Deaths Due to Child Abuse: A 6‐Year Review of Cases in The Cook County Medical Examiner's Office

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.     

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.     

Suicidal or Homicidal Sharp Force Injuries? A Review and Critical Analysis of the Heterogeneity in the Forensic Literature

The differential diagnosis between self-inflicted and nonself-inflicted, suicidal and homicidal, injuries is difficult or impossible in many cases and, above all, cannot be made on the basis of information obtained solely from the autopsy or the medicolegal clinical examination. The purpose of this study is to analyze the literature on suicidal and homicidal sharp force injuries and identify the relevant parameters that may help differentiate between suicidal and homicidal deaths. To achieve this goal, a review of 595 potentially relevant articles was performed. After excluding the nonrelevant papers by screening the titles, all abstracts were reviewed, and articles meeting the inclusion criteria underwent a full-text review. The following parameters were compiled into a table: number of cases, localization of the injuries, and number of injuries. The data were statistically analyzed and compared with those available in the forensic literature. On the basis of the heterogeneity of data revealed by the present review, a simple and short checklist of the parameters that should be included when reporting suicides and homicides by sharp force has been proposed.     

Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children

Defendants accused of inflicting fatal abdominal injuries to children occasionally raise the defense that the injuries were caused by cardiopulmonary resuscitation (CPR). The purpose of this study is to answer the question: Does closed chest CPR result in fatal blunt abdominal injuries that can be mistaken for homicidal assault? To that end, a retrospective study was conducted of all homicidal blunt abdominal injuries in children 10 years and younger from the Dade, Broward, and Palm Beach Medical Examiner's Offices from 1981 through 1997. These were compared to cases of children who died of natural causes during the same time period in Broward County who had CPR (control group 1) and to children who died of nonvehicular accidental blunt abdominal trauma (control group 2). Children with life-threatening head injuries were excluded. Medical examiner records, autopsy reports, documenting photographs, and clinical records were reviewed. The data analyzed included subject demographics, whether CPR was performed and by whom, and autopsy findings. Thirty-three child homicides with fatal abdominal injuries were reviewed. Twenty-four (73%) of the homicides received CPR. There was no difference in the nature and severity of injuries between the 24 children who received CPR and the 9 who did not. Three hundred and twenty-four cases of pediatric natural deaths were reviewed, all of which had CPR. No traumatic abdominal injuries were found in any of the children who died of natural causes. Only four children who died of natural causes had evidence of extraabdominal trauma related to CPR. No cases of nonvehicular accidental blunt abdominal trauma were identified during the 17-year period, although there were nonvehicular accidental fatalities due to extraabdominal injuries. The likelihood of CPR-related primary abdominal trauma in child homicides is very low.     

Rare and Severe Maxillofacial Injury Due to Tear Gas Capsules: Report of Three Cases

Tear gases are used by police or armed forces for control of riots or social events or by the general population for private self‐defense. These agents are used widely throughout the world, but some harmful effects have reported. In addition, despite well‐defined chemical side effects documented in the literature, data are insufficient regarding mechanical injury due to tear gas capsules. We report three cases of severe maxillofacial injury in patients who had these capsules fired from tear gas guns directly to their faces. The capsules penetrated the patients' faces, causing potentially fatal injuries. To our knowledge, reports of this kind of injury related to tear gas capsules are very rare in the literature. In conclusion, tear gas guns may be very dangerous in terms of human health and they may cause severe injuries, especially when they are not used according to strict guidelines.     

