesting that violence was a common feature of their life. Despite the fact that this material was recovered from an industrial area in the upper Walbrook Valley of London, the evidence for trauma, their context and associated archaeological and environmental evidence reveals that these deposits are markedly different from other published examples of human remains from the Walbrook stream and River Thames, and may represent the remains of headhunting by the Roman army and/or defeated gladiators.

Management of blunt pulmonary injury.

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Death is due to Hemorrhagic Shock as a Result of Cranio-Cerebral Trauma-Accidental

Deaths due to fall from height, form an important area of study due to diversity of the injuries sustained, complexity of the patterns involved and various phenomenon's associated there with. The medico-legal autopsy aims at deciding whether the death was attributed purely to the height. It also helps in ruling out the various contributing factors like drugs, alcohol and co-existing natural disease. The study of pattern of external and internal injury may together indicate the primary site of impact and height from which the fall has occurred. The determination of actual or probable anatomical site of primary impact may be useful in reconstruction of the events, which led to fatal falls. Presence of multiple blunt force injuries makes it hard to differentiate between falls induced injuries and those that have been inflicted before the fall and often disagreement predominates regarding the height at which death results. Thus a careful study of total injury pattern is of vital importance in every case. In the difficult scenario of assessing the manner of death, meticulous autopsy in combination with visit to the scene of occurrence that includes observation of ground nature and presence of any intervening object is of extreme help.

Timing of blunt force injuries in long bones: The effects of the environment, PMI length and human surrogate model

Timing of blunt force trauma in human bone is a critical forensic issue, but there is limited knowledge on how different environmental conditions, the duration of postmortem interval (PMI), different bone types and different animal models influence fracture morphology. This study aims at evaluating the influence of the type of postmortem environment and the duration of the postmortem period on fracture morphology, for distinguishing perimortem from postmortem fractures on different types of long bones from different species. Fresh limb segments from pig and goat were sequentially left to decompose, under 3 different environmental circumstances (surface, buried and submerged), resulting in sets with different PMI lengths (0, 28, 56, 84, 112, 140, 168 and 196 days), which were then fractured. Fractured bones (total=325; pig tibia=110; pig fibula=110; goat metatarsals=105) were classified according to the Fracture Freshness Index (FFI). Climatic data for the experiment location was collected. Statistical analysis included descriptive statistics, correlation analysis between FFI and PMI, Mann–Whitney U tests comparing FFI medians for different PMI's and linear regression analysis using PMI, pluviosity and temperature as predictors for FFI. Surface samples presented increases in FFI with increasing PMI, with positive correlations for all bone types. The same results were observed in submerged samples, except for pig tibia. Median FFI values for surface samples could distinguish bones with PMI=0 days from PMI≥56 days. Buried samples presented no significant correlation between FFI and PMI, and nonsignificant regression models. Regression analysis of surface and submerged samples suggested differences in FFI variation with PMI between bone types, although without statistical significance. Adding climatic data to surface regression models resulted in PMI no longer predicting FFI. When comparing different animal models, linear regressions suggested greater increases in FFI with increasing PMI in pig, compared to goat, in both surface and submerged environments, although statistically not significant. No differences were found between environments except for buried vs. submerged goat samples and surface vs. buried/submerged tibia pig samples. FFI showed a weak association with PMI and it seems to be affected by various factors, such as different bone types, decomposition environments and climatic factors. Nonetheless, the FFI shows promising discriminating power during the early postmortem period. The apparent variation between bone types from different species suggests that extrapolations to humans can be challenging.

