Understanding rib fracture patterns: incomplete and buckle fractures

Reconstructing traumatic thoracic events, especially when soft tissues are absent, requires an advanced understanding of ribcage fracture patterns. The morphology and orientation of ribs complicate the fracture pattern, as a single blow often causes multiple fractures at various locations. Furthermore, fracture types observed in ribs are not explained easily by current bone biomechanic literature. Using evidential skeletal material archived at the Regional Forensic Center, Memphis, the ribs of 43 blunt force trauma cases were analyzed. A total of 195 incomplete fractures and 63 buckle fractures were noted. Incomplete fractures, previously thought to be common in children but rare in adults, were found among individuals ranging in age from 21-76 years. A buckle fracture, failure resulting from compressive instability, has been undefined previously in bone trauma literature but was repeatedly observed in this sample. This study elucidates recognizable rib fracture patterns while emphasizing gross bone examination for force and mechanical factors.     

Rib fractures in infants due to cardiopulmonary resuscitation efforts

Although it is widely known that adults may sustain fractures of the anterior and/or lateral aspects of the ribs due to cardiopulmonary resuscitation (CPR) efforts, relatively little is written about the generation of CPR-related rib fractures in the infant age range. In a series of 70 consecutive autopsies in infants ranging in age from 2 weeks to 8 months, with no history or indications of injury, the parietal pleura of the thoracic cage was stripped and the ribs carefully examined for fracture. Subtle fractures of the anterolateral aspects of the ribs were discovered in 8 (11%) of the 70 cases. In 7 of the 8 cases, multiple ribs were fractured (ranging up to 10 rib fractures), and in 5 of these cases, the rib fractures were bilateral. All of the rib fractures were subtle, had little if any associated blood extravasation, and would have been easily missed had the parietal pleura not been stripped. These anterolateral rib fractures in infants are the likely correlate of anterolateral rib fractures that are not uncommonly seen in the adult population, resulting from resuscitation efforts. The rib fractures are subtle and may not be identified unless the parietal pleura is stripped.     

Characterization and Comparison of Injuries Caused by Accidental and Non‐accidental Blunt Force Trauma in Dogs and Cats

Motor vehicle accidents (MVA) are often difficult to distinguish from non‐accidental injury (NAI). This retrospective case–control study compared animals with known MVA trauma against those with known NAI. Medical records of 426 dogs and cats treated after MVA and 50 after NAI were evaluated. Injuries significantly associated with MVA were pelvic fractures, pneumothorax, pulmonary contusion, abrasions, and degloving wounds. Injuries associated with NAI were fractures of the skull, teeth, vertebrae, and ribs, scleral hemorrhage, damage to claws, and evidence of older fractures. Odds ratios are reported for these injuries. MVA rib fractures were found to occur in clusters on one side of the body, with cranial ribs more likely to fracture, while NAI rib fractures were found to occur bilaterally with no cranial–caudal pattern. Establishing evidence‐based patterns of injury may help clinicians differentiate causes of trauma and may aid in the documentation and prosecution of animal abuse.     

376例肋骨骨折的X线诊断分析

探讨肋骨骨折的X线诊断。对 480例胸部闭合性创伤患者的X线图像及临床资料进行回顾性分析。在 480例中 ,376例 (78 3% )出现肋骨骨折。其中 335例 (89 1% )为多根肋骨骨折 ;348例 (92 6 % )骨折发生在一侧。376例共有 941根肋骨骨折 ,其中 90 3根 (96 0 % )为单根肋骨骨折 ,6 2 3根 (6 6 2 % )骨折发生在腋中线前后。在376例中 ,有 46例在伤后首次后前位胸片中出现部分或全部漏诊 ,占 12 2 %。肋骨骨折患者在摄取后前位胸片的同时应加拍患侧后前斜位 (加用滤线器 )胸片及在伤后 1～ 4周时复查摄片     

A radiographic assessment of pediatric fracture healing and time since injury

Past studies and pediatric bone physiology indicate that younger individuals may heal at a faster rate. Additionally, in adults upper limb fractures heal faster than lower limb fractures; this trend is expected for pediatric fractures. This study aims to evaluate and compare rates of fracture repair in children based on age and skeletal element. Six stages are used to describe the bone repair process in 294 radiographs of tibial and radial fractures from 107 infants and young children. Healing rates are examined using ANOVA and Welch's t-test with a 95% confidence interval. Results indicate that younger individuals spend less time at stage 1, suggesting a delay in the start of healing. Furthermore, forearm fractures heal faster than leg fractures at stages 2 and 3, suggesting a role in the osseous reaction of bone healing. The healing schedule presented may allow the timing of injuries to be estimated from radiographs.     

