Accepted Manuscript

Title: Laryngohyoid Fractures in Suicidal Hanging: A

Prospective Autopsy Study with an Updated Review and
Critical Appraisal

Authors: Lenka Zátopková, Martin Janı́k, Petra Urbanová,

Jitka Mottlová, Petr Hejna

PII: S0379-0738(18)30297-4
DOI: https://doi.org/10.1016/j.forsciint.2018.05.043
Reference: FSI 9338

To appear in: FSI

Received date: 19-4-2018

Revised date: 19-5-2018
Accepted date: 26-5-2018

Please cite this article as: Lenka Zátopková, Martin Janı́k, Petra Urbanová, Jitka
Mottlová, Petr Hejna, Laryngohyoid Fractures in Suicidal Hanging: A Prospective
Autopsy Study with an Updated Review and Critical Appraisal, Forensic Science
International https://doi.org/10.1016/j.forsciint.2018.05.043

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Laryngohyoid Fractures in Suicidal Hanging: A Prospective
Autopsy Study with an Updated Review and Critical Appraisal

Lenka Zátopková1
Martin Janík2
Petra Urbanová3
Jitka Mottlová1
Petr Hejna1 

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1
Department of Forensic Medicine, Charles University, Faculty of Medicine and University Hospital
Hradec Králové, Czech Republic

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E-mail: hejnap@lfhk.cuni.cz
Tel.: 00420 495 836 829

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Fax: 00420 495 836 833
www.uslhk.cz
2
Institute of Legal Medicine and Medico-legal Expertise, Jessenius Faculty of Medicine, Comenius Uni-
versity, Martin, Slovakia
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Laboratory of Morphology and Forensic Anthropology, Department of Anthropology, Faculty of Sci-
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ence, Masaryk University, Brno, Czech Republic
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Highlights

 The prospective study file compromised 178 cases of suicidal hangings.

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 The overall incidence of laryngohyoid fractures reached 72.5% (129 cases).

 Isolated fracture(s) to the thyroid cartilage was the commonest lesion (33.7%).
 The highest frequency of fractures was found in lateral hangings.
 Statistics showed a significant association of their occurrence with the age.
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Abstract
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Laryngohyoid fractures in hanging victims are one of the most studied and paradoxically contradictory
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topics in forensic pathology. According to literary sources, the incidence of laryngohyoid fractures in
hanging varies significantly, from 0% to 100%. To verify the diagnostic significance of these injuries in
hanging, we prospectively and consecutively analyzed the occurrence of laryngohyoid fractures in
a group of 178 suicidal hanging victims (M/F = 150/28, aged 14-94 years, mean age = 50, complete
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suspension = 111 cases, partial suspension = 67 cases) in relation to selected variables (age, sex, weight,
the completeness of body suspension, and ligature knot location). Altogether, we identified the following
types of laryngohyoid fractures in 129 of 178 cases (72.5%): isolated fracture(s) to the thyroid cartilage
in 60 cases (33.7%), combined thyrohyoid fractures in 41 cases (23.0%), isolated fracture(s) to the hyoid
bone in 28 cases (15.7%), and no fractures to the cricoid cartilage or the cervical vertebrae. The highest
frequency of laryngohyoid fractures was found in lateral hangings (right lateral: 26/34, 76.5%; left
lateral: 31/37, 83.8%), whereas the lowest rate was found in anterior hangings (4/11, 36.4%). In lateral
hangings, fractures more often occurred contralaterally to the suspension point. Statistical analysis
revealed significant associations of the occurrence of laryngohyoid fractures with the age of the victim

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(p = 0.028), with the position of the ligature knot on the neck (p = 0.019) and with the age-corrected
weight of the victim (p = 0.026). In addition, we performed a systematic updated review and critical
appraisal of relevant literary sources to report the incidence, fracture patterns, and contributing variables
of laryngohyoid injuries in hanging. Both the results of our study and the provided literary synthesis
show that if evaluated properly, laryngohyoid fractures in hanging may diagnostically offer far more
than just evidence that injury to the neck occurred and may also present research opportunities regarding
several issues that should be further analyzed and explained.

Keywords

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hanging, fracture, hyoid bone, thyroid cartilage, autopsy, contributing variables

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Introduction

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Hanging represents a type of strangulation in which external constrictive forces affecting the neck
originate from the gravitational drag of the weight of a completely or partially suspended human body
[1-7]. Despite historically being one of the most studied forms of violent death in forensic pathology,
hanging remains a frequently debated topic, filling the pages of scientific journals and monographs [2,

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8-16]. The question 'why is it so?' may be answered by the significance of hanging as a mode of violent
death and its insidious similarity in postmortem presentation to other types of strangulation, which are
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mostly homicidal in nature (e.g., ligature strangulation, manual strangulation, palmar strangulation,
mugging, etc.).
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From an epidemiological perspective, hanging is a predominant suicidal method attempted globally by
both men and women [3, 5, 9, 10, 17-38]; accordingly, most hanging deaths are suicidal [2, 3, 5, 6, 10,
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18, 19, 39-43]. In childhood, hanging constitutes a relatively significant proportion of accidental deaths
[24, 39, 44-47]. Moreover, misadventurous hanging is the most frequent cause of unexpected death in
autoerotic paraphilias [13, 24, 47-51]. Although homicidal hangings are extremely rare, they can occur,
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either individually or as part of a murder-suicide scenario, if the victim is overpowered by force,

incapacitated by drugs and poisons, or if the perpetrator exploits the victim’s situational defenselessness
or uses a guileful strategy [5, 6, 9, 10, 24, 40, 42, 47, 52-65]. Additionally, hanging may be arranged
posthumously with the intent to simulate death by hanging or to dissimulate a violent death by other
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means [6, 47, 52, 66, 67]. Additionally, hanging remains the official execution method in many countries
throughout the world [26, 36, 68, 69]. Lastly, hanging and similar practices have become frightening
instruments of terror, lynching, and self-proclaimed law in many unstable or war-torn regions [70].
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According to long-term series, hanging represents the most common type of strangulation and one of
the most frequently investigated forms of violent death in forensic autopsy practice, accounting for an
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overall proportion of medico-legal autopsies of approximately 2.2–14% [2, 10, 24-26, 37, 41, 43-45, 47,
52, 68, 71-74].
From a wide range of internal injuries to the neck induced by hanging, forensic scientists have
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traditionally focused closely on laryngohyoid fractures [8, 75, 76], likely due to the following
motivations: (1) the diagnostic importance of laryngohyoid injuries in forensic autopsy practice, and
(2) the straightforward and meaningful academic concept of laryngohyoid lesions as a research topic.
Furthermore, injury mechanisms involved in laryngohyoid fractures are rather unequivocal, instant, and
mechanistic [8]. The amount of compressive forces applied to the neck can be calculated from the weight
of a suspended body. Moreover, the position of the ligature knot provides information regarding the
prevailing direction of affecting forces, and the course of the ligature(s) around the neck (or the furrow
on the neck) provides a clear impression of the anatomical level and spatial distribution of the applied
external pressure. The hyoid bone and laryngeal cartilages represent solid, anatomically interrelated and

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well-described structures whose injury patterns are predictable, deterministic, and nominal by nature
(fractured or non-fractured). The abovementioned facts together with the unquestionable diagnostic
significance of laryngohyoid fractures render a felicitous and requisite research theme for forensic
pathologists [76-81].
The first medico-legal studies concerning hanging deaths were mostly descriptive. From
a methodological perspective, they provided basic demographic and epidemiological data,
circumstantial observations, surveys of relevant external and internal findings [82-90], and occasionally
suicidal trends in the respective space-time [17, 21, 52, 53, 91, 92]. Some have also provided
conscientious descriptions of laryngohyoid injuries or other anatomopathological findings related to
hanging [21, 39, 81, 92-97]. Later studies, accompanied by those mainly interested in circumstantial
descriptions and autopsy findings [2, 10, 19, 24, 26, 36, 38, 41, 43, 47, 72, 74, 98-102], focused on

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factorial analysis of neck injuries in hanging [1, 3-5, 9, 16, 20, 22, 23, 25, 27-29, 37, 40, 42, 45, 66, 71,
73, 103-109]. Sporadic evaluative studies have compared the effectiveness of various investigative

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methods indicated for the detection of laryngohyoid fractures [3, 22, 110-114]. With the recent
expansion of cross-sectional imaging methods in postmortem diagnostics, further studies interested in

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injury patterns of the laryngohyoid complex in hanging deaths have emerged; however, few cases have
been evaluated thus far [76, 79, 80, 110, 115]. In addition, a few authors have sought to reconstruct the

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probable location of the ligature knot on the neck according to identified internal cervical injuries and
their patterns [1, 40, 104, 116]. Analogously, they attempted to identify traumatic changes to the neck
according to the position of the ligature on the neck or the completeness of body suspension. To date,
isolated studies have assessed morphological peculiarities of the hyoid bone and laryngeal cartilages

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(e.g., morphology, robustness, asymmetry, and calcification/ossification) with respect to their
susceptibility to fracturing during strangulation [117-120].
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Unfortunately, laryngohyoid fractures in hanging are not straightforward. Notwithstanding the overall
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frequency and the depth of knowledge regarding hanging, the incidence and injury patterns of
laryngohyoid fractures in hanging remain two of the most contradictory issues in forensic literature [16,
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23, 103, 106]. Even reference textbooks and manuals of forensic pathology do not concur on the
occurrence and diagnostic significance of laryngohyoid fractures in hanging [96, 97, 121-125], and
recent thematic studies also tend to differ in their results [16, 37, 43, 72, 74, 99, 110, 126]. Additionally,
studies involving factorial analysis of the occurrence of laryngohyoid fractures in hanging have various
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limitations such as retrospective designs, multi-institutional approaches, lack of standardized neck

autopsy procedures, insufficient numbers of subjects in study cohorts, absence of statistical evaluation,
intermixed data, and others.
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Some of these abovementioned shortcomings have prompted us to commence a prospective study

focused on injuries of the laryngohyoid complex in deaths by hanging. In the present study, we analyzed
the occurrence of laryngohyoid fractures as well as the causative roles of selected contributory variables
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(age, sex, weight of the person, location of the ligature knot, and completeness of suspension of the
body) to establish a prospective study file of suicidal hangings. In addition, we provided an updated
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review and critical appraisal of relevant literary sources. We sought to contribute to a better
understanding of the injury mechanisms of laryngohyoid structures in hanging and to potentially
establish a relevant basis of comparison for the complex evaluation of laryngohyoid injuries in other
traumatic events in the future.
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Materials and Methods