列车撞击伤及碾轧伤的损伤形态与成伤机制

目的总结列车撞击、碾轧伤的典型损伤形态，探讨其成伤机制。方法对103例列车撞击伤、84例列车碾轧伤案例进行回顾性分析。结果不同的致伤方式及受害者伤时状态不同，在损伤形态及成伤机制上有所差异。结论典型损伤形态可为推断致伤方式及受害者伤时状态提供依据。     

Fatal Wounds Sustained from “Falling Bullets”: Maintaining a High Index of Suspicion in a Forensic Setting

Celebratory gunfire injuries from “falling bullets” occur when guns are fired into the air during celebrations without realizing that this can cause serious injuries or even fatalities. Fatal celebratory gunfire injury is an uncommonly reported event in the continental United States. Our electronic database was queried for homicides occurring within days of July 4th and December 31st over a 14‐year period. We describe two cases of fatal gunfire injury due to celebratory gunfire occurring during New Year's Eve in Southern Florida. The relevant literature is reviewed. These case reports illustrate that fatal gunfire injuries sustained from “falling bullets” may pose as an unexpected mimic to sudden natural deaths especially in patients with prior medical history. A high index of suspicion to recognize such injury is required particularly during holidays.     

Fatal Injury Caused by a Ram (Ovis Aries) Attack

Animal‐inflicted injuries to humans are a major public health problem around the world resulting in great morbidity, money loss, and mortality. They are related to wild and domestic animals alike. Animals can cause injuries by various mechanisms—biting, stinging, crushing, goring, stomping, butting, kicking, pecking, etc. We present a case of a ram's attack with fatal consequences. A 4‐year‐old, 120 kg jezersko‐sol?ava breed ram with prior history of aggressive behavior inflicted multiple injuries to his 83‐year‐old owner, who died in the hospital a few hours later due to severe blunt force injuries sustained in the attack. The autopsy revealed the cause of death to be multiple injuries of the thorax and the head. Sheep, even though they are not considered aggressive or large farm animals such as cattle and horses, can inflict serious injuries with devastating results.     

A review of blunt force injury homicides of children aged 0 to 5 years in bexar county, Texas, from 1988 to 2009

ABSTRACT: 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.     

Pediatric homicides related to burn injury: a retrospective review at the medical university of South Carolina

Many burn injuries are mistakenly referred to as "accidents" because they occur suddenly and seem unpredictable and uncontrollable; however, injuries often occur in predictable patterns. We reviewed all pediatric forensic cases referred to the Medical University of South Carolina Forensic Pathology Section over a 28-year period from January 1975 to December 2002. There were 124 cases with 121 fire-related fatalities and three scald fatalities. Ninety of the burn victims were in the 0-5-year age group. The manner of deaths showed 108 accidents and 12 homicides (four undetermined). Eleven of 12 burn-related homicides occurred at the home with all of the victims in the 1-8-year age group. The perpetrator of the home fire homicides was the mother in five cases and the sister in one case (two undetermined). Homicide involved a vehicle fire in one case in which the father caused an explosion with an accelerant. The three scald death perpetrators were the father, mother's boyfriend, and an aunt.This retrospective study and review of the literature may reveal patterns useful for evaluation of manner of death. By recognizing scene characteristics, potential perpetrators, and children at risk, we can better classify pediatric burn-related fatalities.     

Fatal traffic injuries among children and adolescents in three cities (capital Budapest, Vilnius, and Tallinn)

Motor vehicle accidental injuries are a frequent cause of death among young children and adolescents. The goal of this study was to compare patterns of injury between three capitals (Budapest, Vilnius, and Tallinn). Information on 190 fatal traffic accidents (69 pedestrians, 14 bicyclists, and 107 motor vehicle occupants) between 2002 and 2006 was collected from databases of medico-legal autopsies. The role of victims in accidents, the location of injuries, cause of death, survival period, and blood alcohol levels were evaluated. One-hundred and forty-one (74%) victims had a passive role in traffic as pedestrians, passengers in cars, or public transport. In victims who died at the scene, the rate of head injury was higher than in cases who received medical treatment (odds ratio = 2.58, CI = 1.2-5.55, p = 0.0127). These results underline the importance of postmortem studies to examine the pathomechanism of fatal traffic accidental injuries and to provide information for the prevention of road traffic accidents against children and adolescents.     

