An unusual blunt force trauma pattern and mechanism to the cranial vault: Investigation of an atypical infant homicide.

This case report presents an unusual fracture pattern in the cranium of a four-month-old infant indicative of child abuse. Upon postmortem examination, the infant presented with numerous bilateral linear cranial fractures running perpendicular to the sagittal suture with depressed and curvilinear fractures apparent on the supra-auricular surfaces of the cranium. Histological evidence indicates multiple traumatic events to the cranium. In addition, the stair-step pattern of a parietal fracture may represent multiple contiguous fractures from repeated loading of the head at different times with variation of the focal points of compressive force. Additionally, the left humerus, left radius, and left ulna have healing metaphyseal fractures, and the left ulna also has an antemortem diaphyseal fracture which resulted in the distal metaphysis being rotated 45 degrees medially. Integration of autopsy, anthropological, and neuropathological reports for this case suggest multiple inflicted injury episodes with a repeated atypical mechanism(s) to the cranial vault of the infant. During investigative interviews, the caretaker admitted to squeezing the infant's head and neck on multiple occasions to quiet the child. This reported abusive mechanism is consistent with the pattern of symmetric cranial fractures and soft tissue injuries indicating asphyxiation. This case report provides forensic investigators with a potential trauma mechanism to explore in cases when a similar pattern of cranial trauma is observed and highlights the need for greater research on fracture propagation and fracture healing in the infant cranium.

Enhanced Bone Regeneration in Variable-Type Biphasic Ceramic Phosphate Scaffolds Using rhBMP-2.

Our aim was to investigate the bone regeneration capacity of powder-type biphasic ceramic scaffold (BCP powder), block-type BCP (BCP block), and collagen-added block-type BCP (BCP collagen) with different concentrations of recombinant human bone morphogenetic protein 2 (rhBMP-2) in an animal model. Four rabbits were assigned to each of the following groups: no graft + rhBMP-2 (0.1/0.2 mg/mL), BCP powder + rhBMP-2 (0.1/0.2 mg/mL), BCP block + rhBMP-2 (0.1/0.2 mg/mL), and BCP collagen + rhBMP-2 (0.1/0.2 mg/mL), i.e., a total of 32 rabbits. Polycarbonate tubes (Φ 7 mm × 5 mm) for supporting scaffolds were fixed into a 7 mm round border. Subsequently, 0.1 mL of rhBMP-2 solutions with different concentrations was injected into the tubes. Both radiological and histomorphometric analyses showed that osteogenesis was not enhanced by increasing the concentration of rhBMP-2 in all groups at both 3 and 6 weeks. Radiological analysis showed that bone formation was higher in the BCP collagen group than in the BCP powder and BCP block groups at both rhBMP-2 concentrations at 3 weeks. rhBMP-2 enhanced bone formation; however, as the concentration increased, bone formation could not be enhanced infinitely. Collagen-added alloplastic graft material may be useful for mediating rapid bone formation in initial stages.

Cranial Suture Mesenchymal Stem Cells: Insights and Advances.

The cranial bones constitute the protective structures of the skull, which surround and protect the brain. Due to the limited repair capacity, the reconstruction and regeneration of skull defects are considered as an unmet clinical need and challenge. Previously, it has been proposed that the periosteum and dura mater provide reparative progenitors for cranial bones homeostasis and injury repair. In addition, it has also been speculated that the cranial mesenchymal stem cells reside in the perivascular niche of the diploe, namely, the soft spongy cancellous bone between the interior and exterior layers of cortical bone of the skull, which resembles the skeletal stem cells' distribution pattern of the long bone within the bone marrow. Not until recent years have several studies unraveled and validated that the major mesenchymal stem cell population of the cranial region is primarily located within the suture mesenchyme of the skull, and hence, they are termed suture mesenchymal stem cells (SuSCs). Here, we summarized the characteristics of SuSCs, this newly discovered stem cell population of cranial bones, including the temporospatial distribution pattern, self-renewal, and multipotent properties, contribution to injury repair, as well as the signaling pathways and molecular mechanisms associated with the regulation of SuSCs.

Skull base trauma: Masking, stimulating or neutral factor for the insidious development of angiosarcoma in a 19-year-old.

Angiosarcoma is a malignancy of endothelial tumor and represents 1-2% of all soft tissue sarcomas, uncommonly found in the head and neck region. The etiology is not clear but there are definite risk factors including chronic lymphoedema, history of radiation, environmental carcinogens and certain familial syndromes. Presented here is a case of a patient treated due to the skull base trauma and diagnosed with this type of tumor.

