Blunt Force Trauma in the Neuro-Cranium: Fracture Propagation Using Current Biomechanics Research and Technology

This paper is to be submitted as partial fulfilment for the course ANA 328: Applied Research Techniques

Ina Keyser 10144383 29 October 2012

University of Pretoria Department of Anatomy

TABLE OF CONTENTS

1. Introduction 2. Statement of Purpose 3. Literature Review 3.1. Theories designed by Gurdjian and Colleagues, Wayne State University 3.2. Gurdjians Followers: Theories Applied, Modified or Suggested 4. Materials and Methods 4.1. Materials 4.2. Methods 5. Ethical Considerations 6. Finances 7. Tables 8. References

4 5

6 7

8 8 9 9 9 10

LIST OF TABLES

1. Table1: Subdivision of Dry Crania Obtained from the Ramond Dart and Pretoria Skeletal Collections 2. Table 2: Subdivision of Cadaver Crania Obtained from the Anatomy Department of the University of Pretoria

1. Introduction [1-3]
Recognition and interpretation of bone fracture patterns are essential components of forensic anthropology. In many cases, accurate trauma analysis may be the only objective means to provide evidence for the determination of time, cause, manner and mechanism of death and in a legal setting, substantiate or reject witness accounts [1]. Forensic anthropologists may contribute to trauma analysis in two primary capacities: a) Determination of time when the injury was induced, i.e. ante-mortem, perimortem or post-mortem; and b) Identification of the mechanism and cause responsible for the trauma, i.e. ballistic, blunt, sharp or thermal trauma or a combination of these mechanisms. Traumatic brain injury (TBI), as a result of cranial fractures obtained in falls, motor vehicle-related accidents and violent abuse (domestic and nondomestic) claims an estimate of 89 000 South African lives annually [2].The cranium is often affected in blunt force trauma, and injury patterns can be complicated and challenging to understand. Post-mortem inspections and autopsies (done for closure to the families; insurance claims; or legalistic proceedings where abuse or assault was evident) indicated that 73% of these cranial fractures were directly related to blunt force trauma [2]. Blunt force trauma is one of the most common and intricate areas of skeletal trauma. Interpretation of the fracture patterns aids in identification of the impact site location, sequencing blows and determining characteristics (such as size and shape) of the weapon or object responsible for the destruction to the cranium [3]. While the analysis of fracture patterns is an important part of forensic anthropology, current research and knowledge is mostly derived from forensic specimens that are examined for trauma analysis in a post-mortem setting. This means that observation occurs long after the trauma is induced and is often hampered by a poor understanding of the event. Not only does fracture interpretation require a welldefined knowledge of physics, biomechanics, taphonomy, anatomy and osteology; the forensic anthropologist should have experience with trauma specimens with known etiology, and/or training involving examination of known bone trauma cases and/or experimentation involving bone fracturing. One of the most cited researchers to contribute to trauma interpretation was Gurdjian. Gurdjian and colleagues conducted research on cranial fracture biomechanics, and extensively published on the topic. Today their work is still considered the golden standard, however the technologies used for propagation and illustration of these fracture patterns, has since become outdated [3]. Due to the nature of the field of forensic anthropology, there is little opportunity to study fracture patterning in a controlled experimental setting. Because this research is deficient and incomplete, there is much speculation about fracture interpretation, as well as reliance on older outdated studies.

2. Statement of Purpose [4-6, 9]

The aim of this experimental study is to determine, describe and illustrate the fracture patterns of blunt force trauma in the neuro-cranium through fracture propagation using current biomechanics research and technology. Objectives are: To re-evaluate the research done by Gurdjian and colleagues [4-6] regarding how the cranial vault responds to blunt impact. The theories published by Gurdjian and co-workers state that cranial fractures initiate at a location other than the impact site and subsequently radiate back towards it. In contradiction, many forensic anthropologists and pathologists have commented and noted that cranial fractures consistently originate from a central impact site and radiate outwards [7]. These conflicting points of views raise the question: which theory is more applicable and correct. To utilize an engineering drop tower system, which accurately simulates blunt force trauma in a controlled environment. The computer programmed drop tower system eliminates unpredictable variables as well as human error that may occur when propagating fractures manually (by hand). To capture the fracture propagation in the bone using a high-speed video. This will allow for the entire fracture event to be viewed and analysed repeatedly without having to conduct the entire experiment once again. All of the resulting data to be compared to results from the original studies as well as to current forensic cases. In conclusion, to create a clinical applicable and comprehensive characterising system or guideline of descriptive terminology. This system must preserve the classical anatomical terminology and nomenclature, for easy comprehension and identification of blunt force trauma.

Uncertainty in blunt force trauma analysis restricts the field of forensic anthropology where the principles of archaeology and physical anthropology are applied in a legal setting. Forensic anthropology mainly aids in creating potential profiles of the remains or to convict perpetrators of violent crimes. A more accurate assessment of the trauma can promote and ensure a quicker and more precise understanding of the events that inflicted the damage to the cranium and to rule out other possible trauma.

