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Injury, Fatal and Nonfatal: Blunt Force Injury

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DOI: 10.1016/B978-0-12-800034-2.00219-6

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 Injury, Fatal and Nonfatal: Blunt Force Injury
JJ Payne-James, Forensic Healthcare Services Ltd., Southminster, UK; Barts and the London School of Medicine and Dentistry,
London, UK; and St George’s Hospital, London, UK
r 2016 Elsevier Ltd. All rights reserved.
This article is a revision of the previous edition article by T.S. Corey, volume 3, pp 84–90, r 2005, Elsevier Ltd.

Abstract

Blunt injury is the most widespread type of injury sustained, ranging from everyday knocks and bumps,
trips and slips to the most severe high-velocity impacts, such as falling from heights or being struck by
vehicles. Forces applied can be both direct and indirect. The nature and range of injury sustained is wide,
and in order to understand the possible consequences of blunt injury it is important to be able to classify
and described them and their possible effects on bodily structures. This chapter gives examples of the
nature of blunt injury and its effects, from minor to major.

Introduction injuries may allow the examiner to interpret many factors

Blunt force, blunt contact, or blunt impact injuries are
those injuries generally caused by objects without sharp
or cutting edges (Payne-James and Hinchliffe, 2011).
Examples of things that cause blunt impact injuries
include fists, hands, feet, baseball bat, truncheon, ham-
mers, metal bars, and plastic drink bottles. These can all
be used to hit an individual. An individual can fall and
strike an object (e.g., brick wall or pavement) causing
blunt impact injury. An individual can walk into an
object and cause blunt impact injury. An individual can
be pushed into or against an object causing blunt impact
injury. A car or train can impact an individual causing
blunt impact injury. The list is endless. Blunt impact to
the human body is probably the most common type of
injury sustained by humans – and all of us regularly
incur bumps and bruises in our activities of daily life, at
work, at leisure, and during sport. Blunt-force injury
also represents a common cause of serious injury and
death. Motor vehicle collisions are one of the leading
causes of death in all countries, whether industrialized or
nonindustrialized (Majdan et al., 2015). Additionally,
many severe injuries occurring in accidental or assaultive
situations at home or work are blunt-force injuries.
These have a high cost to society, as they often result in
loss of productivity or life (Ferrante et al., 2013).
From a forensic standpoint even the most minor injury
may have extreme forensic importance. Frequently such
injuries are so minor or superficial that they are com-
pletely overlooked or ignored by non-forensic healthcare
professionals whose primary role is to assess, treat, and
manage injuries incurred in any setting. Forensic aware-
ness and training is often absent or minimal for those
working in primary care, emergency departments, sur-
gical and trauma settings, and intensive care. Initial fo-
rensic documentation of injury, however, can show
patterns or configurations that can help assist courts and
tribunals to understand the causation of injuries. Such
surrounding their production, such as the instrument
involved, the direction and duration of impact, and the
minimum number of impacts. A clear understanding
of blunt-force injuries and their causation allows the
medical professional to interpret the forces and events
that cause them (Gall and Payne-James, 2011).
Anatomic Regionalization
Various anatomic regions of the body possess unique
compositions and characteristics that affect the injury
patterns resulting from the application of blunt force.
Whenever injury patterns are assessed, the examiner
must consider the substrate – the nature and com-
position of the tissue involved in the impact. Skin
trapped between underlying bony prominences and
impacting surfaces may display injuries such as bruises,
abrasions, and lacerations, as the skin and intervening
soft tissue are compressed between the impacting object
and the underlying bone. These injuries may appear
very different from cutaneous injuries in other areas
of the body in which there is abundant subcutaneous
tissue, or no immediately underlying bone.
The head is arguably a unique region, as the relatively
soft gelatinous brain is encased in a tough fibrous pro-
tective layer (the dura mater), which in turn is encased
within the rigid bony skull. The skull is then covered by
a relatively small amount of soft tissue with a rich vas-
cular supply (the scalp). Added to this is the unique
anatomic location of the head, able to move and rotate
in many directions, atop the neck. Because of these
physical properties, the head and its intracranial con-
tents manifest different reactions to the application of
blunt force, both direct and indirect, and the impli-
cations are considered elsewhere.
The torso of the human body, composed of skin and
soft tissue external to a discontinuous axial skeleton

