Investigative and autopsy findings in sport aircraft-related deaths in southwest Florida

Aircraft designated for sport or recreational use only, including ultralights, experimental aircraft and light-sport aircraft, have become increasingly popular. Because of their relative safety and the rarity of fatalities resulting from crashes of these aircraft, the forensic literature contains little information concerning the pathologic findings in such deaths. We report 9 deaths resulting from 6 sport aircraft crashes in southwest Florida, 6 pilots and 3 passengers. The vehicles involved 3 experimental aircraft, 1 ultralight and 2 "ultralight-like" aircraft. The patterns of injuries included trauma predominantly to the chest (3 cases), abdomen (1) or head (1), as well as multiple blunt force injuries involving the chest and abdomen (1) or the head and torso (3). Extremity fractures were found in only 2 cases, whereas injuries to the symphysis pubis were found in six. No "control-type" injuries were identified. These cases illustrate the varied pathologies associated with deaths due to crashes of sport aircraft and reveal the lack of uniformity associated with the investigations of such deaths.     

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.     

Shopping cart injuries, entrapment, and childhood fatality

Shopping carts may be associated with a variety of injuries, particularly in toddlers and young children. These usually relate to falls from carts or to tip-overs. Injuries that are sustained include hematomas/contusions, abrasions, lacerations, fractures, and fingertip amputations. Fatal episodes are uncommon and are usually due to blunt craniocerebral trauma from falls. A case involving a 19-month-old girl is reported who became entrapped when she inserted her head through the side frame of a cart that had been removed from a supermarket and left at her home address. Death was caused by neck compression. Although rare, the potential for lethal entrapment during unsupervised play means that the presence of stray shopping carts at private residences and in public places, including playgrounds and parks, is of concern. Strategies, such as coin deposits, should be encouraged to assist in the return of such carts to supermarkets.     

Death due to positional asphyxia under severe alcoholisation: pathophysiologic and forensic considerations

In contrary to "physical restraint", describing a fixed body position due to external devices, "positional restraint" is defined as an abnormal body position, resulting from accidental fixation under unfortunate circumstances. We report on a remarkable case of positional asphyxia of an alcoholised young man after a fall down a staircase. On external examination, the body showed petechiae of the conjunctivae and oral mucosa, abrasions on the left zygomatic region and scratch marks, respectively. Neither broken fingernails, etc. nor signs of external violence against the neck were found. Autopsy revealed haemorrhages in the praevertebral cervical musculature and Simon's sign. Haemorrhagic pulmonary edema and cerebral edema were observed; blood alcohol concentration: 2.60 g/l, urine alcohol concentration: 3.26 g/l. As cause of death, positional asphyxia after blunt head trauma has to be considered as well as lethal ethanol intoxication. To us, alcoholisation attributed to the fall and together with unconsciousness following blunt head trauma circumvented self-rescue efforts, and therefore, aggravated the potentially lethal impact of positional restraint.     

A "skin-skull-brain model" for the biomechanical reconstruction of blunt forces to the human head

In order to create and study blunt force wound morphology, a "skin-skull-brain model" had to be designed which would make the laboratory reproduction of a blunt force injury to the head possible. During the evaluation of the "skin-skull-brain model", it was possible to show that injuries inflicted to this model are fully comparable to the morphology of equivalent real blunt forces injuries to humans. Utilization of the "skin-skull-brain model" presents some significant advantages: the model is inexpensive, easy to construct, instantly available for use, and eliminates ethics conflicts. The main advantage of such a model is, in comparison with biological substances, the high reproducibility of experimentally inflicted traumas.     

Biomechanical and morphologic reconstruction of a questionable case of child abuse

A 3-month-old baby died 8 days after admission to the hospital as a result of injuries received under unknown circumstances. The forensic autopsy revealed a fracture of the scull and a severe blunt injury to the head and brain. Histological investigation of the reactive changes at and around the edges of the fracture showed that the trauma could not possibly have been congenital. According to the defendant, the baby boy had been lying on the table used for changing his nappy and almost fell off it. The defendant moved "instinctively" to catch him, and this "reflex movement" caused the injuries observed. The event was then reconstructed by the criminal investigators and this reconstruction, coupled with the authors' biomechanical experiments using stroboscopic recording, revealed that the defendant's statement could not be true, as the force necessary to inflict the injuries was much greater than could be explained by an attempt to catch the baby.     

