Legal Medicine 67 (2024) 102388

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Legal Medicine
journal homepage: www.elsevier.com/locate/legalmed

Differentiating suicide from homicide in sharp-force fatalities with stab

and/or incised wounds: A scoping review
Zainab Fathi AlGheryafi, Fatima Foud Alnasser, Fatima Hussain Almukhtar,
Fatema Abdullatef Aldajani, Fatimah Hussain Al Qassim, Zainab Mohammed Al Zakaria,
Shoq Obeid Alshammari, Ritesh G. Menezes *
College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

A R T I C L E I N F O A B S T R A C T

Keywords: The majority of sharp-force fatalities with stab and/or incised wounds are homicides. However, suicidal sharp-
Sharp-force injury force fatalities with stab and/or incised wounds are also reported. Thus, distinguishing suicidal stab and/or
Light sharp-edged weapon incised wounds from homicidal stab and/or incised wounds is significant from the forensic perspective. This
Manner of death
scoping review primarily summarizes the existing research findings on the differentiation of suicide from ho­
Autopsy
Forensic pathology
micide in sharp-force fatalities with stab and/or incised wounds. The literature was systematically searched on
February 28, 2023, using the PubMed database. A search string formed by a combination of keywords related to
suicide, homicide, and stab and incised wounds yielded 23 records. After applying the eligibility criteria, six
records/studies met the inclusion criteria and were included in the present scoping review. Results showed that
the predictive strength of various parameters, either individually or collectively, in diagnosing the manner of
sharp-force fatality as suicide or homicide is not always hundred percent accurate. Some of the important pre­
dictors of the homicidal manner of death in sharp-force fatalities include clothing damage, presence of defense
injuries, presence of injuries caused by another type of violence other than sharp-force, vertically oriented chest
stabs, and sharp-force injuries in the head and back anatomical sites. Some of the important predictors of the
suicidal manner of death in sharp-force fatalities include the presence of tentative injuries, sharp-force injuries to
the wrist, and the presence of a suicide note.

1. Introduction
Fatalities from sharp-force injuries are commonly caused by stab,
incised, or chop wounds. Stab and incised wounds result from light
sharp-edged weapons. The manner of death in sharp-force fatalities is
often homicidal [1]. However, suicidal sharp-force fatalities are also
reported.
Suicidal stabbing is relatively uncommon when compared to homi­
cidal stabbing. For instance, an autopsy study from the United Kingdom
reported that the number of homicidal stabbings was nearly 8 times
more than suicidal stabbings [2]. Suicide by stabbing is a less common
method of committing suicide when compared to other methods of
committing suicide. For instance, an autopsy study from Saudi Arabia
reported that less than 5% of suicides were caused by stab wounds [3].
On the other hand, a significant proportion of homicides are caused by
stabs. For instance, in Canada, over 25% of homicides were caused by
stabbing [4]. Suicidal incised wounds also form a small proportion of all
the suicides [3]. Comparatively, homicidal incised wounds are more
common than suicidal incised wounds [5]. The profile of injuries in
sharp-force fatalities may include only stab wounds or incised wounds,
or a combination of both stab and incised wounds as both can be caused
by the same light sharp-edged weapon.
Differentiating a suicide from a homicide is a central issue in forensic
pathology practice. Considering sharp-force fatalities with stab and/or
incised wounds, distinguishing suicidal wounds from homicidal wounds
is significant from the forensic perspective. The differentiating process
remains challenging to forensic pathologists as it is complicated with a
weighty proportion of uncertainty, which makes performing a careful
evaluation of all the components of a given case a must to distinguish a
suicide from a homicide. Therefore, we undertook this scoping review

* Corresponding author at: Forensic Medicine Division, Department of Pathology, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman
Bin Faisal University, Dammam 34212, Saudi Arabia.
E-mail addresses: mangalore971@yahoo.co.in, rgmenezes@iau.edu.sa (R.G. Menezes).

https://doi.org/10.1016/j.legalmed.2023.102388
Received 30 September 2023; Received in revised form 25 December 2023; Accepted 28 December 2023
Available online 28 December 2023
1344-6223/© 2023 Elsevier B.V. All rights reserved.
Z.F. AlGheryafi et al.
primarily to summarize the existing research findings on the differen­
tiation of suicide from homicide in sharp-force fatalities with stab and/
or incised wounds. Besides, an attempt is made to identify gaps in
research and recommend future directions.
2. Methods
The methodology for this scoping review included a systematic
search to identify and screen relevant records/studies/articles for in­
clusion (Fig. 1) [6]. PubMed was the database considered for the liter­
ature search. The search was performed on February 28, 2023. A
combination of keywords related to suicide, homicide, and sharp-force
injury (stab/incised wound) was used to identify relevant studies/re­
cords (Table 1). The following final string of keywords was applied:
(“suicide”[Title] OR “suicidal”[Title] OR “self harm”[Title] OR “self”[­
Title] OR “self injury”[Title]) AND (“homicide”[Title] OR “homi­
cidal”[Title] OR “kill”[Title] OR “murder”[Title]) AND (“stab
wound”[Title] OR “stab injury”[Title] OR “stab injuries”[Title] OR
“stabbing”[Title] OR “incised wound”[Title] OR “incised injur­
ies”[Title] OR “cut”[Title] OR “sharp wound”[Title] OR “sharp injur­
y”[Title] OR “sharp injuries”[Title] OR “knife”[Title] OR “thrust”[Title]
Fig. 1. Flow diagram depicting the identification and screening of records for inclusion (adapted from: http://prisma-statement.org/prismastatement/flowdiagram.
aspx).
2
Legal Medicine 67 (2024) 102388
OR “sharp weapon”[Title] OR “scalpel”[Title] OR “sharp force”[Title]).
The search identified 23 records linked to the aim of the present scoping
review about the characteristics differentiating suicide from homicide in
sharp-force fatalities with stab and/or incised wounds.
All the identified records were screened according to the inclusion
and exclusion criteria (Table 2). Initially, the title and abstract of the
identified records were screened by two researchers (the first two au­
thors) independently. The year of publication was not considered as a
criterion for selection of records. Only records published in English were
considered for selection. Records published in other languages, irre­
spective of the availability of the translated version of the abstract, were
excluded. Accordingly, 3 records published in German [7–9], 1 in Polish
[10], and 1 in French [11] were excluded.
Following the initial screening, 18 records were sought for retrieval
of the full-text. The full-text of the retrieved records were assessed for
eligibility by two researchers (the first two authors) after being trained
to do so by a senior researcher (the last author). Any disagreements
between the two researchers were resolved in consultation with the
senior researcher. Records that reported non-fatal cases of attempted
suicide or attempted homicide by sharp-force were excluded [12]. Case
reports that presented either a suicidal sharp-force fatality or homicidal
Z.F. AlGheryafi et al. Legal Medicine 67 (2024) 102388