Alcohol‐Induced Osteopenia Among In‐Custody and Homicide Deaths from the Harris County Institute of Forensic Sciences

Four cases of in‐custody or unlawful death are presented as examples of increased bone fragility with an associated increase in fracture rates due to ethanol‐induced osteopenia. In addition, one of the individuals suffered fractures several weeks premortem, allowing some healing to take place. Using radiographs and physical examination, the ribs from these individuals are compared with those retained from three individuals with no history of alcoholism to illustrate diagnostic characteristics that will be notable using standard autopsy and anthropological procedures. Trabecular bone mass is notably decreased in the alcoholic group leading to a greater chance of fracture occurring during conflict, including arrest and in‐custody situations. The average number of perimortem fractures among the alcoholic individuals is 15, while the control group is six. In the case of the individual with healing, the degree of bone repair on the ribs was less than is expected considering the interval between injury and death.     

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.     

Longitudinal brainstem laceration associated with complex basilar skull fractures due to a fall: an autopsy case

This report describes an autopsy case of a rare longitudinal brainstem laceration associated with complex basilar skull fractures. The victim was a 40-year-old male who died immediately after falling from a roof (9.2m in height) of a factory onto a concrete floor. The postmortem examination revealed an incomplete ring fracture of the base of the skull with longitudinal fractures of the sphenoid (clivus of the dorsum sellae turcicae) and occipital bones, cerebral contusions in the frontal and temporal poles, a longitudinal brainstem laceration at the posterior median sulcus of the pons accompanied with multiple contusional hemorrhages in the brainstem and corpus callosum. Related blunt-force injuries were observed in the parieto-occipital region of the head, shoulder and upper back involving the fractures of the cervical and thoracic vertebrae, and sternum and ribs, indicating a huge impact to the occiput and subsequent impression of the vertebral column into the base of the skull due to violent anteroflexion of the neck, which caused the complex basilar skull fractures, contusions and longitudinal laceration of the brainstem.     

Case report: Forensic anthropological assessment in a suspected case of child abuse from South Africa

Not many case reports of suspected child abuse as assessed solely on skeletal remains are available. Forensic anthropologists have intimate knowledge of normal skeletal anatomy, bone trauma and processes of healing of bone and may therefore be of help in suspected cases of child abuse. Patterns of trauma in juvenile skeletal remains which are suggestive of abuse include fractures in different phases of healing, multiple fractures, typical fractures on ribs and long bones and severe, complicated cranial fractures. The aim of this paper is to report on the findings of the analysis of the skeletal remains of a 3.5 years old boy. Forensic pathological examination indicated that the boy had died from a massive cranial fracture, with multiple injuries present to the rest of the body. After the body had been buried for some time, it was exhumed and we were requested to look for signs of chronic, long-term abuse. Findings included a massive cranial fracture, another fracture in the roof of the orbit, two areas of non-specific subperiosteal bone growth and several untreated carious teeth. No clear healed fracture could be found, except for a possible healed cranial base fracture which stretched transversely across the petrosal bone. This area showed signs of recent bone activity. The court decided that this was not enough evidence of chronic abuse and found the accused guilty of murder but not of chronic child abuse. This case illustrates the difficulty to obtain clear signs of chronic injury on juvenile remains.     

Cardiac laceration and pericardial tamponade due to cardiopulmonary resuscitation after myocardial infarction.

Complications of cardiopulmonary resuscitation (CPR), such as rib fractures and pneumothorax, are not uncommon. The authors report the case of a 69-year-old woman who underwent surgery for a perforated duodenal ulcer. Eighteen hours postoperatively she sustained a cardiac arrest; vigorous resuscitation efforts, using advanced cardiac life-support procedures, failed. At autopsy, she had 350 mL of fresh blood in her pericardial sac, which had caused cardiac tamponade. Three ribs were fractured at the left sternal border. Directly underneath the fractured ribs were a 0.4-cm laceration of the pericardium and an accompanying 0.7-cm laceration of the left ventricle. There was an acute thrombus in the left anterior descending artery. Microscopic examination of the heart showed acute infarction of the left ventricle in the vicinity of the laceration. This case demonstrates that vigorous CPR performed on an acutely infarcted heart can result in lethal cardiac laceration and tamponade.     

Pathological Features of Fatal Crocodile Attacks in Northern Australia, 2005–2014

Eleven deaths from crocodile attacks in the Northern Territory, Australia were reviewed. The male:female ratio was 8:3; age range—10–62 years, average 29.4 years. Four children were included (one boy and three girls, aged 10, 11, and two at 12 years), and there were seven aboriginal victims (64%). The attacks were witnessed in eight cases with the victims swimming in freshwater N = 5, standing on a river bank N = 1, fishing in fresh water N = 1, or diving in the sea N = 1. At autopsy, several distinct patterns of injury were observed ranging from complete traumatic disruption of the body with only incomplete remains for examination (N = 5), to crushing of the head with fractures of the skull (N = 4), crushing of the chest with fractures of the ribs and sternum (N = 2), and avulsion of limbs (N = 4). In one case, there was decapitation. Autopsy evaluations were complicated by decomposition and loss of body parts.     

