14/04/12 Forensic Autopsy of Blunt Force Trauma

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Forensic Autopsy of Blunt Force Trauma

Author: Nicholas I Batalis, MD; Chief Editor: Stephen J Cina, MD, FCAP more...

Updated: Mar 2, 2012

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 struck 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
struck by a firm object, such as a fist, crowbar, bat, or ball. Bite wounds and chop injuries may be considered
variants of blunt force trauma, sharp force trauma, or a class of injuries untothemselves.

Blunt force trauma is routinely involved in cases classified as accidents, as well as in cases of suicide and homicide.
People dying natural deaths often have minor blunt force injuries that do not contribute to death -- small abrasions
or contusions on the skin are commonplace at autopsy. Although 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 (proximate)
cause of death in cases in which the immediate cause of death is a natural disease process. For example,
individuals may die of infections, thromboemboli, or organ failure that occurs as a delayed result of previous blunt
force trauma. In some cases, the injury may have occurred many years before death.

It 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 example, the cause of death of an individual who dies of pneumonia after
being hospitalized 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." The
manner of death should then be certified as "accident."

This chapter focuses on the cutaneous manifestations of blunt force injury. Other chapters will expand on topics
such as closed head injuries, including sequelae of rapid acceleration/deceleration.

Overview of the entity

The severity of injuries inflicted as a result of blunt force trauma is dependent on the amount of kinetic energy
transferred and the tissue to which the energy is transferred. The kinetic energy associated with a moving object is
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equal to one half the mass of that object multiplied by the velocity of the object squared (1/2 mv2). In general, a
somewhat lighter object traveling at high speed will cause more damage than a heavier object traveling at low
speed.[1, 2, 3, 4]

Equally important, however, are the characteristics of the blunt object and the surface that is impacted. Impacts
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 example, a thin metal pipe striking some part of the body would be expected to inflict greater localized injuries
than a broad board of similar mass and velocity striking the same part of the body. Likewise, 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 back, since there will be a more concentrated point of impact on the
head.

The composition, or plasticity, of the tissues impacted also affects the resultant injuries. For example, a person who
is kicked in the chest may have only minimal injuries to the elastic skin surface, whereas deeper, more solid tissues
such as ribs and internal organs (notably, the spleen and liver) may experience fractures and lacerations.

Yet another factor affecting the severity of blunt force injuries is the amount of time the body and the impacting
object are in contact. A longer period of contact allows kinetic energy to be dissipated over a prolonged period,
resulting in less damage to the tissues than an equally forceful impact with dispersion of energy over a brief period.

Definitions
Blunt force trauma: Injuries resulting from an impact with a dull, firm surface or object. Individual injuries may be
patterned (eg ,characteristics of the wound suggest a particular type of blunt object) or nonspecific. Although this
article focuses mainly on external 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. The major types of cutaneous
blunt force injuries are as follows:

Abrasion: A scraping injury to the superficial layers of the skin (epidermis and dermis) that results from friction
against a rough surface (see the following 2 images)

Abrasion on the elbow.

Abrasion on the knee.

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

Two contusions on the skin of the chest.

A contusion on the arm.

Cross section of brain with cerebral contusions on the inferior surface.

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

Two abraded lacerations on the forehead.

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A laceration near the vertex of the scalp.

Avulsion: A 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).

Avulsion of the right leg.

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

Extensive fractures involving the base of skull.

These injuries are often seen in combination with one another. For example, abrasions are often found at the
margins of lacerations. Abrasions, lacerations, and contusions are often noted adjacent to fractures.

Scene Findings
As with most types of traumatic deaths, scene findings often play an important role in the death investigation
process. Examples include blood spatter evaluation and DNA analysis in homicide cases involving multiple blows
with a blunt object, such as a baseball bat, and scene reconstruction following motor vehicle collisions.