Table 1
Database search strategy.
Suicide-related keywords Homicide-related keywords Sharp-force injury-related keywords Final search string of keywords

(“suicide”[Title] OR (“homicide”[Title] OR (“stab wound”[Title] OR “stab injury”[Title] OR (“suicide”[Title] OR “suicidal”[Title] OR “self

“suicidal”[Title] OR “self
harm”[Title] OR “self”[Title]
OR “self injury”[Title])
“homicidal”[Title] OR “stab injuries”[Title] OR “stabbing”[Title] OR
“kill”[Title] OR “incised wound”[Title] OR “incised
“murder”[Title]) injuries”[Title] OR “cut”[Title] OR “sharp
wound”[Title] OR “sharp injury”[Title] OR “sharp
injuries”[Title] OR “knife”[Title] OR
“thrust”[Title] OR “sharp weapon”[Title] OR
“scalpel”[Title] OR “sharp force”[Title])
harm”[Title] OR “self”[Title] OR “self injury”[Title])
AND (“homicide”[Title] OR “homicidal”[Title] OR
“kill”[Title] OR “murder”[Title]) AND (“stab
wound”[Title] OR “stab injury”[Title] OR “stab
injuries”[Title] OR “stabbing”[Title] OR “incised
wound”[Title] OR “incised injuries”[Title] OR
“cut”[Title] OR “sharp wound”[Title] OR “sharp
injury”[Title] OR “sharp injuries”[Title] OR
“knife”[Title] OR “thrust”[Title] OR “sharp
weapon”[Title] OR “scalpel”[Title] OR “sharp
force”[Title])

Table 2
Inclusion and exclusion criteria.
Inclusion criteria
• Any publication date
• English language
• Article type: Research articles
• Study method: Postmortem examination/autopsy-based research [with or without
other relevant data (example: crime scene investigation data, criminological data,
etc.)]
• Subject outcome: Fatal
• Manner of injuries: Suicidal and homicidal injuries
• Subject cohorts: Both victims of suicide and homicide
• Type of sharp-force injuries: Stab and/or incised wounds
• Stab wound: Stabs caused by light sharp-edged weapons
Exclusion criteria
• Non-English language
• Article type: Reviews, case reports, case series
• Study method: Research based on crime scene investigation or criminological data,
but without postmortem examination/autopsy data
• Subject outcome: Non-fatal (attempted suicide, attempted homicide)
• Manner of injuries: Accidental and uncertain manner
• Subject cohorts: Individual cohorts of victims of suicide or homicide
• Type of sharp-force injuries: Chop wounds
• Stab wound: Stabbing caused from penetration of the body by a blunt weapon
(example: iron rod, etc.)
sharp-force fatality with discussion on differentiation of a suicide from a
homicide were excluded [13–17]. Similarly, case series were excluded
[18,19]. All types of review articles without any primary data reported
were excluded [20]. Records that included cases of accidental or un­
certain manner of injuries by sharp-force in addition to cases of suicidal
sharp-force injuries and homicidal sharp-force injuries were excluded
[21]. Records that included cases of chop wounds in the profile of sharp-
force injuries while differentiating suicides from homicides were
excluded because the profile of the weapons causing chop wounds dif­
fers from the weapons causing stab and/or incised wounds in being
heavy versus light [22]. Records that included cases of dyadic deaths
due to sharp-force injuries were excluded [23]. Non-autopsy-based
studies (without any data on postmortem examination findings) on
sharp-force injuries were originally meant to be excluded. However, no
such study was identified.
3. Results and discussion
The narrative structure of the ‘results and discussion’ section is as
follows: the first paragraph under each sub-section is related to the
‘results’ aspect and the second paragraph under each sub-section is
related to the ‘discussion’ aspect.
3.1. Profile of the included articles
criteria and were included in the present scoping review [24–29]. The
demographic profile and salient features of included articles are pre­
sented in Table 3 and Table 4, respectively.
Another related critical review published in the year 2015 [20]
included diverse articles like reports that published separate data on
suicides and homicides, reports on attempted suicides or attempted
homicides, reports on individual cases, and reports published in non-
English languages with the availability of the abstract in English, un­
like the present scoping review. Besides, the literature search strategy
adopted by De-Giorgio et al. [20] differed from the present scoping
review.
3.2. Victim
3.2.1. Personal data
Both gender and age are considered noteworthy demographic data in
terms of the manner of death. The majority of the studies showed a
recognizable male predominance in both suicides and homicides. Ter­
ranova et al. [24] reported that 85% of suicide victims and 58% of ho­
micide victims were male subjects. Similarly, Brunel et al. [25] reported
that 83% of suicide victims and 67% of homicide victims were male
subjects. Karlsson [29] reported a male/female ratio of 3.6:1 and 3.2:1
in the suicide group and homicide group, respectively. Although Scolan
et al. [27] echoed a similar proportion of male victims (82%) in the
suicide group, the proportion of male victims in the homicide group was
49%. A higher age of suicide victims when compared to homicide vic­
tims was found in most studies. In the cohort analyzed by Terranova
et al. [24], the median (interquartile range) age in years for the suicide
victims and homicide victims was 45 (37.75–54.5) and 43.5 (35.25–53),
respectively. Brunel et al. [25] reported a mean age of 48.2 years for
suicide victims and 40.2 years for homicide victims. Similarly, Scolan
et al. [27] reported a significantly higher mean age of suicide victims
(52.8 years) than that of homicide victims (38.9 years). Karlsson [29]
reported the mean age separately for male subjects and female subjects
in each category of the manner of death. Significant differences in ages
were found both between male suicide (mean, 51.5 years) and homicide
victims (mean, 37.1 years) and between female suicide (mean, 46.0
years) and homicide victims (33.8 years) [29]. However, demographic
data on the gender and age of the suicide and homicide victims was not
categorically reported by Racette et al. [26].
In a related critical review by De-Giorgio et al. [20], the calculated
male/female ratio was 3.45:1 in the suicide group. However, the
calculated male/female ratio was 0.32:1 in the homicide group (female:
male = 3.13:1) [20]. This proportion of males and females in the ho­
micide group is in contrast to the findings reported in the studies
included in the present scoping review. The calculated mean age was
46.23 years and 39.11 years in the suicidal and homicidal sharp-force
fatalities, respectively [20], similar to the higher age of suicide vic­
tims reported in the studies included in the present scoping review.

