对冲性眶壁骨折的法医学鉴定

目的 探讨对冲性眶壁骨折在眼眶骨折中的分类及其发生机制以及法医学鉴定要点。方法 对42例对冲性眶壁骨折的法医学鉴定案例进行回顾性研究,全部资料有明确的致伤原因,均进行临床常规检查及双眼影像学检查。结果 对冲性眶壁骨折在眶壁骨折中占6.2％,致伤同侧42眼均表现为眼球钝挫伤,其中视网膜震荡18眼,重影症15眼,CT扫描显示眶壁无骨折。对侧42眼均无眼球钝挫伤及视网膜震荡表现,其中重影症10眼,CT扫描显示均为眶内壁骨折。双侧84眼全部出现视物模糊及视力下降。结论 致伤同侧眼表现为眼球钝挫伤以及对侧眼CT扫描显示眶内壁骨折为诊断对冲性眶壁骨折的主要指标,损伤程度评定为轻伤。     

Azygos vein laceration due to blunt trauma

The azygos vein ascends along the thoracic spine through the mediastinum and drains into the superior vena cava at the level of the fourth thoracic vertebra. Fracture-dislocation of the mid-thoracic spine, as a result of blunt thoracic trauma, can tear the azygos vein. Four such fatal cases (three motor vehicle accidents and one fall) were studied, only one of which was recognized prior to death. The vein can also be torn, in the absence of skeletal injuries, by horizontal acceleration/deceleration forces. The pathologist must consider azygos vein laceration as a possible cause of either hemothorax or hemomediastinum or both in a victim of a blunt chest trauma, if that individual had persistent hypotension during the few hours before death and no identifiable source of hemorrhage can be found postmortem in sites such as the heart, great vessels, lung, and chest wall. A fracture-dislocation of the thoracic spine may not necessarily be present. Azygos vein laceration seems to be an uncommon cause of hemothorax and hemomediastinum; however, this injury is probably more frequent than is implied by the few cases described in the medical literature.     

Death caused by a signal rocket--not an isolated case*

Fatalities related to sporting events are predominantly caused by blunt force injuries especially due to the emotional involvement of crowd, but occasionally other types of trauma are reported as well. A case of very rare trauma caused by shooting with a hand-held parachute signal rocket during a football match is presented. A 17-year-old football fan sustained fatal injuries, a combination of mechanical trauma caused by rocket penetration, as well as extensive thermal burning of the thoracic viscera. Analysis of the event was based on autopsy findings and evidence produced by medicolegal and ballistic experts. Improper use of a hand-held signal rocket, designed for marine distress signals, may cause serious injuries either mechanically, due to explosion, or as a result of thermal discharge. In the reported case, pattern of injuries is discussed, and medical finding corroborated to other available evidence. The presented case is a reminder that the forensic pathologist should be informed accordingly on the type and features of weapon suspected to produce injury, to be able to understand traumatic changes, and look for potential presence of foreign bodies at postmortem examination.     

Analysis of blunt trauma injuries: vertical deceleration versus horizontal deceleration injuries

There are several similarities found in blunt trauma injuries to humans sustained as a result of vertical deceleration (falling) and those sustained as a result of deceleration in a horizontal plane (automobile accidents). However, examination of the patterns of traumatic skeletal injuries can distinguish those injuries associated with falling from heights from those associated with automobile accidents. While there is considerable variation within each type of blunt trauma injury dependent on the angle at which one falls or is struck, there are several characteristic skeletal features associated with each type of trauma. In this study we review both the current literature and human skeletal remains from the University of New Mexico's Documented Collection known to have been subjected to blunt trauma. This collection is used to characterize and differentiate the pattern of skeletal injuries to various parts of the body for each type of trauma. These assessments are applied to investigate the traumatic skeletal lesions observed in a forensic case where the manner of death is unknown. Analyses suggest two possible scenarios that would explain the death of the individual investigated, with death most likely related to a vehicular-pedestrian accident.     

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.     