166 Encyclopedia of Forensic and Legal Medicine, Volume 3 doi:10.1016/B978-0-12-800034-2.00219-6


Figure 1 External skin surface of a child dying of blunt abdominal
trauma. Note the absence of significant injury on skin surface of the
abdomen.
which protects and supports the visceral organs, may
suffer marked, even lethal internal injuries whereas the
external skin surface appears undamaged. This may
occur due to the pliability of the external soft tissues,
such that forces are transmitted through the more
superficial tissues to damage the deeper fixed internal
and vital organs. Blunt forces impacting the torso will
cause varied injury responses, depending on many fac-
tors, including, but not necessarily limited to, the angle
of force, the angle of impact in relationship to the ana-
tomic configuration (longitudinal loading vs. side im-
pact), and the composition of the body at the impact site.
For example, impacts identical in duration, amount of
force, and direction may create different injury patterns
depending on whether the impact occurs in adults
or children on the skin overlying the vertebral column
or ribs, or the mid-portion of the anterior abdomen,
with its insulating adipose tissue and lack of rigid bony
structures (Kessel et al., 2014). In injuries over the bony
prominences of the torso, cutaneous abrasions, lacer-
ations, and bruises, with or without underlying frac-
tures, are likely resulting injuries. In contrast, blunt
impacts to the soft pliable abdominal wall may result
in serious injury to vital organs with relatively little
external evidence of injury (Figures 1 and 2).
Blunt forces acting upon the extremities will cause
varied injury responses as well, depending on the many
factors elucidated above. Again, the composition of the
tissue at the impact site affects the appearance of the
wound pattern as much as the type, force, and duration
of impact. The same type and force of blunt impact may
create different injury patterns depending on whether
the impact occurs on the skin overlying the lateral
Injury, Fatal and Nonfatal: Blunt Force Injury 167
Figure 2 Internal findings of the child depicted in Figure 1. Massive
hepatic lacerations resulting in complete transection caused by blunt-
force injury.
malleolus of the ankle (with relatively little in the way of
soft tissue between the skin surface and the bony pro-
tuberance), or the upper one-third of the thigh, with its
more abundant adipose tissue and heavy musculature
encasing the shaft of the femur.
Nature of injuries will be artificially separated for
descriptive purposes into various types. First, injuries to
the skin and soft tissues will be considered, followed
by bony injuries, and finally blunt impact injuries to
internal viscera. In reality, a single impact may cause
injury to all three structure types within a given ana-
tomic location.
Blunt Injuries to the Skin and Subcutaneous Tissues
Blunt-force injuries to the skin surface and immediately
underlying tissues have the potential for causing a range
of injury.
Blunt injury can be caused by direct or indirect forces.
Blunt impact injuries can be described (in terms of force
applied) as being weak, weak/moderate, moderate,
moderate/severe, severe. The more forceful the impact
the more likely that visible marks will be evident.
Examples of direct forces can be punches to the face, or
being struck on the head by a blunt implement such as
a baseball bat. In such cases injury is seen at the site of
impact. Indirect blunt forces, for example, twisting or
bending can cause injury away from the point of force
application (e.g., joint damage when a limb has force
exerted on it). Impacts where internal organs are subject
to shearing forces (e.g., brain and liver) can cause sub-
stantial injury to organ substance. A blunt impact blow
or force can cause a range of symptoms (of which
the individual complains) or signs (visible evidence) –
dependent on a number of factors including force,
location, and impacting surface – which range from
no visible evidence of injury, to tenderness or pain
at the site of impacts, reddening (not bruising), swelling,
168 Injury, Fatal and Nonfatal: Blunt Force Injury

(a) (b)

Figure 3 (a) This is diffuse non-specific bruising caused by repeated beating with a hand to the buttocks. (b) This is a non-specific bruise
caused by a fall from a height of 3 m onto the buttocks.

(a) (b)

(c) (d)

Figure 4 Abrasions (a) Simple abrasions with superficial skin loss caused by impact to concrete surface. (b) Extensive superficial abrasion to
volar forearm, caused by climbing over a brick wall. (c) Multiple facial abrasions caused by impact from kicks with shod foot. Linearity of abrasion
pattern (see arrow) allows determination of orientation of foot when kicking. (d) Linear scratches caused by fingernails – these are linear
abrasions.

bruising (contusions), abrasions (grazes), cuts (lacer-
ations), and broken bones. Each of these may be present
alone or in combination. Figures 3(a) and (b) show
examples of bruises; Figures 4(a–d) show examples
of different types of abrasion; Figures 5(a–b) show
examples of lacerations. Blunt-force skin surface trauma
may cause injury to internal organs and tissues
which may not exhibit any of the above signs. Simple
reddening (that is not bruising) is caused by a force or an
impact that increases blood flow to the affected area and
may be present for only a few hours. Bruises are caused
by blunt contact to body tissues and the coloration effect
is a result of blood leaking out of damaged blood vessels
under the skin. They can also be caused when blood
extravasates out into tissues (e.g., after failed or previous
cannulation of veins for medical purposes or after drug
 Injury, Fatal and Nonfatal: Blunt Force Injury 169

(a) (b)

Figure 5 Lacerations. (a) Laceration to right ear caused by direct impact with a baseball bat. (b) Superficial lacerations to mouth region caused
by direct punch.