Our study materials included suicidal hanging cases registered to the Department of Forensic Medicine
in Hradec Králové (Faculty of Medicine in Hradec Králové, Charles University, Prague, Czech
Republic) over a consecutive period of three years. We predefined the following inclusion criteria: cause
of death – hanging; manner of death – suicide; resuscitation – no attempts; and postmortem interval
(PMI) before autopsy ≤ 120 hours. We set the following exclusion criteria: congenital or acquired

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anomalies of the laryngohyoid complex, hanging with partial or complete decapitation, lack of
circumstantial data, and significantly advanced decomposition.
The post-mortem diagnostic assessment of the study cases included the autopsy findings and results of
all indicated additional investigations (X-ray examination, histology, toxicology, etc.), which we
evaluated and interpreted in the context of reported circumstances (e.g., death certification protocols,
medical examiners’ statements, police reports of incidents with witness statements).
According to the completeness of bodily suspension, we categorized all study cases into two groups,
namely, A – complete suspension, and B – incomplete suspension. Additionally, we categorized the
cases into 4 subgroups according to the location of the ligature knot on the neck (suspension point) as
follows: I – posterior hanging: suspension point in the posterior midline; II – anterior hanging:
suspension point in the anterior midline; III – right lateral hanging: suspension point on the right side of

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the neck; and IV – left lateral hanging: suspension point on the left side of the neck.

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In all study cases, we applied the so-called ‘dry neck’ dissection approach for optimal evaluation of
cervical injuries with preparation of the neck after opening and evacuation of the cranial cavity and

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thoracic cavity. The first step involved visual and palpatory examination of cervical organs in situ and
their subsequent layer-by-layer anatomic preparation. The second step followed removal of the cervical

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organs from the body and included careful defleshing of the hyoid bone and laryngeal cartilages to fully
expose their osseous/cartilaginous surfaces. We determined the intravital origin of laryngohyoid
fractures by means of the visible hemorrhaging alongside the fracture sites and/or adjacent soft tissues.
The dissection process conformed to the recommendations of the European Council of Legal Medicine

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[15]. To minimize interindividual variability when evaluating autopsy findings, the senior author of the
study (PH) personally dissected or individually supervised every hanging case included in the study.
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The chi-square test of independence was the main tool used for the statistical evaluation (analyses
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provided using NCSS software for Windows). We considered p ≤ 0.05 a significant result and p ≤ 0.001
a highly significant result.
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To provide a timely systematic review of laryngohyoid fractures in hanging, we carefully searched

MEDLINE and Google scholar from the dates of their inception through Mar 2018, with no language
restrictions. We used the following search terms: hanging, hyoid bone, thyroid cartilage, cricoid
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cartilage, fracture, and autopsy. We also included studies and supplementary materials identified from
the references of the included articles. The electronic database searches were supplemented with manual
searches for key scientific textbooks and manuals in the field as well as previously published review
articles, conference abstracts, and archival data dedicated to this topic. When necessary, we contacted
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study authors to supplement incomplete reports of the original papers.

Results
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In the given 3-year period, the department registered a total of 2226 autopsy cases. Hanging cases
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constituted 8.3% of the department’s case load irrespective of the present study’s inclusion or exclusion
criteria (185 cases altogether).
The actual study group consisted of 178 cases of suicidal hanging that complied with the predefined
criteria (5 cases failed to meet the inclusion criteria and 2 cases complied with the exclusion criteria).
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Males (n = 150; 84.3%) outnumbered females (n = 28; 15.7%). The mean age of the individuals was
49.9 years. The youngest individual was a 14-year-old girl, and the oldest proband was a 94-year-old
female. One-quarter of the probands were younger than 25 years of age, and the same proportion was
older than 62 years. The weight of the subjects ranged from 46 to 130 kg. Ninety-six cases of typical
hanging (53.9%) and 82 cases of atypical hanging (46.1%) were included. Full-suspension hanging
accounted for 111 cases (62.4%), while incomplete hanging accounted for only 67 cases (37.6%). The
distribution of hanging cases in the subgroups according to the position of the knot on the neck was as

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follows: posterior hanging (I): 96 cases (53.9%); anterior hanging (II): 11 cases (6.2%); right lateral
hanging (III): 35 cases (19.7%); and left lateral hanging (IV): 36 cases (20.2%).

Incidence of laryngohyoid fractures

Of 178 cases, the authors identified laryngohyoid fractures in 129 cases (72.5%). At least one fracture
of the hyoid bone occurred in 69 cases (38.8%), whereas fracture of the thyroid cartilage occurred in
101 cases (56.8%). A total of 28 individuals (15.7%) showed an isolated hyoid bone fracture, 60 de-
ceased individuals (33.7%) had an isolated fracture of the thyroid cartilage, and 41 individuals (23.0%)
had a combined fracture of the thyrohyoid complex. The identified fractures were exclusively limited to
the greater horns of the hyoid bone and/or the superior horns of the thyroid cartilage. Altogether, 57
individuals (32.0%) had a single laryngohyoid fracture, 50 individuals (28.1%) showed a two-fold laryn-

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gohyoid fracture, and 16 deceased individuals exhibited a three-fold fracture (9.0%). A four-fold laryn-
gohyoid fracture was observed in only 6 cases (3.4%). Tables 1 and 2 present the incidences of laryn-

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gohyoid fractures within the study file in further detail.

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Occurrence of laryngohyoid fractures according to age
The mean age of individuals with a laryngohyoid fracture was 49.9 years, while the average age of

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persons with no laryngohyoid fracture was 50.1 years. The t-test failed to identify a significant
association between age and the occurrence of laryngohyoid fractures. After rearranging the probands
into two age cohorts (1: younger than 40 years, 2: older than 40 years), the chi-square test confirmed a

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significant association between age and the occurrence of laryngohyoid fractures, with injuries occurring
more frequently in the probands older than 40 years of age (p = 0.028). The same test identified a
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statistically significant association between age and the occurrence of fractures to the thyroid cartilage
(p = 0.006). In contrast, the test failed to prove this correlation independently for the hyoid bone (p =
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0.067).
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Occurrence of laryngohyoid fractures according to sex

Of 150 male probands, 109 (72.7%) exhibited laryngohyoid fractures. A similar proportion of fractures
was observed among female cases, with fractures identified in 20 of 28 cases (71.4%). The chi-square
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test revealed no significant association between gender and the occurrence of laryngohyoid fractures
(p = 0.999). The same test failed to reveal a significant relationship even when applied to the hyoid bone
(p = 0.687) or the thyroid cartilage (p = 0.712) individually. When the ages of the victims were
considered, the chi-square test for four-pole pivot tables failed to show any significant association
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between sex and the incidence of laryngohyoid fractures (p = 0.768).

Occurrence of laryngohyoid fractures according to weight

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The average weight of the probands with a laryngohyoid fracture was 78.7 kg, and the average weight
of the probands with no laryngohyoid fracture was 74.3 kg. The t-test showed no significant association
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between the weights of the victims and the occurrence of laryngohyoid fractures (p = 0.070).
Nevertheless, the independent statistical assessment demonstrated a significant association between the
weights of individuals and the occurrence of fractures to the thyroid cartilage (p = 0.037), but no such
association was demonstrated for the hyoid bone (p = 0.211). After age correction (see the variable of
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age above), the chi-square test for four-pole pivot tables confirmed a significant association between the
weights of the victims and the incidence of laryngohyoid fractures (p = 0.026).

Occurrence of laryngohyoid fractures according to the type of suspension

The incidence of laryngohyoid fractures in the full-suspension group was 75.7% (84 of 111 cases), while
the incidence in the incomplete suspension group was 67.2% (45 of 67 cases). The chi-square test did
not show a significant association between the completeness of suspension and the occurrence of
laryngohyoid fractures (p = 0.230). Therefore, the occurrence of laryngohyoid fractures was independent

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of the type of suspension. The individual statistical assessment for the hyoid bone and thyroid cartilage
did not show any significant relationship (p = 0.194 and p = 0.996, respectively). After age correction,
the chi-square test for four-pole pivot tables failed to demonstrate any significant association between
the type of suspension and the incidence of laryngohyoid fractures (p = 0.556).

Occurrence of fractures of the laryngohyoid complex according to the position of the knot
The highest number of laryngohyoid fractures was found in the left lateral hanging (IV) group, with
fractures identified in 31 of 37 cases (83.8%). In the right lateral hanging (III) group, fracturing of the
laryngohyoid complex was evident in 26 of 34 cases (76.5%). In the posterior hanging group (I), at least
one laryngohyoid fracture was evident in 68 of 96 cases (70.8%). In the anterior hanging group (II), at
least one laryngohyoid fracture occurred in 4 cases (36.4%; all were complete suspensions). For further

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details, see Tables 3 and 4.

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The chi-square test identified a significant relationship between the location of the knot on the neck and
the occurrence of laryngohyoid fractures (p = 0.019). Nevertheless, the individual statistical assessment
did not confirm a significant relationship between the location of the knot on the neck and the occurrence

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of fractures to the hyoid bone (p = 0.100) or the thyroid cartilage (p = 0.390).