Traumatic bilateral vertebral artery dissection

Traumatic vertebral artery dissection is not often seen by forensic pathologists, and cases investigated are scarce in the forensic literature. We present the case of a 40-year-old woman cyclist who was struck by a car while wearing a helmet, and was neurologically near normal immediately thereafter at Emergency. She presented 48 h later with acute right hemiparesis, decreasing level of consciousness, and unsteadiness. CT revealed massive cerebellar infarction. CT angiography was normal. The patient died in coma 7 days after injury and autopsy revealed bilateral edematous cerebellar infarction and bilateral vertebral artery dissection. Rotational neck injury and mural tear in the wall of the Atlantic parts of both vertebral arteries is suggested as the possible mechanism of the arterial injury. Head and neck injuries are reported as a precipitating cause of vertebral artery injury. The possible influence of trauma may be further underestimated if longer intervals between vessel dissection and ischemia occur. The current case illustrates that "talk-and-die" syndrome may be due to occult vertebral artery dissection, possibly bilateral. In forensic cases of delayed death after mild trauma to the head and neck, the vertebral arteries should be examined for the cause of death.     

Death Due to Coronary Artery Insufficiency Following Blunt Trauma to the Chest

There have been numerous reports of sudden cardiac death following blunt trauma to the chest, but there is lack of such references in forensic literature. It is the court of law which makes decision about trauma precipitating natural events. The forensic pathologist is scientifically trained in the medical field and would be in a better position to give clear picture about the victim's general status at the time of death, exact nature and severity of the illness he is suffering from if any. He can also assess the nature and severity of injuries sustained, and thus, his opinion as to the possible role played by the traumatic event in bringing about the death is valuable. This paper will discuss the mechanism of cardiac injury or possible cardiac injury and sudden death of an apparently healthy 36‐year‐old male following blunt chest trauma sustained during alleged assault by his neighbor.     

Nonfracture-associated fatal fat embolism in a case of child abuse

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.     

眼部损伤程度法医学鉴定60例分析

目的探讨眼外伤的特点及其损伤程度法医学鉴定要点。方法对60例眼外伤的法医学鉴定案例进行回顾性分析,对所有案例按照性别、年龄、职业、致伤物及损伤类型进行分类研究。结果眼外伤中农民、工人占61.7%,钝性损伤达85.0%,且大多属单纯挫伤,占63.3%。结论眼外伤大多属钝性外力所致,眼底病变是影响视力的重要原因,对外力与视力受损关系的评价要充分考虑致伤物种类、打击部位及伤前眼病史等诸多因素的影响。     

肩袖损伤法医学鉴定研究进展

肩袖损伤是一种临床常见的肩关节病,成因复杂且症状有时不甚明显,缺乏特征性表现,容易被漏诊及误诊。在法医学鉴定中,时常遇到肩袖损伤的案例,判定该类案例是创伤所致、自身疾病抑或属于伤病共同作用导致是目前摆在法医鉴定人面前的难点问题。但因找不到客观的鉴别指标,容易使鉴定工作进入盲区,也时常引起当事人对鉴定意见的质疑,甚至长期的上访缠诉,引发社会的不稳定。基于此,从肩袖解剖结构、损伤机制、临床表现、鉴别诊断及法医学鉴定等方面展开论述,有助于为此类案件的鉴定提供参考。     

Severe Cardiac Rupture by Only One Blow to the Chest in a Young Boy: An Autopsy Case

Cardiac rupture by blunt chest trauma is commonly seen after motor vehicle accidents and falls; however, it is rarely caused by a blow to the chest. We herein report an autopsy case of a high school boy who sustained severe right ventricular rupture by only one knee kick to the chest during a quarrel. He was hospitalized and developed cardiopulmonary arrest. Emergency surgery was performed, but the patient died. The autopsy revealed no external severe trauma or deformation, but the side wall of the right ventricle contained a large V‐shaped laceration. The other thoracic organs had no injuries. This case illustrates that severe cardiac rupture can occur by only one blow to the chest. Blunt cardiac injuries can occur even if no severe injuries are present on the body surface. We should consider the possibility of severe cardiac injuries regardless of the presence of external injuries.     

