Contributions from Forensic Imaging to the Investigation of Upper Cervical Fractures

Abstract: Injuries to the upper cervical spine (UCS) are common in traumatic deaths and postmortem computed tomography (PMCT) may contribute to the forensic investigation. This study presents PMCT in comparison with autopsy in the examination of UCS injury. Thirteen consecutive cases with UCS fracture and/or cranio‐cervical dislocation were examined with PMCT and autopsy, and the findings were correlated. Neither of the techniques identified all UCS injuries. Fractures of atlas and axis were best visualized with PMCT whereas cranio‐cervical dislocation was better identified during autopsy. Serious injuries were present after both high‐ and low‐energy trauma. Medico‐legal autopsy in combination with PMCT produced a thorough evaluation of UCS injuries. By combining these procedures detailed investigations, including accident reconstruction and injury pattern analysis, can be performed. This study supports the routine application of PMCT, as a supplement to the medico‐legal autopsy of deaths with UCS injuries.     

An Uncommon Accident and Unusual Cause of Death—A Fatal Domestic Ram Attack

Domestic animal attacks are not common; their fatal attacks are even rarer. Herein, a case of a 78‐year‐old woman attacked by a ram is presented. She sustained multiple head and chest injuries. The autopsy findings and the inspection of the scene revealed that the fatal aortic injury had been caused by direct force from the front, which subsequently caused a powerful anteroposterior chest compression, resulting in an incomplete tear by flexion and compression of the aortic arch. The aortic dissection propagated in both an ante‐ and retrograde direction, with intact adventitia. However, due to a rise in pressure in the formed false lumen, dissection propagated downward to the base of the heart, and further into the subepicardial adipose tissue, forming a subepicardial hematoma. This hematoma gradually compressed the proximal sections of the coronary arteries, impairing their filling, and producing a myocardial ischemia. In addition, circulation had probably been already disturbed by the right‐sided pneumothorax, as well as a possible pneumomediastinum.     

Domestic Predation of an Elder: A Fatal Dog Attack Case

We present the case of a 91‐year‐old woman lived alone at her home with two domestic dogs, that is,, a Labrador Retriever and a Staffordshire Bull Terrier and found dead. The investigation of the scene revealed that the Bull Terrier's jawbone and chest were covered with blood. The autopsy revealed multiple, histologically confirmed, life‐threatening skin and bone lacerations without scavenging marks. The punctures and tearing of each of the wounds on the skin were compatible with bites. A left humeral fracture and multiple fractures of the right facial bones were observed. The death was attributed to external hemorrhages due to several dog bites. A veterinary physical and behavioral examination indicated that the Bull Terrier was involved in the attack. A domestic predation hypothesis was deemed here most likely due to the presence of food supplies at the scene, the dog's previous history of attack, and the breed of the dog.     

Flail Chest Following Failed Cardiopulmonary Resuscitation

Following the death of a woman with blunt force chest trauma, the question was asked how common was the finding at autopsy of a flail chest in decedents after failed cardiopulmonary resuscitation. It was suggested in court that this was an uncommon occurrence. To address this issue, autopsy cases in adults (>18 years) with rib fractures attributable to cardiopulmonary resuscitation were taken from the files of Forensic Science SA over a 7‐year period from 2008 to 2014. Flail chest injuries were defined as those arising from fractures at two sites in at least three consecutive ribs. From 236 cases with rib fractures attributed to resuscitation, a total of 43 flail chest injuries were found in 35 cases (14.8%). The majority occurred in the 60‐79‐year‐old age group. These data suggest that flail chest injuries are a more common sequelae of cardiopulmonary resuscitation than has been previously appreciated in autopsy cases, particularly in the elderly.     

The Role of Postmortem Computed Tomography in the Evaluation of Strangulation Deaths

We explored the value of postmortem computed tomography (PMCT) to augment autopsy in evaluating strangulation fatalities. A literature search identified 16 studies describing autopsy findings in 576 deaths and two studies describing autopsy and PMCT findings in six deaths. Similar cases were identified from our institution, yielding 130 deaths with autopsy findings and 14 deaths with both autopsy and PMCT findings. The presence of laryngohyoid fracture and soft tissue hemorrhage was compared from autopsy and autopsy+PMCT cases. The detection rates of fractures in autopsy and autopsy+PMCT cases were not significantly different. PMCT identified all fractures observed at autopsy and five fractures not identified. While PMCT may not detect soft tissue injuries in decomposed remains or subtle internal hemorrhages in neck injury, it is equally able to detect bony injuries as autopsy and might surpass autopsy in detecting subtle fractures. We conclude PMCT is useful to supplement autopsy in strangulation cases.     