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Of the observed variables, only age (p = 0.028) and the position of the ligature knot on the neck (p =
0.019) were found to have statistically significant associations with the occurrence of fractures of the
laryngohyoid complex in hanging. In addition, after age correction, body weight was found to have a
statistically significant association with the occurrence of laryngohyoid fractures (p = 0.026).

Discussion
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1. Laryngohyoid fractures – not only hanging
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Injuries to the anterior neck structures constitute a sempiternal topic in forensic pathology. In particular,
laryngohyoid fractures are one of the most important findings in the autopsy practice of any
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knowledgeable forensic physician [122], serving as a sign to the dissecting pathologist to question the
actual cause and manner of death. However, they do not represent severe injuries on their own, but they
have strategical importance from an investigative perspective as they may imply substantial violence
against the neck and its vital structures [76, 127]. Especially in strangling incidents, laryngohyoid
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fractures account for considerable compression of the neck and may indicate both the direction and
intensity of the affecting blunt forces [8, 128-130].
Strangulations, particularly throttling and homicidal ligature strangulation, are the most common cause
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of laryngohyoid fractures [111, 131, 132]. Nevertheless, these fractures can occur in any case of blunt
force injury either as an isolated trauma event or more frequently as part of more complex damage to
the head and/or neck [95, 111]. They can develop due to a direct blunt impact or as a result of an indirect
mechanisms causing strong muscle strains, or they can be attributed to both mechanisms (e.g., falls from
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height, agonal falls, traffic accidents, sport accidents, accidental blows, or assaults) [95, 103, 133-153].
Their less common causes include cervical or cranial penetrating injuries such as sharp force trauma,
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impaling injuries, gunshot injuries, explosions [139, 154, 155], or specific medical procedures involving
the neck (e.g., endotracheal intubation, triple airway maneuver, or the Sellick maneuver) [133, 139, 156-
159]. A higher incidence of laryngohyoid fractures was observed in cases of battered alcoholic syndrome
and in chronic alcoholics [131, 160]. Additionally, sporadic reports of stress fractures to the hyoid bone
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induced by intense muscle contractions such as by vomiting/retching, forcible swallowing, and yawning
have been found [161-163]. Further category of laryngohyoid fractures includes those generated by
pathological processes, such as tumorous infiltration or osteonecrosis [164, 165].

2. Incidence of laryngohyoid fractures in hanging

Surprisingly, the occurrence of laryngohyoid fractures in hanging cases represents one of the most con-
tradictory issues in forensic pathology [8, 166]. According to the literature, the frequency of laryngohy-
oid fractures varies considerably, from 0% to 100%, with recent thematic analyses revealing differing

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results [10, 16, 28, 37, 42, 43, 72, 74, 100]. Numerous authors have concluded that the incidence of
laryngohyoid fractures in hanging ranges from somewhat often to frequent or even regular [2-5, 10, 19,
22-24, 27-29, 36, 38-42, 47, 53, 66, 71, 73, 76, 79-81, 83-85, 87-91, 93, 95-99, 103, 105-112, 114, 115,
126]. Such speculations contradict studies showing that the occurrence of fractures in less than 15% in
hanging cases [9, 16, 18, 21, 25, 37, 43, 74, 82, 86, 92, 94, 100, 113, 122, 167-170]. However, some
authors have failed to identify a single laryngohyoid fracture even within extensive study files of hang-
ing cases [17, 20, 25, 26, 52, 72, 75, 171]. A meta-analysis of available studies by Godin et al. corrobo-
rated a mean incidence of 37% for laryngohyoid fractures in hanging. For more details, see Tables 5 and
6.
Most authors have reported that the thyroid cartilage is more susceptible to fracturing in hanging than
the hyoid bone or any other tracheolaryngeal structures [4, 5, 18, 39-41, 53, 66, 79, 81, 84, 86, 91, 93,

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95, 96, 105-111, 114, 122, 123, 126, 167, 172]. In contrast, some studies have found an equal or even
higher incidence of hyoid fractures [2, 3, 8-10, 16, 19-25, 27-29, 36-38, 42, 45, 47, 71, 73, 74, 80, 85,

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87-89, 92, 94, 98-100, 112, 113, 115, 170]. The meta-analysis by Godin et al. demonstrated that isolated
fractures of the superior thyroid horn were the most common type of laryngohyoid fracture in hanging

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victims [66]. Isolated fracture of the greater horn of the hyoid bone was the second most frequently
identified fracture, followed by combined thyrohyoid fracture [66]. In our study file, isolated fracture of

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the superior thyroid horn was the most common type of laryngohyoid fracture. Combined thyrohyoid
fracture was the second most frequently identified type of fracture, followed by bilateral fracture of the
superior thyroid horns and then isolated fracture of the greater hyoid horn. For more details, see Table 2.

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Fractures to the epiglottis, hyoid body, thyroid plates, inferior thyroid horns, cricoid cartilage, or the
cervical part of the trachea sporadically occur in hanging [9, 18, 22, 23, 73, 84, 85, 91, 93, 95, 106-109,
126, 166, 173, 174], none of which were identified in our study file. Unexpectedly, a prospective study
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by Sharma et al. revealed a higher incidence of fractures to the thyroid plates than to the superior thyroid
horns. The authors rationalized that this difference may be due to the prevailing use of soft materials for
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ligatures by suicide victims (e.g., sarees and chunnis), which may produce broader constricting bands
and therefore more extended pressure over the anterior neck structures [73]. In a comparative study of
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hanging and non-hanging strangulations, Godin et al. failed to identify any fracture to the cricoid
cartilage in the hanging group, whereas the incidence of cricoid cartilage fractures was 20.6% in non-
hanging strangulations [66]. Consequently, the same authors considered cricoid fractures in alleged
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suicidal hangings to be a highly suspicious finding and suggested that these fractures were an indication
of homicide, which should alert every dissecting pathologist to conduct further circumstantial
investigations in these cases [66]. By contrast, Khokhlov used stereomicroscopy to identify fractures of
the cricoid cartilage in 13 individuals in a prospective file containing 137 suicidal hanging cases (9.5%)
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[111]. Similarly, Missliwetz described 13 cases exhibiting fractures to the cricoid cartilage in the
prospective study consisting of 500 hanging cases (2.6%) [93]. For more details, see Tables 5 and 6.
We might ask, ‘What is causing the divergence among reported data regarding laryngohyoid fractures
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in hanging?’, but no single clear-cut answer exists. Many authors believe that the timing of research
studies may play an important role in the conflicting reports [8, 22, 28, 41, 103, 106]. Paparo and Siegel
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and later Sharma et al. clearly demonstrated how a difference in the occurrence of laryngohyoid fractures
might affect both retrospective and prospective approaches even within the confines of one department
of forensic medicine [41, 109]. Prospective studies are extremely motivated by issues that define the
purpose of their research scope; we can safely conclude: ‘Seek and ye shall find.’ In retrospective stud-
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ies, scientists analyze existing de facto data that were not collected with the primary intention of possible
further research [8]. Accordingly, most prospective studies have revealed a higher proportion of laryn-
gohyoid fractures in hanging than retrospective studies [22, 27, 84, 97, 106]. For more details, see Tables
5 and 6. Nevertheless, one exception is a study by Hlavaty et al., which did not confirm a greater pro-
portion of internal injuries in prospectively studied hanging cases than in retrospectively analyzed hang-
ing cases [16].
Another factor related to the abovementioned discrepancies in the occurrence of laryngohyoid fractures
in hanging in the literature may be the consistency of study groups [28, 93, 99, 105, 126]. Individuals

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across referenced studies cannot possibly be demographically, ethnically, and constitutionally homoge-
nous or have used the same technique to commit their suicide acts. Several authors have unanimously
emphasized a causative role of the variability of the age distribution within study files, which is sup-
ported by the results of our study [6, 22, 74, 109, 126]. Some authors have demonstrated preferential
usage of soft materials for hanging ligatures (e.g., sarees, chunnis, pajamas, or pants), which is not
a consistent modus operandi for all regions in the world [26, 73, 74]. We can propose other composi-
tional factors with potential causative roles, such as the predominant sex, preponderant race, prevalent
body habitus, preferred type of ligature knot, prevailing hanging techniques, and others. Moreover, we
must consider all unpredictable random influences and inherent vagaries surrounding each case of hang-
ing that can modify post-mortem findings [71].
Additionally, the thoroughness of autopsies varies from case to case and from department to department,

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with no exception for hanging cases [4, 22, 25, 28, 36, 41, 103, 105, 109]. The authors of the article
have witnessed all possible approaches and techniques of ‘how to dissect a laryngohyoid framework’,

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from meticulous skeletonisation to imprecise examinations that are sometimes even reduced to a palpa-
tory evaluation with no dissection at all. Unfortunately, forensic pathology lacks internationally binding

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standards for autopsy proceedings and benchmark comparisons that the entire global forensic commu-
nity should consistently follow [19, 41, 111]. We reason that some data concerning laryngohyoid frac-

SC
tures may be overestimated if researchers included cases with non-vital laryngohyoid fractures in their
files [3, 103].

