Forensic Autopsy of Blunt Force Trauma

Overview
Deaths resulting from blunt force trauma are some of the most common cases encountered by the practicing forensic pathologist. Whereas other forms of traumatic death (eg, gunshot wounds, sharp force injuries) occur under a relatively limited number of circumstances, deaths resulting from blunt force trauma occur in a variety of scenarios. For instance, almost all transportation fatalities including those involving motor vehicle collisions, pedestrians being struc! by vehicles, airplane crashes, and boating incidents result from blunt force trauma. Other deaths resulting from blunt force trauma involve jumping or falling from heights, blast injuries, and being struc! by a firm object, such as a fist, crowbar, bat, or ball. "ite wounds and chop injuries may be considered variants of blunt force trauma, sharp force trauma, or a class of injuries untothemselves. "lunt force trauma is routinely involved in cases classified as accidents, as well as in cases of suicide and homicide. #eople dying natural deaths often have minor blunt force injuries that do not contribute to death $$ small abrasions or contusions on the s!in are commonplace at autopsy. %lthough it is important to document evidence of blunt force trauma in all autopsies, one should not immediately assume that blunt force trauma is the cause of death. For purposes of death certification, it should be noted that blunt force trauma may be the underlying (pro&imate) cause of death in cases in which the immediate cause of death is a natural disease process. For e&ample, individuals may die of infections, thromboemboli, or organ failure that occurs as a delayed result of previous blunt force trauma. 'n some cases, the injury may have occurred many years before death. 't is important to understand that the designated manner of death in such scenarios must include the causal factor that made the decedent susceptible to the disease state, namely the underlying injury which initiated the chain of events ultimately leading to death. For e&ample, the cause of death of an individual who dies of pneumonia after being hospitali(ed for several days for treatment of blunt force injuries following a motor vehicle collision should be certified as )acute bronchopneumonia complicating blunt force injuries due to a motor vehicle accident.) *he manner of death should then be certified as )accident.) *his chapter focuses on the cutaneous manifestations of blunt force injury. Other chapters will e&pand on topics such as closed head injuries, including se+uelae of rapid acceleration,deceleration.

Overview of the entity

*he severity of injuries inflicted as a result of blunt force trauma is dependent on the amount of !inetic energy transferred and the tissue to which the energy is transferred. *he !inetic energy associated with a moving object is e+ual to one half the mass of that object multiplied by the velocity of the object s+uared (-,. mv.). 'n general, a somewhat lighter object traveling at high speed will cause more damage than a heavier object traveling at low speed. /-, ., 0, 12 3+ually important, however, are the characteristics of the blunt object and the surface that is impacted. 'mpacts involving a large surface area $$ either with regard to the impacting object or with regard to the tissues being impacted $$ will result in a greater dispersion of energy over a larger area and less injury to the impacted tissues. For e&ample, a thin metal pipe stri!ing some part of the body would be e&pected to inflict greater locali(ed injuries than a broad board of similar mass and velocity stri!ing the same part of the body. 4i!ewise, an impact on a small area of a curved surface, such as the head, will cause greater damage than would be caused were that same impact to occur on a flat surface, such as the bac!, since there will be a more concentrated point of impact on the head. *he composition, or plasticity, of the tissues impacted also affects the resultant injuries. For e&ample, a person who is !ic!ed in the chest may have only minimal injuries to the elastic s!in surface, whereas deeper, more solid tissues such as ribs and internal organs (notably, the spleen and liver) may e&perience fractures and lacerations. 5et another factor affecting the severity of blunt force injuries is the amount of time the body and the impacting object are in contact. % longer period of contact allows !inetic energy to be dissipated over

a prolonged period, resulting in less damage to the tissues than an e+ually forceful impact with dispersion of energy over a brief period.

Definitions
Blunt force trauma: 'njuries resulting from an impact with a dull, firm surface or object. 'ndividual injuries may be patterned (eg ,characteristics of the wound suggest a particular type of blunt object) or nonspecific. %lthough this article focuses mainly on e&ternal injuries, blunt force trauma may cause contusions and lacerations of the internal organs and soft tissues, as well as fractures and dislocations of bony structures. *he major types of cutaneous blunt force injuries are as follows6 Abrasion: % scraping injury to the superficial layers of the s!in (epidermis and dermis) that results from friction against a rough surface (see the following . images)

Contusion (bruise): 7emorrhage into the dermis, subcutaneous tissues, deep soft tissues, and internal organs as a result of rupture of blood vessels following impact with a blunt object or surface (as shown below).

% contusion on the arm.

8ross section of brain with cerebral contusions on the inferior surface.

Laceration: % bursting of the s!in or other tissues resulting from compression or stretching associated with impact by a blunt object or surface (see the following images).

*wo abraded lacerations on the forehead.

% laceration near the verte& of the scalp.

Avulsion: % more severe form of laceration in which the soft tissues, musculature, and,or bone are torn away from the normal points of attachment (as seen in the image below).

%vulsion of the right leg.

Fracture: % brea!, rupture, or separation of tissue (most often bone) resulting from an impact (see the following image).

3&tensive fractures involving the base of s!ull.

*hese injuries are often seen in combination with one another. For e&ample, abrasions are often found at the margins of lacerations. %brasions, lacerations, and contusions are often noted adjacent to fractures.

9ross 3&amination and Findings

*he individual types of blunt force trauma discussed above do not always occur individually: they often occur in combination. *hat is, one may encounter abraded contusions, abraded lacerations, and lacerated contusions (as depicted in the images below). *he appearance of a blunt force injury is determined by several variables, including the impacting weapon or surface, the anatomic site impacted, and individual factors including s!in elasticity and coagulability status.

