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.     

无骨折脱位型颈脊髓损伤法医学鉴定25例分析

目的 探讨无骨折脱位型颈脊髓损伤案例中外伤与损害后果因果关系法医学鉴定的要点.方法 收集25例无骨折脱位型颈脊髓损伤的法医学鉴定案例资料,总结被鉴定人的年龄、致伤方式、影像学检查结果、自身颈椎退变情况、临床表现、主要诊疗情况、预后情况等,按照损伤与损害后果相关程度分为直接原因、主要原因、同等原因、次要原因、无原因进行伤...     

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.     

交通事故致胸、腰椎损伤致残等级评定447例分析

目的探讨车祸致胸、腰椎损伤程度与伤残程度的关系,总结伤残评定经验,探寻其规律性。方法选择胸、腰椎损伤的鉴定447例,重新审查诊断,分析治疗措施,评价胸腰部活动度丧失程度及神经功能障碍情况,分析损伤程度与后遗障碍之间的关系,综合评定伤残。结果胸、腰椎损伤类型及数量并不决定其胸、腰部活动障碍程度及神经损伤后遗症严重程度;椎体损伤的部位与胸腰部活动度障碍关系密切;神经损伤主要集中在T1至L2段脊柱损伤;椎体损伤医院误诊率较高。结论伤残评定应分析损伤与后遗症严重程度的因果关系,以损伤所致后遗症为评残依据,重点关注脊柱功能的丧失程度。     

Injuries of the Head from Backface Deformation of Ballistic Protective Helmets Under Ballistic Impact

Modern ballistic helmets defeat penetrating bullets by energy transfer from the projectile to the helmet, producing helmet deformation. This deformation may cause severe injuries without completely perforating the helmet, termed “behind armor blunt trauma” (BABT). As helmets become lighter, the likelihood of larger helmet backface deformation under ballistic impact increases. To characterize the potential for BABT, seven postmortem human head/neck specimens wearing a ballistic protective helmet were exposed to nonperforating impact, using a 9 mm, full metal jacket, 124 grain bullet with velocities of 400–460 m/s. An increasing trend of injury severity was observed, ranging from simple linear fractures to combinations of linear and depressed fractures. Overall, the ability to identify skull fractures resulting from BABT can be used in forensic investigations. Our results demonstrate a high risk of skull fracture due to BABT and necessitate the prevention of BABT as a design factor in future generations of protective gear.     

The Effects of Continuous Application of the TASER X26 Waveform on Sus scrofa,

This study investigated and evaluated the safety margins of the continuous long duration (up to 30 min) effect of the TASER X26 waveform, using a Sus scrofa model. Long duration continuous stimulus has not been evaluated on humans or human surrogates prior to this study. Swine were used as models due to similarities with humans in their skin and cardiovascular systems. Very long duration was used to determine both exposure dose and possible adverse physiological effects of dose. The trial began with an application of 10 min, and subsequent animals received increasing exposure time up to a survived maximum duration of 30 min. At the onset of this work, it was hypothesized that there would be a time limit after which most animals would not survive consistent with increased dose response. However, this hypothesis was not supported by the experimental results. All animals (10 of 10) survived up to 3 min. Seven of the 10 animals survived up to a 10‐min exposure and 3 of 5 animals with a 30‐min target exposure survived the full exposure. Surviving animals were recovered and observed for 24 h, with no postrecovery deaths. This suggests that swine (based on physiology) will not experience a fatal event when exposed to the TASER X26 for a continuous 3 min. Conclusions regarding longer duration (10–30 min) are not as certain due to the small sample sizes at these time intervals.     

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.     

Correlative Factors for Organic Psychotic Symptoms in Patients Following Traumatic Brain Injury

Objective To investigate the correlative factors for organic psychotic symptoms following trau matic brain injury （TBI）. Methods In the current study, 391 subjects who had undergone forensic iden tification of the organic mental disorders due to TBI were included, both the demographic and posttrau matic information collected. The relevant data were statistically analyzed in those confirmed as organic psychotic syndrome according to Chinese Classification of Mental Disorders 3rd version （CCMD3）. Re suits Fiftytwo subjects （13.3%） were identified as organic psychotic symptoms. The chisquare test showed that the detectable organic psychotic symptoms were associated with the marriage status, damage nature, injury severity and treatment, and the multivariate logistic regression analysis revealed good fitness of treatment and injury severity with the regression model （OR=0.044, 95% CI： 0.0170.114; OR=2.145, 95% CI： 1.201-3.832, respectively）. Conclusion The risks of organic psychotic symptoms following TBI can be involved in the alternative of craniotomy for the cases with trauma and moderate brain injury.     

