J Forensic Sci, 2016

doi: 10.1111/1556-4029.13128
PAPER Available online at: onlinelibrary.wiley.com

PHYSICAL ANTHROPOLOGY

Luısa Marinho1, M.Sc.; and Hugo F.V. Cardoso1, Ph.D.

Comparing Known and Reconstructed

Circumstances of Death Involving a Blunt
Force Trauma Mechanism through a
Retrospective Analysis of 21 Skeletonized
Individuals*

ABSTRACT: Little is known about to what extent the events surrounding death can be reliably reconstructed from blunt force trauma analy-
sis alone. In this study, we reconstruct circumstances of death from a blind blunt force trauma analysis using a sample of 21 individuals of
known death circumstances, obtained from two identified skeletal collections in Portugal. Fresh versus dry bone trauma and probable mecha-
nism of fracture production were identified. The overall pattern of injuries was then used to reconstruct the most likely circumstances of death.
Results show an agreement between the proposed and the reported circumstances for 13 individuals (68.4%), disagreement for 3 (15.8%), and
similarity in 3 cases (15.8%). Although the significant amount of agreement highlights the potential of trauma analysis, the cases with disagree-
ment draw attention to the pitfalls and shortcomings of attempting to reconstruct the death circumstances from skeletal trauma analysis alone.

KEYWORDS: forensic science, forensic anthropology, fractures, perimortem, falls, collisions, blows

In medicolegal death investigations, forensic anthropologists
often work with forensic pathologists to assist in the assessment of
the cause and manner of death from human remains in advanced
state of decomposition or skeletonized. Understanding the mecha-
nisms behind fracture production and typical expressions of
trauma patterns is paramount to reconstruct the events surrounding
death (1). The trauma mechanism is related to the force or combi-
nation of forces that produce skeletal alterations and may be
ascribed to three major classes, namely sharp force, blunt force,
and ballistic (high-velocity) trauma (2). A significant amount of
research has been dedicated to understanding the biomechanics of
sharp (e.g., [3–7]), gunshot (e.g., [8–12]), and blunt force trauma
(e.g., [13–17]). However, the highly variable nature of blunt force
trauma makes this type of injury mechanism probably the most
complex and difficult to interpret on the basis of skeletal character-
istics alone, and certainly one of the most challenging tasks for
forensic anthropologists to undertake (18). In addition, ascertain-
ing the circumstances leading to death of the individual, from the
analysis of blunt force trauma to the skeleton and without any fur-
ther contextual data, is not as straightforward as perhaps in cases
involving the other trauma mechanisms (19). Furthermore, the
1
Department of Archaeology and Centre for Forensic Research, Simon
Fraser University, Burnaby, B.C., V5A 1S6, Canada.
*Presented in part at the 83rd Annual Meeting of the American Associa-
tion of Physical Anthropology, April 9–12, 2014, in Calgary, Alberta,
Canada.
Received 14 May 2015; and in revised form 9 Dec. 2015; accepted 2 Jan.
2016.
ability of the forensic anthropologist to reconstruct the circum-
stances of death from blunt trauma analysis without any further
contextual data is still insufficiently explored.
A fair amount of research exists addressing issues related to the
determination of cause and manner of death from the well-
preserved cadaver, where information is integrated from clinical
data, the death scene investigation, and from the pattern of injuries
sustained to the soft tissues seen during autopsy (e.g., [20–26]).
However, the success of applying existing clinical and forensic
data to forensic anthropology case work, and the testing of
hypotheses related to the determination of circumstance and man-
ner of death in skeletonized human remains from blunt force
trauma analysis, has not been sufficiently addressed. To the best of
our knowledge, the exceptions have been the occasional case
report (e.g., [27–29]) or a few experimental studies (e.g., [30–33]).
The main purpose of this study was to evaluate whether the
circumstances of death can be reliably reconstructed and to what
extent, from the analysis of blunt force trauma evidence on a
sample of modern human skeletal remains of known violent
cause of death. Analysis of the individuals of known circum-
stances of death, from a known skeletal reference collection,
provided/offered the unique opportunity to assess the level of
agreement between the perimortem events re-created from
trauma analysis on one hand, and on the other, the medicolegal
information about the actual circumstances of death. This pro-
vides an important test of the applicability and reliability of
using the available clinical and forensic data used to interpret
blunt force trauma, to move from the reconstruction of the injury
mechanism to the reconstruction of the circumstance of death.