After applying the eligibility criteria, six studies met the inclusion

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Z.F. AlGheryafi et al. Legal Medicine 67 (2024) 102388

Table 3
Demographic profile of articles that met the inclusion criteria.
Reference Year of Authors Journal name Study location Years of data included in the
publication study

[24] 2020 Claudio Journal of Forensic Sciences Institute of Legal Medicine 1997–2019 (23-year period)
Terranova, et al. of the University of Padua, Italy

Department of Legal
Medicine in the Health Unit of Venice, Italy
[25] 2010 Christophe Forensic Science International Department of Forensic Medicine and Pathology at 1986–2008 (23-year period)
Brunel, et al. the Raymond Poincare Hospital, Garches, France
[26] 2008 Stephanie Forensic Science Medicine and Quebec Province, Canada 5-year period*
Racette, et al. Pathology
[27] 2004 V. Scolan, et al. American Journal of Forensic Toulouse Region, France 10-year period*
Medicine and Pathology
[28] 1998 Thore Karlsson Forensic Science International Department of Forensic Medicine in Stockholm, 1983–1992 (10-year period) &
Sweden 1993-1995 (3-year period)
[29] 1998 Thore Karlsson Forensic Science International Department of Forensic Medicine in Stockholm, 1983–1992 (10-year period)
Sweden

*Specific years – not mentioned.

