A case of fatal fulminant fat embolism syndrome following multiple fractures resulting from a fall.

Fat embolism syndrome is a life-threatening condition in which fatty substances enter the circulation and cause respiratory distress and neurological symptoms. It can occur following trauma and severe fat embolism occurring soon after trauma is known as fulminant fat embolism syndrome. Although fat staining of the lungs is helpful for diagnosing fat embolism syndrome at autopsy, clinical and other information is needed to determine the relationship between cause of death and the syndrome. In this report, we describe the macroscopic, microscopic, and computed tomography (CT) findings specific for fat embolism that were observed in a patient with fulminant fat embolism syndrome who died soon after the injury. An 85-year-old woman fell from a bath stretcher during assisted bathing and died 3 h later. Autopsy revealed fractures of the left femoral neck and other bones, as well as large amounts of fat-like material in the right and left pulmonary arteries. Histological examination of the lung with Oil red O staining showed extensive fat vacuoles. Based on these findings and postmortem CT images of the fractures and fatty globules in the pulmonary arteries detected prior to death, the cause of death was determined to be blunt force trauma, with fat embolism syndrome playing a significant role. This case is an example of fulminant fat embolism, which can be fatal in a short period of time, and demonstrates that CT performed postmortem but before autopsy can be useful in detecting fat embolism syndrome due to trauma.

A multidisciplinary investigation of chronic animal abuse: Collaboration between veterinary forensics and forensic anthropology.

An unknown juvenile female mixed breed dog was found non-ambulatory on a dead-end street in an urban setting adjacent to a public park. During initial veterinary examination, she was assessed to have untreatable injuries and was humanely euthanized. The forensic veterinarian requested consultation from a forensic anthropologist to assist with documenting antemortem skeletal trauma. Analyses of skeletal tissues indicated numerous injuries in various stages of healing diagnostic of non-accidental injuries. Veterinary forensic cases may benefit from collaborative analysis of bony remains by forensic anthropologists.

Skull Fracture Patterns and Morphologies Among Fatal Motorcycle Traffic Accident Victims in Vietnam.

ABSTRACT: We aim to describe morphological structures of skull fractures and relevant factors in motorcycle accident victims in Vietnam. This work represents a retrospective cross-sectional study based on forensic reports of fatal motorcycle accident victims. Between January 2013 and August 2019, a total of 226 fatal motorcycle accident patients with skull fracture diagnoses were enrolled. Linear and depressed fractures were the common patterns (46.0% and 37.2% of cases, respectively), whereas stellate (11.5%) fractures were rare. Fractures of the temporal bone (68.6% of cases) and basilar skull (60.6%) were the most common, whereas fractures of the parietal bone were the least common (9.7%). Two or more patterns of skull fracture were recorded in 25.5% of cases, and 2 or more fracture locations were recorded in 76.6% of cases. Fractures of the parietal bone were associated with victims not wearing a helmet. In addition, fractures of the basilar skull were more likely to occur among victims with alcohol consumption. We found the common pattern of skull fractures was linear and depressed fractures, and the common location of skull fractures was temporal and basilar bone. Further studies that include larger sample sizes and collect more information should be conducted to better understand relationships between skull fractures and related factors.

Patterning of fractures in a case of intimate partner homicide (IPH).

South Africa is a country overwhelmed by crime and violence, with very high incidences of abuse against women and children. It is not often that a case of intimate partner homicide is seen in a forensic anthropological context. Here, we report on such a case where the remains of the victim had been buried for some time. The victim was a middle-aged female, while the suspect was a younger adult male. The deceased had suffered massive, repeated trauma during her lifetime with healed fractures and evidence of soft tissue trauma to virtually all parts of her body. A partly healed rib fracture indicates that the abuse continued until shortly before her death. She ultimately succumbed after suffering trauma to her head and face after reportedly being hit by a brick, evidence of which can be seen as perimortem fractures of the face. It is important for forensic anthropologists to identify specific patterns and report on the presence of healed fractures, as they can raise suspicion as to the possibility of chronic abuse. In this case, the evidence suggests a very long period of extreme and repeated trauma, which were apparently not reported or noticed by family members or the medical fraternity.

Elevated Bone Hardness Under Denosumab Treatment, With Persisting Lower Osteocyte Viability During Discontinuation.