Vertebral artery laceration mimicking elder abuse

Elder abuse was first described almost 30 years ago. Today, approximately 1 in 25 elders is abused each year in the United States. A newly described form of domestic violence, the incidence of elder abuse will surely increase as the elderly population grows. Physical abuse/inflicted trauma is generally considered the most extreme form of elder mistreatment and includes blunt trauma, sexual assault, traumatic alopecia, and burns. Elder homicide is usually due to gunshot wounds, blunt trauma, stab wounds, or asphyxia. However, the difficult aspect of assessing the possible elder abuse homicide victim is delineating such inflicted trauma from accidental trauma. We report the case of a 94-year-old "demented" male, who reportedly fell out of his wheelchair. He was transported to a local emergency room, where he became unresponsive during examination. He experienced respiratory distress and was pronounced dead shortly thereafter. At autopsy, he had periorbital contusions and a midline abrasion between the eyes, with underlying supraorbital contusion. The skull, brain, and spinal cord were unremarkable for signs of trauma. The major traumatic finding was in the neck region. Neck dissection revealed hemorrhage extending from the base of the skull to the level of T-1 and anteriorly about the soft tissues, strap muscles, and vasculature. The strap muscles were individually examined and were free of hemorrhage. The carotid arteries and jugular veins were unremarkable. The larynx, hyoid, and thyroid were intact, with only surrounding hemorrhage. Further examination revealed a horizontal fracture of the C5 vertebral body and a medial laceration of the left vertebral artery at the C5 level; subarachnoid hemorrhage was absent. What initially appeared to be trauma to the neck, worrisome for strangulation or blunt force trauma, was a large retropharyngeal hematoma from the left vertebral artery laceration. Traumatic rupture of the vertebral artery usually occurs at the C1 and C2 levels, with resultant subarachnoid hemorrhage. This is an especially vulnerable location since it is where the artery turns and then enters the skull. Associated injuries include spinal cord transection or contusion, brachial plexus injury, pharyngoesophageal injury, and vertebral fractures. Retropharyngeal hemorrhage may result from deep neck infection, tumor, and trauma. Hemorrhage associated with trauma often involves flexion of the cervical spine, followed by hyperextension. The accumulation of blood slowly impinges on the pharynx/larynx and vasculature structures. The exact injuries and etiology of the hemorrhage must be determined to distinguish strangulation from blunt force trauma. The presentation of signs and symptoms can be helpful in assessing the decedent; however, in the practice of forensic pathology such a history is more often lacking.     

Unsuspected meningoencephalitis in a case of assault by blunt force trauma

Reported is a case of an assault causing extensive blunt force injuries in which the clinical, radiologic, and postmortem findings were all consistent with death resulting from brain damage arising from the assault. The assailant was charged with murder. Subsequent full neuropathologic (including histologic) examination revealed the unsuspected finding of a widespread meningoencephalitis but no evidence of significant traumatic brain damage. The contributions of the infective process and of the trauma to death were felt to be unclear and a guilty plea to attempted murder was accepted. This case highlights the importance of a full neuropathologic examination, including histology, in cases of trauma to the head, even when the cause of death may initially appear obvious.     

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.     

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.     