3.2.2. Psychiatric history
The presence of a history of a clinical psychiatric diagnosis raises the
suspicion of suicide. Terranova et al. [24] reported that 70% of the
suicide victims had a history of clinical psychiatric diagnosis, and 50%
of them were on treatment with pharmacological therapy. Karlsson [29]
reported a history of suicidal ideation and previous suicide attempts in
53% and 27% of the suicide victims, respectively. However, Brunel et al.
[25], Racette et al. [26], and Scolan et al. [27] did not report on the
psychopathology of the victims.
In a related critical review by De-Giorgio et al. [20], a psychiatric
history of previous suicidal attempts was positive in 20.38% of suicide
victims and absent in 79.62% of suicide victims where the related in­
formation was available. Moreover, a history of clinical psychiatric
diagnosis was present in 49.31% of the suicide victims and absent in
50.69% of the suicide victims where the related information was
available [20]. Depression followed by schizophrenia were the two most
common clinical psychiatric diagnoses reported [20].
3.2.3. Suicide notes
The presence of a suicide note may indicate the victim’s motive in
cases of suicide. Terranova et al. [24] reported that 50% of the suicide
victims had written a suicide note explaining the reasons to commit
suicide. Karlsson [29] reported that 18% of the suicide victims had left a
written suicide note. However, Brunel et al. [25], Racette et al. [26], and
Scolan et al. [27] did not report the presence or absence of suicide notes
in cases of suicide.
When present, a suicide note indicates suicide. Nevertheless, it
should be noted that a false suicide note may be planted by the murderer
to simulate suicide. In a related critical review, De-Giorgio et al. [20] did
not analyze suicide notes. Not all suicide victims leave behind a suicide
note [30,31]. The presence of a suicide note is a predictor of the manner
of death being a suicide. However, the absence of a suicide note does not
exclude suicide as the manner of death.
3.3. Scene of death
Scene of death investigation is important in determining the manner
of death [32]. Examination of the scene of death provides possible
predictors of suicides and homicides. Such predictors include the pres­
ence of a suicide note, the site of recovery of the weapon, and the site of
blood traces. The presence of an evidentiary suicide note at the scene of
death in cases of suicide is discussed under section 3.2.3. Here, the site of
recovery of the weapon and blood traces are reported and discussed.
3.3.1. The weapon
Terranova et al. [24] reported that the weapon was found in all
suicides and 83.3% of homicides. The weapon was recovered near or
inside the body in 85% and 56.6% of suicides and homicides, respec­
tively [24]. A kitchen knife was the most commonly used light sharp-
edged weapon in both suicides (70%) and homicides (80%) [24].
Karlsson [29] reported that kitchen knives (33.33%) and razor blades
(30.48%) were the most frequently used light sharp-edged weapons in
suicides. In homicides, kitchen knives were used in 38.51% of the cases,
and razor blades were not used even in a single case [29]. The use of
weapon-type knives (e.g., stiletto, dagger, bayonet) was significantly
higher in homicides than suicides [29]. However, Brunel et al. [25],
Racette et al. [26], and Scolan et al. [27] did not report the site of re­
covery of the weapon.
In a related critical review, De-Giorgio et al. [20] did not report
findings related to the site of recovery of the weapon. The recovery of
the light sharp-edged weapon beside the victim’s body may indicate a
suicide, but not necessarily always because the murder weapon may be
left behind near the victim’s body by the murderer to simulate suicide
[33]. On the other hand, the absence of the weapon from the scene of
death may indicate a homicide [34]. In suicides, household sharp-edged
objects like the kitchen knife are commonly used. In homicides, the
murder weapon may vary from kitchen knives to weapon-type knives.
3.3.2. Blood traces
Terranova et al. [24] reported that traces of blood far away from the
body were found in only 10% of suicides. However, traces of blood far
away from the body were found in nearly half (47%) of the cases of
homicide [24]. Blood on the victim’s palms was found in 70% and
63.3% of suicides and homicides, respectively [24]. However, Brunel
et al. [25], Racette et al. [26], Scolan et al. [27], and Karlsson [29] did
not report on the scene of death investigation findings related to
evidentiary traces of blood.
In a related critical review, De-Giorgio et al. [20] did not report
scene-of-death examination findings related to evidentiary blood traces.
The absence of distant blood traces may indicate a suicide, but not
necessarily always. Pelletti et al. [13] reported an unusual case of sui­
cidal stabbing disguised by the victim as a homicide by alteration of the
scene of death during the last minutes of life. Distant evidentiary traces
of blood were recovered in this case of self-stabbing [13].
3.4. Necroscopic findings
Forensic autopsy plays a key role in the determination of the manner
of death [35]. Forensic autopsy findings include the findings of the ex­
amination of the clothes, examination of the body, and autopsy ancillary
investigations [36]. In this section, damage to victim’s clothing, wound
characteristics, associated injuries, and postmortem toxicological

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Z.F. AlGheryafi et al. Legal Medicine 67 (2024) 102388

Table 4
Salient features of the studies that met the inclusion criteria.
Reference -Type of study Overall cases included in the study Study objective Take home message
-Documents
reviewed

Terranova -Retrospective 51 cases of sharp-force fatalities (20 suicides To identify relevant parameters to -In most cases of suicidal and homicidal sharp-force
et al., 2020 study and 31 homicides) distinguish between suicidal and fatalities, differentiation is achievable through an
- Autopsy and homicidal sharp-force fatalities integrated evaluation of postmortem external
[24] allied reports* examination and death scene investigation findings.
-This differentiation is not possible in all cases.
-Examination of victim’s clothes for damage is of
paramount importance in differentiating suicidal and
homicidal sharp-force fatalities
Brunel et al., -Retrospective 118 cases of sharp-force fatalities (48 To identify reliable parameters to -Differentiation of suicidal and homicidal sharp-force
2010 study suicides and 70 homicides) differentiate suicidal and homicidal fatalities is achievable through an integrated
-Autopsy reports sharp-force fatalities evaluation of autopsy findings and death scene
[25] investigation findings.
-This differentiation is not possible in all cases.
-Hesitation injuries are common in suicidal sharp-
force fatalities.
-Defense injuries are common in homicidal sharp-
force fatalities.
Racette et al., -Retrospective 207 cases of sharp-force fatalities (58 To compare features of hesitation - Differentiation of suicidal and homicidal sharp-
2008 study suicides and 149 homicides) injuries and defense injuries in force fatalities is achievable through an evaluation of
-Autopsy and suicidal and homicidal sharp-force hesitation injuries and defense injuries.
[26] allied reports* fatalities -Hesitation injuries are more commonly found on the
anterior aspect of upper limbs.
-Defense injuries are found on the anterior aspect as
much as the posterior aspect of upper limbs.
-Hesitation injuries are often grouped.
-Defense injuries are often dispersed on upper limbs.
-A smaller number of defense injuries are linked to a
higher blood alcohol concentration in the victim.
Scolan et al., -Retrospective 70 cases of stabbings (17 suicides and 53 To identify variables that enable to -In stabbings, the presence of several wounds, the
2004 study homicides) meaningfully differentiate suicidal victim’s clothing damage, and vertically oriented
-Autopsy and and homicidal stabbing fatalities chest wounds are suggestive of homicide.
[27] allied reports*