The Frequency of Cranial Base Fractures in Lethal Head Trauma

The interpretation of cranial base injuries has never been investigated from a purely anthropological perspective. Very little exists in forensic literature in order to interpret the significance of cranial base fractures. We analyzed 296 cases of deaths due to skull–brain injuries. The frequency of vault fractures was 75.7% and that of base fractures was 91.9%. We observed the distribution of cases of death according to manner of death and manner of injury and number of fossae involved. These observations were analytically compared to different variables (age, sex, manner of injury, and mode of injury). The study presented the proportion of base fractures associated with vault fractures, and the frequency of absence of base fracture in subjects with no vault fractures. Interesting associations of base fractures to age and manner of death are shown.     

Further investigations into the speed of cerebral swelling following blunt cranial trauma

An anesthetized sheep model of traumatic brain injury (TBI) has been developed to assess early changes in intracranial pressure (ICP) following closed head injury. Immediately after TBI, a transient (<10 min) hypertensive response occurred, followed by significant and prolonged systemic hypotension. ICP demonstrated a biphasic response, being seven times baseline values of 8 ± 2 mm Hg 10 min after injury, decreasing to 25 ± 2 mm Hg by 30 min, and then increasing to values exceeding 30 mm Hg by 4 h postinjury. ICP was always significantly higher than baseline values, which combined with hypotension, reduced cerebral perfusion pressure to less than 60% of normal. This early and sustained increase in ICP after craniocerebral trauma acutely alters cerebral perfusion pressure and brain oxygenation and provides a potential pathophysiological explanation for immediate clinical manifestations in humans following significant TBI.     

Modification of the Marmarou and Foda model of diffuse axonal injury (DAI) improves percentage survival of rats at 24 h and increases the amount of DAI identified

More than two decades ago, Marmarou published a valid model for producing diffuse axonal injury (DAI) in rats. Since then, both mild and severe injuries have been obtained by researchers using the original method and a weight of 450 g. However, the diffuse brain injuries produced in rats were only similar to those seen in humans when the rats sustained severe brain injuries. In these cases, rat mortality in the original article was around 50%, and the cause of death was prolonged apnea post-impact. Rat survival after impact is critical for studying the progression of DAI. In order to explain the cause of death in human victims with cranial trauma who do not show gross brain injury, testing for the presence of DAI is essential. Thus, in order to minimize local and cervical injuries to increase rat survival, attention should be paid to the following aspects: a wider head protector disc should be used, the head of the rat should be elevated at the time of impact, and the foam bed should be soft enough to allow the movement caused by acceleration. With our modified method, rat survival increased by 30% compared to the original model (80% versus 50%). Moreover, 85.7% of rats demonstrated DAI after 24 h of survival. With these modifications, injuries appear in the same locations as in humans; thus, the method is suitable for the study of traumatic DAI in humans.     

Injury pattern in fatal automobile accident passengers due to rear-end collisions

The article reports on the injury pattern seen in fatally wounded car passengers after rear-end collisions on motorways. The study material included 5 rear-end collisions, in which 9 car occupants (5 drivers and 4 front-seat passengers) were killed. The change in velocity (delta v) was above 60 km/h in all the reported cases. The injury pattern showed the following characteristics: extensive soft-tissue traumatization (subcutaneous haematomas, blood-filled pockets, "décollements") not discernible from outside on the back of the trunk, mostly in the lumbosacral region; dorsal serial rib fractures, often combined with fractures of the spine (including the sacrum and the coccyx) and/or the pelvis; ruptures of the aorta at the typical sites of predisposition; ruptures of the liver and spleen (particularly at the visceral surfaces).     