人体胸廓骨骼三维有限元模型的构建及生物力学分析

目的建立完整的人体胸廓骨骼三维有限元模型,并探索力作用变化趋势。方法对尸体胸部进行多层螺旋CT(multislice computed tomography,MSCT)扫描,使用有限元建模软件根据CT图像数据对胸廓骨性结构进行三维重建并生成有限元模型,模拟胸廓右季肋部遭受速度为4、6与8m/s的钝性物体正面击打,分析胸廓受击打后的应力、应变分布情况。结果成功构建解剖学高仿真度的人体胸廓有限元模型,模型体网格平均质量0.7。生物力学分析结果显示胸廓受击打后发生局部弯曲及整体变形,应力与应变产生于初始打击部位肋骨,后沿肋骨向两侧传播,并于肋骨后侧及近胸骨处集中,6m/s与8m/s的打击速度可造成打击部位肋骨应变值超出相应强度极限,发生骨折。结论应用有限元建模分析软件能够建立符合真实情况的高质量的人体胸廓三维有限元模型,且模型可用于分析外力作用下胸廓骨性结构的应变趋势,为胸部损伤的致伤方式推断提供了新的途径和方法。     

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.     

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.     

The Erratic Behavior of Lesions in Burnt Bone

This study analyses depressed fractures (by blunt force trauma) and circular full‐thickness injuries (drill injuries and gunshot wounds) in charred bones. Fifty bovine ribs (total 104 lesions) were divided into three groups. The first group consisted in 20 depressed hammer‐produced fractures; in the second one, 60 round drill‐holes were produced (30 circular, 30 semicircular); in the third group, 12 fleshed and 12 skeletonized ribs were hit by 9‐mm bullets. Each specimen was carbonized in an electric oven up to 800°C. Morphological and metric analyses were performed before and after: morphological features were preserved, but depressed fractures showed an increase in their dimensions (p‐value < 0.05); the drilled holes shrunk (p‐value < 0.01); the charring cycle increased the number of fractures in samples with gunshot wounds differently in fleshed and defleshed ribs. This study showed the complex behavior of charred bone, for what concerns the interpretation of trauma and how caution should be applied.     

Structural analysis of human rib fracture and implications for forensic interpretation

Patterns of rib fractures are of significant clinical and forensic interest. Linking patterns of rib fracture with specific physical events provides a foundation for understanding the nature of traumatic events that are associated with rib fracture in forensic contexts. In this study, isolated human ribs (n = 8) were end-loaded to failure to investigate: (i) local deformations (bone strain) prior to and during structural failure, (ii) location of ultimate failure, and (iii) fracture mode. Structural properties of ribs were used to calculate theoretical stresses to determine whether such calculations could be used to predict site of fracture. Ribs fractured on the sternal side of midshaft in all experiments, but mode of failure varied with transverse, buckle, spiral, and "butterfly" fractures observed. Comparison of calculated stress with observed strain values suggest that experimental, rather than theoretical, approaches will be most productive in furthering understanding rib fracture in forensic contexts.     

Homicidal commotio cordis in two children

This paper's objective is to describe two cases of fatal commotio cordis resulting from the deliberate striking of children's chests by adults with their fists. These deaths involve two male children, ages 3 years and 14 months. The clinical histories, events in the households prior to the deaths, behaviors of the children, autopsy findings, and investigation results are all similar. In both cases, fatal blows were delivered to the anterior chest with a closed fist. Both children collapsed immediately, unable to be resuscitated. Confessions were obtained in both cases by investigators soon after the children's deaths. Autopsies showed chest contusions in only one child, presumably due to knuckle impact. The cardiac rhythms noted by paramedics were ventricular fibrillation and asystole. Due to the lack of physical findings, an immediate and thorough investigation is critical. An accurate history of events preceding death must be obtained.     

Hyoid fracture and strangulation.

Observation of hyoid fracture in skeletonized remains offers potentially valuable information on the history of the skeleton or evidence of foul play, or both. Perimortem hyoid fracture frequently indicates manual strangulation, although ligature strangulation, hanging, and other forms of trauma to the neck cannot be ruled out without additional evidence. Such fractures are rare in children and infants, since the hyoid components are not fully ossified and are more flexible than in adults. Both antemortem and postmortem origins of the fractures must also be considered.     

A case of a fatal Himalayan black bear attack in the zoo

We present a case of a 22-year-old male, who was found inside the cage of Himalayan black bears in the Belgrade Zoo. The victim attended the Belgrade Beer festival the previous night, drinking a lot of beer and acting aggressively. A medico-legal autopsy was performed at the Institute of Forensic Medicine in Belgrade. Autopsy findings showed numerous excoriations all over the body surrounded by bruises, as well as spindle-shaped, oval, and partly irregular wounds of variable size, large defects of skin and subcutaneous soft tissue, fractures of the thyroid and cricoid cartilage, and fracture of ribs. Postmortem toxicological analysis revealed the presence of ethanol in vitreous humor and urine and 11-nor Δ9 tetrahydrocannabinolic acid found in the urine. We discussed similar cases from the available literature in different regions of the world. In conclusion, we pointed out that the presented case does not follow the general pattern of Himalayan bear attacks.