The Cane Sword

This report provides an overview of the injuries caused by a unique blade‐type weapon known as a cane sword. The cane sword usually consists of a blade that is stored in a cylindrical “cane” that can be released at the handle to reveal the hidden blade within. The victim of the case was found to have a stab wound in the left mid‐back that caused perforation of both the lower and upper lobes of the left lung, resulting in a left hemothorax. Upon autopsy, it was concluded that the patient died from injuries caused by the stab wound to the back. Given the shape of the wound and the fact that the weapon itself was found at the site of the homicide, the weapon that caused the injury was believed to be a cane sword. This case will inform forensic pathologists, law‐enforcement officers, emergency medical personnel, and physicians about rare weapon, the cane sword.     

Unusual injury pattern in a case of postmortem animal depredation by a domestic German shepherd.

A case is presented of a 38-year-old woman with skeletization of the head, neck, and collar region and a circumscribed 26-cm x 19-cm defect on the left chest with sole removal of the heart through the opened pericardium but undamaged mediastinum and lungs. The injuries showed V-shaped puncture wounds and superficial claw-induced scratches adjacent to the wound margins that have been described as typical for postmortem animal depredation of carnivore origin and derived from postmortem animal damage by the woman's domestic German shepherd. The circumscribed destruction of the left chest with unusual opening of the pericardium is explained by the physiognomy of the muzzle of the German shepherd and differs from previous reports. Any case presented as postmortem animal mutilation should be viewed with skepticism and undergo a full autopsy.     

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.     

原发性脑干损伤出血形态及分布特征分析

目的观察分析原发性脑干损伤出血灶的形态及分布特征,为法医学鉴定提供依据。方法选取34例原发性脑干损伤出血案例,常规制作病理切片,采用HE染色观察出血灶的形态及位置分布特征,并统计两者之间关系。结果原发性脑干损伤出血形态以裂隙样出血多见（61．6％）。出血灶位置分布组间比较显示,不同纤维走行和组织密度交界处、动脉周围、神经根等处以裂隙样出血多见（P〈0．005）;室管膜下主要表现为灶性出血（P〈0．001）;神经核团内出血较少,且裂隙样出血、灶性出血比例较为接近。结论不同纤维走行和组织密度交界处、动脉周围、神经根处的裂隙样出血是原发性脑干损伤的直接依据;神经核团内出血具有重要的法医学价值。     

Evaluation of aortic injury in driver fatalities occurring in motor vehicle accidents in the State of Maryland for 2003 and 2004

Incorporating epidemiological and pathologic factors, a retrospective analysis of aortic injury and driving fatalities was conducted. To better understand the mechanism of injury, data were compiled for decedent demographics, autopsy and toxicology findings, and accident circumstances, with emphasis on directional impact. Review of the autopsy files of the Office of the Chief Medical Examiner in the State of Maryland in 2003 and 2004, identified 150 cases of aortic injury recorded in 537 autopsied drivers. Aortic lacerations occurred in 96% of the cases with aortic injury, two thirds of which were complete or near complete transections. A large percentage of cases involved a side impact collision. Consistent with extant research on frontal and lateral impacts, the majority of aortic injuries occurred at the ligamentum arteriosum. Also, the mechanism of aortic injury seems to be similar for side and frontal impact collisions, involving a combination of rapid deceleration forces along with chest and/or upper abdominal compression. This study emphasizes the importance of side impact collisions as a cause of aortic injury. Aortic lacerations have a high mortality rate and better motor vehicle design may prevent this type of injury.     

Diagnosis of electrical skin injuries. A review and a description of a case.

