Bilateral First Rib Anomalous Articulations with Pseudarthroses Mimicking Healing Fractures in an Infant with Abusive Head Injury

Bilateral symmetric bone nodules were observed in the anterolateral first ribs of an infant with shaking injuries at autopsy. The location prompted diagnostic considerations of healing fractures versus anomalous articulations with pseudarthroses. The forensic pathologist worked with forensic anthropologists and pediatric radiologists to evaluate autopsy findings and compare premortem and postmortem X‐rays. Gross examination of the bones by the pathologist and anthropologists confirmed bilateral, callus‐like bone nodules in first‐rib locations associated with pseudarthroses. Histologic examination of one of the bones further showed features most consistent with pseudarthrosis, not a healing fracture. Radiologists then compared multiple premortem and postmortem radiographs that showed no remodeling of the bone over a 2‐week interval between the time of injury and death, which would be unexpected for a healing fracture in an infant. This multidisciplinary approach resulted in the appropriate diagnosis of pseudarthroses due to anomalous articulations, an uncommon finding in forensic pathology.     

Site of discovery in the bath tub. Evaluation of a fatality after four years using postmortem roentgen diagnosis]

On the one hand the following case demonstrates the problems of finding a dead body in the bathroom and on the other hand the importance of postmortem x-ray examinations. The corpse of an 65-year-old woman was discovered in her bath tub. At the body's feet there was a hair dryer. Investigations concerning murder were negative, circumstances appeared to be unsuspicious. That was why a postmortem examination was not performed. -4 years later murder had to be considered. After manual strangling the deceased and the hair dryer were layed into the bath tub. The corpse was exhumed and taken to a forensic autopsy. It was found that the hyoid bone and the superior horn of the thyroid cartilage were both fractured on the right. Damages caused by the preparation itself were excluded by using serial roentgenographs. These observations in combination with histological findings and the results of further investigations convincingly supported the suspicion of strangling by hand.     

Estimating the timing of long bone fractures: correlation between the postmortem interval, bone moisture content, and blunt force trauma fracture characteristics*

There is very limited knowledge about how long perimortem fracture characteristics persist into the postmortem interval (PMI). Therefore, in this study, 60 porcine long bones were exposed to natural taphonomic conditions and fractured with a steel bone breaking apparatus every 28 days throughout a 141-day period. Differences between macroscopic blunt force trauma fracture characteristics (fracture angle, surface morphology, and outline) were examined to determine if they varied over time or in relationship to bone moisture content (ash weight) and overall assessment. There are significant relationships between (1) PMI and percent ash weight (%AW), fracture surface, and fracture angle and (2) %AW and fracture surface and fracture angle. Bone moisture content correlates significantly with fracture morphology and other characteristics commonly used by forensic anthropologists to determine the timing of traumatic injuries. However, fracture characteristics normally associated with perimortem trauma can persist long into the PMI.     

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.     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

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.     

电击兔肢体所致骨损伤后的实验性研究

目的220V交流电击兔肢体后,观察电击部位骨表面的病理改变,为法医病理诊断电击伤提供客观、量化的指标。方法用220V交流电作为损伤电压。动物分为:生前电击组、死后5m in电击组、腐败组及正常对照组。每组骨骼标本均进行肉眼检察、X线检测及SEM观察;同时运用能谱仪测量电击部位元素的种类及含量。结果①电击部位骨皮质SEM下骨皮质紊乱、小孔穴形成、周围高密度影环绕,且钙、磷元素升高,碳元素下降是诊断电击伤的指标,并能鉴别生前、死后电击伤及腐败骨。②小孔穴的形态及钙、磷、碳元素的变化可用于推断电击时间。结论电击造成骨组织的形态及电击部位元素的改变可作为鉴别生前、死后电击伤、腐败骨和推断电击时间的指标。     

