Journal of Forensic and Legal Medicine 69 (2020) 101890

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Journal of Forensic and Legal Medicine

journal homepage: http://www.elsevier.com/locate/yjflm

Review of the pattern of traumatic limb lesions sustained in cases

of hanging
Mark Mc Cabe a, *, Noorusamah Nadia Fyzul b, Linda Mulligan c, Michael Curtis c, Marie Cassidy c
a
Department of Histopathology, Cork University Hospital, Wilton, Cork, Ireland
b
Department of Clinical and Translational Research, University College Dublin, Belfield, Dublin, Ireland
c
Office of the State Pathologist, Griffith Avenue, Whitehall, Dublin, Ireland

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

Keywords: This retrospective study sought to identify a regular pattern of limb bruising which occurs in association with
Forensic science suicidal or accidental hanging. Following exclusion of cases suspicious for homicide, 82 consecutive cases of
Asphyxia hanging from a 10-year period were retrospectively reviewed to identify the pattern of traumatic limb injury in
Hanging
each case. Relevant information such as location, toxicology, and type of suspension was also noted. 72% of the
Limb lesion
Trauma
reviewed cases had traumatic limb lesions, the majority of which occurred on the posterior upper limb and the
Toxicology anterior lower limb. Although the distribution of limb injury in our study mirrored that found in the literature,
the incidence is much higher than in previous studies (7.4–20%). This could either be due to differences in
confounding factors such as intoxication and location of hanging or differences in the practice of recording of
limb trauma in hanging between centres. Neither type of suspension nor location of hanging were significantly
associated with an increased incidence of traumatic limb injury. Positive toxicology was found to increase the
likelihood of sustaining limb injury (p ¼ .044084). In conclusion, the presence of this well documented pattern of
traumatic limb lesions in cases of hanging should not always raise suspicion of foul play.

1. Introduction body movement responses, including convulsions and alternating pha­

Between 2005 and 2016, 87 suspicious cases of death by asphyxia
due to hanging were reported to the State Pathologist’s Office in Ireland.
Asphyxia refers to death resulting from oxygen deprivation of the brain.
The most common mechanisms of asphyxial deaths are mechanical, that
is, they physically obstruct cerebral arterial perfusion or airflow through
the respiratory tract.1 Asphyxias caused by external pressure to the neck
are grouped under the broad term ‘Strangulation’. This term in­
corporates hanging, manual strangulation, ligature strangulation and
strangulation not otherwise specified.2 Hanging can then be defined as a
form of mechanical asphyxia which occurs due to suspension of the body
by a ligature which encircles the neck, the constricting force being either
the complete or partial weight of the body.3 Hangings may also be
classified by intent for example accidental, homicidal, suicidal, auto­
erotic, post-mortem and judicial.4
External post-mortem examination of hanging victims often reveals
bruising, abrasions and lacerations which can raise the suspicion of
homicide. However, recent studies of filmed hangings have demon­
strated that asphyxia by hanging is associated with a complex pattern of
ses of decerebrate and decorticate rigidity (5,6). These movements lead
to a pattern of bruises and abrasions which have thus been described in
the literature as a normal constituent of death by hanging. The usual
areas of the body which are classically involved are the posterior aspect
of the upper limbs and the anterior aspect of lower limbs.7 The pattern of
movement could potentially be altered by a number of factors including
the type of hanging or intoxication. Death by hanging occurs through
several mechanisms (vasovagal reflex, carotid compression, venous
compression etc) and different contributions of each of these mecha­
nisms could alter the pattern of movement and therefore the distribution
of traumatic limb lesions seen at post mortem.8
In a forensic context, when examining cases of hanging, it is essential
to determine which patterns of bruising suggest that a person died by
suicidal hanging and which could indicate homicide. In this study, we
reviewed the pattern of limb injury in suicidal and accidental hanging
victims as well as factors which could potentially alter it such as
intoxication, location, and manner of hanging.