Karlsson, -Retrospective − 279 cases of sharp-force fatalities (105 To develop models for -The models developed cannot replace a forensic
1998 study suicides and 174 homicides) – MODEL SET discrimination between suicidal and pathologist but may be used as an aiding tool by the
-Autopsy and created by multivariate projective statistical homicidal sharp-force fatalities forensic pathologist.
[28] allied reports* methods and logistic regression analysis -Predictors of homicidal manner of death in sharp-
− 67 cases of sharp-force fatalities (27 force fatalities: clothing damage, blood alcohol level,
suicides and 40 homicides) – TEST SET presence of defense injuries, presence of injuries
validation caused by another type of violence other than sharp-
force, vertically oriented chest stabs, upper extremity
sharp-force injuries (except wrist and front of the
elbow), head and back sharp-force injuries
-Predictors of suicidal manner of death in sharp-force
fatalities: presence of tentative injuries, history of
suicidal ideation, wrist sharp-force injuries, presence
of suicide note, sharp-force injuries to the front of the
elbow
Karlsson, -Retrospective 279 cases of sharp-force fatalities (105 To identify variables of importance -In sharp-force fatalities, a higher number of wounds
1998 study suicides and 174 homicides) in the differentiation between in the head and lower extremities, and a higher
-Autopsy and suicidal and homicidal sharp-force number of vertical chest stab wounds are suggestive
[29] allied reports* fatalities of homicide.

*
Allied reports – example: police investigation reports, autopsy ancillary investigation reports (e.g. toxicology reports), etc.

analysis findings are reported and discussed. Besides, a section on
postmortem radiology is included.
3.4.1. Clothing
Terranova et al. [24] reported that the presence of clothing damage
(injuries to clothing) caused by the light sharp-edged weapon was
directly associated with homicide. Clothing damage was present in 20%
and 71% of the suicides and homicides, respectively [24]. Scolan et al.
[27] reported significantly more frequent clothing damage (presence of
slashes) in homicides. The absence of clothing or raised clothing in the
region of the stabs indicates suicide [27]. Karlsson [29] reported a sig­
nificant difference in the proportion of clothing damage wherein injuries
to clothing in association with wounds were present in 5% of suicides
and 79% of homicides. However, clothing description was not reported
by Brunel et al. [25] and Racette et al. [26].
Victim’s clothing may play a crucial role in differentiating suicides
from homicides. In a related critical review by De-Giorgio et al. [20],
clothing damage was absent in 76.55% of suicides and present in
23.45% of suicides where the information on clothing was available. In
cases where this information was available, the corresponding pro­
portions for homicides were 25.91% and 74.09%, respectively [20].
3.4.2. Wound characteristics
3.4.2.1. Type of wounds. Brunel et al. [25] reported that incised wounds
occurred preferentially in suicides (39.6% of suicides versus 8.6% of