Patterns of trauma in conflict victims from Timor Leste

Understanding population-level trauma patterns has implications for the recognition of war crimes and crimes against humanity. Trauma data were abstracted from autopsy and anthropology reports for 105 victims from the 1999 conflict in Timor Leste. A significant number of individuals displayed no evidence of injury. No trauma was found in 25% of the sample, while a further 5% had only minor, nonlethal wounds. Where trauma was evident, sharp force injuries were most common (35%), followed by gunshot (20%) and blunt force (13.33%). Timorese frequencies of trauma differ significantly from percentages found in prior reports of mass killings from Cambodia, Bosnia, Croatia, and Afghanistan but closely resemble reported trauma patterns in Rwanda. Decomposition and percentage of body recovered were shown to have a significant impact on the presence/absence of trauma. Complete, fleshed remains were 10.4 times more likely than skeletal remains to have evidence of major or lethal trauma.     

Potentially lethal complications of tracheostomy: autopsy considerations

Tracheostomy is widely used to facilitate respiration by protecting the airways. It may be performed to relieve upper airway obstruction from congenital stenoses or from acquired conditions such as foreign body impaction, swelling from neck trauma or anaphylaxis, benign or malignant tumors, and infection. Tracheostomy may also be performed in individuals with respiratory impairment who require suctioning for accumulated mucoid secretions and in those with obstructive sleep apnea. Review of autopsy files and the literature was undertaken to demonstrate the range of lethal circumstances that may involve tracheostomy. Unexpected death may result from incorrect positioning of an endotracheal tube with failure of oxygenation, tracheal perforation with pneumothorax, mucus plugging, accidental extubation, and hemorrhage from tracheovascular fistulas. Lethal tracheovascular fistulas usually involve the innominate artery and result from mural perforation by the tip of a tracheostomy tube, mural necrosis from a high-pressure cuff, prolonged intubation, radiotherapy, and low tracheal incisions. Increased movement of tubes in patients with impaired consciousness and excessive head movements may also increase the chances of hemorrhage, as may infiltrating tumors. Given the wide range of potential fatal mechanisms that may be found in such cases, careful autopsy evaluation and dissection will be required to demonstrate the exact nature and site of the lethal lesion in individuals who underwent tracheostomy and die unexpectedly.     

Punched with a fist: the etiology of a fatal depressed cranial fracture

We report a case in which a 33-year-old man was discovered unconscious following a fistfight with another man. Emergency neurosurgical efforts to repair a depressed temporoparietal skull fracture and associated brain injuries were unsuccessful. The forensic anthropologist and pathologist worked in tandem to sort out a complex combination of cranial evidence, including healed antemortem trauma, perimortem blunt force trauma, remote and recent neurosurgical intervention, and the craniotomy cut performed at autopsy. The victim had suffered head injuries and a right temporoparietal craniotomy ten years prior to death. The perimortem cranial fractures were centrally located within a surgically repaired roundel of bone involving portions of the right temporal and parietal bones. Reportedly, the victim was punched on the right side of his head as he was lying on the ground with the left side of his head against an asphalt surface. A primary question in the case was whether a blow with a fist could have produced the observed cranial injuries. To adequately answer that question, known data on the minimum amount of force required to fracture the temporoparietal region were compared to data on the amount of force generated by a blow with a fist. A biomechanics expert demonstrated that a single blow with a fist to the rigidly supported head of the victim could generate the required force to produce the observed fractures. The previous medical condition possibly predisposed the victim to the cranial fractures and contributed to the depressed nature of the fractures. Although depressed cranial fractures do not typically result from a blow with a fist, it was determined in this case that the fracture pattern was consistent with a punch to the head.     

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.     

Feasibility of Contactless 3D Optical Measurement for the Analysis of Bone and Soft Tissue Lesions: New Technologies and Perspectives in Forensic Sciences

Abstract:  In forensic pathology and anthropology, a correct analysis of lesions on soft tissues and bones is of the utmost importance, in order to verify the cause and manner of death. Photographs, videos, and photogrammetry may be an optimal manner of immortalizing a lesion, both on cadavers and skeletal remains; however, none of these can supply a detailed three-dimensional (3D) modeling of the lesion. Up to now, only the use of casts has given us the possibility of studying deep lesions such as saw marks with an accurate and complete 3D reconstruction of bone structure. The present study aims at verifying the applicability of 3D optical contactless measurement for the accurate recording of soft tissue and bone lesions, in order to develop a unique and precise method of registering and analyzing lesions, both in forensic pathology and anthropology. Three cases were analyzed: the first, a car accident with blunt force skin injuries; the second, a murder with blunt force injury to the head applied with a metal rod; the third, a series of sharp force knife and saw lesions on bone. Results confirm that 3D optical digitizing technology is a crucial tool in the immortalization of wound morphology in the medico-legal context even on "difficult" substrates such as cut marks and saw marks on bone.     