An unusual, deep lingual hemorrhage as a consequence of ligature strangulation

During the course of the daily practice of forensic pathology, little or no attention is generally devoted to the tongue (if it is even removed at all during the autopsy examination) except in a handful of relatively well-defined situations. In some other instances, such as injuries involving the neck and laryngopharyngeal organs, the tongue may be removed, but examined in only a cursory manner, since the serious pathology which caused or contributed to death is most often located in adjacent structures. While the postmortem examination was being carried out on a victim of ligature strangulation who exhibited relatively sparse external and laryngeal findings of significance, a unique and apparently heretofore undescribed patterned hemorrhage was discovered within the deep musculature of the tongue, having an appearance and contour identical to that of the curved edge of the subjacent hyoid bone. In difficult cases where strangulation is suspected as well as other potentially medicolegal problems with trauma involving the neck organs, a detailed inspection of the tongue through an easily accomplished dissection technique may provide invaluable information as to the mechanism of injury.     

Observational Case Series: An Algorithm Incorporating Multidetector Computed Tomography in the Medicolegal Investigation of Human Remains after a Natural Disaster

An algorithm incorporating multidetector computed tomography (MDCT), digital radiographs, and external examination was used to triage cases for noninvasive or complete autopsy after a natural disaster. The algorithm was applied to 27 individuals who died during or soon after the earthquake that struck the Republic of Haiti on January 12, 2010. Of the 27 cases reviewed, 7 (26%) required a complete autopsy to determine cause and manner of death. In the remaining 20 (74%), cause and manner of death were determined with a reasonable degree of medical certainty after review of circumstances, an external examination, and postmortem imaging by MDCT and digital radiography (noninvasive autopsy). MDCT was particularly useful in detecting skeletal fractures caused by blunt force injury which were not evident on digital radiographs. The algorithm incorporating postmortem MDCT can be useful in the triage of human remains for autopsy after a natural disaster.     

Healed fractures of the larynx and lingual bone in forensic autopsy]

Laryngohyoid fractures are a frequently investigated matter, especially in the forensic literature. On the other hand, there are only very few (old) forensic reports of such fractures in survived cases. However, healed fractures are not seldom found in forensic autopsies: In a personal series of 1160 forensic autopsies (adult persons) a careful dissection of the laryngohyoid complex was done by 1 investigator. Only a macroscopic examination of the cartilages was carried out; radiographs and histological slices were not regularly made. Therefore only a part of existing old fractures is detectable; for example, healed fissures are not visible with this simple method. Furthermore, asymmetries of the thyroid laminae cannot be declared as posttraumatic without additional examination, because this condition is described as possible anatomic anomaly. From that, the injury frequencies presented here only mark the lower threshold of the existence of such findings. Healed fractures of the upper thyroid horns and the major hyoid horns can be easily detected even in a routine examination, if healing resulted in a fixed dislocation or apposition of bone surrounding the former fracture site. In the present series, this was the predominant localization of old fractures: the upper thyroid horns (43 cases), followed by the hyoid cornua (12 cases), a combination of both sites (5) and cricoid fractures (5). Of the total 65 healed fractures (5.6%), 35 were found in the group of 290 chronic alcoholics (12.1%) and only 3.4% in non-alcoholics. In the subgroup of middle-aged alcoholics, the fracture rate increased up to 19%. However, this group did not present a higher rate of fresh laryngohyoid injuries (not related to strangulation) than the other cases. The old fractures probably resulted from minor "daily" injuries (like falls), which are common, especially in chronic alcoholics. The frequency of such findings should be in mind if an apparently fresh fracture, found in an actual autopsy, should be related to the cause of death: there is a real chance, that this fracture occurred prior, and without causal connection to the factors resulting in death. Therefore a histological examination of the age of this finding is necessary. Cricoid fractures are quite uncommon, except in serious external neck trauma. In 1 of our 5 cases, this fracture was caused by repeated cruelty, finally resulting in death.     