5
Z.F. AlGheryafi et al.
homicides). The presence of both stab and incised wounds occurred
preferentially in homicides (35.7% of homicides versus 16.7% of sui­
cides) [25]. The presence of injuries caused by blunt impact in associ­
ation with sharp-force injuries was seen only in homicides (7.1% of
homicides versus 0% of suicides) [25]. Stab wounds alone were found in
43.8% and 48.6% of suicides and homicides, respectively [25]. The
presence of associated fall-related injuries was not a significant param­
eter in differentiating suicides and homicides [25]. Karlsson [29] re­
ported the presence of other types of injuries (blunt-impact injuries,
firearm injuries, or contusions from attempted strangulation) in 28% of
homicides. Injuries caused by another type of violence were reported in
7% of suicides [29]. In the study by Scolan et al. [27], it was found that
the presence of other types of injuries in association with stab wounds
did not provide significant prediction of the manner of death. Terranova
et al. [24] and Racette et al. [26] did not report on the predominance of a
type of injury (stab wounds only, incised wounds only, both stab and
incised wounds, or both blunt-impact injuries and sharp-force injuries)
by the manner of death (suicide or homicide).
In a related critical review, De-Giorgio et al. [20] did not report the
association of types of injuries by the manner of death. Oshima and
Kondo [19] did not find injuries caused by other types of violence in the
8 cases of sharp-force fatalities reported by them.
3.4.2.2. Number of wounds. In the study by Terranova et al. [24], the
median (interquartile range) values of the total number of wounds
(excluding hesitation injuries in suicides and defense injuries in homi­
cides) were 3 (1–5.25) and 7 (2.5–15) in suicides and homicides,
respectively. Brunel et al. [25] reported that the total number of wounds
was not a significant predictive parameter in classifying the manner of
death as suicide or homicide. The mean (±S.D.) of the number of
wounds was 8.6 (±18.8) and 11.5 (±14.7) in suicides and homicides,
respectively, with a wide range of overlap between suicides and homi­
cides [25]. Besides, the quantification of wounds (number of wounds ≤
3 versus number of wounds > 3) did not provide a significant prediction
of the manner of death [25]. However, Scolan et al. [27] reported that
the total number of wounds differed significantly between suicides and
homicides, with the mean (±S.D.) values of 2.5 (±0.48) and 11 (±1.75)
in suicides and homicides, respectively. Karlsson [29] reported a sig­
nificant difference in the total number of wounds between suicides and
homicides when vertical chest stab wounds were compared. The corre­
sponding mean values were 0.09 (±0.37) and 0.70 (±1.39) for suicides
and homicides, respectively [29]. However, the difference in the total
number of horizontal chest stab wounds between suicides and homicides
was insignificant [29]. Racette et al. [26] did not report on the predic­
tive value of the total number of wounds in classifying the manner of
death as suicide or homicide.
In a related critical review, De-Giorgio et al. [20] reported the mean
of the number of injuries to be 2.4 and 3.8 in suicides and homicides,
respectively. The corresponding S.D. was not provided [20]. Occasion­
ally, cases with a large number of stab wounds are reported in suicidal
stabbings. Rautji et al. [37] reported a case of suicidal stabbing with 15
cavity-deep stab wounds to the chest.
3.4.2.3. Anatomical sites of wounds. In the study by Terranova et al.
[24], the common anatomical sites of suicidal wounds included the
anterior aspects of the neck, abdomen, and left side of the chest. The
most common anatomical sites of homicidal wounds included the
anterior aspect of the neck, the anterior aspect of the left side of the
chest, the back, and the anterior aspect of the abdomen [24]. The head
was the anatomical site of wounds in homicides but did not feature in
suicides [24]. Brunel et al. [25] reported that the distribution of wounds
by anatomical sites was a significant predictive parameter in classifying
the manner of death as suicide or homicide. A higher likelihood of sui­
cidal manner of death was predicted if wounds were located in
anatomical regions constituting the anterior aspects of the neck, chest,
6
Legal Medicine 67 (2024) 102388
abdomen, and forearms to the exclusion of other anatomical regions
[25]. A higher likelihood of homicidal manner of death was predicted if
wounds were located in anatomical regions constituting the head, nape
of the neck, limbs, and hands to the exclusion of other anatomical re­
gions [25]. In the study by Karlsson [29], a significant difference was
noted in suicides and homicides when the head, anterior aspect of the
abdomen, and lower extremities were the anatomical sites of wounds.
The head was the anatomical site of wounds in 1.90% and 27.01% of
suicides and homicides, respectively [29]. The abdomen was the
anatomical site of wounds in 9.52% and 26.44% of suicides and homi­
cides, respectively [29]. The lower extremities were the anatomical site
of wounds in 2.86% and 18.97% of suicides and homicides, respectively
[29]. Suicidal wounds were not found in the region of the back and
genitals [29]. In the study by Scolan et al. [27], it was found that the
anatomical site of wounds did not provide a significant prediction of the
manner of death. Racette et al. [26] did not report on the predictive
value of the anatomical site of wounds in classifying the manner of death
as suicide or homicide.
The anatomical site of wounds is a strong predictive parameter of the
manner of death (suicide or homicide), according to some studies. In a
related critical review by De-Giorgio et al. [20], chest (36.2%), upper
limbs (24.4%), and abdomen (18.3%) were identified as the top three
anatomical sites of suicidal wounds when the related information was
available. The chest (54.1%), lower limbs (16.1%), and abdomen
(13.3%) were identified as the top three anatomical sites of homicidal
wounds when the related information was available [20]. The lower
limbs were the anatomical sites of wounds in only 0.8% of suicides [20].
The back was the anatomical site of wounds in 0% and 1.4% of suicides
and homicides, respectively [20]. The head was the anatomical site of
wounds in 3.1% and 5.7% of suicides and homicides, respectively [20].
The neck was the anatomical site in 17.2% and 9.3% of suicides and
homicides, respectively [20].
3.4.2.4. Orientation of wounds. Brunel et al. [25] reported that the
longitudinal axis of stab wounds situated at the anterior aspect of the
trunk (chest and abdomen) was a significant predictive parameter in
classifying the manner of death as suicide or homicide. A higher likeli­
hood of homicidal manner of death was predicted when the axis of stab
wounds was vertical [25]. In the study by Scolan et al. [27], a significant
difference in the presence of vertical chest stab wounds in suicides and
homicides was reported. Vertical chest stab wounds were not found in
suicides, whereas such wounds were frequent in homicides [27].
Karlsson [29] reported a significant difference in the number of vertical
chest stab wounds in suicides and homicides. However, the difference in
the number of horizontal chest stab wounds in suicides and homicides
