Histologic evidence of repetitive blunt force abdominal trauma in four pediatric fatalities

In cases of acute fatal child abuse, certain injuries, including cutaneous blunt force trauma, skull fractures, subdural hematomas, intra-abdominal hemorrhage, and retinal hemorrhages are common and well described in the pediatric and forensic literature. These gross findings at autopsy, when taken into consideration with scene investigation and interviews with caregivers, may indicate both a clear manner and cause of death. In such cases, the discovery of additional pathologic changes attributable to older abusive injuries helps support a conclusion of death due to inflicted trauma. We discuss four cases of fatal child abuse in which acute blunt force abdominal trauma was the cause of death. In each of these cases, careful examination with proper sectioning and microscopy of select abdominal tissues revealed that the acute tissue trauma was superimposed on a background of older, healing injury. This older trauma was characterized by classic histologic elements of tissue repair, including fibroblast proliferation, early scar formation, increased vascularity, and hemosiderin-laden macrophages. Iron and trichrome stains were used to confirm the presence of hemosiderin and fibrosis in all four cases, but the recognition of fibroblast proliferation and a reactive vascular pattern was best seen on routine hematoxylin and eosin stains. The gross and microscopic autopsy findings, along with available investigative information, established the diagnosis of chronic physical abuse.     

Disseminated neonatal herpetic infection simulating abusive anal trauma

Potential simulators of premortem trauma present problems of misinterpretation and possible false accusations of caregivers. A case of unsuspected neonatal herpes is reported with associated perianal ecchymosis that raises the possibility of sexual abuse. The decedent was an 8-day-old newborn infant who was born by Cesarean section and treated for 5 days postdelivery for sepsis. The newborn infant was discharged home but returned 2 days later with probable sepsis and new onset of perianal hemorrhage. She died 1 day later with autopsy, revealing neonatal disseminated herpetic infection with early anal involvement consisting of microscopic ulcerations with leukocytoclastic-like vasculitis and rare viral cytopathic changes. These histological changes produced grossly appearing anal ecchymosis with an absence of typical herpetic vesiculopapular lesions, which simulated abusive trauma. This case highlights the importance of considering occult neonatal herpes with associated perianal ecchymosis when presented with possible abusive anal trauma in a newborn infant.     

A case of traumatic osteomyelitis in a victim of child abuse

A premature black female infant born at 31 weeks gestation with history of 4 weeks in the newborn intensive care unit was discharged healthy to the care of her mother and was lost to follow-up. At age 4 months the infant was found dead in bed. There was no history of trauma and no external injuries were noted. There was no attempt at resuscitation. Coroner's autopsy showed acute bronchopneumonia, 3 partially healed skull fractures, a chronic subdural hematoma, chronic intracerebral hemorrhage, retinal hemorrhages, multiple healing rib fractures, a fractured fibula, and a partially healed fracture of the distal right radius. The fracture of the right radius showed a medullary abscess of the bone surrounded by scar tissue and containing pus and granulation tissue. We believe this inflicted fracture became secondarily infected by a hematogenous route. The final diagnosis of the cause of death was pneumonia secondary to multiple blunt force trauma, and the manner of death was diagnosed as homicidal. This is believed to be the first reported case of osteomyelitis in a context of child abuse.     

Suicide by blasting caps: a case study of rare cranial trauma

Suicide is a deliberate act of ending one's life. Suicide by use of any explosive device, when not involved in a terrorist act, is quite rare in occurrence when compared with other methods routinely utilized. In this paper, we present to the medicolegal community a case of an adult male who committed suicide with blasting caps and the subsequent extensive damage to the cranial hard tissue. Although the cause and manner of death were relatively straightforward, consultation with forensic anthropologists was requested for an anthropological trauma assessment of the highly fragmented skull. After the skull was cleaned and reconstructed, the analysis revealed similarities between blasting cap trauma to the head and high velocity gunshot trauma to the head. Therefore, in a case where some evidence may have been removed or destroyed, forensic analysis involving trauma of this magnitude could result in a misinterpretation of the true mechanism responsible for the osseous damage. In this case, cooperation among the law enforcement agency, coroner's investigators, the forensic pathologist, and forensic anthropologists provided a comprehensive death case analysis.     