Deaths Due to Sharp Force Injuries in Bexar County, Texas, With Respect to Manner of Death

In the United States, there is a paucity of studies examining sharp force injuries (SFIs), defined as an injury inflicted by cutting or stabbing with a sharp instrument. Few studies exist that discriminate between the injury patterns of suicidal or homicidal deaths incurred by SFI. In this retrospective study, all deaths secondary to SFI were evaluated at the Bexar County Medical Examiner's Office from January 1988 through May 2010. Exclusion criteria were deaths occurring more than 24 hours after injury and wounds obscured by healing or extensive medical intervention. The following data were analyzed: age of decedent, sex, wound location, number of wounds, type of SFI (stab vs incised), visceral organ or vascular injury, concomitant injuries, and manner of death. Defensive injuries in homicides and hesitation marks in suicides were also recorded. A total of 418 deaths met inclusion criteria: 349 homicides, 54 suicides, 12 accidents, and 2 where the manner of death could not be determined.The average age of homicide victims was 35 years, whereas that of suicide victims was 47 years. Gender was not significantly different between the homicide and suicide groups. Homicide victims incurred a greater number of wounds per case compared with suicides, 5.3 versus 4.1, respectively, and had a greater number of stab wounds, 3.3 per case compared with 0.7 per case, respectively. Incisional wounds were statistically greater in suicides, with an average number of 3.3 per case compared with 2.1 in homicides.Injuries to the head, chest, and back were more common in homicides when compared with suicides, whereas injuries to the abdomen and extremities were more frequent in suicides. Comparison of major visceral and vascular damage between homicides and suicides revealed statistically greater injury to the heart, lungs, and thoracic vessels in homicides, but there was a greater frequency of injury to the vasculature of the extremities in suicides. The presence of additional (non-SFI) injuries was more common in homicides than in suicides. Hesitation marks/tentative wounds occurred in 35% of suicides, whereas defensive injuries occurred in 31% of homicides. This epidemiological study can assist the forensic pathologist in determining the most probable manner of death from SFI but does not substitute for a thorough examination of the circumstances of death and a meticulous autopsy.

Fatalities Due to Indigenous and Exotic Species in Florida

Florida's climate is suitable for many potentially hazardous animals, including both indigenous and exotic species, which are frequently kept as in zoos or as pets. This has resulted in many unforeseen fatal encounters between animals and the ever expanding human population. While the literature and knowledge pool for more common types of deaths referred to medical examiner/coroner's offices is abundant, the appreciation of wildlife and exotic pet-related deaths is far less widespread. We report seven animal attack-related deaths that occurred in Florida. The inflicted injuries included blunt and sharp force injuries, asphyxia, drowning, and envenomation. The underlying cause of death, however, was always a result of the human/animal interaction and in many cases related to human error and failure to appreciate the potentially dangerous behavior of nondomesticated species. These cases illustrate the varied circumstances and pathophysiologies associated with deaths due to indigenous and exotic species and the importance of the multidisciplinary approach in the medicolegal investigation of these cases.

Sharp Force Injury Toolmark Evidence Collection, Preservation, and Examination

This article is intended to provide information to the forensic pathologist about proper collection and preservation of toolmark evidence from sharp force injury events. Other topics include case histories, research related to toolmarks in cartilage and bone and toolmark examiner procedures for preparing specimens for examination. In cases where there is probative value in comparing a knife or other bladed implement to a toolmark left in bone or cartilage, it is essential that there is communication between the forensic pathologist and a toolmark examiner. With proper collection, preservation and examination of toolmarked objects by the forensic pathologist, a toolmark examiner may be able to identify or eliminate a suspect blade as having produced the defect, providing valuable information to the law enforcement and judicial community.