* Corresponding author.
E-mail address: mccabem6@tcd.ie (M. Mc Cabe).

https://doi.org/10.1016/j.jflm.2019.101890
Received 30 July 2019; Received in revised form 10 December 2019; Accepted 15 December 2019
Available online 23 December 2019
1752-928X/© 2020 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
M. Mc Cabe et al.
Fig. 1. A man suspended from prison cell window bars. The suicide note is seen
in the foreground. The bed is the only furnishing, which he appears to have
stepped off.
Fig. 2. Bruising seen on the right forearm and hand of the man in Fig. 1. There
was also an abrasion on the right shin. This case illustrates the fact that patients
can develop traumatic limb lesions even in the absence of surrounding objects
which they could strike their limbs against during the agonal sequence.
2. Materials and methods
All available reports of cases of suicidal or accidental hanging
investigated by the Office of the State Pathologist in Ireland over a 10-
year period (2006–2015) were manually retrieved from the secured
files (n ¼ 87). One case where foul play or homicide could not be ruled
out and four cases which showed extensive post-mortem changes such as
decomposition, animal predation, or skeletonization were excluded
from the study (n ¼ 82). These cases were retrospectively reviewed to
determine the most common traumatic limb lesions, association be­
tween location of hanging and incidence of traumatic limb lesions, and
relationship of positive toxicology with traumatic limb lesions.
To identify the pattern of traumatic limb lesions, cases with a history
2
Journal of Forensic and Legal Medicine 69 (2020) 101890
Fig. 3. A man suspended from the roof in an internal narrow passageway with
surrounding furniture present.
Fig. 4. The man in Fig. 3. Note lower limb congestion and blood blisters from
vertical suspension. In contrast to the previous case, no limb trauma is seen
despite the hanging taking place in a narrow passageway with surrounding
furniture. These cases suggest that a mechanism besides physical contact with
surroundings during the agonal sequence could be at play in producing trau­
matic limb lesions in hanging cases.
of an altercation or accident prior to hanging were excluded so as to
minimise the inclusion of traumatic limb lesions not associated with
hanging. The remaining 65 cases were retrospectively reviewed to
identify the pattern of limb injuries on each patient.
Personal information and potentially identifiable characteristics
were not recorded. All data was anonymised by removing all personal
details and assigning new case numbers. Information such as the loca­
tion of the event, nearby furnishings, toxicology and type of hanging was
noted. Information was sourced from police reports, coroner’s autopsy
requests, crime scene photos, and pathologist scene visit reports if
available. For each victim, bruising, abrasions and lacerations present
over the body, excluding the head and neck, were documented on body
diagrams which were subsequently superimposed on each other. Old or
healing traumatic lesions, as indicated by the reporting pathologist,
were not included. Statistical analysis of the correlation between
different factors and the presence of traumatic limb injury was carried
out using a chi-square test (see Fig. 6).
Fig. 5. Incidence of different types of traumatic limb lesions in
hanging victims.
M. Mc Cabe et al.
Fig. 6. Incidence of traumatic limb lesions by type of hanging.
Traumatic limb lesions from every hanging victim who had not been
involved in a documented physical altercation or accident in the hours
before their hanging (n ¼ 65) were mapped on body diagrams and
superimposed on each other to create Fig. 7 below. Lesions on the
anterior upper limb and posterior lower limb were rare whilst lesions on
the posterior upper limbs and anterior lower limbs were much more
common.
3. Results
3.1. Demographics of hanging victims
Of the initial 82 cases reviewed, 56 were male and 26 were female.
There was a slight youthful preponderance with more victims falling
within the under 20 age group (n ¼ 16) than the over-41 age group (n ¼
14). The incidence of hanging in men was higher than in women in all
age groups, except in those over 60 years.
3.2. Types of traumatic limb lesions
External examination of all 82 cases revealed that abrasions (56.1%)
were the most common traumatic lesions acquired, followed by bruising
(43.9%). Lacerations were very rare. Of note, 28% of the victims ac­
quired no traumatic limb lesions (Fig. 5).
3.3. Incidence of traumatic limb lesions in relation to type of suspension
The number of complete hangings (40) and partial hangings (36) was
almost the same. An increased incidence in traumatic limb lesions in
complete hangings (75%) compared to partial hangings (66.7%) was
observed.
3.4. Pattern of traumatic limb lesions in hanging victims
Traumatic limb lesions from every hanging victim who had not been
involved in a documented physical altercation or accident in the hours
Fig. 7. The Distribution of Limb Lesions found in this study. Note the similarity
in distribution when compared with the diagram from the literature below.
3
Journal of Forensic and Legal Medicine 69 (2020) 101890
before their hanging (65 cases) were mapped on body diagrams and