3. Literature Review
3.1. Theories designed by Gurdjian and Colleagues, Wayne State University [4-6, 9]
One of the most extensive and elaborative series of blunt force trauma studies was conducted in the 1940s and 1950s by Gurdjian and colleagues at Wayne State University, USA. A neurosurgeon and an anatomist, Gurdjian was fascinated with the fracture patterns and mechanics of trauma in the human skull. In 1945 Gurdjian and co-workers began their research on blunt force trauma by considering induced fracture lines in monkeys, dogs (wet specimens) and dry human crania. During this study, Gurdjian developed his methods of using stress coat, a dry brittle varnish designed to indicate areas of tensile strain in the material (bone) that it coats, and thus predict fracture patterns. Stress coat was applied directly on top of the bone for each experiment after which a blunt force was exerted on the skulls [8]. Fracture lines (also referred to as cracks) in the stress coat were examined to determine the areas of the skull that were under the most strain from the specific blunt force impact applied. From this series of studies, Gurdjian and colleagues developed a collection of theories to explain the biomechanics of skull fractures. These initial theories included the direction and pattern of fracture propagation and the supporting biomechanics. Gudjian and colleagues proposed that the neurocranium develops areas of in-bending or intending and out-bending in response to the blunt force impact. The force caused an intending of the bone directly underneath the impact site location and a zone of out-bending in the adjacent bone. The theory was developed that the areas of out-bending experienced a high concentration of tensile force, inducing fracture initiation. Fractures were thought to initiate in these remote zones of out-bending then radiate back towards the original point of impact. This was because the out bending is selective and may be localized to a certain part of the skull where a linear fracture is initiated due to the resultant tearing-apart forces [9]. This area of out bending could also occur at a considerable distance from the point of application of the blow [9]. In some cases it was noted that the area of greatest out-bending may be diagonally opposite the point of the applied blow [9]. This pattern was defined as an undulating type of movement with simultaneous intending in the region of impact and out bending at the border of the area of intending[5]. Initial failure and fracture was proposed to commence in the regions of out-bending. Once fracturing began, it extended, in the opposite direction, toward the point of impact [9]. Simply, it states that the direct blunt force impact of the skull first caused distortion and failure in the surrounding areas, after which the fracture travelled back toward the impact site. Gurdjian reviewed that the cracks appear on the outside of the skull in the regions in which the bone bends outwards and initial fractures may occur at a considerable distance from the point of the application of the blow [9]. The forces exerted on the skull caused a fracture to originate at a moderately further distance away from the point of impact. According to the stress coat research,

a blow to the right frontal region of the skull, for example, may result in an area of out-bending in the left parietal region and a subsequent linear fracture in the left parietal region radiating back towards the right frontal impact site. Multiple fractures could occur in different locations with each radiating back towards the impact site [5].

3.2. Gurdjians Followers: Theories Applied, Modified or Suggested

Gurdjian and co-authors theories were universally applied to trauma interpretation and specifically blunt force trauma. The entire scientific community was encouraged to apply these conclusions and definitions as a predicative model for impact site location. Gurdjian and colleagues stated, on the basis of this study it should be possible to predict the position of the fracture line fairly accurately when the location of the blow is known; or if the fracture line is found on the x-ray film, the position of the blow producing it may be determined [6]. Often cited, Berryman and co-authors has held fast to Gurdjians work and theories for multiple experimental studies regarding fracturing patterns [10]. Berryman and co-authors have produced a large amount of trauma research which provided an affluence of biomechanical exemplars in the field of forensic anthropology. The use of Gurdjians models can be seen in their explanation for blunt force fracture patterns. Berryman and Symes [11] claim that fracture patterns are often created with the initial fracture formation occurring in the area of out-bending, remote from the point of impact. Galloway [12] also agrees with Gurdjians findings in his book, Broken Bones: Anthropological Analysis of Blunt Force Trauma. He states that fracture initiation may begin at a site distant from impact, due to considerable out-bending of the bone. Forensic pathology has also utilized the Gurdjian theory. DiMaio and DiMaio [13], a gold standard in the field, used Gurdjian as the basis for blunt trauma interpretation. They confirm that the area of impact is bent inward while adjacent and more distant areas are bent outward [13]. The area of out-bending was where the first fracture could occur and as DiMaio notes this occurs at quite some distance from the area of intending. Knight [14] also refers to Gurdjian in his explanation of blunt force trauma fracture patterning in the cranium. He notes that after a blunt impact, there is surprising large deformation and distortion to the shape of the skull. Knight refers to this deformation as the struck hoop analogy [14]. The aforementioned scientists and authors are a clear indication of the reliance of the forensic community on Gurdjians publications. Gurdjians theories and research have played a central role in forensic science and fracture pattern interpretation.