3. Morphology of laryngohyoid fractures

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Medical dictionaries define the word ‘fracture’ as damage to the continuity of the bone or cartilage.
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Nonetheless, the character of laryngohyoid fractures in hanging is not monotonous as their injury pat-
terns vary from complete disruption across simple dislocated breaks to undislocated fractures, small
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infractions and scarcely visible fissures [36, 121]. Forensic pathologists’ meticulousness in scrutinizing
and categorizing laryngohyoid injuries in their study cases remains indeterminate; we can only hypoth-
M

esize that researchers equipped with various investigative tools (e.g., X-ray, post-mortem computed to-
mography and micro-tomography, and dissection stereomicroscopy) can reveal more concealed laryn-
gohyoid injuries than researchers using standard diagnostic approaches.
ED

Weintraub discerned three basic types of fractures of the hyoid bone [175]. The first type is inward
compression fracture, which occurs due to lateral compressive forces that break and dislocate one or
both greater horns of the hyoid bone towards its mid-longitudinal axis and may simultaneously over-
PT

stretch and breach the periosteum on the outer side of the fractured bone structure(s). In the second type
of fracture, namely, antero-posterior compression fracture, the affecting forces break and dislocate one
or both greater horns of the hyoid outward. Accordingly, the periosteum may be torn on the inner side
E

of the injured hyoid horn(s). A combined inward-outward compression fracture to both greater horns of
the hyoid bone may also manifest. The last injury pattern encompasses traction fractures (also known as
CC

tug fractures or avulsive fractures) that occur due to soft tissue pulling rather than direct injury to the
bone [172]. The final position of broken fragments and the character of fractures both allow further
deductions and implications. All three types of hyoid fracture can occur in hanging. The clinical classi-
fication of hyoid bone fractures proposed by Lakhia et al. distinguishes the following types: fracture of
A

the body (mainly due to direct trauma), fracture of the lesser horn, and fracture of the greater horn [140].
Horn fractures can be further classified as closed (displacement inward/outward) or compound (dis-
placement externally/into the pharynx). We assume that the thyroid horns and the hyoid bone yield to
similar fracturing mechanisms. Nevertheless, we failed to find any usable classification for fractures of
the thyroid cartilage in the relevant literature. No researchers have scrutinized the possible diagnostic
significance of thyrohyoid fracture patterns or fracture micromorphology in various types of strangula-
tion (or blunt trauma events in general) and the occurrence of various types of fracture with respect to
selected variables. We believe that this particular topic would benefit from further research.

8
The morphologic features and localization of laryngohyoid fractures in hanging are not well presented
in the scientific literature [8]. For the hyoid bone, fractures can occur anywhere alongside the greater
horns (but most often on the borderline between the middle and distal thirds), at the junction between
the greater horns and the body of the hyoid bone, and rarely in the hyoid body itself [80, 119, 120, 176].
Fractures to the hyoid body sporadically appear in hanging cases. Multiple or multilevel fractures of the
hyoid bone, especially its greater horns, are possible. Fractures may be either complete or incomplete,
and the usual fracture patterns are oblique or transverse lesions. For the thyroid cartilage, fractures pri-
marily appear at the superior horns [28, 96]. In experiments, Bockholdt et al. demonstrated that these
fractures are typically located near the base of the horn [177]. Naimo et al. confirmed that the base of
the superior horn was a vulnerable site for fractures via postmortem computed tomography (pmCT)
[79]. Khokhlov observed these fractures mostly in the base or inferior third of the superior horn (in 66%

T
of cases) [111]. Bilateral fractures of both superior horns occur often [121]. Fractures are usually in-
complete, but complete separations can also appear. The fracture pattern of the thyroid cartilage is often

IP
analogous to that of the hyoid bone. Fractures to the inferior thyroid horns or thyroid plates occur rarely;
they have primarily been reported in hanging cases in which broad soft ligatures were used [3, 73].

R
Few studies have evaluated morphological peculiarities of the hyoid bone and laryngeal cartilages (e.g.,
morphology, robustness, asymmetry, and calcification/ossification patterns) in terms of their suscepti-

SC
bility to fracturing in strangulations or blunt injury in general [101]. Pollanen et al. noted that morpho-
logical characteristics such as the length of the hyoid bone or the steepness of the greater horns were
influential in the occurrence of hyoid fractures [118, 178]. After collaborating with Ubelaker, Pollanen

U
later contradicted the original statement [118, 119]. Mukhopadhyay identified three morphometric de-
terminants of the hyoid bone (width, anterior-posterior length, and length of the greater horns) that can
N
differentiate fractured and non-fractured hyoids in hanging cases [120]. A study by Urbanová et al.
suggested potential interactions between hyoid bone morphology and the mechanism of hyoid damage,
A
revealing that V-shaped hyoids were more prone to fractures in violent deaths than U-shaped hyoid
bones [117]. Coincidently, these morphological types also reflect patterns of the sexual dimorphism
M

observed in hyoid bones.

Anatomical variations, congenital defects, and acquired anomalies of the hyoid bone and laryngeal car-
tilages further complicate evaluations of laryngohyoid injuries [79, 96, 110, 179]. Agenesis of the thy-
ED

roid superior horn(s) or the hyoid lesser horn(s) may give the impression of fracture and/or separation
[106, 180, 181]. Similarly, developmental fragmentation of the superior horn or the presence of larger
triticeal cartilage or carotid atheroma may also imply a laryngohyoid fracture [41, 92, 106, 182-184].
Inexperienced forensic pathologists often confuse flexible joints between the hyoid body and its greater
PT

horns or the elastic connections of the thyroid superior horns with the thyroid body for fractures [80,
106, 123, 173]. Additionally, other thyrohyoid anatomical peculiarities, such as fusion of the thyroid
superior horns with the hyoid greater horns or ossification of the stylohyoid ligament (Eagle syndrome),
E

may render thyrohyoid structures more susceptible to trauma. For instance, Naimo et al. detected anom-
alies of the thyroid cartilage via pmCT in 180 cases of 431 investigated individuals (41.8%) [79]. In
CC

particular, inexperienced forensic pathologists may misinterpret various artifacts, anatomical idiosyn-
crasies, developmental changes, and acquired lesions of the laryngohyoid complex and erroneously
evaluate them as existing fractures and vice versa [131, 179].
A

Another issue is the vitality of laryngohyoid fractures identified at autopsy, or via stereomicroscopy or
post-mortem imaging. According to classical forensic pathology textbooks and manuals, a laryngohyoid
fracture must express some gross and/or microscopic hemorrhaging at the sites of the break to be judged
as vital [96, 103, 123]. Bleeding usually has a glare in osseous and cartilaginous tissues, beneath the
periosteum or perichondrium, or in adjacent soft tissues [16, 123]. In other instances, hemorrhaging may
be less conspicuous and require histological verification [123, 185]. The vital origin of laryngohyoid
fractures may indicate complementary histological features such as an inflammatory reaction and fibrin
depositions [185]. Unfortunately, post-mortem experiments have been able to produce laryngohyoid
fractures with accompanying extravasations that were indistinguishable from vital hemorrhaging [186].

9
Additionally, decomposition can both mask and mimic hemorrhaging at the fracture lines, thus preclud-
ing objective evaluation [185].
Researchers usually defined how they addressed fracture vitality in their study files [3-5, 16, 22, 25, 40,
53, 66, 75, 81, 83, 84, 96, 103, 106, 109-112, 115, 167], while other authors did not mention this issue
in their respective methodologies or discussions [2, 9, 10, 17-29, 36-39, 41-43, 47, 52, 71-74, 79, 80,
82, 84-89, 91-95, 98-100, 103, 105, 107, 108, 113, 114, 126, 171]. Post-mortem laryngohyoid fractures
can occur; they may occur due to prolonged suspension time, resuscitation attempts, body extrication,
manipulation and transportation, strong-arm external examination or incautious evisceration and dis-
secting techniques [22, 28, 38, 106, 123, 187]. In contrast, blood perfusion in the neck may be limited
due to the forceful constriction that occurs in typical complete hangings; thus, interstitial hemorrhaging
may be minimal or completely absent in definite vital hanging cases [106]. In addition, laryngohyoid
fractures may develop in association with terminal convulsing, thus occurring relatively late when cir-

T
culation becomes inefficient [3, 106]. Careful handling of the body before autopsy and vigilant post-

IP
mortem examination minimize the risk of artifactual laryngohyoid injury. In addition, scanning of the
body prior to autopsy may conceivably exclude possible dissection-related artifacts.

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4. Detection of laryngohyoid fractures

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Forensic pathologists have used a wide spectrum of investigative instruments to detect laryngohyoid
fractures. Standard diagnostic procedures include careful inspection of the laryngeal prominence, gentle
neck palpation, conscientious evisceration, and careful dissection of cervical organs with skeletonisation
of the laryngohyoid framework. Therefore, some authors strongly advocate preparation and meticulous

U
skeletonisation of the hyoid bone and laryngeal cartilages in a laboratory setting [19, 111, 188]. In all
suspicious cases, pathologists are advised to evaluate neck structures after opening and evacuating the
N
cranial cavity and after removing intrathoracic organs in the avascular field (so-called ‘dry neck’ dis-
section). However, the pulling and rending of cervical structures during evisceration can easily produce
A
artificial injury and even accidental severing of the most prominent and fragile elements of the laryngo-
hyoid complex. Maxeiner noted the disadvantage of forceful, blunt opening of the larynx after scissoring
M

its posterior wall in the standard autopsy procedure [189]. By using such a technique, one may easily
overlook fissures and non-dislocated fractures of the cricoid cartilage and infractions to the posterior
part of the anterior commissure of the thyroid cartilage [189]. For optimal evaluation of laryngohyoid
ED

injuries, Adams et al. recommended anatomic layer-by-layer dissection with in situ inspection of the
cervical structures [190].
Stereomicroscopy is another effective diagnostic method for revealing inconspicuous laryngohyoid frac-
PT

tures. Higher magnification and an out-of-body approach in the laboratory setting allow better structure
exploration and diagnostic precision [19]. Stereomicroscopy excels in uncovering undislocated fractures
and barely visible infractions and fissures [36]. Khokhlov corroborated that stereomicroscopy diagnos-
tically surpasses visual and palpatory examination of the laryngohyoid complex and represents the ‘gold
E

standard’ for detecting ‘hidden’ fractures of the laryngohyoid framework and trachea [8, 111]. Similarly,
CC

Kováčová et al. concluded that among all modern imaging techniques (e.g., scanning electron micros-
copy and laser scanning), stereoscopy should be regarded as the method of choice for examining dry
skeletal trauma of the laryngohyoid complex, mostly due to its cost- and time-effectiveness [191]. Re-
cently, other authors have noted that routine visual and palpatory investigations are only helpful for
A

orientation and declared that stereomicroscopy is a definitive diagnostic tool for revealing laryngohyoid
lesions [3, 10, 19]. Stereomicroscopy enhanced with 1% toluidine blue solution highlights fractures in
a bluish color. However, Charoonnate et al. concluded that toluidine-blue stereomicroscopy lacks oper-
ating flexibility, reducing its diagnostic advantages to some extent [3]. Most recently, Scheirs et al.
developed a non-destructive capillary action-based method to enhance fracture lines and bone defects
by coloring the bones with Talens® black Indian ink. This easy-to-use method enables detection of
barely visible laryngohyoid fractures and their subtyping [192].

