Ballistic long bone fracture pattern: an experimental study.

When dealing with badly preserved cadavers or skeletal human remains, the assessment of death circumstances remains challenging. When forensic evidence cannot be taken from the skin and soft tissue, the information may only be deduced from more resistant elements such as bone. Compared to cranial gunshot injuries, reliable data on ballistic long bone trauma remains scarce. This study aims to define ballistic fracture characteristics in human long bones. The shaft of 16 femurs and 13 humeri from body donors was perpendicularly shot with a 9-mm Luger full metal jacket bullet at an impact velocity of 360 m/s from a distance of 2 m. Some bones were embedded in Clear Ballistics Gel®, and some were shot without soft tissue simulant in order to better visualise the fracture propagation on the high-speed camera. The fractures were examined macroscopically and compared between the sample groups. We consistently found comminuted fractures with a stellate pattern. Fracture details were classified into entrance, exit and general characteristics. For some traits, we detected different occurrence values in the group comparison. The results indicate that some of the traits depend on bone properties such as shaft diameter, bone length and cortical thickness. The presence of ballistic gel also influenced some fracture traits, emphasising the relevance of soft tissue simulant in osseous gunshot experiments. This study revealed new insights in the detailed fracture pattern of human long bones. These may serve as guidelines for the identification and reconstruction of gunshot trauma in human long bones.

Experience in surgical treatment of type â ¡ odontoid fractures: A report of two cases and review of the literature.

Two cases of type Ⅱ odontoid fractures were reported to share our experience in surgery treatment of such cases. A 33-year-old woman with comminuted type Ⅱ odontoid fracture and a 42-year-old man with fracture end hardened type Ⅱ odontoid fracture received surgical treatment in our hospital. Though imaging examination suggested that these two patients were suitable for anterior screw fixation, we encountered difficulties during the operation. The two patients eventually underwent posterior C1-C2 fusion surgery and recovered well. According to the experience of these two cases, we found that the fracture line angle and the degree of comminution are two important factors affecting surgical decision-making. Although anterior screw fixation is the ideal choice for type Ⅱ odontoid fractures with anterior superior to posterior inferior fracture line, it may not be the best choice for comminuted or fracture end hardened type Ⅱ odontoid fractures.

Dislocation of Internal Organs of the Neck and Trunk Into Crush Injuries of the Head: Case Report on a Truck-to-Pedestrian Accident.

The authors report on a case of a 43-year-old male pedestrian struck and run over by a truck. The accident was accompanied by a mechanism of injury resulting in a unique autopsy picture of trunk and head injuries. The internal organs of the neck (larynx, trachea, esophagus), chest (lungs, thoracic aorta), and part of the abdominal cavity (bottom of the stomach and fragments of the liver) were dislocated in the direction of the head. The result was a traumatically deformed, crushed skull characterized by an extensive gaping wound with excerebration. The organs were dislocated through a channel formed by the rupture of soft tissues and comminuted fracture of the base of the skull. Parts of internal organs (larynx, trachea, and aorta) were turned 180° around the transverse axis of the body. This report, due to its unusual character, may be useful during detailed analysis of potential injury mechanisms in traffic accidents involving pedestrians.

Differentiation between perimortem trauma and heat-induced damage: the use of perimortem traits on burnt long bones.

Burnt human remains present a difficult interpretative dilemma to forensic pathologists and anthropologists. Distinguishing postmortem damage in long bones as a result of fire damage from perimortem fractures is an important challenge in trauma analysis. During our case investigation of a burnt body from a fiery car crash, distinct perimortem traits on long bone fractures were still distinguishable along the charred areas. Next to timing of fractures and shortening the perimortem time gap suggesting that the fractures occurred when soft tissue was still present, the traits make it possible to distinguish blunt trauma caused by the accident from heat-induced bone damage. Applying this specific perimortem pattern could be an additional macroscopic tool to interpret blunt force trauma more accurately in the analysis of burnt remains.

Axe injury pattern in homicide.

Chop or slash wounds are produced by sharp-edged tools such as an axe, or a machete. This paper presents a case of a violent death of a 57 year-old-man. Autopsy revealed deformation of the right side of the head. A total of 23 slash, stab and cut wounds as well as contused lacerations were identified on the scalp as well as the face and the neck. In addition, superficial abrasions and bruises were identified on the skin. The immediate cause of death was due to extensive brain contusion following fragmentation of the neurocranium. The injuries resulting in the death of the victim were sustained during an assault on the head with an axe, which was used both as a slashing tool and a blunt instrument.