(a) (b)

Figure 6 (a and b) Tramline injuries caused by rapid impact resulting in parallel linear bruises with central sparing. These cases show two
tramline bruises caused by strikes from a police ASP baton.

injection). The blood degrades over a period of time

with a number of apparent color changes in the skin.
This is not the same as the reddening and swelling that
may occur after a slap or a scratch which may disappear
after 6 h or so. In some cases although blood vessels may
be damaged, there may be no visible evidence on the
skin. In certain cases it may take more than a few hours
for any bruise to become apparent (as the blood diffuses
through damaged tissue). The most severe injuries are
likely to be caused by the most solid objects rather than
objects that are softer and will alter shape. Injuries are
seen at the point of contact of impacting object on the
body. Bruises may migrate away from the point of
contact by gravity after a period of time, or if internal
injury may give no precise indication of the site of injury.
In some cases patterns of injury may indicate whether a
Figure 7 Patterned injury: Patterned imprint of glove material worn
particular impacting object was involved. Such patterns when punching male on face.
may give a representation of the shape of the object
causing the injury.
In the absence of any such patterns, a bruise or imprints, finger marks, footwear patterns, or finger marks
abrasion may be termed nonspecific. Examples of such (Figure 8). Often such patterns are caused where blood
patterns may include tramline bruising (Figures 6(a) and vessels are damaged but at the periphery of the object
(b)), clothing patterns (Figure 7), hand imprints, finger (e.g., baton, hand, or finger), providing an outline of the
170 Injury, Fatal and Nonfatal: Blunt Force Injury

impacting object (Figures 9(a–c)). Such patterns generally
require sudden impacts of at least moderate-severe force.
In some cases scarring – in the form of hyperpigmentation
(darker coloring) may persist showing the pattern of
implement used to cause an injury – for months and
years after the injury (Peel et al., 2003) (Figure 10).
Bony and Joint Injuries
A fracture may be defined as an interruption in the
structure of a bone. There are various types of fractures,
as described in more detail in other articles elsewhere.

Figure 10 Long-term visible patterned marks of repeated beating

Figure 8 Multiple-clustered bruises on the left upper arm, in a with a flexible stick. The hyperpigmented tramline appearance is
3-year-old consistent with grip marks. clearly visible some years after initial injury.

(a) (b)

(c)

Figure 9 Patterned injury. (a) Patterned imprint caused by impact with 2" x 2" length of wood. (b) Patterned injury caused by impact with (c)
matched broken wooden chair leg.