Can Birth Trauma Be Confused for Abuse?

Abstract: An unexpected infant death is usually investigated with a complete autopsy. If evidence of prior trauma is found at autopsy in these cases, suspicion is raised for nonaccidental trauma. In a young infant, the residua of trauma received during birth has the potential to be incorrectly interpreted as nonaccidental trauma. We report a the findings of a 4 1/2‐month‐old‐infant that died unexpectedly with a healing linear skull fracture and a circular lesion over the calvarium found at autopsy. Though this lesion was concerning, the remainder of the autopsy and the histological findings did not support a diagnosis of recent trauma. Review of the literature describing birth injuries made the diagnosis of healing, residual birth trauma more convincing in this case.     

An unusual blunt force trauma pattern and mechanism to the cranial vault: Investigation of an atypical infant homicide

This case report presents an unusual fracture pattern in the cranium of a four-month-old infant indicative of child abuse. Upon postmortem examination, the infant presented with numerous bilateral linear cranial fractures running perpendicular to the sagittal suture with depressed and curvilinear fractures apparent on the supra-auricular surfaces of the cranium. Histological evidence indicates multiple traumatic events to the cranium. In addition, the stair-step pattern of a parietal fracture may represent multiple contiguous fractures from repeated loading of the head at different times with variation of the focal points of compressive force. Additionally, the left humerus, left radius, and left ulna have healing metaphyseal fractures, and the left ulna also has an antemortem diaphyseal fracture which resulted in the distal metaphysis being rotated 45 degrees medially. Integration of autopsy, anthropological, and neuropathological reports for this case suggest multiple inflicted injury episodes with a repeated atypical mechanism(s) to the cranial vault of the infant. During investigative interviews, the caretaker admitted to squeezing the infant's head and neck on multiple occasions to quiet the child. This reported abusive mechanism is consistent with the pattern of symmetric cranial fractures and soft tissue injuries indicating asphyxiation. This case report provides forensic investigators with a potential trauma mechanism to explore in cases when a similar pattern of cranial trauma is observed and highlights the need for greater research on fracture propagation and fracture healing in the infant cranium.     

Abusive Pediatric Thoracolumbar Fracture Due to Forced Hyperextension: Case Report,Biomechanical Considerations,and Review of the Literature

Pediatric thoracolumbar fractures are rare due to the physiological differences which afford greater resilience to the immature spine. Most pediatric thoracolumbar fractures occur as the result of high energy trauma, such as motor vehicle accidents, and modes of reasonable accidental injuries are limited by age and developmental capabilities of the child. These fractures can occur as the result of inflicted blunt force trauma and child abuse, and in most cases, the mechanism of injury to the spine is not known. We report the death of a 29-month-old man due to blunt force trauma to the back and forced hyperextension of the thoracolumbar spine causing fracture of the fourth lumbar (L4) vertebral body. A complete forensic examination revealed a previous healing fracture of the anterior aspect of the L4 vertebral body, with acute disruption of the anterior longitudinal ligament overlying the fracture site, complete fracture of the vertebral body, and fatal retroperitoneal hemorrhage. We present a review of the biomechanical considerations of the pediatric spine, a survey of pediatric spinal fractures, and a review of the literature on pediatric abusive thoracolumbar fractures. In this case, there was never a provided explanation for how the injury occurred; however, understanding the biomechanics of the pediatric spine allowed for the determination of the mechanism, force required to produce this specific pattern of abusive spinal injury, and the manner of death.     

Skull Fracture with Brain Expulsion in a One-Level Jumping-Fall

Abstract:  Here presented is the case of a one-level jumping-fall with extensive skull fractures and brain expulsion. The body was found on the basement floor at the foot of the stairs. At the autopsy, the skull was extensively fractured, with about half of the brain expulsed several feet away from the body. The cause of death was established as a craniocerebral trauma with brain expulsion. The circumstances and manner of death were still unclear at that time. A low fall seemed very unlikely considering the severity of the skull and brain damage. The police investigation clearly revealed that the man, in a paranoid psychotic state, attacked his wife with a knife and then was witnessed by his children to have hit his head several times with a hammer. Afterwards, they saw him running to the top of the basement stairs and jumping to the bottom of the stairs head first.     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

