Review Article

Medicine, Science and the Law

0(0) 1–8
A forensic evaluation of ! The Author(s) 2018
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DOI: 10.1177/0025802418755588
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Roger W Byard1,2

Abstract
Impalement injuries transfix a victim in an inescapable or helpless position. A study was undertaken at Forensic Science
SA from 2002 to 2016 of all impalement deaths. There were six vehicle accidents (M:F¼5:1; age 14–67 years, average age
38.5 years) involving impalements with a tree branch (n¼2; groin and chest), a metal pipe (n¼2; leg and head), a metal
bridge railing (groin) and a metal fence post (chest). Two cases (both males, aged 47 and 18 years) had slipped on fences/
gates, with impalements of the ankle and groin. A case of suicide (male, aged 80 years) was impaled through the head on
a bolt fixed to the floor. A homicide case (male, aged 27 years) involved impalement through the chest by a spear from a
spear gun. In certain cases (e.g. with anogenital injuries), differentiating accidental from inflicted impalement injuries may
be difficult. In equivocal cases, adequate scene evaluations with photographic documentation are required prior to
autopsy, ideally with the object available for examination.

Keywords
Impalement, vehicle crash, industrial, sexual, autoerotic, child abuse

Introduction
Deaths due to impalement are rarely encountered in
most medico-legal practices. To determine the range
of injuries and situations that may result in lethal or
near-lethal impalement, the literature was reviewed.
Although most reported cases have been associated
with survival after surgical correction, they have been
included in this review, as most were potentially lethal,
and they also serve to demonstrate the range of injuries
that may be encountered. In addition, a search of the
files at Forensic Science SA (FSSA), Adelaide,
Australia, over a 15-year period was also conducted
for specific cases where deaths had been attributed to
impalement.
Definitions
One of the difficulties that arises with diagnosing
impalement deaths is in trying to determine to what
exactly ‘impalement’ refers. For example, a number
of definitions consider that to impale is merely to
pierce with something pointed.1 This of course would
include very superficial knife or needle wounds which
are certainly not usually considered impalements in
forensic settings. Others use terminology that better
fits with historical records and contemporary practice
by requiring that a sharp object transfixes the victim,2
that is, to impale is to ‘fix in an inescapable or helpless
position’.1 This would be in keeping with the earliest
records of impalement which described the torture of
captives by skewering their bodies on pointed stakes
(Figure 1).3,4
Thus, although it can be said that ‘impalement is the
penetration of an organism by an object such as a
stake, pole, spear or hook, by complete perforation
of the central body mass’,5 transfixion and immobilisa-
tion are also important components. Clinical defini-
tions have ranged from transfixing a body cavity or
extremity by a rigid object of variable size,6 to having
a foreign body penetrate and embed in a body part
with the object still remaining in the wound,7 to
being suspended by the impaling object.8 Although
some definitions specify that impalement must only
involve the torso, well-documented cases have been
1
Forensic Science SA, Australia
2
School of Medicine, The University of Adelaide, Australia
Corresponding author:
Roger W. Byard, Discipline of Anatomy and Pathology, Level 3, Medical
School North Building, The University of Adelaide, Frome Road,
Adelaide, 5005, SA, Australia.
Email: roger.byard@sa.gov.au
2 Medicine, Science and the Law 0(0)

Figures 2 and 3), a tree branch in the right inguinal

region (driver in car), a metal bridge railing in the left
inguinal region (rollover, driver ejected onto bridge)
and a metal fence post in the right upper chest (driver
in car). The pedestrian was impaled through the head
by a metal bar from a truck, and the motorcycle rider
lost control and was launched into a tree, impaling the
left side of his chest on a branch.
The two cases where decedents had slipped on
fences/gates involved inverted suspension with postural
asphyxia in a 47-year-old man who was suspended
upside down by his right ankle that had been impaled
by a sharpened fence post, and impalement of the left
groin in an 18-year-old man on gate finials with death

Figure 1. A 16th century French engraving depicting death by

impalement.

described where splintered wood has impaled the neck

(e.g. traversing the pharynx in a motorcycle rider,9 or
where objects have impaled the face and head. With all
of these definitions, gunshot and shrapnel wounds
would be classified as penetrating and not impaling
trauma.10

Materials and methods

Figure 2. Impalement through the right leg and into the upper
A search was conducted of autopsy files at FSSA, left thigh by a metal bar.
Adelaide, Australia, between 2002 and 2016 for all
cases where death had been attributed to some form
of impalement injury. Impalement had to be either the
cause of or a major contributor to death.