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario,Canada, 1990-1995

Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS). We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists. All deaths (age <17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed. Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inflicted trauma. The nature and frequency of the various injuries was determined. The frequency of the shaken baby syndrome, and the types and frequency of ano-genital injuries were also studied. Twenty-one cases of fatal CAMS were found in the study period. Most cases had significant recent head injury with intra-cranial hemorrhage (71%). Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%), blunt abdominal trauma with visceral injuries (14%), and fractures (18%). Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome. Many children with fatal head injuries had evidence of older head trauma (38% of all cases). A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%). Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome. Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury. A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment. All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.     

Breaking point? An analysis of fatal stab wounds to the torso in Ireland between 2011 and 2018, examining the extent of rib fractures

This study examines the pattern of rib injuries occurring in cases of fatal torso stab wounds in Ireland between 2011 and 2018. It has been suggested by previous studies that rib fractures are not commonly sustained in stab wounds to the torso. We wanted to ascertain whether this was the case, as our data suggested that rib fractures were frequent, and where a rib is fractured there is a higher chance of organ injury and death, making this an important area of study. One hundred and forty seven cases of fatal stab wounds from an eight-year period were retrospectively reviewed. Fatal stab wounds to other body areas, were excluded; leaving a total of 104 cases with stab wounds to the torso. We found that 69.2% of cases had rib injuries, a figure significantly higher than previously reported. Our data suggests that stab wounds to the torso often fracture ribs, putting the underlying organs at increased risk of injury and perhaps contributing to fatality. The amount of force needed to cause a rib fracture can be difficult to quantify and indeed from the high percentage of rib fractures sustained in our data it appears that the ribs may be fractured regardless of the amount of force used; this is borne out by the finding that self-inflicted injuries also caused rib fractures. Our study shows that other factors, such as anatomical positioning and wound depth may have a greater bearing than force in terms of whether a rib fracture is sustained.     

船舶螺旋桨损伤特点及成伤机制

目的总结船舶螺旋桨损伤的主要特点,探讨螺旋桨损伤的特点及形成机制,探索螺旋桨损伤与碎尸的鉴别方法。方法收集浙江省湖州地区1994─2005年尸检的100余例船舶螺旋桨损伤案例,对螺旋桨造成的损伤（擦划伤、表皮剥脱、创、骨折和全部离断创）的特点,以及衣着特征,进行回顾性分析。并与常见碎尸案中使用的工具造成的断面特征进行比较。结果船舶螺旋桨损伤是高速旋转螺旋桨的巨大劈力和机械切削所造成的损伤;碎尸是人为使用锐器切割或砍击尸体。两者由于形成机理、作用力及反作用力大小不同,导致损伤断面呈现不同的特征。结论船舶螺旋桨损伤具有独特的特征,可与碎尸损伤进行鉴别。     

Unusual Elevator-Related Deaths: A Report of Two Cases

We present two cases of elevator-related deaths that occurred in two different elevators, and deaths were caused by a similar, but unusual, mechanism. An elevator is a platform or compartment housed in a shaft for raising and lowering people or things to different levels. Elevator-related deaths and injuries are rarely reported in the literature. In most of these cases, cause of death was attributed to falls. It seems that most of the elevator accidents may be attributed to factors related to device maintenance inadequacies or even to device malfunctioning. In our cases, both elevator cars were not equipped with full-length inner doors, thus allowing both accidents to occur. Since 2014, the European Union adopted a relative directive, which imposes the need to equip all elevators with such full-length doors. The enforcement of the above-mentioned EU Directive is crucial, in order to prevent similar accidents in the future.     