This paper presents a brief review of the results of research in the area of electrical skin injuries. It also includes a case report of a 5-year-old girl noted on her admission to the hospital to have injuries to the skin of her chest and left arm. Histological examinations demonstrated that the skin lesions were segmental and showed necrosis and inflammation. Deposits of calcium salts distinctly located to collagen fibers were observed below the regenerated epidermis at the periphery of two skin lesions of the chest wall, in the lower part of dermis at the periphery of a skin lesion of the left arm, and within connective tissue adjacent to elastic arteries and peripheral nerves from the thoracic cavity. The pattern of calcification localized to collagen fibers and situated both superficially and deeply in the skin in a zone of viable tissue close to necrotic tissue is characteristic of electrically induced lesions. Although there have been reports of deposition of calcium salts on collagen fibers after application of calcium salts in high concentration at the skin surface, the collagen calcification in the pattern observed in this patient is probably diagnostic of electrical injury.     

Asphyxia Homicides in Finland, 1983–2012

Finland has one of the highest homicide rates in Western Europe, and almost every tenth homicide is caused by asphyxiation. Reliable statistics, a strict legislation, and an exceptionally high medico-legal autopsy rate formed a base for a nationwide analysis of asphyxia homicides (n = 383) during 30 years. The cases were identified through multiple records, and all the forensic pathology case files were studied in detail. In more than one out of five cases, there were indications of staging, and the homicide was revealed first at autopsy in close to one in ten cases. The vast majority of the homicides took place in private locations and involved persons known to each other. Every third victim was an intimate partner, and every tenth a child. Almost half of the victims died from manual strangulation, one in three from ligature strangulation. Smothering, choking, neck compression with a firm object, and thoracic compression were more rare methods. Drownings were excluded from this study material. Of all the victims, 7% had no observable external injuries. Petechiae were recorded in approximately in 61%, laryngohyoid fractures in 47%, and vocal cord hemorrhages in 16% of the cases. Every tenth female victim had genital injuries. Toxicological analyses were performed in close to all of the cases, and almost three out of four victims tested positive for blood alcohol. The various aspects of the demographics and autopsy findings covered in this study contribute reliable and accurate data to further strengthen the spectrum of observable medico-legal characteristics of asphyxia homicides.     

An Unplanned Complex Suicide by Multiple Blank Cartridge Gunshots and Cutting

Blank firing guns are readily accessible in most countries due to an absence of legal regulations. These weapons are capable of causing lethal injuries. We report a rare case of secondary (unplanned) complex suicide committed with a knife and blank cartridge pistol. A 59‐year‐old man was found dead with three superficial incisions in his neck and a gunshot wound to the chest. The external examination revealed an entrance wound in the left chest region consistent with contact shooting. The appearance of a muzzle imprint suggested two discharges. The autopsy showed a slightly hemorrhaged but otherwise intact pericardium, blood in the pericardial sac, and a channel‐like defect in the anterior wall of the left cardiac ventricle. The cause of death was attributed to cardiac tamponade. To the best of our knowledge, this is the first reported case of unplanned complex suicide involving an unmodified blank firing gun.     

Acute Fatal Coronary Artery Dissection Following Exercise‐related Blunt Chest Trauma

Coronary artery injury such as acute coronary dissection is an uncommon and potentially life‐threatening complication after blunt chest trauma. The authors report an unusual autopsy case of a 43‐year‐old healthy man who suddenly collapsed after receiving a punch to the chest during the practice of kung fu. The occurrence of the punch was supported by the presence of one recent contusion on the left lateral chest area at the external examination and by areas of hemorrhage next to the left lateral intercostal spaces at the internal examination. The histological examination revealed the presence of an acute dissection of the proximal segment of the left anterior descending coronary artery. Only few cases of coronary artery dissection have been reported due to trauma during sports activities such as rugby and soccer games, but never during the practice of martial arts, sports usually considered as safe and responsible for only minor trauma.     