© 2016 American Academy of Forensic Sciences 1

2 JOURNAL OF FORENSIC SCIENCES
Materials and Methods
A total of 21 fairly complete human skeletons of known iden-
tity and known circumstances of death were analyzed. Twenty
individuals were selected from the identified skeletal reference
collection housed at the National Museum of Natural History
and Science (NMNHS), in Lisbon, Portugal (34), and one was
selected from the Collection of Identified Skeletons curated at
the Life Sciences Department, University of Coimbra (CEI-UC),
Portugal (35). These individuals were selected first on the basis
of having a reported or suspected violent cause of death and
then confirmed as having a blunt force trauma (BFT) mechanism
involved. Violent deaths due to other mechanisms, namely gun-
shot wounds, were not considered. As reported or suspected vio-
lent deaths require a forensic autopsy, information about cause
and manner of death for each individual was obtained from the
autopsy reports, which were traced back to the archives at the
National Institute of Legal Medicine and Forensic Sciences, in
the southern (Lisbon) and centre (Coimbra) delegations. In addi-
tion to cause and manner of death, available information about
the events leading to death was also collected from the autopsy
records that, in some cases, included newspaper clippings report-
ing the incident. Demographic information about each individual
(i.e., sex, age, and date of death) was obtained from the records
in each collection and used to confirm the identity of these indi-
viduals in the medicolegal archives. The single case from the
CEI-UC is a 21-year-old male and the remaining 20 cases
include 14 males and six females from the NMNHS collection.
The male subsample includes three children of eight, nine, and
10 years old. In the adult segment, ages range from 20 to 82
(mean = 58, SD  22) years in the female subsample, and from
27 to 63 (mean = 45, SD  11) years in the male subsample.
Reported and proposed circumstances of death were classified
according to an adaptation of the International Statistical Classi-
fication of Diseases and Related Health Problems – 10th Revi-
sion (ICD-10) of the World Health Organization (36), which
falls under section XX – “External causes of morbidity and mor-
tality”. This WHO classification does not discriminate between
the accidental or intentional nature of the event. In this study,
the circumstances of death were classified according to the fol-
lowing categories: (i) pedestrian injured in collision with unspec-
ified motor vehicle, (ii) pedestrian injured in collision with
railway train, (iii) pedal cyclist injured in collision with unspeci-
fied motor vehicle, (iv) car occupant injured in unspecified traf-
fic collision, (v) unspecified fall from standing or from low
height, (vi) unspecified fall from high height, (vii) unspecified
fall from height unknown, and (viii) contact with blunt object.
While the WHO ICD-10 distinguishes only two categories of
falls – unspecified fall on same level and unspecified fall from
one level to another –, in this study falls were classified into the
new categories v, vi, and vii described above. This adaptation,
which is specific to this study, added more detail and incorpo-
rated concerns from the forensic literature about the height of
the fall (37–39). A fall was classified as occurring from a stand-
ing height or from a low height if it occurred from a height not
substantially higher than the standing individual, regardless of
other factors affecting the fall. Here, this category only included
one case of a fall down a set of stairs. Other falls were consid-
ered to be from high height, as they were described as occurring
from a position that was substantially higher than the standing
height of the individual, namely from a bridge or a wall. A final
category included falls from height unknown if no specific cir-
cumstantial data were provided to classify height.
The skeletal remains of each individual were observed at a
macroscopic level, only with the aid of a low-magnifying glass
(109). The sample had been previously selected from the collec-
tions and no information about cause, manner, or circumstances
of death (nor its classification) was provided to the analyst,
except at the end of the study. The first author was the primary
analyst with the second author, an experienced and trained oste-
ologist/forensic anthropologist, supervising all the observations.
Individuals in the sample include only those cases with identifi-
able perimortem BFT to the skeleton, that is, those with clear
evidence of biomechanical fracture characteristics of fresh bone.
The presence of these characteristics was identified according to
published reference criteria (40–44). Trauma analysis was carried
out in each set of individual remains by (i) identifying the indi-
vidual bones fractured; (ii) identifying the type of fracture based
on the degree and pattern of breakage; (iii) identifying the proba-
ble point of impact for each fracture; (iv) classifying the forces
involved as of relatively higher or lower energy; and (v) identi-
fying a probable direction of loading.
Once a descriptive trauma analysis had been completed for
each case, a reconstruction of the most likely mechanisms of
fracture production and of the circumstances of death was under-
taken through a careful interpretation of the distribution and pat-
tern of injuries. Allocation of each individual in one of the eight
categories described above was carried out on the basis of a set
of criteria which identified the most typical or frequent expres-
sions of skeletal trauma associated with each of the categories,
obtained after an extensive review of the existing literature. In
other words, each individual was allocated in the most likely cat-
egory if the specific pattern of skeletal injuries had been identi-
fied as the most typical or frequent pattern of lesions for that
specific category, or shared most of the features of that category.
Yet, assigning individuals in these categories based on skeletal
trauma analysis is far from being straightforward as it is possible
to observe great variation in fracture patterns produced by the
same injury mechanism, as well as there are similarities on the
appearance of fractures resulting from different mechanisms.
Because of this variation, individuals could only have been allo-
cated to the most likely category. In some cases, two likely cate-
gories were selected based on a pattern of injuries that was
largely compatible with those two circumstances, but one could
not have been selected over the other. In reality, reconstructing
the circumstances of death was an exercise in diagnosing events
compatible with the individual pattern of skeletal injuries, where
a subjective opinion was generated with regard to one or two
most likely circumstances. As most, if not all, forensic anthro-
pologists will generate their opinions in a similar way, this study
provides not only a reliability test of the diagnosing tools uti-
lized here but also of the subjective nature of the final allocation.
The typical or most frequent type and pattern of skeletal injuries
found in each of the categories and used as classification criteria
are described below.
In pedestrians injured in collision with motor vehicle, the
majority of cases results in fractures of the lower limbs (45–47).
The specific location of the fracture depends on several factors
that include the height of the individual, as well as the height
and morphology of the vehicle (27,32,46). Concurrent tibia and
fibula fractures, which result either from direct or indirect forces
acting upon the lower leg, are a further indication that the inju-
ries resulted from a collision between a pedestrian and a motor-
ized vehicle (45,47). Individuals showing tibial fractures or
concurrent tibial and fibial fractures indicative of a single impact
at the level of the lower leg, with or without other injuries
 MARINHO AND CARDOSO . BLUNT FORCE TRAUMA IN 21 CASES OF KNOWN DEATH CIRCUMSTANCES 3