Persistent Retinal Iron in Abusive Head Trauma

Retinal hemosiderin deposition is a histologic indicator of sustained hemorrhage but cannot be used to precisely estimate the elapsed time since an episode of trauma. A 5‐month‐old male infant was admitted to hospital after acute deterioration. Examination revealed encephalopathy, subdural hematomas, and retinal hemorrhages consistent with abusive head trauma (AHT). At the age of 3, he was readmitted to hospital with spontaneous osteopenic fracture of the right femur. The patient deteriorated and died after unsuccessful resuscitation. Ophthalmopathological investigation showed atrophy of the retina and optic nerve and hemosiderin deposition in both eyes. Retinal hemosiderin deposition is currently generally assumed to disappear within 6–8 weeks after the occurrence of hemorrhage in AHT. This case report describes an infant with bilateral retinal hemosiderin depositions due to hemorrhages sustained from AHT occurring 32 months prior to death. Implications of this finding for the interpretation of retinal hemosiderin depositions in AHT are discussed.     

Traumatic Death in Ankylosing Spondylitis

Abstract: Ankylosing spondylitis (AS) is a chronic rheumatic disease that causes spinal rigidity with an increased risk of spinal fractures. We present a case report where a middle‐aged man, in apparent good health, died following a fall from his bike. Postmortem computed tomography (CT) showed several fractures in the cervical and thoracic spine, with displacement into the spinal canal as well as spinal changes consistent with AS. The cause of death was determined to be upper spinal cord injury caused by cervical spinal fractures that were facilitated by spinal rigidity from AS. Further investigation into the medical records revealed that the decedent had previously been treated for AS. This case report illustrates the importance of obtaining a detailed medical history when investigating deaths, including nonfatal conditions, such as AS. Furthermore, it shows the value of CT in the evaluation of the mechanism and manner of death.     

Perimortem or Postmortem Bone Fractures? An Experimental Study of Fracture Patterns in Deer Femora*

The determination of perimortem trauma is important for forensic anthropologists. Characteristics of bone fractures such as sharp edges, presence of fracture lines, the shape of the broken ends, fracture surface morphology, fracture angle on the Z-axis, and butterfly fractures are said to differentiate perimortem from postmortem trauma. A Drop Weight Impact Test Machine was used to break 76 deer femora of various ages since death. The results of this study suggest that the characteristics listed above are unreliable at differentiating a perimortem fracture from a postmortem fracture in a forensic case. There are, however, statistically significant differences between fresh bones broken less than 4 days old and dry bones broken 44 days or 1 year old after death.     

Fatal acute intracranial injury, subdural hematoma, and retinal hemorrhages caused by stairway fall

We describe an infant with an acute subdural hematoma, a fatal head injury, and severe hemorrhagic retinopathy caused by a stairway fall. His cerebral and ocular findings are considered diagnostic of abusive head trauma by many authors. Our literature search of serious injuries or fatalities from stairway or low-height falls involving young children yielded 19 articles of primary data. These articles are discrepant, making the classification of a young child's death following a reported short fall problematic. This case report contradicts the prevalent belief of many physicians dealing with suspected child abuse that low-height falls by young children are without exception benign occurrences and cannot cause fatal intracranial injuries and severe retinal hemorrhages. The irreparable harm to a caregiver facing an erroneous allegation of child abuse requires physicians to thoroughly investigate and correctly classify pediatric accidental head injuries.     

Early Signs of Fracture Repair in the Human Rib Cage: Implications for Forensic Casework

The decomposed body of a woman discovered beneath a collapsed structure was examined at the C.A. Pound Human Identification Laboratory. Despite a mix of rib fractures with and without indications of healing, it is most likely that all fractures occurred as a result of a single, compressive event. Signs of intramembranous, and possibly direct, fracture healing at the incomplete fractures without signs of endochondral ossification at the complete fractures suggest the individual died very shortly—but not immediately—after injury. Given the case circumstances, the findings inform immediate cause of death. This case study highlights that differential healing as a result of a single event is possible. Further, it illustrates the importance of careful examination of micro‐discontinuities/cracks that can occur in association with major fractures. Fracture healing and dating data are discussed, as is the possible need for critical evaluation of the antemortem/perimortem boundary.     