Trace Evidence
In certain cases, it may be helpful to examine the skin surface and wounds for trace evidence. This may involve
looking for paint, metal, or glass fragments on a body that was struck by a hit-and-run motor vehicle; identifying
embedded fragments of a weapon used to assault someone; or identifying a tool mark left in a bone underlying a
blunt force impact site. Such trace evidence may be used by forensic science technicians to help identify the
vehicle or weapon that caused the injuries.

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Gross Examination and Findings

The individual types of blunt force trauma discussed above do not always occur individually; they often occur in
combination. That is, one may encounter abraded contusions, abraded lacerations, and lacerated contusions (as
depicted in the images below). The 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 skin elasticity and
coagulability status.

Abraded contusion on the back.

Two abraded lacerations on the forehead.

One common type of blunt force injury is the so-called brush-burn abrasion. Brush-burn abrasions are broad, dried
abrasions that often have a yellow-orange or orange-red coloration. These abrasions are caused by dragging or
scraping the surface of the skin against a rugged surface; they are most often encountered when a body slides on
pavement. These abrasions are sometimes called "road rash."[1] (See the following image.)

Brush-burn type abrasion on the left flank.

In some cases, a patterned abrasion or contusion may result when an object impacts the skin. 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. Such 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 strikes a body during a hit-and-run collision.
In such scenarios, it is advisable to take 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.

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Patterned abrasion on the head due to impact by a motor vehicle.

Patterned abrasion on the flank inflicted by a crowbar.

Chop injuries are sometimes regarded as a variant of blunt force trauma. These injuries result from impact of the
skin 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 axes, propellers, and lawnmower blades (as shown in the image below).

Several chop injuries inflicted by a boat propeller.

Finally, one must know that the degree of blunt trauma evidenced on the surface of the skin may not be indicative
of the degree of underlying injuries or the cause of death.[1, 2, 3, 4] Severe, deep scalp lacerations may overlie a
skull free of fractures, brain injuries, or hemorrhages. Alternatively, a child may have little or no evidence of injury
on the skin, yet have devastating internal injuries. Commotio 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.
The 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 dissections

In 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 specialized dissections.

Among such cases are those involving blunt force injuries of the neck. If a compressive, crushing force was thought
to impact the neck, it may be advisable to perform a layer-by-layer anterior neck 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 examined for fractures. After the dissection is
complete, the neck organs should be removed so that the anterior cervical spine may be examined. If hemorrhage
or fractures are noted, one may choose to remove and examine the spinal cord in order to document any pertinent

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injuries.

Anterior neck dissection demonstrating hemorrhage within several strap muscles.

In other scenarios, particularly motor vehicle related fatalities with nonlethal injuries documented by routine
autopsy, a posterior neck dissection may be required to document the cause of death. In this procedure, a linear,
vertical incision is made from the mid occiput to the upper spine. The soft tissues are then dissected away, so that
the deep muscles, ligaments, and cervical vertebrae can be examined for injuries. At this point, the spinal cord may
be removed from the posterior aspect and examined for injury. In cases in which cervical subluxation is suspected,
the brainstem should be initially sectioned in the sagittal midline to identify subtle pontomedullary lacerations.

Special dissections may be required 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] Although some rib fractures may be identified without doing so, stripping the
pleura allows for a much more detailed examination and may help detect fractures that would otherwise go
unnoticed (see the image below).

Rib fractures exposed after peeling away the parietal pleura.

Another procedure often performed in suspected child abuse cases is removal of the ocular globes in order to
examine the retinae and optic nerves for foci of hemorrhage. After 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 fixative) for fixation. The eyes
are later sectioned to examine for hemorrhages; the presence of hemorrhage may be further evidence of blunt
force trauma (as shown below).

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

At the completion of a suspected child abuse autopsy, the pathologist will often make incisions or cutdowns into the
skin of the back and extremities to further document injuries to bone and soft tissue. Because of the skin's
elasticity, the skin surface may be free of trauma; however, deeper tissues may have been injured. Incisions

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through the skin may show deep muscular hemorrhage and/or bony fractures (see the following image).