Results
Ten cases were identified involving six vehicle acci-
dents, two falls on fences, one suicide and one
homicide.
The six vehicle accident cases were between 14 and
67 years of age (average age ¼ 38.5 years). In four
cases, the decedent was the driver of a vehicle, one
was a pedestrian and one was the rider of a motorcycle.
Deaths were due to multiple injuries in three cases,
chest impalement in two cases and head impalement
in one case. Impalements involved a metal pipe from Figure 3. An X-ray of the case shown in Figure 2,
an oncoming truck in the right leg (driver in car; demonstrating the depth of penetration into the left thigh.
Byard 3

from exsanguination (details of these two cases have

been previously published11).
The case of suicide was that of an 80-year-old man
who placed his head on a bolt inserted into a concrete
floor and then dropped a weight onto his head, result-
ing in impalement with death from craniocerebral
trauma (details of this case have also been previously
published12).
The homicide case involved a 27-year-old man who
was impaled through the left side of his chest by a spear
fired from a spear gun which had passed from the left
side of his chest (Figure 4) through his diaphragm,
colon, pancreas, aorta, liver and right lung, embedding
in the intercostal muscles of the right chest wall
(Figure 5).
A case of a 29-year-old man who died of accidental
hanging during autoerotic activity was excluded from
the present study. Although he had a broom handle
inserted into his anus which had perforated his
rectum, the lack of any significant haemorrhage pre-
cluded its involvement in the lethal episode.