An atypical impaling injury of the iliofemoral region

A 46-year-old man with a history of chronic alcoholismwas found at his home address dead lying next to barrelsfilled with flammable liquids and an iron picket fence witha gate into a nearby a forest area (Fig. 1). Examination ofthe scene revealed blood traces with pubic hair coveringthe surface of some of the iron spikes of the gate (Fig. 2).An emergency doctor evaluated the decedent and describeda bizarre tear-like wound of the right femoral region.Because of the unclear cause-of-death determination, thebody was referred for a medico-legal autopsy evaluation.External examination of the adequately nourished,174 cm, 80 kg adult male showed an apparent, channel-like tissue defect of the right femoral region with evidenceof multiple blunt impacts, as well as superficial sharp forcewounds, over the entire anterior surface of the body(Fig. 3). On the right anteromedial aspect of the proximalportion of the femoral region there was an extensive(20 9 20 9 13 cm), obliquely oriented, and irregularlyshaped laceration (Fig. 4a). The wound path penetrated andtransected the quadriceps femoris muscle, the right femoralartery, and vein and entered the right inguinal region(Fig. 4b). The wound track then ascended through theretroperitoneal space and pierced the right psoas majormuscle. There was pronounced hemorrhage into the softtissues along the wound channel and around the pubicregion (Fig. 4c). In addition, four cm to the left of theabove laceration, another obliquely oriented skin perfora-tion was discovered measuring three cm in its largestdimension, that communicated with the impaling wound.The anorectal area was free of injuries. As indicated,multiple abrasions, contusions, and sharp force woundswere also found: on the ventral aspect of the upperextremities there were multiple, small, irregularly shapedcutaneous abrasions, and one deep cutaneous laceration inthe left cubital fossa; on the anterior aspect of the thoraxthere were two oval contusions and multiple longitudinalabrasions. External examination of the lower extremitiesalso disclosed multiple abrasions, contusions, and superfi-cial incised wounds. Internal examination did not show anyother injuries except those described. Toxicological eval-uation of blood revealed a blood alcohol level of 220 mg/dL. Further toxicological investigations of the blood andurine were negative.The cause of death was extensive external blood losscaused by transection of the right femoral artery and veinas a result of an atypical impaling injury.It appeared that the decedent, under the influence ofalcohol, tried to climb over the picket fence and wasaccidentally impaled through the right femoral region.Thus, the manner of death was classified as accidental. Weassume that repeated falls prior to the fatal event and theuncoordinated movements and striking of the body againstthe fence while impaled was a plausible explanation for themultiple blunt force injuries on the anterior aspect of thebody.DiscussionRare injuries, such as impalements are sometimesencountered at autopsy. Impaling injuries usually result

Animal-induced Injuries of Humans

doi:10.3415/VCOT-13-04-0050 One of our areas of focus in VCOT has long been the management of traumatic injuries in animals. Traumatic injuries in animals can arise from racing, falls, vehicular impact, and attacks from other animals, among other things. In the previous issue of VCOT was a report by Jordan and colleagues about the high risk of injury of vital structures, especially airways, sustained by dogs and cats that were bitten in the cervical region by other dogs (1). Aggressive behaviour by “man’s best friend” culminates in a surprisingly large number of bite wound injuries, and occasional deaths, of humans as well. Xiaowei and colleagues report that approximately 5000 patients are treated annually at the Peking University People’s Hospital in Beijing China for animalinduced injuries. From this population base, they conducted a prospective, randomized study comparing infection rates and cosmetic appearance of dog-bite wounds treated by primary or delayed wound closure (2). We are happy to see this paper published in VCOT because it provides a welcome boost to our mission to be a journal that encompasses comparative traumatology. Moreover, it is also a reminder of the need to look for opportunities to conduct well-designed prospective studies, in place of the usual retrospective clinical studies. To my knowledge, this is the first paper that we have ever published from China, and the first about animal-induced injuries in humans. Veterinarians are acutely aware of the risks of being injured by their patients. The types of injuries sustained by people are influenced by the species of the “attacking” animal (3). Large animals, including horses and cattle, produce blunt force injuries by kicking, crushing or trampling. This is particularly the case with massive animals like the elephant, in regions where human civilization encroaches upon the animal habitat (4). By contrast, sharp force injuries from carnivores, most often dogs, produce punctures and degloving injuries as well as lacerations and crushing. A search of PubMed revealed numerous studies of animal-induced injuries in humans. One surprising statistic from an epidemiologic study from Iceland was that the main cause of traumatic spinal cord injury in sport and leisure activities was horse-riding accidents, followed by winter sport accidents, especially among women (5). It made me realize that I had better be more careful with skiing, and to forget about any plan to resume horse riding.

