Ligature Knot Research Articles

A meta-analytic review of the frequency and patterning of laryngohyoid and cervical fractures in cases of suicide by hanging.

The frequency and distribution of fractures are commonly utilized to assist in interpreting the manner of death. In cases of alleged suicide by hanging, however, the evidence base for the frequency and patterning of laryngohyoid and cervical vertebrae fractures resulting from such blunt force traumatic events is limited and so fractures cannot be reliably used to assist in interpreting the manner. Using meta-analytic techniques, this study aimed to estimate frequency and distribution of fractures in the context of relevant intrinsic and extrinsic variables. A systematic review of the literature identified 20 studies with relevant data (8523 cases of suicide by hanging). Meta-analyses identified the frequency and distribution of fractures present and how fracture frequency was affected by the subgroups of age, sex, completeness of suspension, ligature knot position and study design. Results indicated that fracture frequency was variable, there was no unique patterning, and high levels of heterogeneity were present in all variable sub-groups. Age was the only subgroup to show differences. Findings suggest that neck fracture frequency is inconsistent and cannot be predicted by the chosen variables. Subsequently, neck fractures in isolation should not be given weight in medico-legal interpretations of a hanging death as suicidal.

Long Drop Suicidal Hanging with Autopsy Finding of Cervical Spine Fracture: A Rare Case Report

Cervical fracture is a rare presentation in suicidal hanging but a common finding in judicial hanging where the person is dropped from a calculated height, resulting in fracture dislocation at the level of 2nd-3rd or 3rd-4th cervical vertebrae. In case of long drop hanging cervical fracture with or without dislocation is commonly found; possibly due toa greater tractional force due to longer height of suspension. We describe acase of an average built male weighing 72 kg who hanged himself by jumping off a roof top, with a drop length of 4.14m. On autopsy in addition to common findings of a hanging case, complete transection ofspinal cord and fracture dislocation of cervical vertebrae C2-C3 were found along with hematoma. In this case of long drop hanging, there was fracture of cervical spine with ligature knot being placed at sub-occipital position which is a rare autopsy finding.

Laryngohyoid fractures in suicidal hanging: A prospective autopsy study with an updated review and critical appraisal

Laryngohyoid fractures in hanging victims are one of the most studied and paradoxically contradictory topics in forensic pathology. According to literary sources, the incidence of laryngohyoid fractures in hanging varies significantly, from 0% to 100%. To verify the diagnostic significance of these injuries in hanging, we prospectively and consecutively analyzed the occurrence of laryngohyoid fractures in a group of 178 suicidal hanging victims (M/F=150/28, aged 14–94years, mean age=50, complete suspension=111 cases, partial suspension=67 cases) in relation to selected variables (age, sex, weight, the completeness of body suspension, and ligature knot location). Altogether, we identified the following types of laryngohyoid fractures in 129 of 178 cases (72.5%): isolated fracture(s) to the thyroid cartilage in 60 cases (33.7%), combined thyrohyoid fractures in 41 cases (23.0%), isolated fracture(s) to the hyoid bone in 28 cases (15.7%), and no fractures to the cricoid cartilage or the cervical vertebrae. The highest frequency of laryngohyoid fractures was found in lateral hangings (right lateral: 26/34, 76.5%; left lateral: 31/37, 83.8%), whereas the lowest rate was found in anterior hangings (4/11, 36.4%). In lateral hangings, fractures more often occurred contralaterally to the suspension point. Statistical analysis revealed significant associations of the occurrence of laryngohyoid fractures with the age of the victim (p=0.028), with the position of the ligature knot on the neck (p=0.019) and with the age-corrected weight of the victim (p=0.026). In addition, we performed a systematic updated review and critical appraisal of relevant literary sources to report the incidence, fracture patterns, and contributing variables of laryngohyoid injuries in hanging. Both the results of our study and the provided literary synthesis show that if evaluated properly, laryngohyoid fractures in hanging may diagnostically offer far more than just evidence that injury to the neck occurred and may also present research opportunities regarding several issues that should be further analyzed and explained.

Sub-occipital ligature knot in a case of long drop suicidal hanging with rare autopsy finding of cervical spine fracture

BackgroundHangman’s fracture (Fracture of cervical vertebrae) in hanging is usually described into the context of judicial type of hanging where the individual is dropped from a calculated height with sub-mental or sub-aural position of ligature knot. Such a long drop with typical upper cervical vertebral fracture is a rare entity in a case of suicidal hanging.Case presentationWe have described such a case where an average built deceased weighing 62 kg hang himself with a nylon rope by jumping from a branch of tree with a drop length of 6.3 m, which was sufficiently long enough to cause soft tissue injuries, transection of larynx along with fracture and dislocation of cervical spine at C2-C3 level contrary to the fact that position of ligature knot was in sub-occipital area. Hence, this rare case is discussed with reference to the probable mechanism involved in causation of such internal injuries.ConclusionIn our case of long drop hanging, we found fracture of cervical spine when ligature knot was placed at sub-occipital position which is a rare autopsy finding. We also noticed deep laceration of skin and transection of larynx as extremely rare finding in hanging caused by flexible and blunt nylon rope used as ligature material.