%braded contusion on the bac!. abraded lacerations on the forehead.

*wo

One common type of blunt force injury is the so$called brush$burn abrasion. "rush$burn abrasions are broad, dried abrasions that often have a yellow$orange or orange$red coloration. *hese abrasions are caused by dragging or scraping the surface of the s!in against a rugged surface: they are most often encountered when a body slides on pavement. *hese abrasions are sometimes called )road rash.)/-2 (;ee the following image.)

"rush$burn type abrasion on the left flan!.

'n some cases, a patterned abrasion or contusion may result when an object impacts the s!in. Whereas nonspecific blunt force injuries provide no hint as to what may have caused them, a patterned abrasion or contusion recapitulates some features of the impacting object. ;uch patterns may be of importance in identifying a weapon used in an assault or in identifying a tire or other part of a vehicle that stri!es a body during a hit$and$run collision. 'n such scenarios, it is advisable to ta!e photographs with a scaled ruler to help identify the object (see the images below). Overlaying the injury with plastic wrap and tracing it with a pen can also provide useful documentation.

#atterned abrasion on the head due to impact by a motor vehicle. #atterned abrasion on the flan! inflicted by a crowbar.

8hop injuries are sometimes regarded as a variant of blunt force trauma. *hese injuries result from impact of the s!in by a heavy object with a somewhat sharp facet, causing a wound that has attributes of both sharp force and blunt force trauma. Depending on how sharp the weapon is, these may resemble either gaping lacerations or large cuts with marginal abrasion and are often associated with underlying fractures./.2 Objects that commonly cause chop injuries include a&es, propellers, and lawnmower blades (as shown in the image below).

;everal chop injuries inflicted by a boat propeller.

Finally, one must !now that the degree of blunt trauma evidenced on the surface of the s!in may not be indicative of the degree of underlying injuries or the cause of death. /-, ., 0, 12 ;evere, deep scalp lacerations may overlie a s!ull free of fractures, brain injuries, or hemorrhages. %lternatively, a child may have little or no evidence of injury on the s!in, yet have devastating internal injuries. 8ommotio cordis, a sudden cardiac arrhythmia caused by blunt impact to the chest $$ often by a ball, steering wheel, or some other object $$ is another type of blunt force injury. *he object may leave a patterned injury or there may be no evidence of injury at all, in which case, one would need to rely on scene investigation, witness statements, and other sources to determine the cause of death.

Special issections
'n most instances, a review of the medical record and a standard, complete autopsy are all that is necessary to document significant blunt force injuries: however, certain cases may call for more speciali(ed dissections. %mong such cases are those involving blunt force injuries of the nec!. 'f a compressive, crushing force was thought to impact the nec!, it may be advisable to perform a layer$by$layer anterior nec! dissection, by which hemorrhage may be identified in the individual strap muscles (as seen in the image below). Once the muscles are dissected away, the cartilages of the trachea and the hyoid bone should be e&amined for fractures. %fter the dissection is complete, the nec! organs should be removed so that the anterior cervical spine may be e&amined. 'f hemorrhage or fractures are noted, one may choose to remove and e&amine the spinal cord in order to document any pertinent injuries.

%nterior nec! dissection demonstrating hemorrhage within several strap muscles.

'n other scenarios, particularly motor vehicle related fatalities with nonlethal injuries documented by routine autopsy, a posterior nec! dissection may be re+uired to document the cause of death. 'n this procedure, a linear, vertical incision is made from the mid occiput to the upper spine. *he soft tissues are then dissected away, so that the deep muscles, ligaments, and cervical vertebrae can be e&amined for injuries. %t this point, the spinal cord may be removed from the posterior aspect and e&amined for injury. 'n cases in which cervical sublu&ation is suspected, the brainstem should be initially sectioned in the sagittal midline to identify subtle pontomedullary lacerations. ;pecial dissections may be re+uired to thoroughly document blunt force trauma in children in which there is suspicion of abuse. One such dissection involves stripping the parietal pleura from the pleural cavities after all thoracic organs have been removed. /.2 %lthough some rib fractures may be identified without doing so, stripping the pleura allows for a much more detailed e&amination and may help detect fractures that would otherwise go unnoticed (see the image below).

<ib fractures e&posed after peeling away the parietal pleura.

%nother procedure often performed in suspected child abuse cases is removal of the ocular globes in order to e&amine the retinae and optic nerves for foci of hemorrhage. %fter the brain has been removed, wedge$shaped cuts are made into the anterior fossae in order to remove the orbital plates. Once removed, the eyes may be gently dissected away from the surrounding soft tissues, then placed in formalin (or other fi&ative) for fi&ation. *he eyes are later sectioned to e&amine for hemorrhages: the presence of hemorrhage may be further evidence of blunt force trauma (as shown below).

8ross section of the left eye and optic nerve demonstrating hemorrhage surrounding the optic nerve.

%t the completion of a suspected child abuse autopsy, the pathologist will often ma!e incisions or cutdowns into the s!in of the bac! and e&tremities to further document injuries to bone and soft tissue. "ecause of the s!in=s elasticity, the s!in surface may be free of trauma: however, deeper tissues may have been injured. 'ncisions through the s!in may show deep muscular hemorrhage and,or bony fractures (see the following image).

8utdown of the posterior aspect of the left leg showing no injuries.

%lthough the aforementioned procedures may be performed on any decedent, they are most often utili(ed in child fatalities.