Denosumab is a potent osteoclast inhibitor targeted to prevent osteoporotic bone loss and thereby reduce fractures in the aging population. Recently, an elevated risk of rebound fractures following denosumab discontinuation was identified, unless patients were transitioned to an alternative antiresorptive medication. How denosumab affects the interaction of mechanosensitive osteocytes and bone quality remains unknown. We hypothesized that denosumab influences osteocyte function contributing to bone reorganization and increased fractures during discontinuation. Bone quality and osteocytes were assessed in archived iliac crest bone biopsies obtained from patients with high fracture occurrence from 2011 to 2016. Biopsies were obtained due to high fracture occurrence prior and during osteoporosis therapy from (i) patients with at least two semiannual subcutaneous injections of 60 mg denosumab, (ii) patients with rebound fractures during discontinuation, and (iii) patients of a treatment-naive group. In total, biopsies from 43 individuals were analyzed (mean age, 65.5 ± 12.1 years). Our results showed that during denosumab treatment, iliac cortical bone had a higher bone tissue hardness compared to treatment-naive bone (p = 0.0077) and a higher percentage of mineralized osteocyte lacunae (p = 0.0095). The density of empty osteocyte lacunae was higher with denosumab compared to treatment-naive (p = 0.014) and remained high in trabecular bone during discontinuation (p = 0.0071). We conclude that during denosumab treatment, increased bone hardness may contribute to improved fracture resistance. In biopsies from patients with high fracture occurrence, denosumab treatment reduced osteocyte viability, an effect that persisted during treatment discontinuation. High-resolution imaging of osteocyte viability indicates a role for osteocytes as a potential future mechanistic target to understand rebound bone loss and increased fractures with denosumab discontinuation.

Closed-head injuries followed by detached brain tissue in the external auditory canals.

We describe five cases of fatally injured males (occupational accident, car driver, pedestrian, motorcyclist and suicidal jump from great height) with one universal autopsy finding - the presence of brain tissue in one or both auditory canals. Internal examination revealed that all victims had multiple head fractures with dura lacerations. In four cases, the petrous part of the temporal bone was fractured (hinge fracture), while in one case the fracture of both the petrous part of the temporal bones and the occipital bone (ring fracture) was present. In all of these cases, considerable pressure was applied to the head, pushing brain tissue equally in all directions (due to incompressibility of the tissue). The tissue followed the path of least resistance, going through the lacerated dura into the fractured petrous part of the temporal bones and finally reaching the middle ear cavity and auditory canal. This phenomenon is almost exclusively encountered in closed-head injuries. In an open-head injury, brain tissue would be expelled through the open bone fracture and scalp wound. The presence of brain tissue in the ears could indicate a hinge or ring fracture in a closed-head injury which occurred as the result of excessive impulse force or considerable pressure applied to the head, i.e. the head was compressed and/or squeezed.

Fatal gyroplane crash.

Gyroplanes are mainly used for sports aviation. Experience is required when flying these special aircraft because in 40% of gyroplane crashes, the passengers do not survive. Herein, a fatal gyroplane crash of a tandem-seat gyroplane with two occupants is reported. The occupants, both 49-year-old males, fell from a height of approximately 20 m to 30 m. In both cases, the cause of death was polytrauma with typical findings of deceleration trauma. The pilot, who probably lost his helmet in the crash, had a ring fracture at the base of his skull. As there is not much literature on autopsy findings in the case of light aircraft crashes, these autopsy findings are presented and discussed.

Morphology of the Posterior Malleolar Fracture Associated With a Spiral Distal Tibia Fracture.

OBJECTIVE: To define the pathoanatomy of the posterior malleolus fracture associated with a spiral distal tibia fracture to guide clamp and implant placement when treating these common injuries. DESIGN: Retrospective cohort. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: One hundred twenty-two spiral infraisthmal tibia fractures identified from a cohort of 922 tibia fractures undergoing intramedullary nailing over a 7-year period. MAIN OUTCOME MEASUREMENTS: We collected instances of intra-articular extension seen on preoperative, intraoperative, or postoperative imaging. For patients with a posterior malleolus fracture and computed tomography imaging, we used an axial image 2-3 mm above the articular surface to create a fracture map. RESULTS: Intra-articular extension was present in 84 patients (68.9%), with posterior malleolus fractures occurring most commonly (n = 59, 48.4%). Other fractures included plafond fractures (n = 8), medial malleolus fractures (n = 7), anterior-inferior tibiofibular ligament avulsions (n = 5), and other anterior fractures (n = 5). Forty-one of 44 (93%) posterior malleolus fractures with cross-sectional imaging were Haraguchi type I (posterolateral-oblique type) with an average angle of 24 degrees off the bimalleolar axis. The remaining 3 were type II (transverse-medial extension type) fractures. Posterior malleolus fractures were visible 61% of the time on preoperative radiographs. DISCUSSION: Posterior malleolus fractures occur in approximately half of spiral distal tibia fractures and are consistently posterolateral in their morphology. This study can be used to enhance evaluation of the posterior malleolus intraoperatively (eg, ∼25 degrees external rotation view), and if the typical variant of posterior malleolus is identified, clamps and lag screws might be applied accordingly.