Morphological changes in lungs of patients with spinal injuries died in hospital

Morphological characteristics of changes in the spine and lungs in patients with spinal injuries dead in hospital are described. Spinal edemas were detected in all cases. Edemas were found even in subjects dead at the place where the injury was inflicted. Morphological changes in the lungs were characterized by a phase-wise process, depended on the volume of injury, duration of hospitalization, medical care rendered, and manifested by disorders of blood content of the organ, development of tissue edema, and pneumonia. These data do not rule out the development of pneumonia in patients with spinal injuries.     

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.     

Unusual neck lesion in a pedestrian caused by a road accident

The authors describe a road accident that occurred in the Trieste region of Italy in 1998, wherein a pedestrian experienced a mortal injury. During the on-site examination, the forensic officer in charge noticed, in addition to dispersed abrasions, bruises, and fractures, an unusual position of the head with a highly unusual motility of the cervical rachis and, above all, an apparent whitish fibrous elastic cord, 7-8 cm long, which came out of the mouth. The cord was found to be a segment of the spinal cord, expelled and driven into the mouth cavity by the impact. This represents an interesting case because of the specific dynamics of the accident and the type of lesion involved. This kind of spinal cord injury, in particular, is infrequent among pedestrians involved in road accidents in comparison with other road casualties.     

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.     

脑外伤后短时间内死亡尸体脑干病理变化

建立脑干机械性损伤（肉眼无明显改变）致迅速死亡的动物模型,应用免疫组化、分子生物学、电镜及图像分析等方法,研究脑千损伤的物质基础——神经元、轴索、胶质细胞、血脑屏障。研究结果表明：脑外伤后短时内死亡是脑干损伤的结果,白蛋白、纤维联结蛋白、神经微丝蛋白、胶质纤维酸性蛋白、原癌基因c－Fos等可作为诊断脑干损伤早期病变的指标。在实验研究的基础上,将上述指标应用于怀疑脑干损伤致死案例,验证了这些指标的实用价值,以期为脑外伤后短时间内死亡案例的死因判定提供客观证据,为颅脑损伤的临床救治工作指明重点。     

The occurrence of cervical fractures in victims of judicial hanging.

Cervical vertebrae from 34 victims of judicial hanging were examined. In only six cases was there a fracture of the axis and only one other fracture was seen in the series. The fractures were of two types. Three were the traditional 'Hangman's fracture' whilst three were of a type previously unreported. The incidence of fracture was unassociated with drop, date age or hangman. The results of the post mortems on these subjects were reviewed and found to be grossly inaccurate with regard to fractures. The results indicate that the traditional hangman's fracture occurred in only a small proportion of cases of judicial hanging. The cause of fractures and cause of death in judicial hanging are discussed with a brief history of judicial hanging in this country.     

A Biomechanical Evaluation of Skull–Brain Surrogates to Blunt High‐Rate Impacts to Postmortem Human Subjects

The field of forensic injury biomechanics is an emerging field. Biomechanically validated tools may assist interdisciplinary teams of investigators in assessing mechanisms of blunt head trauma resulting in skull fractures. The objective of this study is to assess the biofidelity of spherical, frangible skull–brain (SB) surrogates. Blunt impacts were conducted at 20 m/s, using an instrumented 103 g rigid impactor, to the temporo‐parietal region of four defleshed cephalic postmortem human subjects (PMHS). Force–deformation response, fracture tolerance, and fracture patterns were recorded for comparison to spherical skull–brain surrogates. Three brain substitutes were assessed: 10% gelatin, lead shot with Styrofoam and water. Force–deformation response of the skull–brain surrogates was similar to defleshed PMHS up to the point of fracture; however, none of the surrogates fractured at tolerance levels comparable to the PMHS. Fracture patterns of the skull–brain surrogates were linear and radiating, while PMHS fractures were all depressed, comminuted.     

大鼠心肌早期缺血内皮素的表达

为探讨心肌缺血后内皮素在心肌组织内表达的变化。用免疫组化SABC法研究内皮素的表达情况。结果发现缺血60min后 ,缺血区心肌细胞呈局灶性阳性 ;缺血120min后 ,血管平滑肌、内皮细胞及心肌细胞浆均呈阳性着色。对照和缺血30min组心肌组织未见有阳性反应。上述各组HE染色未见明显病理改变。