Autopsy Features of Fatal Donkey Attack.

Lethal donkey attacks have very rarely been described. The case of a 65-year-old man who was found deceased on a country road with 2 domestic donkeys nearby is, therefore, reported. Examination of the body revealed contusions and lacerations of the face and scalp, a comminuted fracture of the left maxilla, comminuted fracturing of the right radius and ulna and of the left anterior superior iliac spine, a flail chest, and pulmonary contusions. In addition, there were bite marks on the left thigh, right buttock, right axilla/upper arm, and left cheek which corresponded to the dental arcades of the donkeys. Death had resulted from blunt chest trauma due to an attack by 1 or 2 donkeys. Deaths and serious injuries are much more commonly caused by horses; however, this case shows that even domesticated donkeys may also rarely be capable of inflicting significant trauma and so should be approached with circumspection.

Fatal Transorbital Intracranial Penetrating Injury Due to a Bicycle Brake Handle.

Transorbital intracranial injuries are uncommon and mostly accidental in nature. These injuries are usually associated with high mortality. The key to preventing this mortality involves an early diagnosis of intracranial injuries and immediate and appropriate management. Any delay can pose a serious risk to the patient's life. A case of a 55-year-old man who had experienced an accidental self-fall while riding a bicycle is presented. Initially, he was treated at a primary health center. He was referred to the tertiary care institute due to unavailability of ancillary investigation at the primary health center. He was declared dead on arrival at the casualty in the tertiary institute. On autopsy, it was observed that the injury above the right side of the upper eyelid was penetrating the right side roof of the orbit and the right cerebral cortex and brainstem. The highlighting feature of the case is that, despite the fatal penetrating brain injury, the eyeball did not sustain any major injury.

The effect of fracture comminution on the reliability and accuracy of radial head sizing.

BACKGROUND: Radial head implant sizing can be based on the maximum head diameter (D-MAX), the minimum head diameter (D-MIN), or the articular dish diameter (D-DISH). The purpose of this study was to assess the reliability of the different radial head sizing techniques and to investigate the effect of radial head fracture comminution on measurement accuracy. METHODS: Ten observers measured 11 cadaveric radial heads with 3 radial head features (D-MAX, D-MIN, and D-DISH diameter). Radial heads were then fractured into 2, 3, and 4 parts, and the measurements were repeated. Variability was assessed by intraclass correlation. The measurements were compared with the intact state to assess the effect of radial head fracture comminution on sizing accuracy. RESULTS: D-MAX and D-MIN measurements were the most reliable among all observers (intraclass correlation coefficients, 0.980, 0.973). The D-DISH measurement was less reliable (intraclass correlation coefficient, 0.643). Radial head comminution did not significantly affect the reliability of any measurement (P > .2). Fracture comminution, however, significantly affected measurement accuracy with D-MAX and D-DISH. With fracture comminution, D-MAX underestimated radial head diameter (-0.4 ± 0.3 mm; P < .001), whereas D-DISH overestimated diameter (+0.5 ± 0.4 mm; P < .001). Comminution did not significantly affect D-MIN (-0.1 ± 0.3 mm; P = .13). DISCUSSION: The D-MAX and D-MIN measurements were more reliable than D-DISH for diameter sizing of intact and comminuted radial heads. Overall, increasing comminution did not significantly affect measurement reliability. However, the accuracy of the D-MIN technique was least affected by comminution, suggesting that D-MIN should be used in selecting the diameter of a radial head implant.

Trap gun: an unusual firearm, aimed at wild animals but causing a silent epidemic of human fatalities.

Among a variety of uncommon firearms of different origin used worldwide, the trap gun used in Sri Lanka is underreported. This is an illegal, locally made, smooth-bore, long-barreled, muzzle-loading firearm with a victim-activated simple trigger mechanism. It is mainly used to protect crops and livestock from the potential harm by wild animals. Trap gun is mounted horizontally on pegs of sticks fixed to the ground. Miscellaneous metal pieces are used as ammunition. A small metal container filled with powdered matchstick heads/firecrackers covered by the striker surface of the matchstick box is used as the percussion cap. A metal hammer is set to hit the percussion cap. Through a lever mechanism, the hammer is kept under tension. The lever mechanism is connected to a trigger cord, which runs across the animal path. The first passerby, a human being or a wild animal, who accidentally trips the trigger cord and activates the trigger mechanism is critically injured. This characteristically damages the lower limbs of the human being. This communication highlights a death due to trap gun injury. The injury pattern caused by trap gun could overlap with that of shotgun and rifled firearm. A meticulous autopsy could sort it out.