Are cranial peri-mortem fractures identifiable in cremated remains? A study on 38 known cases.

Accurate identification and analysis of signs of trauma on human bone is one of the mainstays of forensic pathology. However, when a forensic pathologist has to deal with charred remains, the task become extremely difficult, because tissues are subjected to severe morphological alterations and their assessment can be critically distorted. We analyzed 38 individuals with peri-mortem skull fractures due to falls from height (17 cases), traffic accidents (16 cases), gunshots wounds (5 cases), of which we had the demographic and clinical data and the autopsy report with the description and photographic records of the fracture lines. After autopsy, the bodies were cremated in gas furnaces and the analysis of cremated cranial remains was conducted in order to verify if it was possible to reconstruct the original peri-mortem fractures and verify differences between known peri-mortem and post-mortem fractures. After 90 min and exposure to temperatures up to 1280 °C, in less than a third of cases (11-29%) the original peri-mortem fracture pattern could be found and reconstructed. The edges and the surface of the fractures can preserve their proper morphology, or they can be affected by post-mortem heat-induced fractures and deformations. Interestingly whenever peri-mortem fracture margins showed the evidence of yellow/brownish colouration, a matte appearance was observed, much different from post-mortem fractures, which may provide further food for thought for the identification of peri-mortem fractures after the cremation process.

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.

Autopsy or anatomical dissection: evidence of a craniotomy in a 17th-eighteenth century burial site (Ravenna, Italy).

Surgical procedures undergone in life, autopsies and anatomical preparations can all leave clearly identifiable traces on human skeletal remains. Several studies on skeletons from archeological contexts have identified traces of these practices. However, the distinction between medical/forensic autopsy and anatomical dissections for scientific research can be challenging. We report the case of a middle-aged female skeleton from the cemetery of the church of San Biagio (Ravenna, Italy), dating back to the 17th-19th centuries, that shows signs of a complete craniotomy. In an attempt to clarify the reason for this practice, we analyzed all pathological and non-pathological markers on the skeleton. We carried out anthropological analyses and osteometric measurements to determine the biological profile and the cranial capacity of the individual. Paleopathological investigation and analyses of traumatic injury patterns were carried out using both a morphological and a microscopic approach. While we observed that the craniotomy was performed with a rip saw, we identified perimortem blunt force trauma to the frontal bone and an osteolytic lesion on the inner surface of the frontal bone. No other pathology was recognizable on the skeleton. Our differential diagnosis confidently proved that the craniotomy was due to an autoptsy procedure and was not the result of an anatomical dissection. We believe that, among other possible reasons, failed surgery could likely be the motive behind the ordering of the autopsy.

In vivo evaluation of interactions between biphasic calcium phosphate (BCP)-niobium pentoxide (Nb2O5) nanocomposite and tissues using a rat critical-size calvarial defect model.

Natural or synthetic biomaterials are increasingly being used to support bone tissue repair or substitution. The combination of natural calcium phosphates with biocompatible alloys is an important route towards the development of new biomaterials with bioperformance and mechanical responses to mimic those of human bones. This article evaluated the structural, physical, mechanical and biological properties of a new mechanical improved nanocomposite elaborated by association of fish biphasic calcium phosphate (BCP) and niobium pentoxide (Nb2O5). The nanocomposite (Nb-BCP) and the pure BCP, used as a positive control, were obtained by powder metallurgy. The density, porosity and microhardness were measured. The structural analysis was determined by X-ray diffraction (XRD) and the biological properties were studied in histological sections of critical size calvaria defects in rats, 7, 15, 30, 45 and 60 days after implantation of disks of both materials. Morphological description was made after scanning electron microscopy (SEM) and optical microscopy analysis. After sintering, the Nb-BCP nanocomposite presented four crystalline phases: 34.36% calcium niobate (CaNb2O6), 21.68% phosphorus niobium oxide (PNb9O25), 42.55% ß-tricalcium phosphate (Ca3(PO4)2) and 1.31% of niobium pentoxide (Nb2O5) and exhibited increases of 17% in density, 66% in Vickers microhardness and 180% in compressive strength compared to pure BCP. In vivo study, showed biocompatibility, bioactivity and osteoconductivity similar to pure BCP. SEM showed the formation of globular accretions over the implanted nanocomposites, representing one of the stages of bone mineralization. In conclusion, the BCP and Nb2O5 formed a nanocomposite exhibiting characteristics that are desirable for a biomaterial, such as bioperformance, higher ß-TCP percentage and improved physical and mechanical properties compared to pure BCP. These characteristics demonstrate the promise of this material for supporting bone regeneration.