Cutdown of the posterior aspect of the left leg showing no injuries.

Although the aforementioned procedures may be performed on any decedent, they are most often utilized in child
fatalities.

Histology and Microscopic Examination and Findings

Histologic examination is generally not as important as gross impressions in the evaluation of blunt force injuries.
Generally, one may examine tissue from a suspected blunt force injury for 2 reasons: (1) to identify a lesion as a
true antemortem lesion and (2) to attempt to date a blunt force injury.

The presence of significant extravasation of blood into the tissues suggests some degree of blood pressure and,
by extension, confirms that a contusion is antemortem. If an inflammatory infiltrate is noted at the site of a blunt
force injury, the wound was definitely received before death. The presence of fibroblastic proliferation, hemosiderin
deposition, capillary ingrowth, and other histologic features characteristic of repair indicates an injury occurred
several days before death. In general, the more repair present, the older the wound. However, dating of blunt force
injuries is an inexact science. Both individual and external variables as well as the extent of injury influence the
progress of repair.

Much has been written in both journals and textbooks about the dating of blunt force injuries; currently, there is no
firm, scientific evidence that abrasions and contusions can be dated microscopically with a high degree of
accuracy.[1, 2, 4, 5, 6, 7, 8, 9, 10] Although some authorities delineate specific time frames for use in dating each type of
injury, in practice, nothing has proved to be any more dependable than gross inspection of the injuries. In most
cases of cutaneous and soft tissue injury, the histologic findings should be viewed as an adjunct to the gross
impression.

There does seem to be some merit in using histology to date fractures, albeit the time frames suggested by
histologic examination are general and are not specific to the hour, day, or week. Within 2 days after a fracture has
occurred, an acute inflammatory response occurs at the site of the fracture. In the ensuing days, granulation tissue
formation occurs. Within approximately 1-2 weeks, new bone and cartilage are deposited. A firm callus with a bony
union occurs during weeks 2-6; after this period, no further specific changes occur.[1, 2] Although somewhat
general, this dating scheme may be helpful, especially in cases of suspected repetitive child abuse.

Photography and Documentation

Measurements and descriptions of blunt force injuries on the skin surface should be documented on a body
diagram. Injuries to deeper tissues and internal organs must also be documented either on the same diagram or
elsewhere in the case file. When generating the autopsy report, it is often best to divide the description of injuries
into subsections for the head and neck, trunk, and extremities. Furthermore, one should describe the injuries "from
the outside in." That is, a description of a laceration on the scalp should be followed by that of any deeper scalp
hemorrhage, then associated skull fractures, then associated intracranial hemorrhages and any traumatic injuries
to the brain.

Care should be taken to note whether injuries appear to be acute (recent) or show evidence of healing (resolving).
Fractures go through an orderly process of repair that culminates in remodeled bone. Abrasions first ooze blood,
then scab over, then scar or disappear. Contusions may progress from purple to red to green to brown to yellow
over a period of weeks, depending on the severity of the injury before complete healing. Documentation of the
color of contusions may be as important as their configuration and distribution in some cases.

As with any forensic autopsy, photography is an integral part of the examination. Appropriate photographs vary
according to the individual case and the individual pathologist. They may range from only general overall body
photos without detailed photos of injuries in a death resulting from a motor vehicle collision, to much more extensive
photography in a death involving suspected child abuse. At a minimum, orientation and close-up, scaled
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photographs should be taken of pertinent injuries in cases of suspected homicides.