[Analysis of 130 forensic expertise cases of simple orbital fracture].

OBJECTIVE: To analyze the features of orbital fracture and to discuss its forensic expertise points. METHODS: One hundred and thirty cases of simple orbital fracture from 2010 to 2012 collected from one public security bureau were retrospectively analyzed such as age, gender, tools, position and morphology of the fracture, periorbital and orbital compound injury and the follow-up results after 6 months. RESULTS: In the 130 cases, the wounded were mainly young men and hit by fist. The fracture of simple medial orbital wall accounted for up to 81.5% in all cases. In the periorbital and orbital compound injury, laceration and contusion of eyelid and ethmoidal cellules and maxillary sinus always occurred. After 6 months follow-up, there were 30 cases of comminuted fracture remained enophthalmos compared with the uninjured side. CONCLUSION: It is inappropriate to judge the fracture of simple medial orbital wall as minor injury. We should judge the degree of simple orbital fracture after the injury is stable. Detailed ophthalmology inspection is necessary for forensic expertise of simple orbital fracture.

Characterization of mandibular fractures incurred from battle injuries in Iraq and Afghanistan from 2001-2010.

PURPOSE: The mandible is the most commonly fractured bone in the craniomaxillofacial skeleton among military casualties. The purpose of this study was to characterize the nature and severity of mandibular fractures incurred by US military personnel during combat. MATERIALS AND METHODS: We queried the Joint Theater Trauma Registry from October 2001 to April 2011 using all pertinent International Classification of Diseases, Ninth Revision codes to identify fractures of the mandible. Fractures were then classified based on type and location. Chart reviews were performed on the subset of patients who were treated at San Antonio Military Medical Center to further classify the anatomic pattern and treatment of these fractures. RESULTS: We identified 391 patients with mandibular fractures, of whom 45 were transferred to San Antonio Military Medical Center. Open fractures were seen in 75% of patients. Two or more fractures of the mandible were seen in 51% of patients. Comminuted fractures were present in 84%, and 31% had segmental losses. Eighty-six percent of fractures were operative; two-thirds of patients required a single surgical procedure, whereas the remaining one-third required multiple procedures. Forty-six percent of patients had pan-facial fractures. CONCLUSIONS: Mandibular fractures as a result of combat blast injuries were characterized by a high incidence of open, comminuted, multiple fractures. Associated facial fractures were common.

[Forensic identification of 50 phalangeal fracture cases].

OBJECTIVE: To study the characteristics of forensic identification of phalangeal fracture and to use a combination of medical records, imaging materials, and forensic examination data in identification. METHODS: Fifty cases of phalangeal fracture involved in the forensic identification were collected from 2009 to 2011. The general situation, the distribution of fracture, the fracture morphology, the injury-causing objects and the results of identification were analyzed retrospectively. RESULTS: Majority of the cases of phalangeal fracture were young and middle-aged men. The index finger and distal phalanx fractures were common. There was no difference in the number of phalangeal fracture between left and right hand. Most of the injury-causing objects were knives and sticks, followed by bricks and stones. CONCLUSION: The injury-causing objects and modes are related to the morphology of fracture, the distribution of fracture and the severity of the injury. The comprehensive analysis is helpful in forensic identification of phalangeal fracture.

Reconstruction of comminuted long-bone fracture using CF/CPC scaffolds manufactured by rapid prototyping.

BACKGROUND: Stabilization and bone healing of fractures in weight-bearing long bones are challenging. This study was conducted to evaluate the effect of a scaffold composed of chitosan fiber and calcium phosphate ceramics (CF/CPC scaffold) on stability and fracture repair in weight-bearing long bones. MATERIAL/METHODS: Comminuted fractures of paired radiuses were created in 36 healthy, mature dogs. The left radius of each dog was classified in the experimental group and treated with CF/CPC scaffold, and the right one was not filled, and was used as a blank control. Of the 12 animals in each group that were killed at week 4, 8, and 12 after the operation, 6 were used for histological analysis, and the other 6 used were for biomechanical studies. Both radiuses from each animal were dissected free and stored for these analyses. All the animals underwent X-ray radiograph pre- and post-operatively. Computer-aided rapid-prototyping technologies were adopted for the fabrication of three-dimensional scaffolds with precise geometric control. RESULTS: X-ray showed that the bone fracture area in the experimental group was filled with callus at week 12 after surgery. Histological examination detected slow resorption of the cement and new bone formation since week 4. At week 12, the scaffold material partially degraded and was still present in all specimens. Mechanical testing revealed that the failure strength of the radiuses treated with CF/CPC scaffolds was about 3 times that of the radiuses without implanted scaffolds. CONCLUSIONS: The effect of using CF/CPC scaffold in treating comminuted weight-bearing long bone fractures is satisfactory.