Fractures associated with blunt trauma can be caused by
a variety of direct (with fracture at the point of impact)
and indirect (e.g., bending of bone) force. Twisting
forces can cause spiral fractures or joint disruption.
Assessment of the location and nature of fractures
may help to elucidate the causative events and applied
forces. Precise determination of fracture location may
be important in cases such as pedestrian injuries and
assessment of driver versus passenger in road traffic
collisions. In the living patient, fractures may be docu-
mented by radiographic methods. In the deceased pa-
tient, fractures may be documented through radiographs
or autopsy examination. Thus fractures result from all
types of blunt force in a variety of biomechanical scen-
arios. It should not be assumed that the presence of a
fracture necessarily indicates blunt-force trauma at the
fracture site.
Visceral Blunt Injuries
Blunt forces applied to the torso may result in injuries to
the visceral organs. The head represents a unique
structure and is considered in details elsewhere. Blunt-
force injuries to the visceral organs of the thorax and
abdomen may include bruises or lacerations of the organ
itself, or avulsion of the organ from its pedicle or sup-
porting structures (Goh and Chen, 2014; Mehta et al.,
2014; Shalhub et al., 2014). Mortality and morbidity
of blunt traumatic injuries depend on many factors,
including the organs involved, the degree of trauma,
and access to medical treatment. The degree of injury
apparent on the external skin surface cannot be used
to assess the degree of damage to the internal organs.
This is particularly true in injuries to the abdomen
where it is not uncommon to find severe – even fatal –
internal injuries while the external skin surface appears
atraumatic.
Visceral blunt trauma associated with death often
involves lacerations of either the heart or the liver. In
lacerations of the heart, if the pericardial sac remains
intact, then a hemopericardium with cardiac tamponade
may result in death within minutes. Depending on the
nature of the trauma, this injury may be solely causative
or may be found with other lesser, but contributing in-
juries, such as pulmonary contusions or lacerations
arising from motor vehicle collisions (Ortiz et al., 2014;
Skinner et al., 2014).
Compared to other visceral organs, the liver is rela-
tively friable, has little elastic tissue, and is very vascular.
While clinicians may rate lacerations on a numeric scale
to describe severity, forensic pathologists usually assess
the anatomic location and general size of the traumatic
lesion. Large complex hepatic lacerations may cause
internal exsanguination within relatively short order
(minutes). Blunt traumatic injuries of other solid visceral
organs may, on some occasions, be the sole cause of
Injury, Fatal and Nonfatal: Blunt Force Injury 171
death, but are more commonly seen as contributing
factors in multiple blunt traumatic injuries. These organs
may include the spleen, the pancreas, the lungs, and the
kidneys. When the latter two are involved as the sole
cause of death, the injury pattern often involves dis-
ruption of the large vessels supporting these organs
(Bjurlin et al., 2014; Swaid et al., 2014; Bugaev et al.,
2014; Sivrikoz et al., 2014).
Aging of Injuries
Forensic physicians are frequently asked by investigators
to assess the age of a blunt-force injury. Commonly, a
forensic physician will be asked to assess the age
of bruises. Various old medical texts display charts
on the dating of bruises based on color. Many factors
affect the perception of color of bruises including: (1)
relative depth under the skin of bleeding; (2) volume
of hemorrhage; (3) environmental lighting; and (4)
overlying skin color. Aging of bruises is a notoriously
inexact process and the most authoritative published
work concerning the aging of bruises was published in
1991 in the academic journal Forensic Science Inter-
national. The paper written by Langlois and Gresham
(1991) is entitled ‘The ageing of bruises: a review and
study of the color changes with time.’ The authors
studied bruises of a known age in 369 subjects. They
concluded: “From this study it was only possible to
conclude that a bruise with a yellow color was more
than 18 h old.” They also state: “The colors red, blue
and purple/black could occur anytime within 1 h of
bruising to resolution (up to 21 days in this study).”
However another study showed a lack of interobserver
agreement in the reporting of yellow and emphasized the
variability in the perception threshold for yellow in the
general population and a subject’s ability to perceive
yellow in a bruise declines with age (Munang et al.,
2002). A review of all published data concerning
bruising in children concludes, “A bruise cannot accur-
ately be aged from clinical assessment in vivo or on a
photograph. At this point in time the practice of esti-
mating the age of a bruise from its color has no scientific
basis and should be avoided in child protection pro-
ceedings” (Maguire et al., 2005).
Recent research has involved investigation of
various immunohistochemical markers in an attempt
to narrow the time window further; however, no specific
marker has emerged to date. Even with microscopy,
individual variation exists. In summary, dating of
injuries in general, and contusions in particular, remains
an imprecise science. Although general comments and
subjective terms may be of use, precise timing of injury
duration is not possible with our current state of
knowledge and any professional who claims to be
able to age injuries with precision should be viewed with
skepticism.
 172 Injury, Fatal and Nonfatal: Blunt Force Injury
Summary
With the ‘bumps and scrapes’ of everyday life, blunt
injuries are undoubtedly the most common type of
trauma sustained by humans. More severe blunt trau-
matic injuries are significant causes of morbidity and
mortality, resulting in substantial loss of both product-
ivity and life.
Blunt trauma should be assessed and documented in
several ways as discussed elsewhere. Individual injuries
should be examined and described fully, in written, body
diagram and photographic form. The anatomic location
of the injury is noted. Patterns are assessed for consist-
ency with external objects and body contours. The in-
jury is examined in relation to, and in the context
of, the overall injury pattern. Historical information of
the causative event is then compared to the injury for
assessment of consistency with the size, shape, severity,
and distribution of the injury pattern. Proper docu-
mentation of specific information regarding blunt
injuries allows reassessment at later times and in-
dependent assessment by other parties. Availability of
appropriate records allows peer review and discussion.
Photographic documentation provides a permanent
representation of the injury in question and supplements
the written description and the drawn body diagrams.
Ideally, photographic documentation includes distant
images and close-ups. Photographic documentation is
variable and often poor, but guidelines are published
which advise on best practice (Evans et al., 2014a,b;
Payne-James et al., 2012).
In certain cases, it is often the small blunt injuries to
the external surface that provide more information to
the forensic investigator than the larger, lethal internal
injuries. Such small subtle injuries may help elucidate
the events leading to, or involved in, the death. Proper
appreciation of the importance of such injuries improves
the quality of forensic investigations. Adequate docu-
mentation of any injury allows proper interpretation
when the matter is addressed in the court room.
See also: Children: Physical Abuse. Deaths: Trauma, Abdominal
Cavity − Pathology. Deaths: Trauma, Head and Spine − Pathology.
Deaths: Trauma, Musculoskeletal System − Pathology. Deaths:
Trauma, Thorax − Pathology. Deaths: Trauma, Vascular System −
Pathology. Injury, Fatal and Nonfatal: Sharp and Cutting-Edge
Wounds
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