Study of Nature of Ligature Material, Knot type and Pattern of Ligature Mark in Death Cases Caused by Hanging and Compression of Neck in Ajmer District

Study of Nature of Ligature Material, Knot type and Pattern of Ligature Mark in Death Cases Caused by Hanging and Compression of Neck in Ajmer District

Study on Nature of Ligature Material, Knot type and Pattern of Ligature Mark in Death Cases Caused by Hanging and Ligature strangulation in Ajmer District

Study on Nature of Ligature Material, Knot type and Pattern of Ligature Mark in Death Cases Caused by Hanging and Ligature strangulation in Ajmer District

Ligature Material, Knot type and Pattern of Ligature Mark in Deaths Caused by Hanging and Ligature strangulation

Ligature Material, Knot type and Pattern of Ligature Mark in Deaths Caused by Hanging and Ligature strangulation

Remarkable findings in suicidal hanging

hanging by a tie that was fixed to the upper hinge of a door. His feet were touching the ground. It was known that he had tried to commit suicide before. At medico-legal autopsy a single furrow was found on the neck with a ligature knot behind the left mandibular angle. Dissection of the neck’s soft tissue in layers revealed bilateral fresh hemorrhages in the pharyngeal tonsils with macroscopic delineation of gland follicles (Fig. 1). Fractures of both superior horns of the thyroid cartilage, superficial hemorrhage in the tongue’s base, and petechiae of the facial skin and conjunctivae were also present. Except for brain swelling, pulmonary edema, and severe generalized atherosclerosis, no other findings were observed. Toxicological investigations were negative. The cause of death was declared as hanging and the manner of death was ruled suicide. Case 2 A 74-year-old man was found hanging from the railing of a bridge, freely suspended by a hemp rope with an estimated drop of 3.5‐4 m. The deceased was 160 cm tall and weighed 77 kg. The 1 cm thick rope compressed the neck with a knot on the anterior area of the neck forming a loop that ran above the laryngeal protuberance. The loop ended in a fixed ligature knot behind the left ear. At external examination, dried saliva was found coming out of the right corner of the mouth, draining down over the chin. Autopsy revealed bilateral symmetrical hemorrhages at the sternal insertion of the periosteal-clavicular origin of the sternocleidomastoid muscles, and a complete laceration of all tissue layers between the cricoid cartilage and the hyoid bone that crossed the upper part of the thyroid cartilage and exposed the laryngeal mucosa. The trachea contained a small amount of fine froth with no signs of blood aspiration. A full-thickness transverse laceration, as well as superficial tears in the intima of the right common carotid artery, were also seen proximal to the bifurcation (Fig. 2). Hemorrhages (‘‘Simon’s bleedings’’) beneath the anterior longitudinal ligament of the thoracic and lumbar spine were also present. Toxicological analysis was unremarkable.

Cervical spine injuries in suicidal hanging without a long-drop—patterns and possible underlying mechanisms of injury: an autopsy study

The incidence of cervical spine injuries in suicidal hangings with a short-drop has been reported to be extremely low or non-existent. The aim of this study was to determine the frequency and pattern of cervical spine injuries in suicidal hanging. A retrospective autopsy study was performed and short-drop suicidal hanging cases with documented cervical spine injuries were identified. This group was further analyzed with regard to the gender and age of the deceased, the position of the ligature knot, the presence of hyoid-laryngeal fractures, and the level of cervical spine injury. Cervical spine injuries were present in 25 of the 766 cases, with an average age of 71.9±10.7years (range 39-88years). In 16 of these 25 cases, the ligature knot was in the anterior position. The most common pattern of cervical spine injury included partial or complete disruption of the anterior longitudinal ligament and widening of the lower cervical spine disk spaces, associated with absence of hyoid-laryngeal fractures. Cervical spine injuries are not commonly found in short-drop suicidal hanging, occurring in only 3.3% of all observed cases. Cervical spine injury may be occurring in 80% of subjects aged 66.5years and above. The most common pattern of cervical spine injury included anterior longitudinal ligament disruption of the lower cervical spine, disk space widening, and no vertebral body displacement. These injuries were mainly associated with an anterior knot position, and may be a consequence of loop pressure to the posterior neck and cervical spine hyperextension.