A new approach to recording nasal fracture in skeletonized individuals.

OBJECTIVE: This work describes a new method for recording nasal fracture in skeletonized individuals, suitable for use in biocultural studies of violence and fracture in past societies. METHODS: The method consists in recording the 'side of fracture', 'side of deviation', 'type of fracture', 'other facial fractures', and stage of 'bone remodeling'. RESULTS: A lateral impact force to the facial area is typical of interpersonal violence. This may result in a unilateral nasal fracture and/or a laterally deviated nose. Given the predominance of right-handedness in human populations, side of fracture and, especially, side of deviation, may be useful indices of interpersonal violence. As regards fracture type, although a distal fracture of the nasal bones is the most common type, their comminution may be associated with higher impact forces. The presence of other facial fractures may also be an indicator of high-energy impacts. CONCLUSIONS: Different patterns of nasal trauma may be consistent with different etiologies. SIGNIFICANCE: The method is focused at improving our ability to distinguish the direction and type of impact that caused the injury and, in particular, whether, at a population or sub-group level, such injuries are likely to be predominantly due to violence or to other causes. LIMITATIONS: Well healed fractures of the nasal bones or injury to the septum may be difficult to identify. Also, it is not possible to confirm if nasal and other facial fractures are temporally concurrent. SUGGESTIONS FOR FURTHER RESEARCH: To test this method using skeletal collections with known trauma history or 3D prints of modern nasal injuries of known etiologies.

Head and Brain Postmortem Computed Tomography-Autopsy Correlation in Hospital Deaths.

The use of postmortem computed tomography (PMCT) to support autopsy pathology has increased in recent decades. To some extent, PMCT has also been contemplated as a potential alternative to conventional postmortem examination. The purpose of this study was to investigate the ability of PMCT to detect specific pathologic findings in the head and brain in natural hospital deaths.We examined postmortem CT images and autopsy data from 31 subjects who died at SUNY (State University of New York) Upstate University Hospital between 2013 and 2018. Each subject underwent a noncontrast PMCT and a traditional autopsy. A neuroradiologist analyzed PMCT images for head and brain abnormalities. The autopsies were performed by pathologists who were aware of the radiology results.In our series, PMCT was able to detect the majority of the significant space-occupying lesions, although it was not always reliable in ascertaining their nature. Postmortem computed tomography revealed findings usually challenging to detect at autopsy. Unfortunately, there were also situations in which PMCT was misleading, showing changes that were difficult to interpret, or that could be related to postmortem events. Therefore, we conclude PMCT should be used as an adjunct rather than a substitute to autopsy.

Distinction between perimortem and postmortem fractures in human cranial bone.

Timing of cranial trauma is challenging in forensic cases and literature on the subject is scarce. This study analysed the macroscopic fracture patterns of perimortem cranial fractures and compared them to experimentally reproduced cranial fractures on dry human craniums. The results showed nine traits associated with fresh cranial fractures: undulated margin, flake defects, peels with peel defects, fissures, crushed margins, bridge, bone scales and beveling. All the traits appear on the outer table or on the inner table of the cranium. Although not all characteristics must be present at the same time in all cranial fractures, they do define a new perimortem fracture pattern. Statistical analyses showed that six of these traits (undulated margins, flake defects, crushed margins, bone scales, fissures and peels) are distinctly related with perimortem (fresh) bone conditions. Considering the most discriminant perimortem traits, a decision-making algorithm is developed as a probabilistic approach to distinguish peri- from postmortem cranial fractures with an accuracy of 87%. This algorithm allows the forensic practitioner to incorporate more confidence during cranial trauma evaluation.

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.

Injury pattern and the biomechanical assessment of skull fracture risk in blows with a rubber mallet.