Fibrinolysis in trauma patients: wide variability demonstrated by the Lysis Timer.

Hyperfibrinolysis contributes to the pathophysiology of trauma-induced coagulopathy. At present, systematic administration of tranexamic acid (TXA) is recommended in all patients in the early phase of trauma. However, there is some debate regarding whether TXA is beneficial in all trauma patients. A rapid and accurate tool to diagnose hyperfibrinolysis may be useful for tailoring TXA treatment. We conducted a proof-of-concept study of consecutive adult trauma patients. A first blood sample was obtained at the time of pre-hospital care (T1). Patients received 1 g of TXA after T1. A second sample was obtained on arrival at the emergency unit (T2). We examined coagulation, fibrin and fibrinogen formation and degradation. Fibrinolysis was assessed by determining tissue plasminogen activator (t-PA) antigen and plasminogen activator inhibitor 1 (PAI-1) activity and global fibrinolysis capacity assay using a device developed by Hyphen BioMed: the Lysis Timer (GFC/LT). The study population consisted of 20 patients (42 ± 21 years, index of severity score 32 ± 21). Both coagulation and fibrinolysis were altered at T1. GFC/LT values exhibited hyperfibrinolysis only in five patients. Principal component analysis carried out at T1 showed two main axes of alteration. The major axis was related to coagulation, altered in all patients, while the second axis was related to fibrinolysis. GFC/LT was mainly influenced by PAI-1 activity while fibrin monomers were related to the severity of trauma. At T2, GFC/LT exhibited the marked effect of TXA on clot lysis time. In conclusion, GFC/LT demonstrated huge variation in the fibrinolytic response to trauma.

Terrorist explosive belt attacks: specific patterns of bone traumas.

In cases of terrorist bomb attacks, the issue of victim identification is the principal aim. For investigators and justice, terrorists must also be identified in a timely manner. The fragmentation of bodies caused by explosive devices however makes this operation difficult. The cases presented correspond to six autopsies of perpetrators carrying explosives. Their explosive belts produced different body sections on areas correlated with the location on the body of carrying explosive charges. Indeed, cross-sectional areas are the signature of the level of explosive devices on the body, and some fracture features through the damage of certain areas of constitutional weaknesses are specific elements to consider. These elements can allow a quick distinction between victims and terrorists, in order to assist in the medico-legal process of identification.

Atypical Suicide by Submachine Gun.

In case of suicide, the presence of multiple entrance wounds is always suspicious. We report the case of a man who committed suicide by shooting himself three times in the chest and the skull with a submachine gun. The weapon seems to have been initially pointed in the precordium area with a lethal lesion of the proximal aorta. Two other projectiles were fired by the weapon and hit the neck and the skull of the deceased. The presence of three entrance wounds despite a first fatal wound could finally be explained by the characteristics of the weapon and wounds. Most suicides related to multiple gunshot wounds are explained by a first nonlethal shot but the use of an automatic weapon can also be found. In these last cases, medicolegal and criminalistics aspects become important in differentiating suicide and homicide.

An unusual case of pulmonary fat embolism following blunt trauma.