Discussion
The majority of impalement injuries in civilian practice
result from vehicle crashes or accidents at construction
sites. Three general categories have been proposed to
include those associated with (1) vehicle collisions, (2)
sexually motivated activities in the anogenital region
and (3) falls.13 An alternate classification proposes
type 1 injuries where a body impacts with a stationary
object, such as a fall at a building site or ejection from
a vehicle, and type 2 when a moving object penetrates a
stationary body, when, for example, an object intrudes
into a vehicle cabin.14 Both of these types were present
in the current series. The resultant injuries may
have elements of both blunt and sharp force trauma
with considerable tissue destruction as well as organ
penetration.6
Figure 4. The shaft of a spear protruding from the left lower
chest wall (arrow).
Figure 5. The spear shaft in Figure 4 grooved the under surface
of the spleen (a) (arrow) and then penetrated the colon,
pancreas, aorta, liver, diaphragm and right lung before the tip
embedded in the intercostal muscles of the right chest wall (b)
(arrow).
Survival has been documented after quite major
impalement injuries. An important part of treatment
at the scene is not to remove the penetrating object,
as this may result in catastrophic haemorrhage.
This was documented by Bill in 1862 when he noted
that arrows should be left in situ, as they tended to
tamponade vascular injuries by plugging wounds.15,16
For this reason, it is standard medical practice to cut
off excessive lengths of the intruding object to facilitate
transfer to hospital in those who have survived the
event, while leaving the impacted part in situ.6
Another of the problems with impalement by large
foreign objects is that they may carry fragments of
clothing, organic material and soil into the depths of
wounds (Figure 6), thus exacerbating the risk of serious
infection from contaminated material in survivors.13,17
With lethal cases, the penetrating object has often
been removed from the body, and so assessment of
the nature of the injury at autopsy relies upon a clear
4 Medicine, Science and the Law 0(0)
Figure 6. Impalement of the thigh by a metal bar, showing a
considerable amount of clothing and foreign material that had
been carried through the wound by the object.
Figure 7. Although there was no impaling object present at
autopsy, scene photographs clearly show the impacted vehicle
against a tree with broken lower branches, one of which had
impaled the driver’s chest.
description of the scene, ideally with photographic
documentation and examination of the object
(Figure 7).
Vehicle related
Vehicle crashes may cause impalements from a wide
range of objects and mechanisms, as can be seen
from the five cases in this study. External objects that
have impaled occupants of vehicles have included metal
guard rails, wooden fences, tree branches and metal
reinforcing rods (rebar).6,14,18–20 Objects intrinsic to
the vehicle have included a windshield wiper, rear
view mirror, steering wheel lock and gear sticks.21–24
Passengers, drivers, pedestrians, motorcycle riders
and cyclists may all be impaled during accidents.
Very rarely, high-impact crashes may be associated
with self-impalement when a fragment of long bone
that has been dislodged penetrates other parts of the
body. An example occurred in a 32-year-old motorcy-
clist who had his chest wall and lung impaled by a
fragment of broken humeral shaft.25 Fractured rib
ends may cause cardiac lacerations,26,27 although this
is more a case of fracture displacement than impaling,
as it may also may occur with cardiopulmonary
resuscitation.28
Improper restraints can lead to impact with objects
inside a vehicle. This occurred with a 15-month-old girl
who accelerated forward from her unrestrained posi-
tion in a car seat into a bag of knitting supplies, sus-
taining an impalement injury to her right chest from a
large knitting needle.10 Impalement may also occur
with airplane crashes, as was demonstrated by an ultra-
light pilot who sustained, and survived, a through and
through chest wound from the tail boom of his craft
after it had stalled and crashed.29
Industrial
One of the most well-known and earliest documented
industrial impalements was that of Phineas Gage, a 25-
year-old railway foreman who had a 3 cm diameter
iron bar blown through his left frontal lobe when
explosives that he was tamping into a hole prematurely
detonated.30 Falls from platforms or ladders at con-
struction/work sites are a more common occurrence,
resulting in death or serious injuries, often from
impalement on metal concrete reinforcing rods or
steel bars.31–33 If a piece of work equipment such as a
screwdriver has been landed on during a fall, it is pos-
sible that this may have been tidied up by co-workers
who may not recognise the significance of the object for
determining the cause of a penetrating injury.34
Sexual
Anogenital impalements may be genuinely accidental
in cases of falls from heights or from adolescent horse-
play.35 Accidental impalements may also occur in cases
of autoerotic activity, such as the case of a male who
died following a fall onto a chair leg that he had
inserted into his anus.19 Injuries from inserted rectal
foreign bodies may range from lethal lacerations of
the rectum due to a shoe horn,36 to survivable lacera-
tions of the mesentery, stomach, diaphragm and peri-
cardium from a broom handle.37 Transvaginal
impalements may occur during consensual sexual activ-
ity and result not only in injuries to the vagina with
significant haemorrhage, but also to the rectum,
Byard
bladder, mesentery and omentum.38,39 Homicides with
impalement may also have a sexual focus.
Homicides
Sexual attacks have included cases with impalements to
the perineum utilising objects such as sharp sticks or
billiard cues that have caused lethal or potentially
lethal abdominal and thoracic injuries.40,41 Insertion
of a segment of metal pipe into the rectum which
passed through the intestine and lodged in the right
kidney in a 21-year-old man caused death in combina-
tion with ligature strangulation.42 Objects such as
broom or mop handles may be forcefully inserted
into victims’ rectums; such a case involved a 39-year-
old man who survived injuries to his rectum, dome of
the bladder, mesentery, liver and right lung.41
Other types of assaults resulting in impalements
involve a wide range of weapons including spears and