Ancillary and Adjunctive Studies

Most autopsies of deaths resulting from blunt force injuries do not require additional ancillary studies, because the
cause and manner of death can be ascertained from the standard autopsy and, when necessary, special
dissections. That being said, postmortem radiography is essential in deaths involving suspected child abuse. In
such cases, a full body skeletal survey should be performed in order to detect all bony injuries, both acute and
remote. Also, if a body is severely burned in a motor vehicle collision or explosion, then radiographs may be
warranted to ensure that there are no bullets or other important evidence within the body. Lastly, radiographs of
the lower extremities may be useful in hit-and-run pedestrian fatalities to document the presence of "bumper
fractures."

Common Mistakes
There are several pitfalls in the evaluation of blunt force trauma or supposed blunt force trauma. Some involve
misinterpreting minor or resuscitative injuries as being severe injuries inflicted in the antemortem period; others
involve diagnosing blunt force trauma when, in fact, there is no trauma at all.

One of the most common errors is confusion and improper usage of the terms "cut" and "laceration." Lacerations
are irregular, often abraded, ragged defects in the skin caused by bursting of the skin by compression between an
impacting blunt surface and an underlying bony structure. Cuts, also called incised wounds, are clean-edged,
sharp force injuries resulting from a sharp edge being sliced across the skin. This distinction is clinically significant
as lacerations may be associated with underlying fractures and visceral lacerations or contusions, whereas cuts are
not.

As previously mentioned, injuries seen on the skin may not be indicative of the force required to cause them. One
finding that is often confused with inflicted contusions and/or elder abuse is senile purpura.[2] As individuals age,
the skin thins, making it extremely fragile and easy to injure; this thinning of the skin may also occur in conjunction
with the use of certain medications, such as steroids. Even very slight trauma such as might be caused by brushing
against a door can lead to senile purpura. In such instances, there is superficial hemorrhage with little or no
extravasation of blood in the underlying tissues (see the following image).

Senile purpura on the left arm.

Resuscitative efforts may cause injuries to the body that may be confused with injuries that cause death. These
iatrogenic artifacts include oral contusions/lacerations resulting from intubation; skin and soft tissue hemorrhage
resulting from intravascular catheter placement (see the image below); abrasions resulting from defibrillation;
bladder mucosal hemorrhage resulting from the placement of Foley catheters; and rib fractures caused by
compression during cardiopulmonary resuscitation (CPR).[11, 12, 13, 2, 14, 15, 16] For this reason, hospital workers,
emergency medical care technicians, and other healthcare providers should be advised to leave all medical
therapy in place in the event a patient dies. The pathologist can then readily correlate any perimortem injuries with
evidence of medical intervention.

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Ecchymosis on the right hand associated with intravascular catheter placement.

Rib fractures resulting from CPR are often symmetrical and occur in the anterior or lateral aspects of the ribs; only
rarely do they occur in the posterior aspects. Fractures have been noted to occur in up to 30-40% of adults who
receive CPR; they occur much more infrequently in children.[11, 12, 13, 15] In addition, aggressive CPR, especially if
performed by an inexperienced healthcare provider, may result in injury, including contusions and lacerations, to
internal organs. Great care should be taken, however, in blindly accepting a claim that a hepatic laceration with
massive internal bleeding was the result of CPR; many, if not all, of these cases are likely to be inflicted, intentional
injuries.

One finding that an inexperienced pathologist, investigator, or clinician may misinterpret for a contusion is the so-
called Mongolian spot. These hyperpigmented spots or patches are most often found on the sacrum of infants, and
they occur in people of all races (up to 90% of Native Americans, 80% of Asians, and 10% of whites).[17] Mongolian
spots often have a blue-green coloration and are solitary (as seen in the image below); however, these spots may
take on various colorations and may be multifocal, even extending up the spine. One must not confuse Mongolian
spots with contusions and make a diagnosis of child abuse; if there is any question as to the etiology, the lesion
should be incised. A Mongolian spot should have no hemorrhage, whereas with a contusion, hemorrhage will be
present in the skin and subcutaneous tissues. Histologically, dendritic melanocytes reside in the dermis creating an
appearance similar to that of a blue nevus.