What are the patterns of injury and displacement seen in lateral compression pelvic fractures?

BACKGROUND: Lateral compression (LC)-type pelvic fractures encompass a wide spectrum of injuries. Current classification systems are poorly suited to help guide treatment and do not adequately describe the wide range of injuries seen in clinical practice. QUESTIONS/PURPOSES: We therefore (1) defined the spectrum of injuries that compose LC fractures with respect to both anterior and posterior ring injuries, with particular focus on the morphology of sacral fractures, and (2) identified fracture patterns associated with displacement at presentation. METHODS: We retrospectively reviewed 318 LC pelvic fractures. Displacement of the anterior pelvic ring was identified and measured on plain radiographs and posterior displacement was identified by CT. RESULTS: All 318 patients had an anterior injury and all but 13 (4%) had a posterior injury; 263 of the 318 fractures (87%) included a sacral fracture, with 162 of 318 (51%) having an anterior incomplete sacral fracture, 53 (17%) a complete simple fracture, and 48 (15%) a complete comminuted fracture. Forty-two of 318 (13%) had a crescent fracture. One hundred six of 318 (33%) were displaced at presentation. There was a higher incidence of initial displacement observed in fractures including bilateral rami fractures, a comminuted sacral fracture, or a crescent fracture. CONCLUSIONS: LC pelvic fractures represent a heterogeneous group of injuries with a wide range of associated fracture patterns. In particular, there is a wide range of fracture types represented by injuries classified as LC1 (involving any sacral fracture). Fractures with more complex sacral fractures, crescent fractures, or bilateral pubic rami fractures tend to have higher degrees of initial displacement. LEVEL OF EVIDENCE: Level IV, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.

Suspected paradoxical undressing in a homicide case.

Paradoxical undressing is a phenomenon associated with fatalities due to severe hypothermia, which is characterized by the act of active undressing, despite low ambient temperatures, as a consequence of peripheral vasodilation. A 51-year-old man was found lying naked and inanimate on a road. Articles of his clothing were scattered in surrounding bushes. A nearby handrail showed a partially washed away bloodstain pattern. A forensic autopsy was used to distinguish whether death was due to a hypothermic fatality or whether the deceased was a victim of an accident or homicide. Medicolegal autopsy revealed craniofacial dissociation with injuries to the thorax and extremities and established choking/asphyxia due to deep aspiration of blood in combination with external blood loss as the cause of death. In the absence of hypothermia-related signs and toxicological findings the case was considered to be a homicide. Police investigation led to the conviction of a man who confessed to having kicked and hit the victim and forced him to take off his clothes in a humiliation-related scenario.

Investigating reverse butterfly fractures: An experimental approach and application of fractography.

Butterfly fractures are expected to form with the transverse portion on the tension side and the wedge portion on the compression side of a bent bone, however wedges have also been observed in the reverse orientation and are reported to be frequent in concentrated 4-point bending. To investigate how these fractures form, concentrated 4-point bending experiments were performed on nine human femora and documented using high-speed video. Videos showed the wedge portion formed as fracture initiated in tension, branched obliquely, then curved to terminate on the tension face. The transverse portion formed as a crack traveled between the curved fracture branch and the compression face. Fractography was also applied to evaluate fracture surfaces. At least one fractography feature was present in all femora and 32/35 bone fragments examined. Fracture propagation sequences interpreted using fractography matched those observed on video, demonstrating the utility of this method for evaluating complex fracture patterns.

Primary hemiarthroplasty versus conservative treatment for comminuted fractures of the proximal humerus in the elderly (ProCon): a multicenter randomized controlled trial.