10
Traditional X-ray examination and more recently pmCT, micro-computed tomography (microCT),
nano-computed tomography (nanoCT) and 3D printing are additional diagnostic modalities that allow
accurate forensic exploration of the laryngohyoid complex both in living and deceased subjects with
high diagnostic exactitude and objectivity [110, 112-114, 129, 193, 194]. Preliminary pmCT studies
focusing on strangulation deaths have shown a considerable diagnostic yield, albeit in a limited number
of probands [79, 80, 110, 112]. Yen et al. and Kempter et al. demonstrated that pmCT may reveal laryn-
gohyoid fractures that classic autopsy did not detect [110, 115]. More recently, Schulze et al. proposed
a gas bubble sign visible on pmCT as a valuable indicator of laryngohyoid fracturing in non-putrefied
bodies. The same authors disclosed that this particular finding may facilitate not only postmortem eval-
uations but also investigations of clinical cases of strangulations [76]. In addition to cervical injuries,
cross-imaging techniques reveal information concerning the spatial relationships among the laryngohy-

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oid elements, their developmental anomalies and general morphological and structural characteristics
[79, 80]. In addition, images processed before autopsy can reveal the positions of laryngohyoid frag-

IP
ments, which may change during further investigations, and help exclude laryngohyoid fractures possi-
bly generated by a hasty evisceration technique [25, 41]. Accordingly, cervical imaging not only serves

R
as a reliable visual guide for a dissecting pathologist to discern which structures are injured and how to
modify further dissection, but also acts as an independent inner check unbiased by the individual

SC
pathologist. Some authors have advocated X-rays of the evacuated laryngohyoid complex [111, 195].
Finally, ultra-modern imaging techniques, such as microCT and nanoCT, enable assessment of laryn-
gohyoid fractures at the microscopic level, providing access to detailed characteristics of bone tissue
reactions to affecting forces, and allow descriptions of damage in terms of microcrack trajectory, crack

U
density, or crack branching [191]. By employing the strengths of both classical and virtual diagnostic
approaches, we may be able to carry out a rigorous and complex study of laryngohyoid injuries in hang-
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ing deaths.
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5. Factorial analysis of laryngohyoid fractures in hanging
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From a theoretical perspective, injuries to cervical structures in hanging depend on three significant
variables: (1) pressure – the gravitational force, (2) aim – the ligature, and (3) target – neck structures.
The first and most critical variable is the total amount of gravitational force squeezing the neck, which
equals the weight of suspended body mass multiplied by its acceleration. Greater compressive force on
ED

the neck corresponds to more extensive damage to cervical structures. Regardless of all other variables
and circumstantial factors, decapitations in drop hangings have confirmed this simple relationship [77,
196]. The topographical distribution of the squeezing pressure around the neck represents the second
variable [18]. Understandably, anterior or posterior hangings with different types of ligatures may lead
PT

to different injury patterns of the neck as the points of maximum strain are dissimilar. Finally, the third
variable is the general susceptibility of the laryngohyoid complex to mechanical damage depending on
its specific anatomy, topoanatomical relationships, shape, robustness, pliability, and degenerative
E

changes.
CC

Forensic pathologists have sought to explain the variability in the occurrence of laryngohyoid fractures
in hanging by evaluating a wide range of contributing variables such as age, gender, weight, complete-
ness of body suspension, type of ligature, width of the ligature, the number of wraps, the course of the
ligature around the neck, location of the ligature knot, the type of ligature noose, and suspension time
A

[4, 22, 23]. A brief critical appraisal of these contributing variables is presented below.

5.1 Age
With increasing age, the structures of the laryngohyoid complex lose their elasticity and become more
mineralized and brittle and therefore more susceptible to mechanical damage [5, 78, 79, 167]. Most
studies, including ours, have statistically confirmed a significant association between the age of hanged
individuals and the incidence of laryngohyoid fractures [3-5, 9, 18, 22, 27-29, 36, 38, 40, 42, 47, 66, 71,
73, 93, 96, 99, 103, 105-107, 109, 126, 167, 172]. By contrast, Davison and Marshall’s study evaluating

11
105 suicidal hangings identified laryngohyoid fractures in 47 suicide victims, including 22 individuals
under the age of 40 years and 25 subjects over the age of 40 years [39]. Luke et al. found that laryngo-
hyoid fractures tend to be age-independent in free suspension hangings, while they tend to be progres-
sively age-dependent with lesser degrees of suspension and increasing support [71]. Samarasekera and
Cooke demonstrated a higher incidence of laryngeal injuries in individuals over 40 years of age regard-
less of the degree of suspension [107]. Ronge et al. observed higher frequencies of both hyoid and thy-
roid fractures in relation to age in females but not in males [29]. Surprisingly, a few authors did not
confirm age as a significant factor for laryngohyoid fractures in hanging [23, 39, 79, 108].
Age-related changes of the hyoid bone and laryngeal cartilages include alterations in size, shape, geom-
etry, pliability and mechanical integrity. The hyoid bone originates from six ossification centers, two
each in the body, greater horns, and lesser horns. The connection between the hyoid body and both

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greater horns is flexible after birth as it functions as a diarthrosis, or an articulated junction [80, 176].

IP
Moreover, an inexperienced pathologist may mistake a flexible junction for a fracture [75, 80]. Bony
fusion between the greater horns and the hyoid bone rarely occurs before the age of 20 years [96]. In
some individuals, these connections remain mobile throughout their entire lives [80]. Miller et al. de-

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scribed bilateral non-fusion in nearly 30% of individuals who were 70 years of age or older [197]. Before
total ankylosis, the hyoid bone tends to fracture at locus minoris sites of ongoing bony fusions [159,

SC
198]. Once bony fusion is complete, the probability of fracturing increases, and fractures tend to appear
alongside the greater horns [80, 118, 119, 128, 178]. Fractures are most commonly found in the posterior
two-thirds of the greater horns [8, 80, 120, 128, 176]. Nevertheless, in experiments involving artificial

U
crushing of hyoid bones embedded in resin, Lebreton-Chakour et al. observed fractures at the junction
between the body and the greater horns in 48% of cases, alongside the distal part of the greater horns in
N
49% of cases, and at the median part of the hyoid body in the remaining 3% of cases [199]. Naimo et al.
revealed that in hanging fractures, the incline occurs at a mean angle of 50° between the hyoid body and
A
the greater horn [80].
The thyroid cartilage begins to calcify after adolescence and then develops in sexually dimorphic pat-
M

terns [79, 200]. In males, thyroid calcification begins earlier and progresses more rapidly and com-
pletely. The inferior thyroid horns calcify completely between 21 and 26 years of age. The superior
thyroid horns calcify between 25 and 31 years of the age. Total calcification of the lower parts of both
ED

thyroid laminae appears at approximately 40 years of age. In the first half of the 5th decade of life,
paramedial pegs arise on both thyroid plates and form posterior windows. During the second half of the
5th decade of life, a middle peg emerges in the anterior midline, which later transverses the thyroid plate
upward in the first part of the 6th decade of life, thus constituting the anterior windows. In males, calci-
PT

fication of the thyroid cartilage culminates at approximately age 60. Conversely, female thyroid carti-
lages calcify more slowly and incompletely. Calcification of the inferior horns starts after the age of 28
years on average, and mineralization of the superior horns appears 30 years later. The anteromedial parts
E

of both thyroid plates often remain relatively flexible for the entire life of an individual (the typical
anterior and posterior windows do not develop) [79]. The cricoid cartilage calcifies with age only par-
CC

tially [5]. Additionally, some portions of the stylohyoid ligament ossify in both sexes; the entire hyoid
apparatus rarely becomes ossified [176].
A

5.2 Sex
Sexually dimorphic patterns of calcification of the thyroid cartilage and ossification of the hyoid bone
strongly imply the possibility of dissimilar impacts of compressive neck forces on the integrity of the
laryngohyoid complex in hanging [120, 198, 201]. Several autopsy studies have confirmed a higher
incidence of laryngohyoid fractures in males [4, 9, 25, 66, 73, 106, 107, 126]. Nonetheless, several other
studies have revealed no significant relationship between gender and the occurrence of laryngohyoid
fractures [5, 23, 37, 42, 71, 105, 167]. Duband et al. substantiated a higher occurrence of fractures in
males, although only in the thyroid cartilage [28]. In their bifurcated study, Paparo and Siegel revealed

12
a surprisingly higher incidence of laryngohyoid fractures among women; the authors were unable to find
a plausible explanation for this result [109]. A female predominance was also observed by Morild [22].
Clement et al. stressed the necessity of interpreting the relationships among all contributing factors,
including sex, and the occurrence of laryngohyoid fractures in relation to age [126].
In addition to sexually dimorphic calcification patterns, both laryngeal cartilages and the hyoid bone
exhibit sex-related differences in morphological features, robustness, and topoanatomical relations [109,
159, 198]. Moreover, certain gender-related differences regarding preferred ligature types and hanging
‘techniques’ can be speculated. On average, males weigh more than females, and they have more devel-
oped cervical musculature [22, 109].

