[Forensic imaging of sharp force injuries]. / Forensische Bildgebung der scharfen Gewalt.

BACKGROUND: Answering legal questions is everyday routine in forensic medicine. The reconstruction of violent crimes following attacks with sharp and/or pointed instruments is usually complex and can hardly be adequately answered using traditional forensic methods such as autopsies. For this reason, clinical and postmortem radiology has become the ideal complement to forensic medicine. METHODS: While classic X­ray is unsuitable to image soft tissue injuries, and magnetic resonance imaging is too expensive, too complex and also not available everywhere, multislice computed tomography (MSCT) has now emerged as the method of choice in forensic imaging for the assessment of the consequences of sharp force injuries. ACHIEVEMENTS: Forensic imaging, especially MSCT, offers an indispensable addition to reconstruction, particularly after stab wounds. In many cases, it is at least equal to, and in some cases superior to, the classic autopsy in the assessment of stab wounds, the reconstruction of the sequence of events or the assessment of (life-threatening) injuries. CONCLUSIONS: The forensic radiological assessment after sharp violence requires experience in both the field of radiology and forensic medicine. Provided that both disciplines work closely together, forensic radiology can be an essential tool in the care for victims of violence.

Hidden Inferior Vena Cava Injury: A Case of Missed Diagnosis after Preoperative CT and Laparotomy.

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

Self-inflicted very-low-velocity penetrating head injury: A CARE-compliant case report.

RATIONALE: Low-velocity penetrating head injury (PHI) is rare, comprising 0.2% to 0.4% of head traumas, but can be devastating and is associated with significant morbidity and mortality. No previous case of very-low-velocity PHI due to self-inflicted stabbing with a gimlet has been reported. PATIENT CONCERNS: A 62-year-old man was admitted to the hospital with bleeding head and abdominal wounds after stabbing his abdomen with a gimlet, and then hammering the same gimlet into his forehead and removing the gimlet himself. DIAGNOSES: Upon examination at admission, stab wounds were present on the forehead and the right upper quadrant. Computed tomography (CT) of the head revealed a bone defect in the left frontal bone and showed the intracranial path of the gimlet surrounded by mild hemorrhage and pneumocephalus. Magnetic resonance imaging (MRI) confirmed a small amount of hemorrhage with pneumocephalus but no vascular injury. INTERVENTIONS: Conservative treatment without surgery. OUTCOMES: Follow-up MRI on hospital day 58 showed no abscess or traumatic intracranial aneurysm. The patient achieved full recovery of motor and mental functions with conservative treatment and was discharged on hospital day 69. LESSONS: Very-low-velocity PHI might be successfully treated with conservative treatment.

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds.

INTRODUCTION: This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso. METHODS: Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020. RESULTS: A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study. CONCLUSIONS: Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

Anterior approach for a stab wound with penetrating rebar injury causing incomplete cauda equina syndrome in lumbosacral spine lesion: a case report and literature review.

PURPOSE: To report a unique case of incomplete CES following a rebar penetrating injury in perineal region with retro-pulsed fragment, which was treated with anterior approach and discuss suitable surgical approach. METHODS: Incomplete cauda equina syndrome caused by non-missile penetrating injury is extremely rare. A 26-year-old male patient presented incomplete cauda equina syndrome due to a penetrating rebar wound from his perineal region to the lumbosacral spine. Computed tomography demonstrated a bony fragment broken from S1 body compressing into the spinal canal. RESULTS: By anterior approach, we performed partial corpectomy of L5, decompression by retrieving the bony fragment and L5-S1 interbody fusion. The patient had a significant recovery, and no clinical complication was found after over 2-year follow-up. CONCLUSION: It is challenging to determine the optimal strategy of surgical treatment for penetrating spinal injuries with retained foreign bodies, here we suggest an anterior approach situation that has the advantage of being able to effectively perform decompression and prevent iatrogenic damages of thecal sac and nerve rootlets.

Use of different imaging techniques in stab wound analysis.

Stab wound analysis is a relatively new field of study in forensic science, and there is currently much debate regarding the effectiveness of the analysis due to a lack of validation studies. Furthermore, the underlying viewpoints on the success of stab wound analysis vary. Examination of cut marks, for example, can reveal a variety of characteristics which can be used to determine the type of weapon that was used to inflict them. However, published studies are not consistent when identifying knife blade characteristics, instead considering a wide variety of morphological aspects and their potential value in forensic scenarios. The existing research methodology is therefore inadequate to reliably inform in such contexts, and future experimental design should be influenced by the conditional variance in stabbings in order to provide reliable findings. The research presented here takes a systematic approach to the problem, compiling the published literature (up to September 2023) on the use of different imaging methods applied to stab wound examination to create a taxonomy to examine trends in methodological approaches in both research and investigative settings. This approach identified that published studies could be classified as either morphological or morphometrical, and further sub-classified based on their degree of success and the findings reached. This emphasises the importance of prioritising research into mark data, and the need for a multi-technique, multi-disciplinary approach. A decision tree was created to illustrate which mark attributes should be studied for which purpose, and using which imaging method(s). Furthermore, the research presented identifies two key areas in stab wound research which should be the focus of standardisation efforts, namely methodological procedures and mark characteristic collection. Knife markings are difficult to interpret, but further research and standardisation of kerf mark analysis, as highlighted here, will improve the efficiency and reliability of both forensic investigations and future experimental studies.