Shark‐Inflicted Trauma: A Case Study of Unidentified Remains Recovered from the Gulf of Mexico*

Abstract: Here, we present a case of an unidentified male whose remains, except for the right arm, were recovered from the Gulf of Mexico 10 years prior to osteological analysis by forensic anthropologists. After the poorly preserved soft tissue was removed and the bones cleaned, forensic analysis revealed an unusual series of hard tissue trauma later attributed by a shark expert as shark scavenging and/or predation. Identified were five unique hard tissue trauma patterns that are bite mark artifacts produced by sharks: punctures without fractures, punctures with associated fractures, striations with bone shaving, overlapping striations, and incised bone gouges. The cooperation among experts provided a comprehensive death case analysis and a better understanding of shark‐inflicted trauma on human skeletal remains.     

Characterization and Comparison of Injuries Caused by Accidental and Non‐accidental Blunt Force Trauma in Dogs and Cats

Motor vehicle accidents (MVA) are often difficult to distinguish from non‐accidental injury (NAI). This retrospective case–control study compared animals with known MVA trauma against those with known NAI. Medical records of 426 dogs and cats treated after MVA and 50 after NAI were evaluated. Injuries significantly associated with MVA were pelvic fractures, pneumothorax, pulmonary contusion, abrasions, and degloving wounds. Injuries associated with NAI were fractures of the skull, teeth, vertebrae, and ribs, scleral hemorrhage, damage to claws, and evidence of older fractures. Odds ratios are reported for these injuries. MVA rib fractures were found to occur in clusters on one side of the body, with cranial ribs more likely to fracture, while NAI rib fractures were found to occur bilaterally with no cranial–caudal pattern. Establishing evidence‐based patterns of injury may help clinicians differentiate causes of trauma and may aid in the documentation and prosecution of animal abuse.     

Differential diagnosis of traumatic skull findings in infants: residues after vacuum extraction

If autopsy findings in an infant show traumatic changes on the skullcap, these are not always the result of a postnatal trauma due to child abuse, a fall or another accidental event. With regard to differential diagnosis a birth trauma should also be kept in mind, so that the history of the delivery is important. The spectrum of possible residues after vacuum extraction (circular fracture and/or elevation of the outer table of skull bones, subperiostal and intraossal haematoma, extradural and subdural haemorrhage) is demonstrated by means of three examples from the forensic autopsy material.     

Patterns of Trauma Induced by Motorboat and Ferry Propellers as Illustrated by Three Known Cases from Rhode Island*

Abstract: Understanding patterns of trauma is important to determining cause and manner of death. A thorough evaluation of taphonomy, trauma, and bone fracture mechanisms is necessary to reconstruct the circumstances of the death. This study examines the skeletal trauma caused by boat propeller strikes in terms of wound characteristics and location based on three cases from Rhode Island. These case studies review the traumatic characteristics caused by propeller injuries and highlight the anatomic regions most likely to sustain skeletal trauma. With this information, investigators may be able to identify propeller trauma even in severely decomposed remains. The discussion of boat propeller trauma also raises issues regarding how forensic anthropologists and forensic pathologists classify trauma (specifically blunt force vs. sharp) and highlights semantic issues arising in trauma classification. The study also discusses why these propeller cases should be classified as blunt trauma rather than sharp or chop/hack trauma. Ultimately, the authors urge consistency and communication between pathologist and forensic anthropologists performing trauma analyses.     

Death of a 6-year-old boy with mental retardation: accident versus child abuse

This case study involved death of a 6-year-old child with a history of mental retardation secondary to meningitis at 11 months, spastic quadriplegia, seizure disorder, and hydrocephaly with a remote ventriculoperitoneal shunt placement and gastric tube feedings. Reportedly, the child was co-sleeping with his mother when she awoke and discovered him lying prone and not breathing on the carpeted floor next to the bed. He was transported to the hospital and died in the emergency room of unknown causes. The medical examiner assumed jurisdiction of the body. The external examination revealed petechial hemorrhages on the neck and face, with patterned linear pressure abrasions on the chest, arms, and face. X-rays revealed leg fractures of different ages. This case emphasizes the importance of coordination of death scene investigation, medical history review, and autopsy results through a forensic team approach to determine the accurate cause and manner of death.