Pathologic features of fatal falls from height

Deaths due to falls from height are common in urban settings. At the time the body is found, it is often unclear whether the mode of death is accident, suicide, or homicide. To assess the injury pattern in fatal falls from height with special regard to criteria that might be helpful in discrimination between accident, suicide, and homicide, respectively, we reviewed 68 medicolegal autopsy cases (22 females, 46 males, age range 13-89 years) of fatal falls from height regarding demographic data, findings at the death scene, results of the postmortem examination, psychiatric history, and toxicologic findings. Among the 68 cases, there were 34 suicides, 23 accidents, and 11 unclarified cases, in 3 of which homicide was suspected. In general, suicides were from greater heights than accidents (mean height 22.7 m for suicides and 10.8 m for accidents, respectively; 79% of suicides from more than 16 m). Strikingly, severe head injuries predominantly occurred in falls from heights below 10 m (84%) and above 25 m (90%), whereas in the group of falls from 10 to 25 m, these lesions were seen less frequently (28%). Neck injuries like muscle bleeds and fractures of the hyoid bone were found in 33% of falls from more than 10 m and did not occur from less than 10 m. Our data stress that the evaluation of pathologic features alone is not sufficient to assess the mode of death in fatal falls from height. Instead, postmortem findings have to be considered within the framework of the subject's social, medical, and psychiatric history in conjunction with findings at the death scene and toxicology results to obtain the clearest possible picture of the circumstances of death.     

CT技术在尸体检验中的应用

自1990年CT首次应用于死后尸体检验以来,不断有学者对其在全身尸体检验中的价值和优势进行探讨。CT用于解剖前的系统检验,对解剖有指导作用,可以与解剖所见互相印证,有时还能弥补解剖检验的不足。本文综述了CT技术在尸体检验中对死因分析、致伤方式推断和个体识别等方面的主要应用价值及其发展趋势,提示CT技术与其他学科联合应用将在法医病理学领域发挥更大的作用。     

Histologic appearance of fractured thyroid cartilage and surrounding tissues

Histological appearances of the fractured superior horns (SH) of the thyroid cartilage and their surrounding tissues were reviewed, with particular reference to signs of vital origin of the fracture. Twenty-nine autopsies with either histories or findings indicating asphyxial neck compression, with a total of 39 fractured SHs, and three autopsies with history of suicidal jump from height with a total of two SH fractures, were examined. Fifteen autopsies with finding of 19 artefactually fractured SHs while removing neck organs at autopsy were used as controls. In the cases of neck compression and victims of jump from height haemorrhages, retraction of fractured SH fragments with invagination or squeezing of the perichondrium, contraction bands, contraction band necrosis and 'opaque fibres', in the adjacent muscle fibres could be seen. Fibrin deposition and/or leucocytic reaction were noted in cases where circumstances of death indicated prolonged death struggle (as in incomplete hanging, resuscitation or homicidal neck compression). However, retraction of fractured fragments and invagination of perichondrium between artefactually fractured SH fragments were observed in both control cases and cases with antemortem trauma to the larynx. Many of these histological findings, including haemorrhages and fractures had not been evident at gross examination. We conclude that histological examination of SHs may not only uncover macroscopically overlooked injuries but also may facilitate the clarification of an injury's vital origin.     

Fracture of the hyoid bone associated with atlantoaxial subluxation: a case report and review of the literature

Hyoid bone fractures secondary to blunt trauma other than strangulation are rare. Only 27 cases have been reported in the literature. They have few, if any, complications, such as dysphagia, hypoxia, cardiorespiratory collapse, laceration of the pharynx, mandibular fracture, thyroid cartilage fracture, and facial fracture. No report of hyoid bone fracture associated with spinal column injury was reported in the English literature. The authors reported a 46-year-old male patient who complained of neck pain and odynophagia after a traffic accident. After systemic examination and cervical CT scan, the diagnosis of hyoid bone fracture at the right great horn and atlantoaxial subluxation was made. The patient was observed in ICU for 48 hours. A nasogastric tube was inserted for feeding. Fifteen milligrams of dexamethasone was given once a day for 3 days to reduce the swelling and pain. We performed a cutaneous traction for the subluxation and carefully watched the hyoid bone and the patient's respiration. No lethal complications occurred. Two weeks later, the patient was allowed to ambulate with cervical collar protection and to resume oral intake. Three months later, he was asymptomatic. This case, with hyoid fracture and atlantoaxial subluxation, is the only case reported in the literature. The importance of hyoid fracture, however, rests not with the rarity of it, but with the lethal potential of missing diagnosis. Nonsurgical management may be effective in most of the cases.     