Acts of violence often result in blunt force trauma. On behalf of the court, forensic experts not only have to assess injuries in terms of morphology or severity, but they also have to give statements regarding the risk of potential fatal injuries. We describe a case of domestic violence where a man hit the head of his wife using a rubber mallet. His wife sustained extensive and multiple parietal scalp lacerations and avulsions with exposure of the cranial bone. A CCT revealed neither skull fractures nor intracranial injuries. Biomechanical measurements were performed using a bowling ball and an animal head representing head surrogates. In comparison to steel hammer impacts we hypothesized longer contact durations and lower maximum contact forces in blows with a rubber mallet. However, contact durations in the magnitude of 3ms do not confirm our hypothesis. The contact forces calculated based on mallet and animal head accelerations were between 2.97kN and 4.68kN. These force values are rather below the parietal fracture thresholds, explaining the absence of parietal skull fractures in the case presented. Moreover, the relatively low Young's modulus comes along with a deformation of the rubber mallet and a decrease in contact pressure. In summary, contact times could be reliably estimated, while contact forces remained largely uncertain.

Postmortem Magnetic Resonance Imaging and Postmortem Computed Tomography in Ligature and Manual Strangulation.

PURPOSE: The aim of this study was to evaluate magnetic resonance imaging (MRI) findings in cases of fatal manual or ligature strangulation. Verification of strangulation by computed tomography (CT), MRI, and at autopsy as well as its detectability in each modality was assessed. METHODS: We retrospectively analyzed 6 manual and ligature strangulation cases between 2013 and 2019 who all underwent a whole-body CT, head and neck MRI, and an autopsy. Two radiologists examined head and neck imaging data and compared the data to autopsy findings. RESULTS: Magnetic resonance imaging showed a high efficiency in verifying intramuscular hemorrhages, which were confirmed in autopsy. Moreover, in one case without a visible strangulation mark, soft tissue injuries associated with strangulation were detected. Fractures, especially thyroid cartilage fractures, were successfully diagnosed by CT. CONCLUSIONS: As MRI showed a successful detection of soft tissue lesions in relation to strangulation, it can serve as an alternative method or provide additional value to an autopsy. Intramuscular hemorrhages are a common finding in manual and ligature strangulation, providing a useful sign of applied pressure on the neck. However, to evaluate fractures, an additional CT or autopsy is recommended.

Growing Skull Fracture of Temporal Bone in Adults: A Case Report and Literature Review.

Growing skull fracture (GSF) is an uncommon post-traumatic complication, which accounts for approximately 0.05% to 1% of all skull fractures. Delayed diagnosis of GSF in adulthood is rare and often involved with a variety of neurological symptoms. Here, we reported an adult patient, with an interval of 17 years from initial head trauma to first diagnosis of GSF. The patient complained of short periods of fainting and bilateral visual hallucinations, with a hard palpable bulge around his right occipitomastoid suture region. Computed tomographic imaging demonstrated an arachnoid cyst extending into right mastoid cavity. Consequently, the delayed diagnosis of GSF was confirmed, and the patient was managed with duroplasty and cranioplasty. At the 8-month follow-up, the patient showed an uneventful postoperative recovery. A comprehensive literature review was also conducted, and a total of 70 GSF cases were identified and summarized. According to the literature review, patients with GSF generally have a history of head trauma in their childhood, and delayed diagnosis is a common situation. Diagnosis of GSF should include complete retrospective medical history, physical, and imaging examinations. Once the diagnosis is confirmed, cranioplasty accompanied with duroplasty might be the most effective way to relieve symptoms and prevent further damage.

Dynamic changes of facial skeletal fractures with time.

To investigate the characteristics of imaging changes with time of facial fractures, patients with facial fractures who had computed tomographic scan were enrolled including 500 patients who were divided into six groups based on the time of scanning: super early (<3 d), early (4-7 d), early-to-medium (8-14 d), medium (15-21d), medium-to-late (22d-2 months) and late stage (>2 months). The data were compared and analyzed. Forty two patients with frontal bone fractures had high-energy impact as the reason of fractures. The fracture line was clear and sharp within one week but blunt and sclerotic due to bone absorption at 2-3 weeks, and might exist for a long time. All patients had soft tissue swelling and paranasal sinus effusion at 1-2 weeks after injury. Air might gather in the adjacent soft tissues and/or intracranially within 3 days of injury if the fracture involved the frontal or other sinuses. Twelve of the 42 patients (28.6%) had intracranial hematoma, and five (11.9%) had epidural effusion. Subarachnoid hemorrhage was mostly absorbed within one week while epidural hematoma was completely absorbed over 3 weeks. Significant changes (P < 0.05) in the fracture lines, effusion of paranasal sinuses, soft tissue swelling and pneumocephalus were observed during the study period. For patients with medial orbital wall fractures, the fracture line was sharp and clear at early stages with concurrent sphenoid sinus effusion, and the fracture line became depressed 3 weeks later with disappearance of sphenoid sinus effusion. Significant changes (P < 0.05) were observed in the sharp fracture line, soft tissue swelling, sphenoid sinus effusion and smooth depression at fracture sites. For nasal fractures, the fracture line was sharp and clear at early stages with concurrent soft tissue swelling which disappeared one week later. The fracture line became smooth three weeks later. A significant (P < 0.05) difference was demonstrated in the changes of fracture line and soft tissue swelling with time. In conclusion, facial fractures have some dynamic alterations with time and identification of these characteristics may help reaching a correct clinical diagnosis with regard to fracture severity and time.