superimposed on each other to create Fig. 7 below. Lesions on the
anterior upper limb and posterior lower limb were rare whilst lesions on
the posterior upper limbs and anterior lower limbs were much more
common.
3.5. Incidence of traumatic limb lesions in relation to location of hanging
In the 82 cases of hanging reviewed, the most common locations for
hangings were prisons (19.5%) and home stairwells (12.2%). The
highest incidence of traumatic limb lesions occurred in various house­
hold rooms such as the garage, bedroom, kitchen, toilet and attic (100%)
as shown in Fig. 8 below. External hangings were uncommon (15.9%)
compared to those which occurred indoors (84.1%). However, the
incidence of lesions was collectively higher in these external locations
than the internal ones (84.6% versus 69.6%). It is interesting to note that
the incidence of lesions did not increase in enclosed areas such as
wardrobes (0%) and passageways (33.3%) despite what would be ex­
pected given the small space (see Figs. 1–4).
3.6. Incidence of traumatic limb lesions in hanging victims in relation to
toxicology
Toxicology reports were available in all cases. In the 65 cases
reviewed, analysis of blood and urine showed alcohol and benzodiaze­
pines such as diazepam and nordiazepam were the most common drugs
found in our cohort (26% and 20% respectively). Positive toxicology
was defined as the presence of one or more drugs in blood or urine.
There was a statistically significant increase in limb lesions in patients
who had positive toxicology at post-mortem (p ¼ .044084, Chi-Square
test) (See Fig. 9).
4. Discussion
Forensic examination in cases of hanging is essential in order to rule
out foul play. Victims may have been murdered and then hanged in such
a way as to create the suggestion of suicide.10 There are a number of
signs that a hanging was not suicidal. These include evidence of ante
mortem trauma, skin injury at the neck, extensive internal injury to the
neck, fractures of the hyoid or laryngeal cartilage, and a horizontal
ligature mark on the neck. This is well documented in the literature
(10–19). The possibility of an accidental hanging should also be kept in
mind.20 Over the years, extensive studies have been carried out to
document which ligature marks and asphyxial signs on the head and
neck are to be expected in suicidal hangings (21–24). However, the
pattern of limb bruising and its incidence has largely been ignored until
recently.
Death by hanging is a multifactorial process which is incompletely
understood. It is thought to be due to compression of blood vessels,
airways, and baroreceptors in the neck. The relative contribution of each
of these three factors varies depending on the type of hanging and the
position of the ligature around the neck. Closure of the airway occurs
either due to direct compression of the trachea by the ligature (requiring
15 kg of direct force)9 or by occlusion of the pharynx by the displaced
root of the tongue.1 Occlusion of venous return is responsible for the
classical congestive signs of hanging.25 The jugular veins are occluded
by any significant pressure on the neck (2 kg of force)9 resulting in
increased venous pressure in the head and reduced cerebral perfusion.26
Compression of the carotid and vertebral arteries and resultant cerebral
hypoxia is another key factor in death by hanging.27 Compression of the
carotids occurs with relatively little force (5 kg)9 whereas compression
of the vertebral arteries requires considerably more pressure to reach
complete occlusion (30 kg).9 As well as obstruction of cerebral blood
flow, pressure on the carotid arteries can result in activation of the ca­
rotid sinus resulting in bradycardia and cardiac arrest through a large
increase in vagal tone.28 Intoxication may compound respiratory
M. Mc Cabe et al.
Fig. 8. A Table showing the number of cases which occurred in each location and the corresponding rate of traumatic limb injury.
Fig. 9. Description of toxicology in this case series.
compromise by reducing respiratory rate and protective reflexes.29
Differing patterns of limb injury could be partially due to differences in
contributions of each of these mechanisms.8
In studies of filmed hangings (5,6), the agonal sequence has been
described. Loss of consciousness (10s � 3s) is closely followed by con­
vulsions (14s � 3s) and then alternating phases of decerebrate (19s � 5s)
and decorticate (38s � 15s) rigidity. Arms are abruptly flexed in the
quick, sudden phase of decortication due to hypoxia in the midbrain as a
result of the loss of blood supply from tributaries of the vertebral ar­
teries. Arms are then extended away from the body in the decerebrate
phase due to impairment of the cerebral cortex via loss of supply from
tributaries from the carotid. The agonal sequence eventually ends with
loss of muscle tone (77s � 25s), end of deep rhythmic abdominal res­
piratory movements (111s � 30s) and the last muscle movement before
death (252s � 149s). It is thought that during these last movements, the
bruising and abrasions are sustained (7,9).
The majority of cases were male which is in keeping with the
4
Journal of Forensic and Legal Medicine 69 (2020) 101890
literature30 which shows a male preponderance in hangings as well as