compatible with a motor vehicle collision, such as cranial frac- considered to be the result of a fall from a height not substan-
tures, were classified in that category of a pedestrian injured in tially higher than the standing individual.
collision with motor vehicle. In the case of children, diaphyseal Trauma to the neurocranium, thorax, pelvis, vertebrae, and
femur fractures were also used as criteria to identify a single lower extremity can result from both direct and indirect forces
impact compatible with a motor vehicle collision (45). acting upon bone, in cases of falls from high height. While some
In pedal cyclists injured in collision with a motor vehicle, the report trauma to the upper extremities to be less common (56–
resulting skeletal injuries are potentially identical to those sus- 58), the resulting pattern in falls from high height is seriously
tained by pedestrians (48). Lesions to the lower leg in this cate- dependent on the region of first impact, whether it is a fall land-
gory can result from the impact with the vehicle or with the ing feet- or headfirst, and whether there is any attempt by the
crank set (45,47,48), but the pattern of fractures can be indistin- victim to protect her/himself from the impact (55,59). Individuals
guishable. Moreover, the most common fatal injuries in cyclists showing evidence of high-energy impacts, such as comminuted
are those sustained to the head (48), but these too are common fractures of the cranium (head-first) or fractures of the thoracic/
in pedestrians hit by a motor vehicle. A distinguishing feature of
car collisions with pedal cyclists, which does not necessarily
translate into an identifiable fracture pattern, is the greater vari-
TABLE 1––Distribution of the reported and the proposed circumstances of
ability of the event as a result of the collisions occurring from death, by each category (adapted from the WHO ICD-10—see text for more
the back or from the front hitting the bicycle first, or laterally details).
directly hitting the cyclist (47,48). As no reliable distinguishing
skeletal features were identified, no individuals were proposed in Reported Proposed
this category. However, the cyclist category was preserved for Circumstance of Death Category (N) (N*)
comparative purposes. Unlike the pedestrian, the cyclist is effec- 1. Pedestrian injured in collision with motor vehicle 8 7
tively travelling on a vehicle potentially at greater speeds than 2. Pedestrian injured in collision with railway train 2 1
that of the pedestrian and can be hit by a motor vehicle indi- 3. Pedal cyclist injured in collision with motor vehicle 1 –
rectly, generating different types of forces. Because of the nature 4. Car occupant injured in traffic collision 1 3
5. Fall from standing or low height 1 4
of our sample, the fact that the skeletal injuries are not distin- 6. Fall from high height 4 8
guishable between these two categories may have been entirely 7. Fall from height unknown 2 –
incidental and not representative of actual differences found 8. Contact with blunt object 2 3
when looking at a multitude of cases. Total 21 26
In cases of pedestrians injured in collision with a railway *Includes seven cases for which two circumstances of death were pro-
train, a high number of body regions and single bones are likely posed and does not include two cases for which no circumstance was pro-
to be involved. Multiple trauma and comminuted fractures char- posed.
acteristic of direct impacts of relatively higher energy are fre-
quently observed (27,49). In these cases, the final pattern and
distribution of injuries are highly dependent on the position of TABLE 2––Results (number of cases followed by percentage in parentheses)
for agreement between the proposed and the reported circumstances of
the individual at the moment of first impact. Individuals showing death, by each category (adapted from the WHO ICD-10—see text for more
a high number of bones of different body regions with fractures details).
indicative of several simultaneous high-energy blunt impacts,
with different directions, were considered to be the result of a Agreement with the Proposed Circumstance
collision of a pedestrian with a railway train.
In cases of car occupants injured in unspecified traffic colli- Reported Yes
Circumstance of
sion, trauma to the cervical spine, namely to C1 and C2, is the Death Category Two Proposed One Proposed
most typical injury expression as a result of horizontal accelera- (N = 19*) Circumstances Circumstance No Similar
tion/deceleration forces acting on the body (27,50). Additional
1. Pedestrian 2 (10.5%) 4 (21%) 2 (10.5%) –
lesions, namely cranial and rib fractures, are also likely to occur, injured in collision
although dependent on secondary impacts and event-specific fea- with motor vehicle
tures. In individuals showing distinctive fractures to the cervical 2. Pedestrian injured – 1 (5.3%) – –
spine (for example, “hangman’s fracture”), with or without other in collision
with railway train
concomitant injuries, these were considered to be the result of a 3. Pedal cyclist – – – 1 (5.3%)
car occupant involved in a traffic collision. injured in collision
The pattern of injuries associated to falls is dependent on with motor vehicle
many factors and varies considerably as can be seen from the lit- 4. Car occupant – – – –
erature. Trauma to the cranium, specifically linear fractures, may injured in traffic
collision
be found in cases of falls from standing or low height, as well 5. Fall on same 1 (5.3%) – – –
as fractures to the hand or forearm depending, for example, on level or from
the state of consciousness previous to the fall and whether there low height
is any attempt to reach out the arms and halt the fall (51–53). 6. Fall from high 1 (5.3%) 3 (15.8%) – –
height
Additionally, indirect trauma to the cervical spine, specifically 7. Fall from height – – – 2 (10.5%)
below C4, is also common in these types of falls (54,55). How- unknown
ever, from the analysis of skeletal trauma alone, falls from stand- 8. Contact with 1 (5.3%) – 1 (5.3%) –
ing or from low height are virtually indistinguishable. In blunt object
individuals showing linear fractures of the base of the cranium Total 5 (26.3%) 8 (42.1%) 3 (15.8%) 3 (15.8%)
and fractures of the cervical spine with or without fractures to *Excludes the two cases for which no circumstance of death was
the forearm (for example, Colle’s fracture), these were proposed.
4 JOURNAL OF FORENSIC SCIENCES