4. Materials and Methods

4.1. Materials

Dry crania from the Ramond Dart and Pretoria Skeletal Collections as well as cadaver crania (wet specimens) at the Prinshof Campus of the University of Pretoria will be used to conduct the experiment. A sub-sample size of 112 dry crania will be used. The sample is divided into equal categories (incl. ancestry, sex and age) to ensure more accurate, valid and unbiased results as indicated in Table 1. Due to the lack of cadavers when compiling a sample using wet specimens, only 32 cadaver crania are available for the experiment. The wet specimens will be subdivided as indicated in Table 2. In total, the sample size will consist of 144 dry and wet crania.

4.2.

Methods

An engineering drop tower system, which accurately simulates blunt force trauma in a controlled environment, will be used to propagate the blunt force trauma to the crania. The computer programmed drop tower system eliminates unpredictable variables as well as human error that may occur when propagating fractures manually (by hand). The fracture propagation in the bone will be monitored and recorded using a highspeed video camera. This will allow for the entire fracture event to be viewed and analysed repeatedly without having to conduct the entire experiment from the start. After the experimentation and collection of the results, it will be analysed and compared to the results from the original studies (done by Gurdjian) as well as to current known South African forensic cases (available from the Department of Anatomy at the University of Pretoria in collaboration with the SAPD). Finally a clinical applicable and comprehensive characterising system or guideline of descriptive terminology will be created. This system will preserve the classical anatomical terminology and nomenclature, for easy comprehension and identification of blunt force trauma.

5. Ethical Considerations
Ethical clearance will be obtained from the Students Ethics Committee of the University of Pretoria and if necessary, from the South African Police Departments and Laboratories where current forensic cases are stored.

6. Funding
The department of Anatomy of the University of Pretoria will cover all the financial costs towards this study.

7. Tables
Table1: Subdivision of Dry Crania Obtained from the Ramond Dart and Pretoria Skeletal Collections AGE: 20-35 years (yrs) 7 7 7 7

RACE

SEX Male Female Male Female

AGE: 36-50 yrs 7 7 7 7

AGE: 51-65 yrs 7 7 7 7

AGE: 65-80 yrs 7 7 7 7

TOTAL 28 28 28 28 112

White Black

Table 2: Subdivision of Cadaver Crania Obtained from the Anatomy Department of the University of Pretoria

RACE

SEX

AGE: 20-40 years (yrs) 4 4 4 4

AGE: 41-80 yrs 4 4 4 4

TOTAL

White Black

Male Female Male Female

8 8 8 8 32

8. References
1. LeCount ER, Apfelbach CW. 1920. Pathologic anatomy of traumatic fractures of cranial bones and concomitant brain injuries. Jam Med Assoc 74:501511. 2. KwaZulu-Natal Deparment of Health, 2001. Available: www.kznhealth.gov.za/headinjury.htm 3. Moritz AR. 1954. The Pathology of Trauma. Philadelphia: Lea and Febiger. Oxnard CE. 1993. Bone and bones: architecture and stress, fossils and osteoporosis. J Biomech 26(Suppl 1):6379. 4. Gurdjian ES, Lissner HR. 1945. Deformation of the skull in head injury: A study with the stresscoat technique. Surg Gynecol Obstet 81:679687. 5. Gurdjian ES, Lissner HR, Webster JE. 1947. The mechanism of production of linear skull fracture; further studies on deformation of the skull by the stresscoat technique. Surg Gynecol Obstet 85:195210. 6. Gurdjian ES, Webster JE, Lissner HR. 1949. Studies on skull fracture with particular reference to engineering factors. Am J Surg 78:736742. 7. Smith OC, Berryman HE, Symes SA, Moore SJ. 1991. Bone fracture I: The physics of fractures. 43rd Annual Meeting of the American Academy of Forensic Sciences, Anaheim, California. 8. Evans FG. 1970. Biomechanical implications of anatomy. Selected Topics on Biomechanics: Proceedings of the C.I.C. Symposium on Biomechanics. 9. Gurdjian ES, Webster JE, Lissner HR. 1950. The mechanism of skull fracture. Radiology 54:313339. 10. Berryman HE, Symes SA. 1998. Recognizing gunshot and blunt cranial trauma through fracture interpretation. In: Reichs KJ, editor. Forensic Osteology: Advances in the Identification of Human Remains. Springfield, IL: Charles C. Thomas. p 333352. 11. Berryman HE, Symes SA, Smith OC, Moore SJ. 1991. Bone fracture II: Gross examination of fractures. 43rd Annual Meeting of the American Academy of Forensic Sciences, Anaheim, California. 12. Galloway A. 1999. Broken Bones. Springfield, IL: Charles C. Thomas. 13. DiMaio VJ, DiMaio D. 2001. Forensic Pathology. Boca Raton: CRC Press. 14. Knight B. 1996. Forenic Pathology. London: Arnold.