the male preponderance for suicide in general in Ireland.31
In our study, abrasions were the most common traumatic limb injury
followed by bruising; with lacerations coming a distant third. This fol­
lows the trend seen in the literature with Sauvageau et al. reporting a
similar distribution. Other studies such as that carried out by Uzun et al.
report only bruising (7,32).
Uzun et al. stated that 56 cases out of 761 (7.4%) suicidal hangings
presented superficial bruises ‘‘attributed to result from the trauma dur­
ing the agonal period’‘.32 A German study reported that 20% of 107
suicidal hanging cases showed ‘‘lesions in various locations, which are
thought to be results of terminal convulsions’’33 and a 10% rate of body
bruises was observed in a study by Cooke and Samarasekera on 233
hangings.34 More recently, an incidence of traumatic limb lesions of
19.8% was reported by Sauvageau et al. (2009) in a 6 year retrospective
study. This rate varied based on the hanging location (open areas versus
enclosed areas) and was attributed to decorticate and decerebrate
M. Mc Cabe et al.
periods of the agonal sequence.7 Our data show a much higher rate of
limb injury in hanging victims with 72% of hangings showing traumatic
limb injury. Possible explanations for this disparity include differences
in levels of intoxication, location of hanging, demographics, and the
contribution of different physiological mechanisms to death. Differences
in the practice of recording of limb injuries in hanging could also ac­
count for the discrepency. Also, the State Pathologist’s office in Ireland
deals only with suspicious deaths, and the presence of obvious traumatic
injuries could potentially have influenced investigators to procure these
services, thus biasing our case cohort.
Based on the known sequence of vigorous antemortem movements in
hanging, one would expect an increased incidence of limb trauma in
hangings in enclosed locations. In 2009, Sauvageau showed in a case
series of 207 cases that hangings in closets and staircases showed an
incidence of limb injury of 56.3% and 66.7% respectively compared
with an overall incidence of 19.8%.7 However, our data show that the
incidence of lesions did not increase in enclosed areas such as wardrobes
(0%) and passageways (33.3%). Additionally, the overall traumatic limb
lesion incidence in external open areas was higher (84.6%) than the
overall internal incidence (69.6%). This and the fact that almost 30% of
the victims acquired no traumatic limb lesions (Fig. 5), suggests that
factors other than the agonal sequence could be partly responsible for
limb trauma in cases of hanging.
63% of cases had positive toxicology. This is lower than a previous
study in Ireland by Arensman et al. who determined that 86.8% of cases
of hanging were intoxicated at the time of their death. Alcohol was the
most common drug discovered on toxicology in our study, which is in
keeping with the literature.35 Expert opinion has held that intoxication
with alcohol or other drugs which inhibit respiratory effort would speed
up death by hanging through a synergistic effect. However, in the only
known filmed hanging of a patient intoxicated with alcohol, Sauvageau
saw no decrease in the time it took for the patient to die. Our study
shows a statistically significant increase in the incidence of traumatic
limb injury in patients with positive toxicology. (p ¼ .044084,
Chi-Square Test). This could be due to alterations in the agonal sequence
or due to minor trauma resulting from lack of coordination prior to the
hanging itself.
Previous studies by the Working Group on Human Asphyxia have
shown that the type of suspension (complete, partial, standing, lying
down) does not correlate with the pattern of traumatic limb injury (7).
Our findings are in agreement with this.
In conclusion, the findings of our study are in line with what has been
previously described in the literature both in terms of the pattern of
injury and the lack of association between type of hanging at the inci­
dence of traumatic limb injury. However, we note a higher incidence of
traumatic limb injury overall compared with previous studies and a
previously undescribed association between positive toxicology and
increased incidence of traumatic limb injury. Limitations of our study
include a biased sample of suspicious cases of hanging, a relatively small
number of cases, and the retrospective nature of the review.
Despite ongoing research into the process of hanging, it remains
poorly understood and further work is required, particularly regarding
the role of intoxication in hanging, the agonal sequence, and the resul­
tant change in the pattern of traumatic limb injury. The presence of
traumatic lesions on the anterior lower limb or posterior upper limb
should not directly raise suspicion of foul play in cases of hanging, with
the caveat that injuries must be interpreted in the overall context of each
case. However, if limb trauma is seen outside of this distribution, ho­
micide should be considered.
Declaration of competing interest
The authors declare that they have no conflict of interest.
5
Journal of Forensic and Legal Medicine 69 (2020) 101890
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