Pathologic features of fatal shark attacks

To examine the pattern of injuries in cases of fatal shark attack in South Australian waters, the authors examined the files of their institution for all cases of shark attack in which full autopsies had been performed over the past 25 years, from 1974 to 1998. Of the seven deaths attributed to shark attack during this period, full autopsies were performed in only two cases. In the remaining five cases, bodies either had not been found or were incomplete. Case 1 was a 27-year-old male surfer who had been attacked by a shark. At autopsy, the main areas of injury involved the right thigh, which displayed characteristic teeth marks, extensive soft tissue damage, and incision of the femoral artery. There were also incised wounds of the right wrist. Bony injury was minimal, and no shark teeth were recovered. Case 2 was a 26-year-old male diver who had been attacked by a shark. At autopsy, the main areas of injury involved the left thigh and lower leg, which displayed characteristic teeth marks, extensive soft tissue damage, and incised wounds of the femoral artery and vein. There was also soft tissue trauma to the left wrist, with transection of the radial artery and vein. Bony injury was minimal, and no shark teeth were recovered. In both cases, death resulted from exsanguination following a similar pattern of soft tissue and vascular damage to a leg and arm. This type of injury is in keeping with predator attack from underneath or behind, with the most severe injuries involving one leg. Less severe injuries to the arms may have occurred during the ensuing struggle. Reconstruction of the damaged limb in case 2 by sewing together skin, soft tissue, and muscle bundles not only revealed that no soft tissue was missing but also gave a clearer picture of the pattern of teeth marks, direction of the attack, and species of predator.     

Complete Cardiac Rupture Associated with Closed Chest Cardiac Massage: Case Report and Review of the Literature

Chest skeletal injuries are the most frequent complications of external chest massage (ECM) during cardiopulmonary resuscitation, but heart and great vessels lacerations that are indeed very rare. We report the case of a 35‐year‐old workman who collapsed and underwent ECM by his co‐workers for almost 30 min. At autopsy, no external injuries, fractures or bruises of the ribs or sternum, were observed. A hemopericardium with a rupture of the heart was found, with no signs of pre‐existent cardiac disease. Bruises of thoracic aortic wall, lung petechiae, a contusion of the liver, and bruises of lumbar muscles were found. The cause of death was due to sudden cardiac death with an extensive cardiac rupture. This is an unusual report of massive heart damage without any skeletal or muscle chest injuries, secondary to cardiopulmonary resuscitation. This kind of cardiac lesions may be considered when thoracic–abdominal trauma, or medical history, is unclear.     

Sharp force injuries in clinical forensic medicine--findings in victims and perpetrators

The injury findings in 58 perpetrators and 158 victims surviving bodily injuries due to sharp force are presented here. Defence injuries were found in 45.9% of the victims without any significant differences between males and females. There was no clear predominance of defence injuries on the left forearm and hand, as is known from autopsy studies; the right and the left hands were affected with an almost identical frequency. Regarding other parts of the victims' bodies, the topographic distribution of injuries showed a marked concentration on the left side (63.7%). The thorax, head and neck were frequently affected (45.9%, 15.3% and 15.3%, respectively), and less often the abdomen (11.1%), the lumbar and gluteal region (6.3%) and the lower extremities (6.1%). In surviving victims with only one singular stab apart from the upper limbs, the incidence of additional defence injuries on the hands and/or forearms was significantly higher (28.3%) than in fatalities. When the perpetrators had unintentionally cut their own hands, the frequency of these injuries on the right and left hands was almost equal.     

Neck and scleral hemorrhage in drowning

The determination of the cause and manner of death for a body recovered from the water can be difficult because of a lack of autopsy findings specific for drowning. This case report describes a 30-year-old man found submerged at the bottom of a hotel pool. An autopsy revealed scleral hemorrhages and fascial hemorrhages of multiple muscles of the anterior and posterior neck bilaterally. No evidence of traumatic injury was on the surface of the body. An investigation by law enforcement found no evidence of foul play. The occurrence of petechial and neck hemorrhage in a body recovered from the water is controversial, and a review of this literature will be given. We suggest that fascial hemorrhages of the muscles of the neck, as well as cephalic hemorrhages, can be explained by drowning-related elevated central venous pressure that is communicated to the head through the valveless veins of the neck.     

A Unique Fatal Moose Attack Mimicking Homicide

Fatalities caused by animal attacks are rare, but have the potential to mimic homicide. We present a case in which a moose attacked and killed a woman who was walking her dog in a forest. Autopsy showed widespread blunt trauma with a large laceration on one leg in which blades of grass were embedded. Flail chest was the cause of death. The case was initially conceived as homicide by means of a riding lawn mower. A review of the case by moose experts and analyses of biological trace material that proved to originate from moose, established the true source of injury. The dog probably provoked a moose, which, in response, stomped and gored the victim to death. The injuries resembled those previously reported from attacks by cattle and water buffalo. Fatal moose attacks constitute an extremely rare threat in boreal areas, but can be considered in traumatic deaths of unknown cause.