was insignificant [29]. Terranova et al. [24] and Racette et al. [26] did
not report on the predictive value of the axis of stab wounds in differ­
entiating a suicide from a homicide.
In a related critical review, De-Giorgio et al. [20] did not report re­
sults related to the orientation of wounds. However, De-Giorgio et al.
went on to discuss the importance of the axis of wounds in differenti­
ating the manner of death as suicide or homicide [20]. It is assumed that
the horizontal orientation of wounds is more common in suicidal sharp-
force fatalities than in homicidal sharp-force fatalities [20].
3.4.2.5. Bone or cartilage wounds. Brunel et al. [25] reported that the
presence of bone or cartilage wounds was a significant predictive
parameter in classifying the manner of death. A higher likelihood of
homicidal manner of death was predicted when bone or cartilage
wounds were found [25]. A higher likelihood of suicidal manner of
death was predicted when bone or cartilage wounds were absent [25].
Karlsson [29] reported a more common incidence of rib and sternal
wounds in homicides in comparison to suicides. Terranova et al. [24],
Racette et al. [26], and Scolan et al. [27] did not report bone or cartilage
wounds in differentiating a suicide from a homicide.
Z.F. AlGheryafi et al.
In a related critical review, De-Giorgio et al. [20] did not report re­
sults on bone or cartilage wounds in distinguishing a suicide from a
homicide. It is assumed that suicidal victims of sharp-force injuries tend
to avoid wounding solid anatomical structures like bones [38].
3.4.2.6. Injury severity score. Brunel et al. [25] reported that the injury
severity score (ISS) was a significant predictive parameter in classifying
the manner of death as suicide or homicide. A higher likelihood of ho­
micidal manner of death was predicted with increasing ISS [25].
Conversely, a lower likelihood of suicidal manner of death was predicted
with increasing ISS [25]. The mean (±S.D.) of the ISS was 15.73 (±8.34)
and 29.17 (±13.27) in suicides and homicides, respectively [25]. The
ISS ranged from 1 to 29 and 10 to 75 in suicides and homicides,
respectively [25]. None other researchers reported on the predictive
value of the ISS in differentiating suicide from homicide in sharp-force
fatalities.
The ISS is one of the anatomical scoring systems used to assess the
severity of traumatic injuries [39,40]. Brunel et al. [25] were the first to
analyze the effect of the ISS in distinguishing suicidal sharp-force fa­
talities from homicidal sharp-force fatalities. The sharp-force injuries
caused by assailants in homicides were more severe than self-inflicted
sharp-force injuries [25]. In a related critical review, De-Giorgio et al.
[20] did not report results related to the ISS in distinguishing a suicide
from a homicide.
3.4.3. Associated injuries
In addition to the fatal wounds or primary wounds inflicted to
commit suicide or homicide, secondary associated injuries like hesita­
tion injuries and defense injuries may be present predominantly in sui­
cides and homicides, respectively.
3.4.3.1. Hesitation injuries. Terranova et al. [24], Karlsson [29], and
Racette et al. [26] reported the presence of hesitation injuries or
tentative injuries in 50%, 62%, and 74.14% of suicidal victims,
respectively. Brunel et al. [25] reported that hesitation injuries were
preferentially found in suicidal victims. In the study by Terranova et al.
[24], the common anatomical sites where hesitation injuries were pre­
sent included the anterior surface of the forearms and neck. In the study
by Racette et al. [26], the common anatomical sites where hesitation
injuries were present included the neck, left anterior thorax, wrists, and
hands. Scolan et al. [27] did not report on the presence or absence of
hesitation injuries in suicidal victims.
In a suicidal milieu, hesitation injuries are superficial injuries. Hes­
itation injuries are non-fatal injuries that may be present in suicidal
sharp-force fatalities. Hesitation injuries, when present, are a feature of
suicidal victims. However, odd cases of injuries mimicking hesitation
injuries are very rarely reported in homicides [29]. In a related critical
review by De-Giorgio et al. [20], hesitation injuries were present in
62.4% of suicidal victims and absent in 37.6% of suicidal victims where
the information on hesitation injuries was available.
3.4.3.2. Defense injuries. Terranova et al. [24], Racette et al. [26], and
Karlsson [29] reported the presence of defense injuries in 64.51%,
61.07%, and 41% of homicidal victims, respectively. Brunel et al. [25]
reported that defense injuries were preferentially found in homicidal
victims. In the study by Racette et al. [26], the common anatomical sites
where defense injuries were present included the hands, arms, and
forearms. Localizations of defense injuries were not reported by Terra­
nova et al. [24], Brunel et al. [25], and Karlsson [29]. Scolan et al. [27]
did not report on the presence or absence of defense injuries in homi­
cidal victims.
In a homicidal milieu, defense injuries are injuries to the extremities.
Defense injuries are categorized as passive defense injuries and active
defense injuries. Passive defense injuries are sustained when the victim
raises the upper limbs in defense, and active defense injuries are
7
Legal Medicine 67 (2024) 102388
sustained when the victim tries to grab the weapon in defense. Defense
wounds, when present in homicides, are unlikely to be fatal. Defense
injuries, when present, are a feature of homicidal victims. However, odd
cases of injuries mimicking defense injuries are very rarely reported in
suicides [24]. In a related critical review by De-Giorgio et al. [20], de­
fense injuries were present in 37.39% of homicidal victims and absent in
62.61% of homicidal victims where the information on defense injuries
was available.
3.4.4. Toxicology
In the study by Scolan et al. [27], toxicological analysis of blood was
negative for alcohol in 73.3% of suicides and 77.8% of homicides where
such analysis was conducted. The differences in these findings were not
statistically significant in the suicide and homicide sub-cohorts [27].
Karlsson [29] reported significantly higher blood alcohol levels in ho­
micides in comparison to that in suicides. Around 15% of the suicide
victims and around 60% of the homicide victims were found to be under
the influence of alcohol at the time of death [29]. Racette et al. [26]
analyzed the correlation between blood alcohol concentration and the
presence of hesitation injuries in suicidal victims and defense injuries in
homicidal victims. This study did not reveal any correlation between
blood alcohol concentration and the presence of hesitation injuries [26].
However, this study revealed a negative correlation between blood
alcohol concentration and the presence of defense injuries [26]. Defense
injuries were absent in every case of homicide where toxicological
analysis found a blood alcohol concentration of more than 250 mg/100
ml [26]. Overall, a higher blood alcohol concentration was linked to a
smaller number of defense injuries in homicidal victims [26]. Around
80% of the homicidal victims with a single fatal wound and absence of
defense injuries were found to be under the influence of alcohol at the