lumbar vertebrae and of the lower limbs (feet-first), were consid-
ered to be the result of a fall from a high height.
In a circumstance involving direct contact with a blunt
object, namely in a situation of assault, traumatic lesions with
single or localized points of impact, especially in the neurocra-
nium and viscerocranium, are most likely to be observed (13).
Both location and type of fracture being produced are highly
dependent on the bone/body region being impacted on and also
on the dimensions and morphology of the impacting surface/ob-
ject (13). Individuals showing single cranial lesions with point
of impact on the frontal or parietal bones and without other rel-
evant injuries were considered to be involved in a situation of
contact with a blunt object. However, this classification will
only detect injuries sustained during an assault and not neces-
sarily those occurring accidentally and injuring other parts of
the body.
For each case, one or two most likely circumstances of death
were proposed by allocating each individual to one or two of the
eight categories. The known circumstances of death obtained
from the autopsy report were also allocated to one of the eight
categories. These were then compared, and the agreement
between the proposed and reported categories was coded as
“yes”, “no”, or “similar”. Agreement was coded as “yes”, if the
reported category matched the proposed category or one of the
two proposed categories. Agreement was coded as “no”, if the
reported category did not match the proposed category or any of
the proposed ones. Agreement was coded as “similar” when the
reported and proposed categories did not match, but the events
were considered to be similar. Specifically, a similarity was con-
sidered between pedal cyclists and pedestrians injured in colli-
sion with motor vehicle and between falls of a certain height
and falls of an unknown height. A disagreement between

FIG. 1––Skeletal diagrams summarizing the findings in category 1—pedestrian injured in collision with motor vehicle (N = 8). Body regions or individual
bones that sustained injuries are colored in grey and include the percentage of cases that contributed to the pattern. Probable points of direct impact are iden-
tified by dots. Location of fractures resulting from indirect trauma or of undetermined point of impact is identified by stars. Arrows identify the probable direc-
tions of force applied.
 MARINHO AND CARDOSO . BLUNT FORCE TRAUMA IN 21 CASES OF KNOWN DEATH CIRCUMSTANCES 5

proposed and actual circumstances of death does not mean that
the observed pattern of trauma was incompatible with the
actual circumstance, just that it was more typical of other
circumstances.
Results
Of the 21 individuals analyzed, one most likely circumstance
was proposed in 12 (n = 12/21, 57.1%) individuals, two likely
circumstances were suggested in 7 (n = 7/21, 33.3%) cases, and
for the other two (n = 2/21, 9.52%) individuals, no circum-
stances were proposed. These two individuals correspond to one
reported case of a car occupant injured in traffic collision and
the other to a pedestrian injured in collision with railway train.
Table 1 summarizes the distribution of both proposed and
reported circumstances of death.
The overall results for agreement between the proposed and
the reported circumstances show that, of 19 individuals
(excluding the two for which no circumstance was proposed),
agreement was found in 13 cases (n = 13/19, 68.4%), if at least
one of the proposed circumstances matched the reported one
(Table 2). Of these 13 cases, eight individuals (n = 8/19, 42.1%)
showed agreement between the single circumstance being pro-
posed and the reported circumstance of death (Table 2). There
was no agreement between the reported and the proposed cir-
cumstance for three individuals (n = 3/19, 15.8%), and for other
three cases (n = 3/19, 15.8%), the circumstances were consid-
ered to be similar (Table 2). The three cases coded as “similar”
correspond to one case of a pedal cyclist injured in collision
with motor vehicle while the death circumstance was proposed
as pedestrian injured in collision with motor vehicle, and the
other two individuals, whose deaths were proposed as being
associated to falls from high height, were reported as falls in
which the initial heights from which they occurred are unknown.
According to each of the categories for the reported circum-
stances, results show that the lower extremity was the most