交通肇事眼损伤鉴定及其VEP检查特征分析

对 30例交通肇事眼损伤鉴定及其VEP检查结果进行回顾性分析 ,旨在探讨交通肇事眼损伤鉴定的特征 ;结果表明 :与普通伤害案件相比 ,(1)交通肇事眼损伤鉴定时合并颅脑损伤 (83% )及多颅神经损伤 (53% )的比例较高 ;导致复视及眼球运动受限 (30 % )的情况较多 ;视神经损伤 (2 0 % )及眶壁骨折 (2 0 % )的发生率较高 ;鉴定时应注重这些方面的检查。 (2 )交通肇事眼损伤鉴定当事人主诉双眼视力下降 (53% )的比例较高 ,雾视法进行伪盲试验受到限制 ,VEP检查显得更为主要。VEP检查是确证视神经损伤的良好方法 ,不同程度的视功能障碍其VEP表现为波形熄灭、波形离散、波幅降低、潜伏期延长不等。另一方面 ,交通肇事后弥漫性脑组织损伤也在眼底及VEP上有一定表现。     

Practical application of the Injury Severity Score (ISS) in expert forensic testimony

The retrospective analysis of the autopsy records of 50 homicides showed that the Injury Severity Score (ISS), a numerical scoring system initially developed to quantify the severity of injuries sustained in road traffic accidents, can also be useful for objectively describing and ranking the overall severity of trauma with regard to forensic issues. The present case report illustrates to what extent the ISS can help to assess the contribution of each assailant in homicides committed by several perpetrators. In the case presented the court was convinced that one perpetrator had inflicted four deep stab wounds to the victim's face (each with bony lesions), 2 stabs to the chest piercing the right lower pulmonary lobe and causing a haemothorax of 200 ml, an abdominal stab wound without involvement of a parenchymatous organ as well as multiple defence wounds of the arms. Thereafter, a second perpetrator was thought to have inflicted several heavy blows with a full water bottle causing severe contusions on the right side of the forehead, the chin, the left side of the face and a spider's web fracture of the frontal bone. Using the ISS an injury severity score of 24 was assigned to the first complex of injuries and a score of 10 to the second complex. The forensic conclusions with regard to prognosis and lethal outcome are discussed.     

"Beaten to death". An autopsy series of homicidal blunt force injuries

Although gunshot is by far the most common means of homicide in the United States, significant numbers of homicides are also perpetrated by other means. Blunt-force injuries are produced by a variety of objects, including hands and feet and many different weapons. Some of these objects produce distinctive patterns of injury of potential evidentiary value. This paper presents a series of 20 consecutive blunt-force homicides in adults. Seventy percent (14 cases) of the victims were men. Thirty percent (six cases) followed an argument or altercation. A number of the weapons used were "weapons of opportunity" seized in the course of the incidents. Sixty-nine percent (nine cases) of known assailants were acquainted with their victims. Few characteristic patterned injuries were seen. Not surprisingly, craniocerebral trauma was the most common cause of death. One half (10 cases) the victims survived their assaults for varying periods of time. Homicides due to blunt-force injury still pose a significant challenge for the forensic pathologist, who must obtain a complete and accurate history of the fatal incident, interpret patterns of injury and other findings at autopsy, and correlate all of the findings to make an accurate ruling of the cause and manner of death.     

17例颈椎外伤合并颈椎退行性病变的伤病关系分析

目的研究颈椎外伤合并颈椎退行性病变的法医学鉴定案件特点,探讨如何利用临床资料,法医学检查和影像学检查等对损伤和病变参与程度进行认定等问题。方法收集17例颈椎外伤合并颈椎退行性病变的法医学鉴定案例,对其年龄分布、损伤方式、损伤程度、影像学表现等进行分析,综合评定伤病关系。结果 17例案件以中老年为主。所有案例均存在椎间盘突出,损伤以过伸性损伤为主。按照影像学表现,将损伤程度和脊椎退变程度进行分级,综合计算伤病参与程度。结论颈椎外伤合并颈椎退行性病变的法医学鉴定案件应综合运用临床资料、法医学体格检查和影像学检查结果进行评定。     

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.     