Fat embolism is markedly underdiagnosed, even though it is a well-known phenomenon following fractures of the long bones, injury to subcutaneous fat tissue, rupture of a fatty liver, surgical operations on fatty tissues, septicemia, burns and barotrauma. Forensic pathologists tend to "simplify" autopsy report conclusion in cases with multiple injuries where fat embolism and exsanguination could be considered to be the concomitant causes of death. Herein we present a case of 24-year-old male who was beaten with a metal rod by several persons. On admission to hospital his vital signs and laboratory findings indicated hemorrhagic shock with gradual respiratory failure; he died 17 h after injury. On internal autopsy examination the subcutaneous tissue of the limbs and back was severely bruised, corresponding to about 35% of the body surface area. He had fractures of several small bones. Injuries of the internal organs were absent, there was no free blood in the body cavities, and all other autopsy findings were unremarkable but suggestive of a significant blood loss. Microscopic examination showed a massive pulmonary fat embolism (grade III according to Sevitt), without systemic fat embolism. The cause of death was attributed to pulmonary fat embolism combined with severe blood loss, following extensive and severe bruising of the subcutaneous tissues and bone fractures.

[Surgical stabilization of multiple rib fractures can shorten inpatient stay].

Flail chest is a common complication in patients with blunt chest wall traumas resulting in high mortality rates. In this case report a 43-year-old woman was stepped on by a horse, thereby receiving multiple rib fractures and pneumohaemothorax. She was not able to wean from epidural analgesia after ten days and maintained a "thoracic floating feeling". In opposition to the non-operative management previously preferred, a surgical stabilization was then performed in the patient, who was discharged only five days later. Thus, surgical fixation of multiple rib fractures may reduce inpatient stay.

Suicide in parachuting: A case report and review of the literature.

Skydiving fatalities are mostly accidental and the result of human errors. However, suicides may be greatly underreported in skydivers. We present the case of a young civilian skydiver who committed suicide by jumping from an altitude of 4000m without activating his chutes. Witnesses reported that the victim had remained in a freefall position until ground impact. Besides an extensive blunt trauma, the autopsy showed an antero-posterior flattening of the body with symmetrical abrasions on its front, which were consistent with a high-energy impact on the ground in a "belly-down" position. Police investigation revealed that the victim had expressed suicidal thoughts in text messages before jumping from the airplane, and examination of his equipment showed that he had disabled the security system allowing the reserve chute to be automatically deployed at low altitude. To the best of our knowledge, this is the first case of suicide of a skydiver that has been described in the scientific literature. A suicidal intent should be assumed in skydiving fatalities involving jumpers with operable but un-activated parachutes on their back. This case highlights the importance of a thorough forensic investigation in such circumstances to ascertain the manner of death.

Cardiothoracic injuries after CardioPump CPR: a report of two cases and review of the literature.

Although many clinical trials have demonstrated its efficacy during active compression-decompression cardiopulmonary resuscitation (ACD-CPR), the Ambu® CardioPump seems likely to cause severe and sometimes lethal injuries. In this paper, we report two cases observed at the Institute of Legal Medicine of Nancy, France. A 67-year-old man collapsed in the street, in the presence of witnesses, and without any sign of trauma. The autopsy revealed a flail chest, a wound of the left ventricle, a rupture of the right ventricle, and a wrenching of the inferior vena cava. A 71-year-old woman was found in her apartment during an accidental fire. The autopsy revealed a sternal fracture, many rib fractures, and a perforation of the superior vena cava, the pericardium, and the heart. Despite articles focusing on complications of the use of the CardioPump in the late 1990s, this technique is still used in practice. These two cases emphasize that iatrogenic injuries must be taken into account in the CardioPump benefit/risk balance and the relevance of its daily use.

An accident at work? Traumatic lesions in the skeleton of a 4th millennium BCE "wagon driver" from Sharakhalsun, Russia.

The study of ante-mortem trauma is a popular and important aspect of palaeopathological analysis. The majority of publications focus on a particular assemblage, skeletal element or type of fracture, with case studies of single individuals with multiple/unusual traumata being much rarer in the literature. This paper presents the case of an adult male from the Bronze Age site of Sharakhalsun, Russia, buried, uniquely, in a sitting position on a fully assembled wagon, who displayed evidence for multiple healed ante-mortem fractures of the cranium, axial and appendicular skeleton. The mechanisms and likely etiologies of the fractures are presented, with reference to modern and 19th century clinical literature, and possible interpretations suggested: that the individual was involved in a severe accident involving a wagon or draft animals, or both, a number of years before his death. The suggestion is also made that the unique burial position of the individual was a form of commemoration by the community of the survival and recovery of the individual from such a serious incident.

Domestic Predation of an Elder: A Fatal Dog Attack Case.