FIG. 2––Skeletal diagrams summarizing the findings in category 2—pedestrian injured in collision with railway train (N = 2). Body regions or individual
bones that sustained injuries are colored in grey and include the percentage of cases that contributed to the pattern. Probable points of direct impact and loca-
tion of fractures of undetermined point of impact are identified by dots and stars, respectively. Arrows identify the probable directions of force applied.
6 JOURNAL OF FORENSIC SCIENCES
FIG. 3––Skeletal diagrams summarizing the findings in category 3—pedal
cyclist injured in collision with motor vehicle (N = 1). Body regions or indi-
vidual bones that sustained injuries are colored in grey. Probable points of
direct impact and location of fractures resulting from indirect trauma are
identified by dots and stars, respectively. Arrows identify the probable direc-
tions of force applied.
affected region in pedestrians injured in collision with motor
vehicle (n = 6/8, 75%), with the tibia (n = 5/8, 62.5%) and the
fibula (n = 4/8, 50%) being the two most frequently fractured
bones (Fig. 1). The only individual (n = 1/8, 12.5%) fracturing
the femur instead of any of the lower leg bones was a child (10-
year-old male). The other child included in this category was an
8-year-old male individual, who only sustained a middle diaph-
ysis tibial fracture. The next most affected regions in the group
of pedestrians injured in collision with motor vehicle were the
neurocranium and the ribs, both with a frequency of 37.5%
(n = 3/8). According to the classification criteria used in this
study, the proposed death circumstances of two individuals in
FIG. 4––Skeletal diagram summarizing the findings in category 4—car
occupant injured in traffic collision (N = 1). The body region that sustained
injuries is colored grey and a star identifies the location of fractures of
undetermined point of impact.
this category were incorrectly classified: one as a car occupant
injured in traffic collision/fall from low height, and the other as
contact with blunt object/fall from low height. The two cases
reported as pedestrians injured in collision with railway train had
in common trauma to the neurocranium, viscerocranium, ribs,
and fibula (Fig. 2). However, for only one individual, the cir-
cumstance of death was proposed in this category, and no cir-
cumstance of death was proposed for the other individual. The
only pedal cyclist injured in collision with motor vehicle sus-
tained fractures to the ribs, sacrum, hip bone, tibia, and fibula
(Fig. 3). This circumstance of death, however, was classified as
pedestrian injured in collision with motor vehicle. The single
case of a car occupant injured in traffic collision only showed
evidence of trauma to the ribs (Fig. 4). However, no circum-
stance of death was proposed for this individual. The only fall
from standing or low height, which was in fact a fall down the
stairs, presented fractures to the neurocranium and cervical spine
(Fig. 5). This case was proposed as either a car occupant injured
in traffic collision or a fall from standing or low height. The four
cases of falls from high height had fractures to the ribs as a
common finding (Fig. 6), and three of these individuals injured
 MARINHO AND CARDOSO . BLUNT FORCE TRAUMA IN 21 CASES OF KNOWN DEATH CIRCUMSTANCES
FIG. 5––Skeletal diagrams summarizing the findings in category 5—fall
from standing or low height (N = 1). Body regions that sustained injuries
are colored in grey. Probable points of direct impact and location of frac-
tures resulting from indirect trauma are identified by dots and stars, respec-
tively. Arrows identify the probable directions of force applied.
both the neurocranium and the viscerocranium (n = 3/4, 75%),
suggesting a head-first impact. The fourth individual in this cate-
gory sustained fractures to the pelvis and to the cervical, tho-
racic, and lumbar vertebrae. All cases in this category were
correctly classified. The two cases reported as falls from height
unknown were both suicidal jumpers, and both had injuries to
the ribs and sternum as a common feature (Fig. 7). The circum-
stances of death of both individuals were proposed as falls from
high height as, among other lesions, one sustained fractures to
the thoracic vertebrae and the other to the lower extremities. The
two cases of contact with blunt object had no mutual fractured
body region or bone (Fig. 8) and only one had the death circum-
stance proposed in this category.
7
Discussion
The reconstruction of the death circumstances from blunt force
trauma analysis in this sample was relatively successful, as a sig-
nificant number of the circumstances were correctly classified
when compared to the ones reported on the autopsy records.
Agreement between the proposed and the reported circumstance
of death was found in eight cases (n = 8/19, 42.1%) where the
only proposed circumstance matched the reported one, and in a
total of 13 individuals (n = 13/19, 68.4%) if at least one of the
two proposed circumstances was in agreement with the reported
circumstance of death. For three other cases, the circumstances
were considered to be similar (n = 3/19, 15.8%) and no agree-
ment was found for only three individuals (n = 3/19, 15.8%).
For two individuals, no circumstance of death was proposed
(n = 2/21, 9.52%). One of these cases was a 43-year-old individ-
ual, whose skeletal remains were reasonably complete (only
three cervical vertebrae, left clavicle, sternum’s body, and pubic
rami were absent), although poorly preserved, particularly the
ribs. The results from the trauma analysis undertaken were,
nonetheless, compatible with the autopsy findings: rib fractures
were the only skeletal injuries described in the autopsy report
and the reported cause of death was internal bleeding as a result
of traumatic lesions to the liver. Such injury was likely the result
of blunt force trauma, compatible with the reported circumstance
in which a car occupant was injured in a traffic collision. This
case is representative of the limitations when dealing with poorly
preserved remains and particularly with scarcity of injuries to the
skeleton that do not allow the identification of a distinct trauma
pattern. The other case with no circumstance of death being pro-
posed refers to a skeleton in a good state of preservation and
reasonably complete that presented massive skeletal injuries
associated with high-energy and high-velocity impacts, but with
comminuted fractures found only in the skull. Besides the cran-
iofacial trauma, multiple fractures were only found in the ribs, in
addition to single fractures in the right radius and fibula.
Although comminuted fractures of the skull are seen in falls
from a high height, in this case the lesions indicated multiple
impact directions. For this reason, neither a fall from a high
height nor any other category was proposed as the death circum-
stance of this individual, which was reported as a pedestrian
injured in collision with a railway train. This case differs sub-
stantially from the other one in the same category, specifically in
the extension of the traumatic lesions. In the case of the pedes-
trian injured in collision with a railway train which was correctly
identified, the injuries included multiple fractures of the skull
and ribs, fractures of both humeri, femora and fibulae, pelvis,
and right tibia (Fig. 9). These two examples of pedestrians
injured in collision with a railway train highlight the influence
of specific factors associated with the event, such as the position
of the individual at the moment of first impact, which have a
major influence on the overall trauma pattern produced, namely
on the number of regions of the body involved. These factors
weighted considerably on the interpretation of the trauma relying
solely on the analysis of the skeletal remains.
There was no agreement between the proposed and the
reported circumstances in only three cases. Although classified
as having no agreement, it is important to emphasize that the
findings are not incompatible with the events that lead to death
of these three individuals, but instead they were more typical of
other circumstances. While fairly complete and reasonably pre-
served, the skeletal remains of these three individuals only dis-
played a limited amount of unspecific injuries, which hindered
8 JOURNAL OF FORENSIC SCIENCES