5.3 Body weight

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Because of body suspension, the weight of a human body plays a major role in the pathogenetic mech-

IP
anisms involved in hanging. A heavier human body may reasonably correspond to a greater strain on
the neck in hanging. In full-suspension hangings, the weight of the body is completely engaged and

R
places a load on the ligature, constricting the neck; therefore, body weight should be naturally linked to
the frequency and multiplicity of laryngohyoid fractures (heavier vs. lighter individuals). Conversely,

SC
in incomplete hangings, the weight of the body seems to be an inconsequential variable as only the
weight of the suspended body acts upon the ligature and contributes to the final compressive force [3,
202]. In these cases, body weight should be considered only proportional to the type of partial suspen-
sion (e.g., standing, kneeling, sitting, or recumbent position) [202].

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The circumferential tension required to occlude the jugular veins has been experimentally shown to be
N
2 kg (19,6 N). Similarly, for occlusion of the carotid arteries, 5 kg (49,1 N) is required. For the trachea,
15 kg (147,2 N) is required for occlusion, and for the vertebral arteries, 30 kg (294,3 N) is required [96].
A
Experiments by Bockholdt et al. including 229 cases of artifactual crushing of the thyroid cartilage
showed that the mean weight necessary to fracture the thyroid superior horn was 3 kg (29,4 N) – men:
M

3,3 kg (32,4 N), women: 2,6 kg (25,6 N). The required compressive force was also dependent on the
degree of ossification of the thyroid cartilage [177]. Lebreton-Chakour et al. reported that the mean force
required to fracture the hyoid bone was approximately 3 kg (2,4 N), and greater compressive force was
ED

required in specimens from younger individuals and from probands with a slighter build [199]. In ex-
periments with fresh human larynges, Travis et al. estimated that the mean force required to fracture the
thyroid cartilage was 14,3 kg (140,3 N), whereas a force of 18,8 kg (184,4 N) was required to fracture
the thyroid cartilage [203].
PT

Few studies have explored body weight as a causative variable in the production of laryngohyoid frac-
tures in hanging [9, 28, 37, 71, 126]. In a retrospective study comprising 632 fully autopsied cases of
hanging, Tugaleva et al. failed to identify laryngeal and hyoid fractures in individuals lighter than 50
E

kg. Moreover, the same study revealed that the incidence of laryngohyoid fractures in deceased subjects
CC

with a normal or below-normal body mass index was half of that in the overweight and obese population
[9]. Clement et al. demonstrated that hanging victims with fractures are taller and heavier than those
without fractures [126]. Duband et al. documented a higher incidence of hyoid fractures in obese indi-
viduals. Consistent with these authors, we confirmed a significant association between the weights of
A

individuals and the occurrence of laryngohyoid fractures. In contrast, Luke et al. demonstrated that
laryngohyoid fractures were independent of height and weight in a prospective study of 61 hanging
cases [71].

5.4 Suspension of the body

The force responsible for tightening of the loop in hanging is mathematically a product of the weight of
suspended body mass and its gravitational acceleration. In this context, a substantial difference should
exist in postmortem findings between fully and partially suspended bodies [74, 105]. In full-suspension

13
hangings, the body falls (travels) freely until the whole length of the ligature is expended, which ulti-
mately constricts the neck. In incomplete hangings, gravitational acceleration may be assumed to be
limited as the body does not fall to the loop and is relatively permanently grounded. Interestingly, our
study confirmed no significant correlation between the completeness of suspension and the overall oc-
currence of laryngohyoid fractures. Numerous relevant studies have arrived at the same conclusion [23,
28, 40, 105, 167]. In contrast, several studies have corroborated an obvious association between the
completeness of suspension and the incidence of laryngohyoid fractures [3, 9, 22, 25, 27, 29, 37, 71, 73,
96, 126]. In addition, Tugaleva et al. observed a higher incidence of laryngohyoid fractures in those
hangings with a long drop [9]. Clement et al. revealed no correlation between the occurrence of fractures
and the type of suspension but reported a significantly higher incidence of fractures in freely suspended
victims older than 40 years of age [126]. Charoonnate et al. paradoxically identified laryngohyoid frac-

T
tures exclusively in their incomplete hanging study group and found no fractures in the hanging cases
with free suspension. They explained that the different outcomes may have been due to a prolonged

IP
convulsion phase during asphyxiation and consequently more prominent agonal movements [3]. Several
authors have observed that a higher frequency of laryngohyoid fractures may be associated with a longer

R
suspension time [4, 22, 109].
Nonetheless, the results of the available studies concerning throat-skeleton injuries in hanging are lim-

SC
ited to a certain extent by the unknown initial acceleration of the body before its suspension and final
constriction of the ligature [23]; did the individual jump into the loop with a forceful take-off, free fall,
or descend smoothly? Different actions of the human body result in variable accelerations and therefore

U
different force momenta [77]. Objective reconstruction of body movement prior to its suspension is
hardly possible; forensic pathologists can only perform calculations with the free portion of the used
N
ligature between its fixation point and the knot on the neck. However, this calculation is questionable as
nobody knows the precise prehanging position of the victim (e.g., standing, hunkering, or sitting) just
A
before the exact moment of the hanging (unless it was witnessed or recorded). Another concern is pos-
sible progression of full-suspension hanging to apparent partial-suspension hanging due to stretching of
M

the ligature, tightening of the knot, elongation of the neck, loss of muscle tone, or crushing of the sus-
pension point [204]. Considering our results and those of many others, we arrive at the following con-
clusion: the completeness of suspension is not an absolute contributing factor to the development of
ED

laryngohyoid fractures. Fractures may occur in incomplete suspensions, and they may not appear in all
hangings with full-body suspension [5, 23, 105, 109, 167].

5.5 Location of the ligature knot

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The total amount of compressive force affecting the neck in hanging is only one factor, while its distri-
bution on the neck is another consideration. In hanging, the external pressure is disproportionate from
case to case, and it may act on the neck at different levels and on various locations of the neck unequally
E

[8]. Nevertheless, the intensity and distribution of constricting forces together with the completeness of
body suspension can determine the specific pathogenesis and consequently result in a wide range of
CC

possible post-mortem findings [2, 8]. Simonsen found that typical hangings are associated with greater
susceptibility to laryngohyoid fracturing and less susceptibility to congestion, while atypical hangings
show a higher frequency of congestion and a lower frequency of laryngohyoid fractures [4]. Ronge et
A

al. described a higher incidence of hyoid fractures in lateral, anterolateral, and posterolateral hangings,
whereas thyroid fractures appeared most frequently in posterior hangings [29]. Similarly, Betz and Ei-
senmenger revealed the highest incidence of fractures, especially multiple fractures, with the highest
point of the knot at or behind the ears [103].
Our results demonstrated a significant association between the location of the ligature knot on the neck
and the occurrence of thyrohyoid fractures. Several studies have shown the same association [4, 5, 22,
29, 47, 96, 108]. This correlation is not surprising as the position of the ligature knot indicates the focus
of the maximal strain against the neck and dictates which neck structures should be spared from pressing

14
forces [53]. In posterior hangings, the maximum strain is produced against the frontal parts of the neck,
with the ligature positioned most commonly between the hyoid bone and thyroid cartilage. In lateral
hangings, the pressing forces concentrate mainly on lateral neck aspects positioned contralateral to the
suspension point. Finally, in anterior hangings, the posterior parts of the neck sustain the most pressure,
thus sparing the most vulnerable frontal aspect of the neck. The aforementioned differences in hangings
may elucidate the dissimilar incidences of laryngohyoid fractures not only in our study subgroups but
also in other researchers’ study files. In contrast, some authors found no association between the occur-
rence of laryngohyoid fractures in hanging and the location of the knot on the neck [3, 23, 37, 40, 73,
103, 126].

5.6 Ligature type, width, and course

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Numerous studies have proven that the type of noose, the ligature’s elasticity and width, and the type of

IP
knot may affect the extent and frequency of neck injuries [23, 25, 105, 196]. Rigid and narrow ligatures
produce deeper and acutely demarcated ligature marks and logically produce a more localized force
effect against the neck structures. In contrast, broad and softer ligatures tend to create less evident liga-

R
ture markings, and due to more planar distribution of the pressure load, less severe cervical injuries [73,
105]. In a retrospective study of 307 hanging cases, Feigin observed a higher frequency of laryngohyoid

SC
fractures with narrow ligatures; however, fractures also occurred with ligatures as wide as 3 cm, and the
ligature width was proven to have no predictive value for the occurrence of laryngohyoid fractures [167].
In addition, Suárez-Peñaranda et al. revealed a significantly higher occurrence of laryngohyoid fractures

U
when a hard-fixed knot was used [23]. In contrast, Luke et al. revealed no significant difference in the
incidence of laryngohyoid fractures with respect to the composition and width of the ligature or the
N
number of wraps [71]. Clement et al. also reported no association between the occurrence of laryngohy-
oid fractures and the width of the ligature [126].
A
The position of the ligature (above, below, or at the level of the thyroid cartilage), its course around the
neck and its relation to the laryngohyoid structures all collectively affect the compressive force distri-
M

bution and determine which cervical structures may be injured and the extent of these injuries. Regard-
ing the position of the ligature on the neck, wider and malleable ligatures tend to produce more pro-
nounced signs of craniocervical congestion.
ED

6. Diagnostic implications of laryngohyoid fractures in hanging

In hanging, forensic pathologists have tried to reconstruct the position of the ligature knot according to
PT

the presence and severity of various hanging-related neck injuries [1, 40, 104]. For instance, the
incidence of laryngohyoid fractures tends to vary according to the position of the ligature knot on the
neck, as shown in our results. Accordingly, the occurrence and the location of laryngohyoid fractures
may retroactively indicate the particular position of the ligature knot, which may be diagnostically useful
E

in cases in which the ligature is unavailable, the ligature has been removed shortly after hanging, or the
CC

ligature mark is too inconspicuous or masked by putrefactive changes. In a study of 557 hanging cases,
Nikolic et al. showed that the frequency of fractures of the thyroid cartilage exhibited statistically
significant differences in relation to the ligature knot position among persons older than 30 years,
indicating the ipsilateral and posterior position of the knot [116]. In contrast, they found that fractures
A

to the hyoid bone were an unreliable predictor of the ligature knot position. We strongly believe that the
occurrence and location of other cervical injuries (e.g., Amussat’s breaches and cervical muscle
hemorrhages) or miscellaneous contextual findings (e.g., saliva traces, anisocoria, and congestion signs)
related to hanging may also exhibit certain associations with the position of the ligature knot, as
confirmed in some factorial studies [1, 40, 104]. Further diagnostic implications related to the position
of the ligature knot warrant a definitive, well-designed evaluative study with multifactorial analysis in
the future.