arrows, as was demonstrated in a case from the FSSA
files of the 27-year-old male who was shot through the
chest with a spear gun. Spears and arrows are, howev-
er, very rare weapons of assault in Western countries,
being found more often in traditional tribal communi-
ties.43 When they are utilised, mechanisms may involve
incised/stab wounds from the sharpened spear/arrow-
heads, rather than deep impalement.7,44 On occasion,
an object such as a curtain rod may be thrown as a
spear and cause lethal head impalement.45
Sharp garden implements such as rakes have been
embedded in victim’s faces.46 A blunt object being used
to beat a victim may also then be used to impale him or
her if it breaks during the assault. Such was the case of
an assault with a golf club which broke, resulting in the
shaft being used to impale the face and neck.47
Suicides
Suicides do not often involve impalement unless this
has occurred inadvertently following a jump from a
height. However, even when present, impalement may
be unrelated to the lethal mechanism. An example of
this was a 51-year-old man found hanging in a psychi-
atric facility. Although a broom handle that he had
inserted into his rectum prior to death had passed
into the peritoneal cavity, the absence of significant
haemorrhage or organ damage excluded this as a con-
tributor to the lethal episode.48 A similar case involved
a 29-year-old man who was excluded from the present
study who died of accidental hanging during autoerotic
activity. He also had a broom handle which had perfo-
rated his rectum, but that was not associated with any
significant haemorrhage.
Rarely suicides may involve firing crossbow bolts
into the head,49 or more elaborate construction of a
5
device to impale the head under a weight. The latter
reflects a high degree of premeditation.12 Whether sui-
cidal insertion of a chopstick into the bladder through
the penis represents impalement or penetration with
perforation is arguable.50
Non-industrial accidents
Impalement injuries may also occur in individuals who
may have jumped from a height such as from a burning
building, or fallen from a building, and landed on
objects such as tree branches.17 This is not only an
issue for humans, as there is a ‘high rise’ syndrome
used to describe injuries sustained by animals who
fall or jump from a height of two stories or more.
Three cats have been reported with impalement injuries
to the chest and abdomen following falls onto spiked
metal railings.51 Impalements may occur during sport
if a competitor is hit by a javelin, or in an individual
who has jumped over tubular metal crossbars.52
Skateboarding at speed may also be associated with
scroto-abdominal impalement.53
Other situations where impalements may occur are
in slipping while crossing over gates or fences, both
potential causes of vascular, bladder or organ inju-
ries.54–56 Falls onto stakes holding up potted plants
and onto broken chairs or chair legs have also resulted
in craniofacial and abdominal impalements.57,58
Miscellaneous
Impalement may be a feature of animal attacks. For
example, the typical goring injury inflicted by large
horned animals such as water buffalo and bulls may
involve transfixion of the limbs, inguinal and perineal
regions, often with damage to the femoral vessels.59 In
aquatic environments, needlefish are long slender fish
with elongated pointed jaws that have caused severe
penetrating injuries of the limbs, head and neck, abdo-
men and chest, which have been rarely associated with
death.60 Puncturing of the chest by a stingray spine
may be lethal. However, it is more of a penetrating
than an impaling injury, although spines may reach
up to 37 cm in length.61,62
An unusual case of chronic impalement with a knit-
ting needle has been reported in a 72-year-old woman
who had used the needle 33 years earlier to induce
an abortion. The 18 cm long metal needle had
migrated to cause a thoracoabdominal transdiaphrag-
matic fistula.63
Issues with children
Children are at a higher risk of certain types of impale-
ment injuries that are not usually found in adults.
Specifically, impalement of the soft palate and
6 Medicine, Science and the Law 0(0)
oropharynx are injuries that result from children falling
while holding objects in their mouths.64 Toddlers are at
highest risk, and common objects include pens/pencils,
musical instruments, toys, sticks, kitchen utensils,
chopsticks and toothbrushes.65,66
While complete recovery is usual from oropharyn-
geal impalement injuries, occasional cases will develop
potentially lethal complications which include retro-
pharyngeal abscess, facial cellulitis, mediastinitis and
pneumomediastinum.65,67 Airway obstruction and sig-
nificant neurological sequelae such as stroke secondary
to injury of the carotid artery with subsequent throm-
bosis may also occur.68–70
Anogenital and perineal impalement trauma in chil-
dren may be accidental or inflicted. Accidental injuries
most often occur when a child is trying to jump over, or
on to, an object such as a billiard cue or a bathroom
plunger.71 Differentiating these events from cases of
trauma due to sexual abuse may be difficult and
requires appropriate police and medical investiga-
tion.72,73 Particular situations that lend themselves to
accidental trauma include climbing in and out of a bath
with slippery surfaces and lack of protective clothing,
and falling in a bedroom while jumping from one bed
to another.74
A rare case of accidental impalement through the
anterior fontanelle by a metal lampshade strut with
lethal cerebral injury has been described.74 Another
unusual although non-lethal impalement involved a
ratchet from an ironing board in the buttock of a
12-year-old child who had tripped and fallen down-
stairs with it.75
Conclusion
Lethal impalement injuries are not common in forensic
practice. However, they may occur from a wide variety
of different mechanisms and affect all areas of the
body. The manner of death may be accidental, suicidal
or homicidal, and age-related variations in the types of
injuries are found. Definitions of what constitutes an
impalement injury are not uniform.
Declaration of conflicting interests
The author declared no potential conflicts of interest with
respect to the research, authorship and/or publication of
this article.
Funding
The author received no financial support for the research,
authorship and/or publication of this article.
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