Arterial-esophageal fistulae in patients requiring nasogastric esophageal intubation

A rare and potentially fatal cause of hematemesis is fistula formation between the esophagus and the vascular system. A case report of a 39-year-old woman with congenital aortic arch anomalies hospitalized for treatment of head injuries demonstrates the potential for iatrogenic esophageal trauma to initiate fistula formation between the esophagus and an anomalous arterial system. A literature review revealed 6 other cases of vascular-esophageal fistulae caused by nasogastric esophageal intubation. It is concluded that aortic arch anomalies increase the risk of esophageal injury and subsequent fistula formation from nasogastric esophageal intubation. In addition, the clinical features and pathologic findings of vascular-esophageal fistulae are reviewed.     

Age-specific peculiarities of manifestations of a craniocerebral injury in children and adolescents with a combined blunt trauma

This study was designed to estimate the frequency of head injuries and selected manifestations of craniocerebral traumas in children and adolescents with a fatal combined blunt trauma. It is included 289 cases of death from a combined blunt trauma (101 original observations and data of 188 archival documents). The victims were categorized into 3 age groups. One group was comprised of cases from 0 to 3 years of life, group 2 included children aged from 4 to 11 years, and group 3 those at the age from 12 to 18 years. The age was shown to significantly influence both the frequency of head injuries and their severity. The maximum values of the two variables were recorded in the youngest age group. The frequency of head injuries and the number of selected manifestations of the craniocerebral trauma decreased with age.     

Retrospective Analysis of Hanging Deaths in Ontario

Hanging deaths from investigation standpoint are rarely problematic. Unusual circumstances can on occasion raise suspicion of foul play. Associated neck injuries are reported in the literature with variable frequency (from 0% to 76.8%). This study retrospectively analyzed 755 hanging deaths in Ontario (Canada) to evaluate the demographic features and circumstances of hanging fatalities, and the frequency of hanging‐related neck injuries. A number of cases showed unusual/special circumstances (e.g., complex, double suicides, restraints). Among 632 cases with complete autopsies, hyoid and larynx fractures were present in 46 cases (7.3%) with the most common being isolated hyoid fractures. The incidence of cricoid fractures was 0.5% and cervical spine injuries, 1.1%. A higher incidence of neck injuries occurred among males, long drop hangings, and in cases with complete suspension. There was a tendency for the number of fractures to increase with increasing age and weight of the deceased.     

An Unusual Case of Predation: Dog Pack or Cougar Attack?

Injuries produced by animals are capable of leaving severe patterns and in some cases may result in the death of the attacked individual. Law enforcement authorities may come to erroneous conclusions about the source of the bites based on their awareness of animals present and similarities of the injuries to the untrained eye, with dreadful consequences. Expertise of a carnivore biologist and an odontologist that indentifies the particularities of bite marks may be useful for identifying the attacking species. We present the investigation of a fatal dog pack attack involving a 43‐year‐old man in Bell Ville (Argentina) where the evidence provided by a forensic dentist and a biologist was categorical for establishing the animal species involved. Because of the unusual characteristics of the wounds and the initial hypothesis made by local authorities of a cougar attack, habits and specific patterns of both dog pack and cougar predation on humans are discussed.     

Injury Patterns Sustained in Fatal Motor Vehicle Collisions with Driver's Third‐Generation Airbag Deployment

The Office of the Chief Coroner for Ontario database for 2011–2012 was used to compare fatal injury patterns in drivers whose third‐generation airbags deployed compared to first‐ and second‐generation airbag deployments and airbag nondeployments with and without seatbelt use. There were 110 frontal and offset frontal crashes analyzed. The small sample size meant that the odds of craniocerebral, cervical spinal, thoracic, and abdominal injuries were not statistically different for airbag generation, deployment status, and seatbelt use; however, the risk of fatal thoracic injuries in third‐ and second‐generation cases was increased. Seatbelt usage in third‐ and second‐generation deployment cases reduced the risk of all injuries except abdominal trauma. High severity impacts and occupant compartment intrusion were frequently observed. The analyses in this retrospective study were challenged by data that were not collated in a standardized way and were limited in details about scene, vehicle, and driver variables.