Bioarchaeological investigation of sharp force injuries to the ribs and lower leg from the battle of Stoney Creek in the War of 1812

Bioarchaeological investigation of sharp force injuries to the ribs and lower leg from the battle of Stoney Creek in the War of 1812

‘Of Human Remains and Weapons in the Neighbourhood of London’: New AMS 14C Dates on Thames ‘River Skulls’ and their European Context

A number of injuries were observed in a recent examination of 150 Thames ‘river skulls’. Eight of these, exhibiting both healed and unhealed blunt force trauma, were sampled for AMS 14C dating. The results span the Middle Bronze Age to the Late Iron Age/Romano-British period, with the majority falling within the Late Bronze Age/Early Iron Age. Given the potential time-span involved, this clustering is striking—particularly as it is consistent with the results of other dating programmes on Thames crania—and appears to confirm the likelihood of an association between human remains and weaponry entering the Thames over this period. In this regard, it is intriguing that the majority of the injuries are the result of blows with a blunt instrument, raising questions over the nature of conflict at this time. Other crania do show sharp force injuries, but have yet to be systematically dated. We discuss these results in the broader context of recent discoveries of human remains and weapons associated with watery places in later prehistory across northern Europe, reinforcing the idea that both are best seen within a context of ritual deposition, though the details vary across time and space.

Effects of mechanical force on cytoskeleton structure and calpain-induced apoptosis in rat dorsal root ganglion neurons in vitro.

BackgroundA sudden mechanical insult to the spinal cord is usually caused by changing pressure on the surface of the spinal cord. Most of these insults are mechanical force injuries, and their mechanism of injury to the spinal cord is largely unknown.MethodsUsing a compression-driven instrument to simulate mechanical force, we applied mechanical pressure of 0.5 MPa to rat dorsal root ganglion (DRG) neurons for 10 min to investigate cytoskeletal alterations and calpain-induced apoptosis after the mechanical force injury.ResultsThe results indicated that mechanical forces affect the structure of the cytoskeleton and cell viability, induce early apoptosis, and affect the cell cycle of DRG neurons. In addition, the calpain inhibitor PD150606 reduced cytoskeletal degradation and the rate of apoptosis after mechanical force injury.ConclusionThus, calpain may play an important role in DRG neurons in the regulation of apoptosis and cytoskeletal alterations induced by mechanical force. Moreover, cytoskeletal alterations may be substantially involved in the mechanotransduction process in DRG neurons after mechanical injury and may be induced by activated calpain. To our knowledge, this is the first report to demonstrate a relationship between cytoskeletal degradation and apoptosis in DRG neurons.

Normal Organ Weights in Men

Organomegaly can be a sign of disease and pathologic abnormality, although standard tables defining organomegaly have yet to be established and universally accepted. This study was designed to address the issue and to determine a normal weight for the major organs in adult human males. A prospective study of healthy men aged 18 to 35 years who died of sudden, traumatic deaths was undertaken. Cases were excluded if there was a history of medical illness including illicit drug use, if prolonged medical treatment was performed, if there was a prolonged period between the time of injury and death, if body length and weight could not be accurately assessed, or if any illness or intoxication was identified after gross and microscopic analysis including evidence of systemic disease. Individual organs were excluded if there was significant injury to the organ, which could have affected the weight. A total of 232 cases met criteria for inclusion in the study during the approximately 6-year period of data collection from 2005 to 2011. The decedents had a mean age of 23.9 years and ranged in length from 146 to 193 cm, with a mean length of 173 cm. The weight ranged from 48.5 to 153 kg, with a mean weight of 76.4 kg. Most decedents (87%) died of either ballistic or blunt force (including craniocerebral) injuries. The mean weight of the brain was 1407 g (range, 1070-1767 g), that of the liver was 1561 g (range, 838-2584 g), that of the spleen was 139 g (range, 43-344 g), that of the right lung was 445 g (range, 185-967 g), that of the left lung was 395 g (range, 186-885 g), that of the right kidney was 129 g (range, 79-223 g), and that of the left kidney was 137 g (range, 74-235 g). Regression analysis was performed and showed that there were insufficient associations between organ weight and body length, body weight, and body mass index to allow for predictability. The authors, therefore, propose establishing a reference range for organ weights in men, much like those in use for other laboratory tests including hemoglobin, hematocrit, or glucose. The following reference ranges (95% inclusion) are proposed: brain, 1179-1621 g; liver, 968-1860 g; spleen, 28-226 g; right lung, 155-720 g; left lung, 112-675 g; right kidney, 81-160 g; and left kidney, 83-176 g.