Peculiarities of combined blunt head injuries in children and adolescents

The objective of the present study was to evaluate the frequency and peculiar features of combined head injuries in children and adolescents who suffered the fatal blunt trauma. A total of 101 corpses and 188 archive records were available for the analysis. The control data group was comprised of 227 original observations of adult corpses. It was shown that head injuries prevail over injuries to other parts of the body in children with combined blunt traumas. The craniocerebral injuries are more frequent in children and adolescents than in adult subjects but their extent is smaller. Fractures of the facial bone skeleton in adults occur twice as frequently as in children. A peculiar feature of craniocerebral injuries in children and adolescents is incomplete splintered fractures and folded deformation of the bone plate. Subarachnoidal hemorrhage occurs equally frequently in children and adults with craniocerebral injuries. Other intracranial manifestations of the injury, such as ruptured brain tunics, epidural and subdural hemorrhage, cerebral contusion and ventricular hemorrhage in children occur less frequently than in adults.     

钝力性心脏外伤实验性研究——隐囊流体压力冲击心前区

本文应用隐囊流体冲击心前区，成功地制造了钝力性心脏外伤，包括心脏震荡、心脏挫伤，心脏裂伤等原发性心脏外伤以及外伤性冠脉血管炎。心肌炎血栓形成，心肌缺血坏死（外伤性心肌梗死）等继发性或迟发性外伤性损伤，指出：心肌膜爆裂（ｍｅｍｂｒａｎｅｂｕｒｓｔ），相应纤维横向膨出畸型变可以作为心脏震荡性外伤的形态学指征：钝力作为原始致伤因素作用于心前区通过压，拉，旋转或剪切力引起心脏各部，包括刺激传导系统，心脏神经组织损伤；心脏挫裂伤等见于左右心壁室中隔，心内膜下并呈播散分布。     

Comparing Known and Reconstructed Circumstances of Death Involving a Blunt Force Trauma Mechanism through a Retrospective Analysis of 21 Skeletonized Individuals

Little is known about to what extent the events surrounding death can be reliably reconstructed from blunt force trauma analysis alone. In this study, we reconstruct circumstances of death from a blind blunt force trauma analysis using a sample of 21 individuals of known death circumstances, obtained from two identified skeletal collections in Portugal. Fresh versus dry bone trauma and probable mechanism of fracture production were identified. The overall pattern of injuries was then used to reconstruct the most likely circumstances of death. Results show an agreement between the proposed and the reported circumstances for 13 individuals (68.4%), disagreement for 3 (15.8%), and similarity in 3 cases (15.8%). Although the significant amount of agreement highlights the potential of trauma analysis, the cases with disagreement draw attention to the pitfalls and shortcomings of attempting to reconstruct the death circumstances from skeletal trauma analysis alone.     

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.     

Walk and Die: An Unusual Presentation of Head Injury

Abstract:  We report three deaths in young adult males following closed blunt trauma to the head and face where the affected individuals were able to walk away from the incident, before subsequently collapsing and dying a short distance from the site of the assault. In each case, due to the rapidity of the posttrauma collapse, the pathologist was faced with a diagnostic difficulty at autopsy; the external examination revealed multiple injuries to the head and face, but internal examinations showed limited findings with no structural explanation for the death. We discuss possible mechanisms that could account for this scenario, the implications of alcohol consumption with a concussive head injury, and parallels that can be drawn with the so-called "talk and die,""talk and deteriorate," and "second impact syndrome." Finally, the possible role of so-called "postexercise peril" is discussed in relation to these deaths.