Attempted Suicide with a Self-Inflicted Penetrating Stab Wound to the Medulla Oblongata Caused by a Pair of Scissors: Case Illustration.

A 78-year-old male patient with a history of psychotic depression was found in the bathroom of his apartment with a pair of scissors driven deeply into the back of his neck. He presented with tetraparesis with residual control over the left lower limb movement. Immediate skull radiograph and brain computed tomography scans revealed the tip of the scissors passing into the foramen magnum. Emergent surgery with midline suboccipital craniectomy and resection of the posterior arch of C1 was performed. The scissors were spontaneously dislocated in the course of surgery. Thereafter, debridement, placement of external ventricular drain and primary closure of the dura and skin were achieved. Post-operatively, the patient was not able to follow any instructions. On the 22nd post-operative day, the patient passed away in palliation. To our knowledge, this is the first reported case of a suicide attempt involving the use of scissors reaching the medulla oblongata.

Traumatic Iliac Arteriovenous Fistula Treated With the Amplatzer Vascular Plug II: A Case Report and Literature Review.

Traumatic iliac arteriovenous fistula is a rare complication of vascular injury. Open surgical repair has an incidence of postoperative complications. In recent years, endovascular treatment has shown better efficacy. We report a 62-year-old female AVF patient with a stab injury history of more than 16 years. Computed tomography angiography (CTA) revealed a large arteriovenous fistula between the right internal iliac artery and the common iliac vein. After considering the patient's relevant conditions, an endovascular approach was satisfactorily performed with the implantation of an Amplatzer Vascular Plug II to interrupt the abnormal vascular communication and maintain arterial and venous patency. The final control images showed closure of the arteriovenous communication.

Surgical exploration for penetrating neck trauma - an audit of results in 145 patients.

BACKGROUND: Selective non-operative management (SNOM) is the current gold standard for the treatment of patients with penetrating neck trauma. The policy revolves around the liberal use of computed tomography angiography (CTA) in those patients who are haemodynamically stable, irrespective of the anatomical zone of injury, aiming at reducing the incidence of negative and non-therapeutic interventions and their potential complications. METHODS: A retrospective audit of results of patients who underwent immediate surgical exploration at the Chris Hani Baragwanath Academic Hospital in Soweto between January 2010 and December 2015 was performed. RESULTS: One-hundred and forty-five (145) patients, with a median age of 28 years (range 18-67 years), predominantly males (93.8%), underwent immediate exploration. Most injuries were caused by stab wounds (92.4%) and affected zone 2 (54.1%) on the left side of the neck (69.6%). The most common presentations were active haemorrhage (29.4%), shock (24.1%) and expanding haematoma (15.1%). A major vascular injury was found in 40%, and aero-digestive organ injury in 19.3%. The rate of negative-non-therapeutic exploration in this cohort was 4.1%. Complications were recorded in 7.6%, and the overall mortality was 9.6% secondary to early uncontrolled haemorrhage, sepsis and occlusive strokes. CONCLUSIONS: The utilisation of SNOM with strict criteria for selection of patients who require immediate surgical exploration versus investigations with CTA results in a low rate of non-therapeutic interventions.

Is diagnostic laparoscopy necessary in the management of left thoracoabdominal stab wounds?

BACKGROUND: The diagnosis of a diaphragmatic rupture and the identification of patients for surgical repair is challenging despite current diagnostic algorithms and imaging technologies. Unless treated on time, acute traumatic diaphragmatic injury due to stab wounds has a high mortality and morbidity rate, with an increasing trend in the presence of organ herniation. In this study, we aimed to investigate the efficacy of diagnostic laparoscopy in patients with an anterior thoracoabdominal stab wound and to compare the follow-up outcomes of cases. METHODS: We retrospectively reviewed our institutional database of patients who were admitted with stab wounds between Oc-tober 2012 and 2022. Patients who underwent diagnostic laparoscopy were divided into two groups depending on the presence of a diaphragmatic injury. We analyzed demographics, the success of computed tomography (CT) imaging in the diagnosis, the presence of hemomediastinum, pneumomediastinum, tube thoracostomy application, associated organ injury, type of surgery, duration of surgery, complications, and the length of stay between the groups. RESULTS: Of the 39 patients with penetrating left thoracoabdominal injury underwent diagnostic laparoscopy, CT had a diagnostic sensitivity of 63.16% (95% Confidence interval [CI] 38.36-83.71%), and a specificity of 100% (95% CI 82.35-100.00%). We could not find a statistically significant difference between the groups in terms of studied variables, while operation time was significantly higher in the diaphragmatic injury group (P<0.01). Fourteen patients had accompanied visceral injuries. CONCLUSION: Diagnostic laparoscopy is still the gold standard particularly in the ER setting, particularly in the absence of an experienced radiologist for 24 h and when the close monitoring of the patient by the same team cannot be provided.

Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study.

BACKGROUND: While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS: Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS: Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS: In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

A Rare Self-Inflicted Stabbing to the Neck Injuring the Distal Trachea and Proximal Esophagus.

Penetrating neck trauma poses a significant risk to multiple vital structures, which if not treated immediately may lead to devastating consequences. Our patient presented after sustaining self-inflicted stab wounds to the neck. He was taken to the operating room for a left neck exploration and median sternotomy, revealing a distal tracheal injury. Following repair of the tracheal injury, an intraoperative esophagogastroduodenoscopy demonstrated a full-thickness esophageal injury 15 cm proximal to the tracheal injury. Both injuries were the result of separate stab entries originating from the same external midline wound. To our knowledge, this case report is unique in bringing this circumstance to the literature, demonstrating the importance of full intraoperative examination to assess for concomitant wounds in stab injuries after the initial pathology has been found and the initial stab trajectory understood.

Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds.

BACKGROUND: This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients. MATERIALS AND METHODS: A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included. RESULTS: Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: -10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013. DISCUSSION: Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.

Radiological detection of sharp force skeletal trauma: an evaluation of the sensitivity of Lodox in comparison to CT and X-ray.

Victims of violent crime often have evidence of sharp force trauma (SFT) which needs to be examined to accurately investigate these cases. The abilities of CTs, X-rays, and Lodox to detect skeletal SFT defects and the minimum number of impacts were assessed, as were their abilities to macroscopically interpret SFT with the aim of identifying the class of weapon used. Ten pigs were, post-mortem, stabbed using a kitchen knife on one side of the body and chopped using a panga on the other side. They were then scanned and macerated. The number of SFT defects, type of SFT, and minimum number of impacts identifiable osteologically were recorded, as well as when using each imaging modality. CTs were most sensitive for detecting stab and chop defects (56.7% and 78.3%, respectively) and the minimum number of impacts (82.8%), while X-rays were least sensitive (17.2% for stab wounds, 46.5% for chop marks, and 43.5% for impacts). Lodox detected 26.8% of stab defects, 59.3% of chop marks, and 58.4% of impacts. The type of SFT for more than 70.0% of identified defects was correctly classified using all methods, while only Lodox had moderate sensitivities for stab wounds (52.4%). When radiological assessments of skeletal SFT are required, CTs should be performed, but Lodox can be used as an alternative. However, dry bone analyses still produce the best results and should be performed whenever possible. Macroscopic interpretations of skeletal SFT to broadly determine the class of weapon used is possible radiologically.

Application of 3D printing in assessment and demonstration of stab injuries.

In stabbing related fatalities, the forensic pathologist has to assess the direction of wound track (thus, the direction of the stabbing) and the weapon's possible characteristics by examining the stab wound. The determination of these characteristics can be made only with a high level of uncertainty, and the precise direction of the stabbing is often difficult to assess if only soft tissues are injured. Previously reported techniques used for the assessment of these wound characteristics have substantial limitations. This manuscript presents a method using today's easily accessible three-dimensional (3D) printing technology for blade-wound comparison and wound track determination. Scanning and 3D printing of knives is a useful method to identify weapons and determine the precise stabbing direction in a stabbing incident without compromising the trace evidence or the autopsy results. Ballistic gel experiment, and dynamic stabbing test experiments prove the method can be applied in safety, without compromising the autopsy results. Identification of the exact knife is not possible with complete certainty but excluding certain knives will decrease the number of necessary DNA examinations, hence it can lower the burden on forensic genetic laboratories. The method addresses many of the shortcomings of previously used methods of probe insertion or post-mortem CT. Insertion of the printed knife into the wound gives a good visual demonstration of the stabbing direction, thus easing the forensic reconstruction of the stabbing incident. After combining the 3D printing with photogrammetry, the achieved 3D visualization is useful for courtroom demonstration and educational purposes.

Development of Diaphragmatic Hernia in Patients with Penetrating Left Thoracoabdominal Stab Wounds.