Normal Organ Weights in Men

It has been shown that cardiac enlargement, whether hypertrophic or dilated, is an independent risk factor for sudden cardiac death, although the definition of what constitutes cardiac enlargement is not universally established. This study was designed to address this issue and to determine normal cardiac weights in adult men. A prospective study was undertaken of healthy men dying from sudden traumatic deaths aged 18 to 35 years. Cases were excluded if there was a history of medical illness including illicit drug use; prolonged medical treatment was performed; there was a prolonged period between the time of injury and death; body length and weight could not be accurately assessed; there was significant cardiac injury; or any illness or intoxication was identified after gross and microscopic analysis, including evidence of systemic disease. A total of 232 cases met the criteria for inclusion in the study during the approximately 6-year period of data collection from 2005 to 2011. The decedents had an average age of 23.9 years and ranged in length from 146 to 193 cm with an average length of 173 cm. Their weights ranged from 48.5 to 153 kg with an average weight of 76.4 kg. Most decedents (87%) died of either ballistic or blunt force (including craniocerebral) injuries. Overall, their heart weights ranged from 188 to 575 g with an average of 331 g and an SD of 56.7 g. Regression analysis was performed to assess the relationship between heart weight and body weight, body length, and body mass index and found insufficient associations to enable predictability. The authors, therefore, propose establishing a reference range for heart weight in men, much like those in use for other laboratory tests including hemoglobin, hematocrit, or glucose. A reference range (95% inclusion) of 233 to 383 g for the adult male human heart is proposed.

A Review of Blunt Force Injury Homicides of Children Aged 0 to 5 Years in Bexar County, Texas, From 1988 to 2009

It is essential that clinical physicians, medical personnel, medical examiners, and law enforcement agencies understand the types of injuries seen and demographics of children affected by intentional blunt force as this understanding can be crucial to the death and/or criminal investigations. An understanding of the injuries can also assist in drawing conclusions regarding how those injuries could have been sustained. This study discusses the types and patterns of injuries seen in blunt force homicides in children younger than 6 years. The study found that male infants are more often intentionally injured than are female infants and that fatal head injuries most frequently occur in the first year of life, whereas most fatal thoracoabdominal injuries occur in the first 3 years of life. In children with head injuries, subdural hemorrhage was the most common finding, followed by subarachnoid hemorrhage. In 2.5% of deaths due to head injury, concurrent neck injury was seen, a percentage far lower than previous literature would suggest if shaking was the primary mechanism of injury. Twelve legal confessions were also reviewed, none of which disclosed a pure mechanism of shaking the infant.

Radiologic Findings in Cases of Attempted Suicide and Other Self-Injurious Behavior

Suicide is one of the leading causes of death in multiple age groups. Therefore, it is important that radiologists be aware of this commonly encountered entity. Attempted suicide may take a variety of forms; those discussed by the authors include sharp force injury, immolation and inhalation, ingestion, hanging, firearm use, jumping from a height, and drowning. Certain radiologic findings are commonly seen in cases of attempted suicide and other self-injurious behaviors. In some cases, especially when the patient is unconscious or is unwilling to provide a history, it may not be apparent that suicide has been attempted until characteristic imaging findings are recognized. Correct identification of suicide attempts on the basis of such findings will ensure that these patients receive appropriate psychiatric treatment. When a suicide attempt is unsuccessful, it is important to be familiar with the complications that may contribute to delayed mortality and morbidity. The radiologist plays an integral role in the acute medical or surgical management of patients who have attempted suicide. In addition, imaging examinations may provide useful forensic information.