Mongolian spot on the buttocks.

Periorbital ecchymoses are another finding that one may misinterpret as an inflicted contusion. Though impacts to
the nose can cause bilateral periorbital hematomas, most of these ecchymoses or "raccoon eyes" do not result
from a direct impact to the skin. Rather they are associated with blood leaking down into the sinuses and periorbital
tissues after a basilar skull fracture involving the orbital roofs (see the following image).

Periorbital ecchymoses.

A similar finding is seen behind the ears following a basilar skull fracture with subsequent hemorrhage into the
mastoid sinuses; this is referred to as Battle's sign.[2]
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Finally, artifacts resulting from drying of the tissues after death, postmortem injuries, or insect activity may mimic
antemortem blunt force trauma. In general, injuries or changes affecting the body after death will have a leathery,
yellowish appearance with little or no hemorrhage or vital reaction. Insect activity often results in superficial, sharply
demarcated, epidermal lesions on exposed surfaces of the body. If the lesions occur relatively close to the time of
death, they may ooze bloody fluid, imparting a hemorrhagic appearance that mimics antemortem abrasion, as seen
in the images below.[18]

Postmortem changes on the chest caused by insect activity.

Postmortem changes on the left ankle caused by insect activity.

Issues Arising in Court

A common question from lawyers and other interested parties is whether a particular surface or weapon could have
caused the injuries seen at autopsy. When a patterned contusion and/or abrasion has been identified, it may be
possible to match a weapon to the inflicted injuries; however, most of the time, this is not the case. Most blunt force
injuries are nonspecific and may be caused by an impact by any number of objects.

When approached with this line of questioning, it is best to acknowledge that the weapon in question could have
caused the injuries (if this is indeed true) but not to definitively say that the weapon did cause the injuries. Although
this may sound like wordsmithery, it could have a profound effect on a trial. For instance, a laceration on the head
caused by a piece of lumber could appear identical to a laceration caused by a bat, a computer monitor, or various
other objects. Therefore, one would not want to be cornered into saying that an injury could only been have caused
by one such object (eg, a bat), when in reality it was caused by a bloody piece of lumber found at the scene. It may
be most honest to say that "this type of weapon could (or could not) have caused the injuries noted at autopsy" and
to be ready to discuss alternatives when questioned at cross-examination.

In a courtroom trial, one may be asked to specify the date on which a blunt force injury occurred. As previously
mentioned, the age of contusions and abrasions occur can only be determined in a general manner. One practical
approach is to consider contusions acute or recent (if they are purple/red/blue and show no histologic repair)
versus resolving (if they are yellow/green/brown/gray and show histologic repair). The dates on which fractures
occur can be determined somewhat more specifically but should not be dated to the minute, hour, or even day. A
similar classification (acute or recent vs resolving) scheme may be used for abrasions. Again, one should not allow
oneself to be forced into testifying to a specific time of injury unless there is other evidence (eg, witness accounts,
video) that correlates with the autopsy findings; doing so could compromise one's entire testimony and stretch the
limits of scientific certainty.

Contributor Information and Disclosures

Author
Nicholas I Batalis, MD Assistant Professor of Pathology and Laboratory Medicine, Medical University of South
Carolina

Nicholas I Batalis, MD is a member of the following medical societies: American Academy of Forensic Sciences,
American Society for Clinical Pathology, College of American Pathologists, and National Association of Medical
Examiners
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Disclosure: Nothing to disclose.

Chief Editor
Stephen J Cina, MD, FCAP Associate Medical Director, University of Miami Tissue Bank

Stephen J Cina, MD, FCAP is a member of the following medical societies: American Academy of Forensic
Sciences, Arthur Purdy Stout Society, College of American Pathologists, Florida Association of Medical
Examiners, Florida Medical Association, and National Association of Medical Examiners

Disclosure: Nothing to disclose.

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Medscape Reference © 2011 WebMD, LLC

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