BACKGROUND: Fractures of the proximal humerus are associated with a profound temporary and sometimes permanent, impairment of function and quality of life. The treatment of comminuted fractures of the proximal humerus like selected three-or four-part fractures and split fractures of the humeral head is a demanding and unresolved problem, especially in the elderly. Locking plates appear to offer improved fixation; however, screw cut-out rates ranges due to fracture collapse are high. As this may lead to higher rates of revision surgery, it may be preferable to treat comminuted fractures in the elderly primarily with a prosthesis or non-operatively. Results from case series and a small-sample randomized controlled trial (RCT) suggest improved function and less pain after primary hemiarthroplasty (HA); however these studies had some limitations and a RCT is needed. The primary aim of this study is to compare the Constant scores (reflecting functional outcome and pain) at one year after primary HA versus non-operative treatment in elderly patients who sustained a comminuted proximal humeral fracture. Secondary aims include effects on functional outcome, pain, complications, quality of life, and cost-effectiveness. METHODS/DESIGN: A prospective, multi-center RCT will be conducted in nine centers in the Netherlands and Belgium. Eighty patients over 65 years of age, who have sustained a three-or four part, or split head proximal humeral fracture will be randomized between primary hemiarthroplasty and conservative treatment. The primary outcome is the Constant score, which indicates pain and function. Secondary outcomes include the Disability of the Arm and Shoulder (DASH) score, Visual Analogue Scale (VAS) for pain, radiographic healing, health-related quality of life (Short-form-36, EuroQol-5D) and healthcare consumption. Cost-effectiveness ratios will be determined for both trial arms. Outcome will be monitored at regular intervals over the subsequent 24 months (1, 3 and 6 weeks, and 3, 6, 12, 18, and 24 months). Data will be analyzed on an intention to treat basis, using univariate and multivariable analyses. DISCUSSION: This trial will provide level-1 evidence on the effectiveness of the two mostly applied treatment options for three-or four part and split head proximal humeral fractures in the elderly. These data may support the development of a clinical guideline for treatment of these traumatic injuries. TRIAL REGISTRATION: Netherlands Trial Register (NTR2040).

Mechanisms of deaths in captive juvenile New Zealand fur seals (Arctocephalus forsteri).

Juvenile seals are sometimes encountered in waters around South Australia with injuries and/or diseases that require veterinary treatment. Two cases are reported where apparently stable animals died soon after being rescued due to quite disparate conditions. In Case 1 a juvenile male New Zealand fur seal (Arctocephalus forsteri) was found unexpectedly dead in its enclosure. A necropsy examination revealed an emaciated juvenile male with no injuries. The intestine was filled throughout its length with melena stool that was due to heavy infestation of the stomach with roundworms with adjacent gastritis. Death was due to shock from upper gastrointestinal blood loss secondary to parasitosis. In Case 2 a second juvenile male New Zealand fur seal (Arctocephalus forsteri) also died unexpectedly in its enclosure. It had been listless with loud respirations since capture. At necropsy there was no blood around the head, neck or mouth, and no acute external injuries were identified. An area of induration was, however, present over the snout with fragmentation of underlying bones. The maxilla was freely mobile and CT scanning revealed multiple comminuted fractures of the adjacent facial skeleton. Examination of the defleshed skull showed fragmentation of the facial skeleton with roughening of bones in keeping with osteomyelitis. Death was attributed to sepsis from osteomyelitis of a comminuted midfacial fracture. These cases demonstrate two unusual and occult conditions that may be present in recently retrieved juvenile fur seals. Failure to establish the correct diagnosis rapidly may result in death soon after capture. The usefulness of imaging techniques such as CT scanning in delineating underlying injuries prior to necropsy is clearly demonstrated.

Prolonged Electro-muscular Incapacitation in a Porcine Model Causes Spinal Injury.

Conducted electrical weapons are designed to cause temporary electro-muscular incapacitation (EMI) without significant injury. The objective of this study was to assess the risk and cause of spinal injury due to exposure to a benchtop EMI device. Porcine subjects were exposed to 19 and 40 Hz electrical stimuli for a prolonged duration of 30 sec. X-ray imaging, necropsy, and accelerometry found that lumbosacral spinal fractures occurred in at least 89% of all subjects, regardless of the stimulus group, and were likely caused by musculoskeletal fatigue-related stress in the lumbosacral spine. Spinal fractures occurred in the porcine model at an unusually high rate compared to human. This may be due to both the prolonged duration of electrical stimulation and significant musculoskeletal differences between humans and pigs, which suggests that the porcine model is not a good model of EMI-induced spinal fracture in humans.

Death with complete decapitation: report of four suicides by train.

Suicide by train with complete voluntary decapitation is an extremely rare event, however, well known and reported in the scientific literature. The authors analyze 4 cases of suicide with complete decapitation by main line or underground train that were subjected to medico-legal autopsies at the Milan Institute of Legal Medicine between 1995 and 2006. Personal, circumstantial, autopsy, and toxicological data were analyzed to define the type and pathologic characteristics of the injuries (vital reaction of wound edges, absence of any signs of defense); alcohol and drug consumption was considered and the victim's psychical profile was outlined.