多层螺旋CT检查在尸体颈椎损伤中的应用

对需要在尸体检验时进行颈椎多层螺旋CT(MSCT)检查的情形进行讨论,研究利用MSCT对疑有颈椎损伤的尸体进行颈椎检查的方法,并对一例疑似颈椎损伤尸体的颈椎提取后进行MSCT检查。发现对疑似有颈椎骨折尸体提取颈椎进行MSCT检查,可以快速精确地显示颈椎的细微骨折及骨折的空间分布,从而推断致伤方式。解决了传统尸检中费时费力,容易漏诊和误诊的问题。     

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.     

论虚拟解剖

“开放式”解剖是法医学死亡调查中的传统手段。随着科技进步和技术发展,现在的断层扫描影像学技术已经可以部分甚至全部取代传统的解剖技术。计算机断层扫描成像技术可以提供个体的损伤或死后变化的二维或三维影像信息．可以充分而客观地反映如骨折、气体检塞、皮下气肿、气压损伤、腐败改变及器官损伤等。这些反映个体损伤或者死后变化的计算机断层扫描成像技术可以为司法实践提供直观、有力的法医学证据。而另一种影像学技术．核磁共振成像技术在探查软组织损伤、器官损伤及非外伤性损伤等方面具有独特优势。但是,如何辨别生前和死后骨折形态的差异,如何调整生前死后变化的信号检查强度等方面。一直没有系统地研究报道。本文将综述有关计算机断层扫描和磁共振成像技术在法医解剖方面的应用,引入“虚拟解剖”的概念．系统地介绍这种独立、客观和微创的新型解剖方式．并对其在法医学死亡调查中产生的影响做出前瞻性预测。可以预见,在今后大量、广泛的法医死亡调查中．“虚拟解剖”将成为一种普遍应用的损伤和死亡的分析鉴定方式。     

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.     

An Examination of the Transition of Fracture Characteristics in Long Bones from Fresh to Dry in Central Florida: Evaluating the Timing of Injury

It is important to conduct timing of injury research analyzing fracture characteristics at known postmortem intervals (PMI) because bone can retain fresh characteristics throughout the PMI. Defleshed pig (Sus scrofa) long bones were fractured weekly in two environments (full sun and shade) over 14 weeks in Central Florida and fracture characteristics were categorized (N = 136) for analysis. Results of analysis of variance (ANOVA) using time in weeks (PMI) as a dependent variable indicate significant relationships between PMI and Fracture Angle (p < 0.001), Fracture Surface (p < 0.001), and Fracture Outline (p < 0.001). Fracture characteristics associated with perimortem trauma (smooth Fracture Surfaces and curved or V‐shaped Fracture Outlines) were commonly observed. Analysis of fracture characteristics for each environment demonstrated similar patterns. Overall, the loss of only fresh fracture characteristics for each bone was noted earlier in the PMI for the Central Florida region than previously reported.     

螺旋CT三维成像技术在疑难骨外伤中的应用价值

目的探讨螺旋CT(SCT)三维(3D)成像技术在法医疑难骨外伤中的诊断价值。方法选择11例骨外伤病人进行X线及螺旋CT3D检查,观察和分析骨折的位置、数量及性质。结果11例中,X线检查共发现肋骨骨折34处,肩胛骨骨折1处,鼻骨骨折2处,掌骨不完全性骨折1处,左胫、腓骨骨折1处,耻骨骨折1处。CT检查共发现肋骨骨折47处,肩胛骨粉碎性骨折1处,鼻骨骨折明显移位1处,排除骨折1处,上颌骨骨折1处,掌骨完全性骨折1处,左胫、腓骨陈旧性骨折1处,骶骼关节脱位1处,第5腰椎椎弓根骨折1处。结合三维图像,冠位状及矢位状重组图像清晰地显示出骨折线的部位、数量、性质和错位、复原等情况。结论螺旋CT三维成像应用对法医复杂骨外伤的客观诊断非常有效,优于常规X线检查。