An unusual complete laryngo-tracheal separation in a suicidal hanging with a drop effect

Case report A 48-year-old man was found in a public garage, having committed suicide by hanging. The rope which he used as ligature was fixed to the garage’s iron fence. The hanging was complete, with a recorded drop of 2‐2.5 m. An autopsy was performed the following day. The deceased was 186 cm tall and weighed approximately 90 kg. The 2 cm wide rope had compressed the neck to approximately 9.5 cm in diameter. The fixed ligature knot was on the posterior area of the neck as in a typical hanging (Fig. 1a), while the loop was below the laryngeal protuberance. After removing the noose a deep, wide strangulation mark was clearly visible (Fig. 1b). Subsequent dissection of the layers of skin and soft tissue of the neck revealed slight bilateral symmetrical hemorrhages at the periosteal-clavicular origin of the sternocleidomastoid muscles, a complete separation of the larynx from the trachea to the cricotracheal ligament, where part of the esophagus (Fig. 2) and a partially fractured anterior part of the cricoid cartilage were clearly visible, and Amussat’s sign (bilateral superficial transverse lacerations in the intimal layer of the carotid arteries visible below its bifurcation) (Fig. 3a, b). No fractures of the hyoid bone, thyroid cartilage, or cervical spine were found. In the region of the lumbar spine, Simon’s sign (hemorrhages beneath the anterior longitudinal ligament) was also present. Other major autopsy findings were consistent with a rapid death. The victim’s blood alcohol concentration was found to be 0.63 g/l. The cause of death was attributed to severe air-way injury due to hanging; i.e. a complete laryngo-tracheal separation.

Anatomopathological findings in hangings: a retrospective autopsy study

In this retrospective autopsy study, we aimed to review the anatomopathological findings observed in cases of hanging death for a five year period and to evaluate the role of contributing factors such as age, sex, type of hanging and localization of the ligature knot. Autopsy reports of 102 hanging cases performed by the Department of Forensic Medicine, Faculty of Medicine of Pamukkale University, between January 2007 and September 2011, were retrospectively reviewed. In the 102 hanging cases 73 of the victims were males (71.6%) and 29 (28.4%) were females, with a mean age of 40.97 ± 17.41 years. All cases were suicidal hanging. Fifty four cases (52.9%) were typical hanging, with the ligature knot located posteriorly. There were petechial hemorrhage on the face and eye lids in 46 (45.1%), ecchymoses of the cervicale muscles in 43 (42.2%), and fractures of the neck structure(s) in 69 cases (67.6%). The incidence of neck structure fractures increased with age. In addition, there was no correlation between the incidence of neck structure fractures and sex or type of hanging.

Significance of Hemorrhages at the Origin of the Sternocleidomastoid Muscles in Hanging

Hemorrhages at the periostal-clavicular origin of the sternocleidomastoid muscles are part of the indirectly induced autopsy findings in death by hanging. In a prospective study of 178 cases of hanging, clavicular hemorrhages were found in 110 cases (a relative frequency of 62%). A statistically significant association between occurrence of hemorrhages and completeness of the victim's body suspension was discovered (P = 0.046) as well as a significant association between the occurrence of hemorrhages and the location of the ligature knot on the neck (P = 0.008). The occurrence of hemorrhages at the clavicular origin of the sternocleidomastoid muscles was independent of age, sex, and weight. This article renews the knowledge of this important vital sign described mainly in the German medicolegal literature.

Hyoid-laryngeal fractures in hanging: where was the knot in the noose?

The aims of this study were to determine the frequency of hyoid-laryngeal fractures in hanging in relation to the position of the ligature knot, to reconstruct the location of the ligature knot in cases of hanging when the furrow is not detectable on the skin, and to identify the possible mechanism of neck structure injuries. We report a retrospective autopsy study which included 557 cases of suicidal hanging: 413 men and 144 women, with an average age of 52.4 +/- 17.8 years. In 57.3% of them, hyoid-laryngeal fractures were found (average age was 54.3 +/- 16.5 years): 15.1% had only hyoid bone fracture, 26% had only thyroid cartilage fracture and 16.2% had both types of injury at the same time. Hyoid-laryngeal fractures were found more often in persons aged over 30 years. Hyoid bone fracture was a weak predictor of ligature knot position in our sample. Fracture frequencies of the thyroid cartilage show a statistically significant difference in relation to the ligature knot position among persons older than 30 years, which indicated the ipsilateral and posterior position of the knot. Absence or presence of any form of hyoid-laryngeal fracture indicated that knot position was anterior or posterior, respectively. The derived data would be useful for cases where the ligature has been removed from the body of the deceased shortly after hanging, where the noose is unavailable, and in cases where the ligature mark has faded such as with soft ligatures removed promptly or in decomposed bodies.