We present the case of a 91-year-old woman lived alone at her home with two domestic dogs, that is,, a Labrador Retriever and a Staffordshire Bull Terrier and found dead. The investigation of the scene revealed that the Bull Terrier's jawbone and chest were covered with blood. The autopsy revealed multiple, histologically confirmed, life-threatening skin and bone lacerations without scavenging marks. The punctures and tearing of each of the wounds on the skin were compatible with bites. A left humeral fracture and multiple fractures of the right facial bones were observed. The death was attributed to external hemorrhages due to several dog bites. A veterinary physical and behavioral examination indicated that the Bull Terrier was involved in the attack. A domestic predation hypothesis was deemed here most likely due to the presence of food supplies at the scene, the dog's previous history of attack, and the breed of the dog.

Suicide by the intraoral blast of firecrackers - experimental simulation using a skull simulant model.

Suicides committed by intraorally placed firecrackers are rare events. Given to the use of more powerful components such as flash powder recently, some firecrackers may cause massive life-threatening injuries in case of such misuse. Innocuous black powder firecrackers are subject to national explosives legislation and only have the potential to cause harmless injuries restricted to the soft tissue. We here report two cases of suicide committed by an intraoral placement of firecrackers, resulting in similar patterns of skull injury. As it was first unknown whether black powder firecrackers can potentially cause serious skull injury, we compared the potential of destruction using black powder and flash powder firecrackers in a standardized skull simulant model (Synbone, Malans, Switzerland). This was the first experiment to date simulating the impacts resulting from an intraoral burst in a skull simulant model. The intraoral burst of a "D-Böller" (an example of one of the most powerful black powder firecrackers in Germany) did not lead to any injuries of the osseous skull. In contrast, the "La Bomba" (an example of the weakest known flash powder firecrackers) caused complex fractures of both the viscero- and neurocranium. The results obtained from this experimental study indicate that black powder firecrackers are less likely to cause severe injuries as a consequence of intraoral explosions, whereas flash powder-based crackers may lead to massive life-threatening craniofacial destructions and potentially death.

Causes and Mechanisms of Death in Fatal Water Buffalo Attacks.

Deaths due to buffalo attack have not been well described. A 72-year-old man was trampled by a water buffalo (Bubalus bubalis) while attempting to move the animal within an enclosed area at an abattoir. At autopsy, there were numerous injuries involving the chest, head, neck, and left upper arm. Blunt force injury had resulted in multiple rib fractures with a flail chest and fracture/dislocation of the mid-cervical vertebrae caused either by physical crushing by the animal against the walls of the enclosure or by stomping. There was also evidence of crush asphyxia with bilateral conjunctival hemorrhages and petechial hemorrhages. In addition, there was a deep degloving injury of the upper left arm compatible with goring by one of the buffalo horns. While large animal attacks may result in death from multiple injuries, careful dissection and examination of specific injuries at autopsy may clarify the complex interaction of lethal mechanisms.

Evaluation of efficacy and indications of surgical fixation for multiple rib fractures: a propensity-score matched analysis.

PURPOSE: The purpose of this study was to assess the effects of recent surgical rib fixation and establish its indications not only for flail chest but also for multiple rib fractures. METHODS: Between 2007 and 2015, 187 patients were diagnosed as having multiple rib fractures in our institution. After the propensity score matching was performed, ten patients who had performed surgical rib fixation and ten patients who had treated with non-operative management were included. Categorical variables were analyzed with Fischer's exact test and non-parametric numerical data were compared using the Mann-Whitney U test. Wilcoxon signed-rank test was performed for comparison of pre- and postoperative variables. All statistical data are presented as median (25-75 % interquartile range [IQR]) or number. RESULTS: The surgically treated patients extubated significantly earlier than non-operative management patients (5.5 [1-8] vs 9 [7-12] days: p = 0.019). The duration of continuous intravenous narcotic agents infusion days (4.5 [3-6] vs 12 [9-14] days: p = 0.002) and the duration of intensive care unit stay (6.5 [3-9] vs 12 [8-14] days: p = 0.008) were also significantly shorter in surgically treated patients. Under the same ventilating conditions, the postoperative values of tidal volume and respiratory rate improved significantly compared to those values measured just before the surgery. The incidence of pneumonia as a complication was significantly higher in non-operative management group (p = 0.05). CONCLUSIONS: From the viewpoints of early respiratory stabilization and intensive care unit disposition without any complications, surgical rib fixation is a sufficiently acceptable procedure not only for flail chest but also for repair of severe multiple rib fractures.