the understanding of the event. The first case was a reported
case of contact with blunt object (see below). The other two
were reported as pedestrians injured in collision with a motor
vehicle, but these two individuals showed no extensive injuries,
namely to the lower extremities, as would be common and dis-
tinctive for this type of circumstance (45). In one of these cases,
lesions were restricted to the cervical spine and the circumstance
of death was proposed as car occupant injured in traffic colli-
sion/fall from low height. In the other case, the autopsy report
describes the event as a collision with a larger vehicle (a truck),
which possibly involved a higher point of impact not affecting
the lower extremities. Circumstances of death in this case were
proposed as contact with blunt object/fall from standing or low
height, as suggested by a tripod fracture.
The aforementioned cases of pedestrians injured in collisions
with a motor vehicle comprise two of eight total cases reported
under this category, with the remaining six cases being correctly
classified. In two of these, a second alternative circumstance of
death was proposed, and for both, the possibility of a fall from a
high height was considered. These are two juvenile individuals
whose skeletons were poorly preserved, incomplete, and showed
a relatively unspecific pattern of trauma. The only observable
lesion was a transverse fracture to the mid diaphysis of the right
tibia in one of the cases, and a transverse fracture to the mid dia-
physis of the left femur plus a linear fracture on the right side of
the occipital in the other case (Fig. 10). The preservation of the
remains and the few and unspecific injuries prevented a more
substantiated interpretation of the event. Thus, two possible sce-
narios were proposed, including the real one which was corrobo-
rated as being a pedestrian injured in collision with motor
vehicle.
In the remaining four individuals reported as pedestrians
injured in collision with a motor vehicle, the single proposed cir-
cumstance of death matched the reported one and they all
showed involvement of the lower extremities (Fig. 1). Injuries to
the lower extremities, particularly the lower legs (Fig. 11), in

FIG. 6––Skeletal diagrams summarizing the findings in category 6—fall from high height (N = 4). Body regions or individual bones that sustained injuries
are colored in grey and include the percentage of cases that contributed to the pattern. Probable points of direct impact are identified by dots. Location of
fractures resulting from indirect trauma or of undetermined point of impact is identified by stars. Arrows identify the probable directions of force applied.
 MARINHO AND CARDOSO . BLUNT FORCE TRAUMA IN 21 CASES OF KNOWN DEATH CIRCUMSTANCES 9

vehicle–pedestrian accidents constitute a recognized pattern in
the literature (32,46). Three of eight reported cases of pedestri-
ans injured in collision with motor vehicle exhibited neurocra-
nium and ribs injuries (Fig. 1), which are likely related to
secondary impacts, whether to the vehicle or the ground, after
the individual is projected (47).
There were three cases classified as “similar”. One of these
was the reported case of a pedal cyclist injured in collision with
a motor vehicle, while the death circumstance was proposed as
pedestrian injured in collision with motor vehicle. In this case, a
fracture of the lateral mass of the left ala of the sacrum, an
acetabular t-shaped fracture, and the separation of the pubic
symphysis on the left hip bone were identified (Fig. 12).
Although multiple trauma to the pelvic “anatomical complex” is
difficult to interpret, the pattern observed is commonly associ-
ated with a high load and sudden lateral impact, likely through
the left great trochanter, with the energy being transferred
through the acetabulum, pubic symphysis, and sacroiliac joint
(60). On the lower left leg, both bones were also injured as a
result of indirect forces (Fig. 12). Overall, the pattern of lesions
seemed compatible with a vehicle–pedestrian accident, with the
primary impact site being located at the level of the great tro-
chanter, and therefore possibly involving a vehicle of larger
dimensions (e.g., bus, truck, van).
The other two individuals classified as “similar” refer to two
cases reported as fatalities in a fall from height unknown, albeit
in both death circumstances were reconstructed as falls from a
high height. While the circumstances of death for these two indi-
viduals were not detailed in the autopsy reports, both had the
manner of death declared as suicidal. The distribution of lesions
(cervical spine, thorax, and upper extremity in one case, and tho-
rax, pelvis, and lower extremity in the other case), associated
with a pattern of trauma suggestive of relatively high-energy
impacts (e.g., transverse fractures of the sterna, oblique fractures