High-quality Digital 3D Reconstruction of Microscopic Findings in Forensic Pathology: The Terminal Pathway of a Heart Stab Wound*

High-quality digital three-dimensional (3D) reconstructions of microscopic findings have been used in anatomical and histopathologic research, but their use in forensic pathology may also be of interest. This paper presents an application of these methods to better characterize the pathway of a stab wound of the anterior surface of the heart in a case of suicide. A portion of the heart wall including the stab wound was serially sectioned for microscopic analysis along the full extent of the wound. Histologic sections were digitally acquired, and a 3D reconstruction was created with ImageJ software for 3D computer graphics. This showed a full-thickness wound path extending to the endocardial surface of the left ventricle, curvilinear in appearance. After correction for shrinkage, 3D reconstruction allowed estimation of the dimensions of the myocardial injury and comparison of the appearance of the wound with the suspected knife used. The curvilinear appearance was considered to reflect injury during myocardial contraction. Complete microscopic sectioning and 3D reconstruction may allow virtual sectioning through various orientations and also provide useful forensic information for selected injuries.     

An unusual case of thermal injuries with a hot glue gun: Deliberate self-harm or maltreatment?

Assessing injuries in forensic medicine casework, examiners are often confronted with the question of self-infliction versus third parties' influence, respectively, deliberate self-harm versus maltreatment. We report the case of a 40-year-old male who presented with numerous partially healed thermal injuries of different age. These burns were shaped like capital letters and little circles, which were arranged in lines in a regular form. The lesions were found on the whole body with exclusion of face, genitals, hands and feet. Furthermore, four bitemarks at the right shoulder were noted. Investigations revealed that the man had been abused by his 25-year-old wife (presumably a borderline personality disorder patient) for at least 1 year. In addition to another series of abuses, the woman may have inflicted the shaped burns with a hot glue gun as punishment for breaking certain "rules" she had established. When assessing injuries of patients in forensic medicine, several considerations regarding etiology have to be taken into account. In principle, the victim's testimony, the anamnesis, the police investigation results and the findings from the forensic physical examination have to be balanced against each other. The injury pattern in the present case showed contradictory single characteristics both of deliberate self-harm and of maltreatment. After forensic analysis, it was assessed as injuries inflicted by an assistant with the patient's consent.     

A schematic representation of the thoracic skeleton for the analysis of multiple fractures]

A scheme of the thoracic skeleton (a superior projection) is suggested for practical forensic medical evaluation. The scheme presents concentrically arranged costal arches connected to the image of the breast bone and the thoracic portion of the spine, with the ordinal numbers of the ribs, vertebrae, and anatomic lines. Special marks indicate rib fractures and other associated signs (repeated injuries, bleedings, whether the injury was inflicted in life or was postmortem, etc.). After the scheme is filled in, one may analyze a three-dimensional image of the injuries to determine the site and direction of an external exposure and its order.     

Sharp Force Homicide in Denmark 1992–2016

Sharp force trauma is a common homicide method. The weapon is typically a knife, which is easily accessible and does not require special skills. We have analyzed all 471 sharp force homicides in Denmark during 1992–2016 with special focus on aspects that are relevant to forensic pathologists, including the distribution of wounds and organ injuries. Most homicides were committed inside with a kitchen knife. The front left thorax was the most common area to be affected by sharp force trauma. In 18.9% of the victims, there was only one sharp injury, the majority on the thorax. The most common trajectory for stab wounds was directly posterior with no deviation to the sides or up/down followed by directly anterior. The heart (including pericardium) and lungs (including hemo- and pneumothorax) had injuries in more than 75% of the victims. 67% of victims were males. Female victims had more sharp force injuries and defense wounds than male victims. Most females were killed in domestic homicides (73.7%), most commonly in partner killings (56.4%). In contrast, many male victims were killed in a setting of nightlife/intoxication (34.0%) most by a friend/acquaintance delivering a few stab wounds. The results clearly show strong sex differences in both victims and offenders. This could be useful for shaping policies and public opinion, and as a route for understanding the developments in interpersonal violence. In the narrow setting of death investigation, our results will provide an evidence-based approach to understanding the injury patterns in sharp force homicide.