BACKGROUND: This study aimed to investigate the consequences of repairing versus not repairing diaphragmatic injury caused by penetrating left thoracoabdominal stab wounds. METHODS: Diagnostic laparoscopy was performed to evaluate the left diaphragm in patients with penetrating left thoracoabdominal stab wounds who did not have an indication for emergency laparotomy. Patients who did not consent to laparoscopy were discharged without undergoing surgery. Post-discharge radiological images of patients who underwent diaphragmatic repair and radiological images of patients who could not undergo laparoscopy, both during hospitalization and after discharge, were evaluated and compared. RESULTS: Diagnostic laparoscopy was performed on 109 patients. Diaphragmatic injuries were detected and repaired in 32 (29.36%) of these patients. Seventeen patients were lost to follow-up. After a mean follow-up of 57.67 months, none of the remaining 15 patients developed a diaphragmatic hernia. On the other hand, 43 patients refused to undergo diagnostic laparoscopy. Twenty of them were lost from follow-up. The diaphragmatic injury was detected in seven of the remaining 23 patients (30.44%) during initial computed tomography (CT) examinations. In this group, the mean follow-up time was 42.57 months, and delayed diaphragmatic hernia developed in one patient (14.30%). Patients who underwent diaphragmatic repair were compared to patients who did not undergo diagnostic laparoscopy but had diaphragmatic injuries detected on their CT. No statistical differences were detected. CONCLUSIONS: Diaphragmatic injuries caused by penetrating stab wounds can sometimes heal spontaneously. However, diagnostic laparoscopy is still relevant for revealing and repairing possible diaphragmatic injuries.

Stab Wound to the Right Ventricle With Creation of Ventricular Septal Defect Managed With an Endovascular Occlusive Patch.

Penetrating trauma to the cardiac box is associated with high rates of cardiac injury, structural complications, morbidity, and mortality. Early identification and intervention of these injuries is paramount to obtaining good patient outcomes. In this paper, we report a 55-year-old male who sustained a single stab wound to left chest which perforated the right ventricle. The patient also sustained a muscular ventricular septal defect (VSD) which led to a prolonged intensive care unit (ICU) course complicated by late pericardial tamponade. We present successful management of this patient's initial injury along with his ICU course culminating in successful endovascular occlusive patch VSD repair.

Global illumination rendering versus volume rendering for the forensic evaluation of stab wounds using computed tomography.

We compared three-dimensional (3D) CT images of stabbing victims subjected to volume-rendering (VR) or global illumination-rendering (GIR), a new technique now available for the reconstruction of 3D CT images. It simulates the complete interactions of photons with the scanned object, thereby providing photorealistic images. The diagnostic value of the images was also compared with that of macroscopic photographs. We used postmortem 3D CT images of 14 stabbing victims who had undergone autopsy and CT studies. The 3D CT images were subjected to GIR or VR and the 3D effect and the smoothness of the skin surface were graded on a 5-point scale. We also compared the 3D CT images of 37 stab wounds with macroscopic photographs. The maximum diameter of the wounds was measured on VR and GIR images and compared with the diameter recorded at autopsy. The overall image-quality scores and the ability to assess the stab wounds were significantly better on GIR than VR images (median scores: VR = 3 vs GIR = 4, p < 0.01). The mean difference between the wound diameter measured on VR and GIR images and at autopsy were both 0.2 cm, respectively. For the assessment of stab wounds, 3D CT images subjected to GIR were superior to VR images. The diagnostic value of 3D CT GIR image was comparable to that of macroscopic photographs.

Variability and specificity of bone cutting mark properties in cases involving stabbing with knives.

Sharp force traumas are frequently encountered in stabbing crime victims. During an examination, the properties of cutting marks in bones are compared with the properties of suspect tools, particularly knives. Therefore, the variation and specificity of knife and cutting mark properties must be known. This article provides the variability and specificity of a set of knife blade and cutting mark properties. Plain and serrated knives are used to create experimental cutting marks in porcine ribs, knife properties are derived from surface acquisitions of the blades and mark properties from Micro-CT data. We consider two conditions, automated stabbing using a motorized stage and manual stabbing. In addition, we study the influence of maceration on marks. For knives, the blade edge angle, blade thickness, and bevel height, and for cutting marks, the shape, the wall angle, the width, and the bevel height are determined and compared. The results show that the relationship between corresponding properties of blades and marks depends on the knife type. For plain knives, the width and wall angle of the marks are dependent on the mark depth and are significantly smaller than the blade properties edge angle and width. For serrated knives, this is not the case. The mark shape only provides slight support for a knife type for marks deeper than the blade bevel height. In conclusion, mark properties are only specific for a particular knife brand and model if the blade properties differ significantly and assuming a specific knife type.