FIG. 7––Skeletal diagrams summarizing the findings in category 7—fall from height unknown (N = 2). Body regions or individual bones that sustained inju-
ries are colored in grey and include the percentage of cases that contributed to the pattern. Probable points of direct impact and location of fractures resulting
from indirect trauma are identified by dots and stars, respectively. Arrows identify the probable directions of force applied.
10 JOURNAL OF FORENSIC SCIENCES
FIG. 8––Skeletal diagrams summarizing the findings in category 8—con-
tact with blunt object (N = 2). Body regions that sustained injuries are col-
ored in grey and include the percentage of cases that contributed to the
pattern. Probable points of direct impact and location of fractures resulting
from indirect trauma are identified by dots and stars, respectively. Arrows
identify the probable directions of force applied.
of the first two ribs, transverse acetabular fractures), contributed
to the interpretation of these as being the result of falls from a
high height. Interestingly, neither of these cases showed injuries
to the cranium, similarly to the other suicide case where a fall
from high height was involved (see below). Although the associ-
ation of manner of death with injury pattern in fall-related deaths
is not thoroughly explored in the literature, Abel and Ramsey
(61) reported a higher frequency of fractures to the cranium in
accidental falls, compared to suicidal jumpers.
The four cases reported as falls from high height were in
agreement with the proposed circumstances of death. Injuries to
the ribs were seen in all of the four individuals (Fig. 4), whereas
fractures to the neurocranium and viscerocranium were seen in
three of these individuals (n = 3/4, 75%). Although these inju-
ries are described as a common feature in fall-related trauma, its
presence and pattern can vary with the height of the fall and
other factors (55,56,59). Only one individual did not show
trauma to the neurocranium nor viscerocranium, and this case
refers to the only case of a fall from a high height reported as a
suicide, with the other cases being accidental falls. Among the
four reported falls from a high height, for one individual, contact
with a blunt object was also proposed as an alternative. These
were the remains of a juvenile individual with massive cranial
injuries where the pattern of fractures observed, involving almost
all cranial bones, suggested a violent impact on the lateral-anterior
right frontal bone, left-posteriorly directed. The frontal bone pre-
sented several linear fractures with loss of bone fragments, most
certainly corresponding to the impact site (Fig. 13). Although
the location of the fractures is more frequent in blows to the
head, the right side lateralization is more common in falls
(62,63). Thus, the distinction between the different causes of
craniofacial injuries was not clear, with the following two
hypotheses being considered: i) a blow of high energy with a
large blunt object to the head and ii) a fall from high height
landing primarily on the frontal.
The only case reported as a fall from low height was the case
of one female adult individual whose death was reported as
resulting from a fall down the stairs, at her residence. The skele-
tal trauma observed was limited to the neurocranium and cervi-
cal spine. A linear fracture running from the frontal to the right
sphenoid and temporal bones was most likely produced by a
direct impact to the right side of the frontal bone (right to left
and anterior-posteriorly directed). An additional injury was
observed in the axis, which exhibited a transverse fracture of the
odontoid and body of C2 (Fig. 14). Both sudden hyperflexion
and hyperextension may result in odontoid injuries, and these
are common both in car occupants injured in traffic collisions
and in falls from standing or low height (50). In this case, and
considering the lack of other injuries, both circumstances were
proposed as possible scenarios.
Only two individuals had the reported circumstance of death
being associated with contact with blunt object. In one, injuries
were restricted to four cervical vertebrae (Fig. 15) and the first
thoracic vertebra (left pedicle oblique fracture). These lesions are
commonly caused by hyperextension induced to the cervical
spine, forcing posterior arches against each other (13). While this
injury mechanism is a common finding in car occupants injured
in traffic collisions (50) as proposed, the reported event was in
fact a workplace accident, in which a metal plate struck the indi-
vidual. This represented one of the three cases of disagreement.
Again, the nonspecificity of injuries affecting the skeletal system
draws attention to the limitations of the anthropological analysis,
with no further contextual information. The other case of contact
with blunt object was the single case from the CEI-UC and the
only one with the manner of death reported as a homicide.
Lesions were limited to a linear fracture affecting the left parietal
and sphenoid bones, and to a few ribs also on the left side.
Besides the hypothesis of contact with a blunt object, a fall from
standing or low height was also considered as a possibility. The
skeletal trauma findings in this individual are illustrative of the
limitations that still exist in determining whether the observed
craniofacial trauma is associated with a fall or a blow to the
head. One of the most often used criteria to distinguish a fall- or
blow-related cranial fracture is the hat brim line (HBL) rule
 MARINHO AND CARDOSO . BLUNT FORCE TRAUMA IN 21 CASES OF KNOWN DEATH CIRCUMSTANCES 11

FIG. 9––Blunt force trauma findings in a case where the circumstance of death was reported as a pedestrian injured in collision with railway train: (A) mul-
tiple linear and probable diastatic fractures of the neurocranium (frontal and both parietal bones are visible); (B) butterfly fracture on the proximal diaphyseal
third of the right humerus (suggesting a high energy force applied posteriorly and anteriorly directed); (C) vertical body fracture slightly left to the midline of
the mandible (suggesting this to be the point of a direct impact posteriorly directed); (D) oblique fracture of the proximal shaft of the right tibia (likely the
result of high-intensity direct impact).

FIG. 11––Blunt force trauma findings in a case where the circumstance of

death was reported as a pedestrian injured in collision with a motor vehicle:
butterfly fracture on the middle diaphysis of the right tibia (suggesting a
direct impact at this level and anterior-posteriorly directed), and a trans-
verse fracture of the right fibula slightly below the level of the tibial fracture
(likely the result of indirect trauma linked to the event which produced the
tibial lesion).

FIG. 10––Blunt force trauma findings in a case where the circumstance of
death was reported as a child injured in collision with a motor vehicle: (A)
linear and diastatic fractures on the right side of the occipital bone, with the
fracture line crossing vertically from the right lambdoid suture to the right
occipital condyle; (B) transverse fracture of the left femur, at the level of
mid diaphysis (direction of the direct impact was not determined).
(51,62,63). Yet, this was not helpful as the point of impact in
this individual was on the left sphenoparietal suture and, accord-
ing to Kremer et al. (64), fractures’ location in the HBL is of lit-
tle use as a diagnostic criterion. Although fractures resulting
from falls are mostly concentrated in this line, fractures from
blows are also frequently found both in the HBL and above it. It
is worth mentioning, although, the problem of indiscriminate use
of the HBL rule as stressed by Fracasso et al. (65), who empha-
sizes that this rule cannot be applied to some circumstances such
as kneeing or sitting position before fall, fall from height or
downstairs falls, falls with irregular floor, or falls with intermedi-
ate obstacles.
In this study, reconstructions of the circumstance of death
relied exclusively on the analysis of skeletal material and
included a thorough assessment of the distribution and type of
fractures involved. This was followed by determining the proba-
ble location and number of impacts, and an interpretation of the
direction of forces and relative energy involved contributed to
generate an overall pattern of injuries and their likely
12 JOURNAL OF FORENSIC SCIENCES

FIG. 12––Blunt force trauma findings in a case where the circumstance of death was reported as a pedal cyclist injured in collision with motor vehicle:
(A) acetabular t-shaped fracture and pubis symphysis separation on the left hip bone; (B) lateral mass fracture of the left ala of the sacrum; (C) fracture of the
anterior tibial eminence (by avulsion of the anterior cruciate ligament) and an incomplete wedge fracture of the medial condyle of the left tibia (superior view
of the tibial plateau; anterior is up); (D) horizontal fracture through the base of the left medial malleolus (often associated with indirect trauma).