Conclusion

15
The occurrence and the injury patterns of laryngohyoid fractures in hanging are some of the most studied
and paradoxically contradictory topics in forensic pathology. According to literary sources, the
incidence of laryngohyoid fractures in hanging varies considerably, from 0% to 100%. Forensic
scientists have attributed this extreme variability in results to various factors, such as dissimilar study
perspectives, uneven study inclusion and exclusion criteria, proband-related heterogeneities (e.g., age,
sex, anthropometric and constitutional characteristics, prevalent hanging methods, preferred ligature
materials, manner of death), non-uniform diagnostic approaches, inconsistent thoroughness of
laryngohyoid preparation, and others. In the present prospective study, we identified the following
laryngohyoid fractures in 129 of 178 suicidal hanging cases (72.5%): isolated fracture(s) to the thyroid
cartilage in 60 cases (33.7%), combined thyrohyoid fractures in 41 cases (23.0%), isolated fracture(s)
to the hyoid bone in 28 cases (15.7%), and no fracture to the cricoid cartilage or the cervical vertebrae.
The factorial analysis revealed significant correlations between the occurrence of laryngohyoid fractures

T
and the age of the victim (p = 0.028) and the position of the ligature knot on the neck (p = 0.019).
Additionally, the weight of the individual after age correction had a statistically significant association

IP
with the occurrence of thyrohyoid fractures (p = 0.026). Clearly, laryngohyoid fractures in hanging
reflect an open research opportunity with a myriad of issues that should be further analyzed using new
diagnostic methods and larger cohorts with a focus on characteristics and contributing variables that

R
have not yet been systematically scrutinized. The authors hope that the present study and updated review
will further clarify the complexities associated with laryngohyoid fractures in deaths by hanging.

SC
Declaration of conflicting interests
The authors report no conflict of interest. U
N
Sources of support
A
This research received no specific grant from any funding agency in the public, commercial, or not-for-
profit sectors.
M
ED
E PT
CC
A

16
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rensic pathology. Forensic science. 1976;7:161-70.
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E PT
CC
A

24
 T
IP
Legends

R
Table 1 presents the overall incidence of laryngohyoid fractures in the study file (RGH – right greater

SC
horn of the hyoid bone, LGH – left greater horn of the hyoid bone, RSH – right superior horn of the
thyroid cartilage, LSH – left superior horn of the thyroid cartilage).

STRUCTURE(S) U
FRACTURES
N
absolute relative
frequency frequency
A
Hyoid bone 69 38.8%
RGH 46 25.8%
M

LGH 40 22.5%
Thyroid cartilage 101 56.7%
ED

RSH 71 39.9%
LSH 72 40.4%
Combined 40 22.5%
E PT
CC
A

25
Table 2 illustrates the incidence and distribution of fractures according to constituent elements of the
hyoid bone and thyroid cartilage within the study file (RGH – right greater horn of the hyoid bone, LGH
– left greater horn of the hyoid bone, RSH – right superior horn of the thyroid cartilage, LSH – left
superior horn of the thyroid cartilage, BGH – both greater horns of the hyoid bone, BSH – both superior
horns of the thyroid cartilage).

FRACTURES
MULTIPLIC-
STRUCTURE(S)
absolute relative ITY
frequency frequency
RGH (isolated) 14 7.9%

T
LGH (isolated) 9 5.1%

IP
Single: 57
RSH (isolated) 14 7.9%
LSH (isolated) 20 11.2%

R
RGH + LGH 5 2.8%

SC
RSH + LSH 26 14.6%
RGH + RSH 11 6.2%
Double: 50
RGH + LSH 1 0.6%
LGH + RSH
LGH + LSH
1
6 U 0.6%
3.4%
N
RGH + BSH 3 1.7%
A
LGH + BSH 7 3.9%
Triple: 16
BGH + RSH 4 2.2%
M

BGH + LSH 2 1.1%

BGH + BSH 6 3.4% Quadruple: 6
ED

TOTAL 129 72.5% –

E PT
CC
A

26
Table 3 shows the frequencies of laryngohyoid fractures in relation to the position of the knot on the
neck. Bold text indicates the highest rates, and the lowest rates are shown in italics. The highest rate of
laryngohyoid fractures was identified in both subgroups of the lateral hanging group (III, IV). The lowest
frequency of fractures of the hyoid bone and the thyroid cartilage was found in the anterior hanging
subgroup (II).

FRACTURE(S) Hyoid bone Thyroid cartilage Combined Overall

KNOT LOCATION n % n % n % n %

T
IP
I (96 cases) 38 39.6% 53 55.2% 23 24.0% 68 70.8%
II (11 cases) 1 9.1% 4 36.4% 1 9.1% 4 36.4%

R
III (34 cases) 15 44.1% 20 58.8% 9 26.5% 26 76.5%

SC
IV (37 cases) 15 40.5% 24 64.9% 8 21.6% 31 83.8%
TOTAL 69 101 41 129

U
N
A
M
ED
E PT
CC
A

27
Table 4 presents the multiplicity of laryngohyoid fractures in relation to the position of the knot on the
neck. Bold text indicates the highest rates, and the lowest rates are shown in italics.

FRACTURE(S) Single Double Triple Quadruple

KNOT LOCATION n % n % n % n %

I (96 cases) 26 27.1% 28 29.2% 12 12.5% 2 2.1%

T
II (11 cases) 2 18.2% 2 18.2% 0 0.0% 0 0.0%
III (34 cases) 15 11 1 2.9% 3

IP
44.1% 32.4% 8.8%
IV (37 cases) 15 40.5% 9 24.3% 3 8.1% 1 2.7%
58 50 16

R
TOTAL 6

SC
U
N
A
M
ED
E PT
CC
A

28
 R I
SC
Table 5 shows the incidences of laryngohyoid fractures in hanging according to results of prospective studies (No. – order number; Design: s – single institution,
m – multiple institution; Study: p – prospective, r – retrospective; Tools: a – autopsy, x – X-ray examination, ct – computed tomography, s – stereomicroscopy;
n – number of individuals included in the study; n(i) – number of evaluated individuals; age – mean age; m – male; f – female; t – typical hanging; a – atypical

U
hanging; iH – isolated lesion to the hyoid bone; iT – isolated lesion to the thyroid cartilage; H and T – conjoint lesions to the hyoid bone and thyroid cartilage;
H and/or T – isolated and conjoint lesions to the hyoid bone and thyroid cartilage; Cricoid – lesions to the cricoid cartilage; nm – not mentioned.

N
De iH iT H and T H and/or T Cricoid
N Stu To

A
Author sig n n(i) age m/f t/a
o. dy ols n % n % n % n % %
n n

M
no no no no 40.3
1 Laiho (1968) s p a 124 124 45.0 3.59 50
data data ─ data ─ data ─ % 1 0.8%
no no 0.7 no no no 54.5 n
2 Dietz (1970) s p a 233 233 127
─ ─ ─ ─
ED p
data
no
data
no
3
no
data
no
data
no
data
0.0
%
46.2
m
n
3 6
Doichinov (1981) s a, x 13 13 data data data data ─ data ─ 0 % % m ─
no no no no no no 54.1 n
4 p 120
PT
Kleiber (1981) s a 222 222 data data data data ─ data ─ data ─ % m ─
no no no 13.6 34.6 19.6 67.8
5 Missliwetz (1981) s p a 500 500 68 339
data data data % 173 % 98 % % 13 2.6%
no no no no no 46.2
E

6 Paparo II (1984) s p a 26 26 2.71 12

data data data ─ data ─ data ─ % 1 3.8%
no no 6.3 10.6 2.5 19.4
CC

7 Paparo I & II (1984) s r, p a 160 160 3.10 10 31

data data % 17 % 4 % % 1 0.6%
no 11.5 3.3 9.8 24.6
8 Luke (1985) s p a 61 61 41.3 5.10 7 2 6 15 0.0%
data % % % % 0
no no no n
A

8.8 30.0 16.3 55.0

9 Polson (1985) s p a 80 80 7 44
data data data % 24 % 13 % % m ─
0.5 13.8 12.5 2.5 26.3
10 s p a, x 80 80 38.7 2.63 11 8 2 21 0.0%
Morild (1996) 4 % 0 % % 0
87.6 6.9 30.5 8.2 45.5
11 Samarasekera (1996) m p a 233 233 16 106
─ % ─ % 71 % 19 % % 1 0.4%
a, no no 19.0 31.4 23.4 73.7
12 Khokhlov (1997) s p 137 137 4.48 26 101
x, s data data % 43 % 32 % % 13 9.5%

29
 R I
SC
no 10.0 22.5 15.0 47.5
13 Green (2000) s p a 40 40 35.0 4.71 4 19
data % 9 % 6 % % 0 0.0%
no no no 0.0 10.8 0.0 10.8

U
14 DiMaio (2001) s p a 83 83 0 9
data data data % 9 % 0 % % 0 0.0%
no

N
15 Dixit (2001) p no no no no no dat n
s a 146 146 data 3.06 data data ─ data ─ data ─ a ─ m ─