Skull fractures in forensic putrefied/skeletonised cases: The challenge of estimating the post-traumatic interval.

The objective of our study was to assess the reliability of the estimation of posttraumatic survival time (PTST) in forensic cases based on microCT and histology of putrefied/dry bone samples with comparison of initial macroscopic fracture classification performed during autopsy. Macroscopic morphological patterns of bone fracture are routinely used in forensic pathology and anthropology to distinguish between antemortem, perimortem and postmortem injuries. Based on macroscopic and microscopic analysis of six craniofacial fractures, our study results illustrate the need to complete macroscopical findings and initial fracture classification with microscopic analysis to avoid any inaccuracy. MicroCT has become a powerful technique to identify early bone healing signs but histology remains the gold standard to estimate the PTST and determine vital fracture based on hemorrhage marker. Raman microspectroscopy can identify a blood clot in the fracture line.

[Ergometric evaluation of impact strength that lead to skull fracture: features of individual methods, typical expert mistakes and methods of their prevention]. / Érgometricheskaia otsenka sily udara, povlekshego perelom cherepa: osobennosti chastnykh metodik, tipichnye ékspertnye oshibki i sposoby ikh predotvrashcheniia.

Two current approaches to the ergometric evaluation of the impact strength that lead to skull fracture are described. Within each of them, the features of particular techniques, typical expert errors, ways and means of preventing them are analyzed. Quantitative data on the contribution of various initial parameters (fracture type, age, bone thickness, skull radius of curvature, body weight, height, etc.) to the result of computational diagnostics are presented.

Experimental and numerical study on the mechanical properties of cortical and spongy cranial bone of 8-week-old porcines at different strain rates.

Pediatric porcines have widely been used as substitute for children in biomechanical research. Previous studies have used entire piglet cranium when testing their properties. Here, the piglet craniums from the frontal and parietal locations were carefully dissected into spongy and cortical part, and tensile tests at different strain rates were then conducted on these two bone types. It is found that the elastic modulus, yield stress, and ultimate stress of the cortical bone were all significantly higher than those of the spongy bone. The ultimate strains of the cortical and spongy bone were similar. Overall, the effect of the position on the mechanical properties did not reach significance. Cortical bone strength from the frontal location was slightly higher than that obtained from the parietal location; however, spongy bone did not show this location difference. The mechanical properties of both the cortical and spongy bone are significantly strain-rate dependent. Specifically, the elastic modulus, yield stress, and the ultimate stress of the cortical bone increased by approximately 123%, 63%, and 50%, respectively, with strain rates ranging from 0.001 to 10/s. For spongy bone, increases were approximately 128%, 73%, and 77%, respectively. Ultimate strain decreased by approximately 37% and 7% for cortical and spongy bone, respectively. An elastic-plastic constitutive model incorporating with strain rate based on a combined exponential and logarithmic function was proposed and implemented into LS-DYNA through user-defined material. The developed model and the subroutine code successfully simulated the strain-rate characteristics and the fracture process of the bone samples.

Pedestrian hit by a car impacted metal pole: reconstructing the head load.

Fatal head injuries are frequently seen in pedestrians hit by motorized vehicles. In our case, the pedestrian sustained a devastating head injury with skull splitting in the mediosagittal plane. A car collided with a traffic sign causing a bending of the pole. The metal pole hit a man standing close beside it; the man had a head injury severity that is more commonly due to falling objects than due to traffic accidents. Assuming a head mass of 5 kg, simplified calculations yield maximum contact forces of ca. 36 kN exceeding mean parietal fracture forces which are in the order of magnitude of 12.5 kN. The influences of the effective body mass and the horizontal distance between the pole and the pedestrian on maximum contact forces are investigated. High contact forces in our case can be mainly explained by the comparably high impact velocity and by a partial mass transfer of the total car mass to the pole.