FIG. 13––Blunt force trauma findings in a case where the circumstance of
death was reported as a child falling from a high height: multiple linear and
diastatic fractures are found throughout the cranium with involvement of the
frontal, left, and right temporal, sphenoid, left and right maxilla, left pala-
tine, occipital, and ethmoid, with the frontal bone most certainly correspond-
ing to the impact site.
mechanisms. Links between specific injuries and events were
established and the most likely causes were proposed. The loca-
tion and frequency of fractures described in each of the cate-
gories used and discussed in this study are not meant to provide
diagnostic criteria, but instead are illustrative of the patterns of
trauma associated with specific circumstances observed in this
FIG. 14––Blunt force trauma findings in the only case involving a fall
down the stairs: transverse fracture of the odontoid and C2 body, which can
result both from sudden hyperflexion and hyperextension of the cervical
spine.
sample. A classification system based on a set of validated crite-
ria is highly desirable to improve the ability of the forensic
anthropologist in distinguishing the different circumstances of
death from the analysis of skeletal trauma. Although it is essen-
tial to recognize the variability of fracture patterns, which can be
consistent with more than one mechanism of injury, results also
suggest that there is considerable potential in identifying these
mechanisms from the analysis of skeletal trauma alone. In an
 MARINHO AND CARDOSO . BLUNT FORCE TRAUMA IN 21 CASES OF KNOWN DEATH CIRCUMSTANCES
FIG. 15––Blunt force trauma findings in a case where the circumstance of death was reported as contact with a blunt object: bilateral posterior arch frac-
tures of C1 and C2 and bilateral laminar fracture of two other lower cervical vertebrae (commonly caused by hyperextension induced to the cervical spine).
actual case, this should be complemented with crucial contextual
information obtained from the examination of the death scene.
Although the identification of perimortem fractures per se was
not the focus of this research, the potential role of taphonomic
factors in concealing essential information is worth highlighting,
by affecting the preservation of the skeleton and by complicating
the interpretation of perimortem features in a fracture (40–44).
Other important limitations of interpreting skeletal trauma
include the possibility of a violent death leaving no evidence on
the skeleton, thus preventing any attempt to reconstruct the
events causing death from skeletal trauma analysis alone. Cases
with no identifiable perimortem trauma will likely be undiag-
nosed as to the circumstances of death, unless information from
the death scene can elucidate the expert. In this study, the small
number of cases in each category of the circumstances of death
prevented further detailed analyses of the patterns of injury, as
more cases could have expanded our knowledge of the similari-
ties, patterns, or trends in skeletal trauma between different cir-
cumstances. Regardless of the limitation, this sample is of
unique value as with archaeological material, there is usually lit-
tle room for corroboration of the proposed hypotheses and with
other similar contemporary identified osteological collections,
there is often little or no opportunity to examine the skeletal
remains of individuals with known circumstances of death. An
important recent exception is the work by Cappella et al. (66),
but also the increasing use of CT scans in a medicolegal setting
(e.g., [67–69]). This imaging technology may provide the critical
data source needed to thoroughly document and subsequently
validate the trends in the location, type, and frequency of frac-
ture patterns produced by different events and classified in dif-
ferent categories. The use of specific categories of death
circumstances and clearly identifying their distinguishing features
have been largely unexplored in forensic anthropology. This is
13
crucial to test whether circumstances of death can be reliably
reconstructed and a first tentative undertaking of the task has
been offered here. In addition, this study presents an advantage
over retrospective studies based on autopsy reports’ findings as
these sometimes lack detailed description of some types, exact
location, and characteristics of fractures; plus, the evaluation of
some fractures might be unintentionally omitted during the
autopsy procedure and become, therefore, underreported (55,66).
Finally, because each of the cases analyzed in this study repli-
cates the conditions under which forensic anthropologists would
be examining remains during an actual forensic case, that is,
incomplete skeletonized remains in various degrees of conserva-
tion and affected by taphonomical factors, this study can be con-
sidered a realistic illustration of the potential and limitations of
skeletal trauma analysis to the reconstruction of the circum-
stances of death.
Acknowledgments
The authors would like to thank Dr. Ana Luısa Santos for
invaluable support and incentive during this study. At the South-
ern Delegation of the National Institute of Legal Medicine and
Forensic Sciences, I.P., in Lisbon (Portugal), the authors would
like to thank Dr. Jorge Costa Santos for providing access to the
autopsy reports and Manuela Marques for the invaluable assis-
tance with the recovery of the autopsy records from the library
archives.
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Additional information and reprint requests:
Luısa Marinho, M.Sc.
Department of Archaeology and Centre for Forensic Research
Simon Fraser University
8888 University Drive
Burnaby, BC V5A 1S6
Canada
E-mail: lmarinho@sfu.ca