Amussat’s Sign in Hanging-A Prospective Autopsy Study

Amussat's sign is typically a transverse laceration of the intimal layer of carotid arteries described in cases of hanging. Subtotal laceration of the carotid artery is not strictly specific for hanging and can be also caused by blunt neck trauma, extreme overstretching, or whiplash-injuries. In a prospective autopsy study of 178 cases of hanging, Amussat's sign was found in 29 cases (a relative frequency of 16.1%). A statistically significant association between the occurrence of tears in the intimal layer of carotid arteries and the victims' age was discovered in the cases studied (the frequency increased with age; p<0.05). The occurrence of Amussat's sign was independent of gender, weight, completeness of the victim's body suspension, and position of the ligature knot on the neck. The study demonstrates the fact that the most probable cause of Amussat's sign is a combination of direct compression of the artery by the rope and indirect stretching because of the gravitational drag produced by the weight of the body.

A Mechanical Study of Ligature Security of Commercially Available Pre‐Tied Ligatures Versus Hand Tied Ligatures for Use in Equine Laparoscopy

To determine a hand-tied ligature knot configuration, suture size, and suture type that would be an acceptable substitute to commercially available ligature knots for use in equine laparoscopic surgery. Three-factor ANOVA with the fixed effects being suture type, suture size, and knot type. The dependent variable was ligature security (load to failure). Commercially available Endoloop and 4 hand-tied slipknot ligatures were compared with a 4-layer square knot. The hand tied ligature knots tested were the 4S modified Roeder knot, the Brooks knot, the modified Roeder knot, and the Weston knot. Two suture sizes (0, 2) of each of 2 suture types (polydioxanone, polyglactin 910) were tested with each hand tied knot. Two types (polydioxanone, polyglactin 910) of size 0 Endoloop were tested. Twenty repetitions of each knot suture type were tested for force to yield on a materials testing machine. Statistical analysis consisted of a 3-way ANOVA with individual comparisons made using the Bonferroni method. Significance was P< or = .05. Only the 4S modified Roeder knot in 2 polydioxanone (103 N) was comparable with the breaking strength of the square knots (157 N). All other knot suture combinations tested were significantly weaker than the square knot (range, 2-18 N). For equine laparoscopy, a 2 polydioxanone 4S modified Roeder knot would be an acceptable alternative to the commercially available Endoloop. Laparoscopic slip knots are commonly used in equine laparoscopic surgery. Various knot configuration and suture size and type combinations will affect the security of the slip knot.

Analysis of neck injuries in hanging.

Retrospective study of suicidal hangings was made on 175 cases (133 male victims, 42 female victims) for a 5-year period. The mean age was 47.33 +/- 17.51 years. The sample was divided in 4 groups according to the position of the ligature knot (anterior, right, left, and posterior hanging). The authors analyzed all visible injuries of soft tissues and bones and cartilage of the neck, and in 150 cases (85.7%), we established that there was at least one injury of these structures (hematoma or fracture for example). The most frequent injury was to sternocleidomastoid muscles. Fracture of throat skeleton was detected in 119 cases (68%). The proportion of fractures increases with age of the deceased. There was no clear correlation between frequency of neck injuries and type of hanging.

A novel ligation forceps can be used as a ligature carrier and knot pusher during laparoscopic surgery.

To extend the usefulness of laparoscopic operations, a secure and easy method for the ligation of large vessels is needed. Herein we describe a novel ligation forceps that can be used as a ligature carrier and knot pusher. A 2-0 suture thread with a knot already tied near one end is hooked in the upper jaw of a novel ligation forceps. After the lower jaw is passed under the vessel or cystic duct, the forceps is closed. When one end of the thread is withdrawn, the knot is trapped in the indentation built into the lower jaw; the ligature is then passed under the pedicle. An extracorporeal ligation can then be performed continuously by the same forceps. The origins of large vessels were ligated safely and easily with this device during 65 laparoscopic procedures (four total colectomies, 12 colectomies, and 49 gastrectomies). Following temporary hemostasis of accidental bleeding with clamping forceps, ligation hemostasis can also be performed using this instrument. This novel ligation forceps permits the secure ligation of vessels or a cystic duct without the need for another device. The proposed method is both easy and inexpensive.

New instrument for laparoscopic ligature

A new technique of applying a laparoscopic ligature is described using a self-designed ligature carrier and knot pusher.

Technique of closing the sinus tonsillaris by suturing the pillars of the fauces with the aid of la force's hollow suture needle and ligature knot fastener

Technique of closing the sinus tonsillaris by suturing the pillars of the fauces with the aid of la force's hollow suture needle and ligature knot fastener