time of death [26]. However, around 90% of the suicidal victims with a
single fatal wound and absence of hesitation injuries were found not to
be under the influence of alcohol at the time of death [26]. Terranova
et al. [24] and Brunel et al. [25] did not report on toxicological analysis
due to the unavailability of data in most cases.
In a related critical review by De-Giorgio et al. [20], toxicological
analysis results were positive in 88 cases of suicide and negative in 132
cases of suicide where the related information was available. In homi­
cides, toxicological analysis results were positive in 144 cases and
negative in 91 cases where the related information was available [20].
However, De-Giorgio et al. did not comment further on the positivity of
the toxicological analysis results. A positive toxicological analysis report
in suicidal victims may indicate a preceding failed suicidal attempt by
poisoning or the employment of an additional method of suicide by
poisoning to ensure a successful suicide. Besides, toxicological analysis
may be positive for medications for a clinical psychiatric diagnosis in
those suicidal victims with a history of clinical psychiatric diagnosis and
on pharmacological treatment for the clinical psychiatric diagnosis. A
positive toxicological analysis report in homicidal victims may indicate
being inebriated or drugged. In the studies included in the present
scoping review [26,27,29], postmortem blood samples were analyzed
for toxicological findings. Blood is the most common biological sample
analyzed for alcohol, drugs, or substances in sharp-force fatalities [41].
Other biological samples [42–44], such as urine, viscera samples, and
hair, were not analyzed. Validated analytical methods [42–44] that
include thin-layer chromatography, high-performance liquid chroma­
tography, and gas chromatography-mass spectrometry are used to
analyze postmortem biological samples for toxicological findings.
3.4.5. Radiology
Radiological imaging modalities play an important role in the post­
mortem setting as one of the autopsy ancillary investigations [45]. None
of the studies included in the present scoping review specifically re­
ported postmortem radiological findings related to sharp-force skeletal
trauma. Such findings were not stated even in a related critical review by
De-Giorgio et al. [20].
Z.F. AlGheryafi et al.
Postmortem radiological imaging modalities can be used to detect
sharp-force skeletal trauma [46]. Skeletal trauma may be missed on a
routine postmortem examination in regions that are difficult to reach
during autopsy [47]. Postmortem computed tomography (CT) scans
easily detect skeletal injuries [48]. CT scans are more sensitive than X-
rays in detecting stab-related osteological defects and the minimum
number of impacts [49]. When radiological evaluation of sharp-force
skeletal trauma is required, CTs should be considered over X-rays.
Further inspection based on the location of sharp-force soft-tissue in­
juries helps in identifying sharp-force skeletal injuries. As an alternative
to routine dissection in certain scenarios or as a supplement to routine
dissection, radiological imaging can be considered in the postmortem
setting to identify sharp-force osteological defects. However, the
detection of sharp-force skeletal trauma needs expertise in radiology and
could be challenging to forensic pathologists untrained in radiology.
4. Conclusion
This scoping review primarily summarizes the existing research
findings on the differentiation of suicide from homicide in sharp-force
fatalities with stab and/or incised wounds. Scene of death investiga­
tion findings and autopsy findings are of paramount significance in
establishing the manner of death. Several parameters that could be
considered in determining the manner of death as suicide or homicide in
sharp-force fatalities with stab and/or incised wounds are mapped. The
parameters are primarily related to the scene of death, the victim’s
clothes, wound characteristics, and the presence of associated injuries.
According to the results, these parameters ranged from being strongly
predictive to less predictive, and no single parameter was conclusive in
differentiating suicide from homicide. Some of the important predictors
of the homicidal manner of death in sharp-force fatalities include
clothing damage, presence of defense injuries, presence of injuries
caused by another type of violence other than sharp-force, vertically
oriented chest stabs, and sharp-force injuries in the head and back
anatomical sites. Some of the important predictors of the suicidal
manner of death in sharp-force fatalities include the presence of tenta­
tive injuries, sharp-force injuries to the wrist, and the presence of a
suicide note.
It should be further emphasized that there is no single absolute
predictor or indicator of the type of manner of death (suicide or homi­
cide) in sharp-force fatalities caused by light sharp-edged weapons.
Instead, the findings related to individual parameters should be inte­
grated with findings related to other parameters and collectively the
manner of death should be determined for a more accurate diagnosis of
the manner of death. In cases where the manner of death cannot be
meaningfully determined, it is prudent for the forensic pathologist to
state the manner of death as undetermined rather than misleading
further investigation in the wrong direction.
The limitations of this scoping review include the search for the
relevant literature in a single database and the exclusion of studies
published in languages other than English. The inclusion of a limited
number of studies in the present review resulted from the stringent
application of the inclusion and exclusion criteria considered in the
literature search methodology. Besides, the search strategy did not
include untagged search terms or the search terms tagged with the
search field tag [All Fields]. The search field tag [Title] was specified
alongside the search terms to be more specific in identifying relevant
studies.
The heterogeneity of data is evident in the various studies [24–29]
included in the present scoping review. Diverse cases of sharp-force
fatalities were included in these studies [24–29]. It is important to
analyze the predictors of suicide and homicide in sharp-force fatalities
caused by light sharp-edged weapons in well-defined distinct cohorts
rather than considering all such cases collectively for analysis and
interpretation. For instance, well-defined distinct cohorts should
consider the inclusion of cases based on the specific anatomical site/
8
Legal Medicine 67 (2024) 102388
region of the fatal sharp-force injury. Accordingly, predictors of suicide
and homicide should be analyzed separately for well-defined cohorts,
for instance, cohort that includes cases of cut-throat fatalities and cohort
that includes cases of fatal chest stabbings. Besides, we recommend a
meta-analytic review of the frequency and patterning of various relevant
parameters to provide the evidence in differentiating suicides from ho­
micides in sharp-force fatalities caused by light sharp-edged weapons.
Funding
Nil.
Ethics approval
Not applicable.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement
None
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