A
no no 0.2 3.8 11.3 5.7 20.8
16 Sharma (2005) p 11
s a 53 53 data data 0 2 % 6 % 3 % % 0 0.0%

M
no
no no no no no
17 Yen (2005) s p a,ct 5 5 no dat n
data data data data data
─ ─ data ─ a ─ m ─
ED no 18.4 13.8 10.3 42.5
18 Allouche (2007) s p a 87 87 37.7 4.80 16 37
data % 12 % 9 % % 0 0.0%
no
no 0.1 no no no
19 Sharma (2008) s p a 66 66 2.30 dat n
data 4 data data data
─ ─ ─ a ─ m ─
PT

no 0.2 0.0 0.0 0.0 n

20 Talukder (2008) s p a 66 66 1.13 0 0
data 7 % 0 % 0 % 0.0% m ─
a, 5.0 33.3 66.7 0.0 100.0
21 Kempter (2009) s p 6 6 33.7 m 2 6
E

ct 0 % 4 % 0 % % 0 0.0%
no 10.0 10.0 25.0 n
CC

22 s p a, s 20 20 42.4 m 2 2 1 5.00 5
Charoonnate (2010) data % 0 % m ─
Le Blanc-Louvry a, no no no 54.5 0.0 0.0 54.5 n
23 p 6
(2012) s ct 11 11 data data data 6 % 0 % 0 % % m ─
no no 0.0 0.0 0.0 n
A

24 Patel (2012) s p a 320 320 1.50 0 0

data data % 0 % 0 % 0.0% m ─
no no 15.5 2.4 0.0 17.86 n
25 Bhosle (2014) p 15
s a 84 84 data 3.67 data 13 % 2 % 0 % % m ─
no 1.3 1.3 0.0 n
26 p, r 2
Hlavaty (2016) s a 75 75 31.8 2.75 data 1 % 1 % 0 % 2.7% m ─
no
27 Rao (2016) p no 0.2 no no no dat
s a, r 264 264 data 0.94 1 data ─ data ─ data ─ a ─ 0 0.0%

30
 R I
SC
1.1 15.7 33.7 23.0 72.5
28 p
Zátopková (2018) s a 178 178 50.0 5.36 7 28 % 60 % 41 % 129 % 0 0.0%

U
N
A
M
ED
E PT
CC
A

31
 R I
SC
Table 6 shows the incidences of laryngohyoid fractures in hanging according to results of retrospective studies (No. – order number; Design: s – single institution,

U
m – multiple institution; Study: p – prospective, r – retrospective; Tools: a – autopsy, x – X-ray examination, ct – computed tomography, s – stereomicroscopy;
n – number of individuals included in the study; n(i) – number of evaluated individuals; age – mean age; m – male; f – female; t – typical hanging; a – atypical
hanging; iH – isolated lesion to the hyoid bone; iT – isolated lesion to the thyroid cartilage; H and T – conjoint lesions to the hyoid bone and the thyroid cartilage;

N
H and/or T – isolated and conjoint lesions to the hyoid bone and the thyroid cartilage; Cricoid – lesions to the cricoid cartilage; nm – not mentioned.

A
M
De- iH iT H and T H and/or T Cricoid
No Stud
Author sig Tools n n(i) age m/f t/a
. y n % n % n % n % %
n n
Chistovich ED 29. no 1.5
1 r 11
(1856) s a 66 66 8 10 data 9 13.6% 2 3.0% 0 0.0% 16.7% 1 %
Maschka no no no n
2 r 3
(1881) s a 153 153 data data data 1 0.7% 2 1.3% 0 0.0% 2.0% m ─
no no
PT
no
3 Haumeder r no no no no dat dat n
data
(1882) s e 26 26 data data data data ─ a ─ a ─ ─ m ─
no no
E

4 Reuter r no no 3.0 no dat dat 105 n

(1901) s a 200 200 data data 0 data ─ a ─ a ─ 52.5% m ─
CC

Ushakov no no no n
5 r 8
(1900) s a 48 48 data data data 6 12.5% 2 4.2% 0 0.0% 16.7% m ─
no no
Smirnov no no no no
6 s r a 135 135 2.29 dat dat n
A

(1928) data data data data

─ a ─ a ─ ─ m ─
Jonáš 100 100 no no 0.6 n
7 s r a 60 192
(1959) 0 0 data data 6 6.0% 116 11.6% 16 1.6% 19.2% m ─
Bukhmas-
8 tova r no no 0 n
(1963) s a 216 216 data 3.17 data 0 0.0% 0 0.0% 0 0.0% 0.0% m ─
Sen Gupta no 0.1 n
9 s r a 101 101 2.48 0 0.0% 0 0.0% 0 0.0% 0 0.0%
(1963) data 9 m ─

32
 R I
SC
Fedorov no no no n
10 r 14
(1967) s a 200 200 data data data 6 3.0% 8 4.0% 0 0.0% 7.0% m ─
James-

U
11 Levi r no no no 79 n
(1967) s a 500 500 data data data 27 5.4% 42 8.4% 10 2.0% 15.8% m ─

N
Luke no no no 21.4
12 s r a 106 28 0 6 1 3.6% 7 25.0% 0.0%
(1967) data data data 0.0% % 0

A
Zavilla no 1.3 n
13 s r a 363 363 4.68 0 0.0% 0 0.0% 0 0.0% 3 0.83%
(1967) data 7 m ─

M
Kodin no no no n
14 r 11
(1972) s a, x 89 89 data data data 9 10.1% 2 2.2% 0 0.0% 12.4% m ─
Su-
no no no
15 zdaľskiy s r
ED a 120 120 3 3 n
data data data
(1972) 2.5% 0 0.0% 3 2.5% 2.5% m ─
Kodin no no no 11.8 n
16 r 13
(1974) s e 34 34 data data data 5 14.7% 4 11.8% 4 % 38.2% m ─
Kapustin 50. no no
PT
17 r 38
(1975) s a 241 241 2 data data 11 4.6% 21 8.7% 6 2.5% 15.8% 1 0.4%
no no
Koroľko
18 no no no no dat dat 6 3.41 n
(1977)
E

s r a 176 176 data data data data ─ a ─ a ─ % m ─

no no
CC

Doichinov no no no no
19 s r a 375 375 dat dat 15.2% n
(1981) data data data data
─ a ─ a ─ 57 m ─
Bowen no no n
20 s r a 201 201 4.88 0 0
(1982) data data 0.0% 0 0.0% 0 0.0% 0.0% m ─
A

no no
Paparo I no no no
21 s r a 134 134 3.19 dat dat 20 n
(1984) data data data
─ a ─ a ─ 14.9% m ─
no no
Ronge no
22 49. no no dat dat n
(1984) data
s r a 146 146 5 3.42 data data ─ a ─ a ─ ─ m ─
Muth no 0.4
23 r 117
(1985) s a 370 370 data 3.81 1 24 6.5% 72 19.5% 21 5.7% 31.6% 0 0.0%

33
 R I
SC
Davison no no no 10.5 16.2 n
24 s r a 105 105 11 47
(1986) data data data % 19 18.1% 17 % 44.8% m ─
Simonsen 52. 0.3 27.5

U
25
(1988) s r a 80 80 6 1.50 1 7 8.8% 22 % 7 8.8% 36 45.0% 0 0.0%
James 45. 11.0 no

N
26 s r a 84 84 10 11.9% 17 20.2% 4 4.8% 31 36.9% 0.0%
(1992) 0 0 data 0
Elfawal no no n
27 s r a 61 61 4.08 0 0.0% 0 0.0% 0 0

A
(1994) data data 0.0% 0.0% m ─
Inanici no 30.0
28 15

M
(1995) s r a 50 50 data 1.27 2 15 30.0% 0 0.0% 0 0.0% % 0 0.0%
no no
29 Betz no no no no dat dat n
(1996) s r
ED a 109 109 data data data data ─ a ─ a ─ 73 67.0% m ─
Feigin no no n
30 s r a 307 307 6.55 9 2.9% 15 7.5% 3 1.0% 27 8.8% 0.0%
(1999) data data m
Nikolić 47. no n
31 s r a 175 175 3.17 28 119
(2003) 3 data 16.0% 70 40.0% 5 2.9% 68.0% m ─
PT

Duband 43. no 34.5

32 20 69.0% 0.0%
(2005) s r a 29 29 5 3.14 data 7 24.1% 3 10.3% 10 % 0
no
E

Naik no
33 no 0.0 dat n
(2005) data
s r a 257 257 data 2.84 8 0 0.0% a ─ 0 0.0% ─ m ─
CC

Sharma no no 0.3
34 5
(2005) s r a 55 55 data data 1 1 1.8% 2 3.6% 2 3.6% 9.1% 0 0.0%
Azmak 41. no 12.5 n
35 s r a 56 56 5.22 26 10 43
(2006) 6 data 46.4% 17.9% 7 % 76.8% m ─
A

Üzün no no 13.9 n
36 s r a 761 761 2.40 177 446
(2007) data data 23.3% 163 21.4% 106 % 58.6% m ─
Suárez-
Pe- 51. no
37 m r a 228 228 3.50 64 61 46 171 75.0%
ñaranda 7 data 20.2
(2008) 28.1% 26.8% % 0 0.0%
no no
no
38 Ahmad r no no no dat dat n
data
(2010) s a 145 145 data 0.71 data data ─ a ─ a ─ ─ m ─

34
 R I
SC
Clement 34. 0.5
39 s r a 206 206 5.06 3 58
(2011) 7 6 1.5% 45 21.8% 10 4.9% 28.2% 0 0.0%
Jayapra- no

U
no no
40 kash s r a 189 189 2.44 5 2.6% 10 5.3% dat 15 7.9% 0.5%
data data
(2012) a ─ 1

N
Godin 34. no n
41 s r a 231 231 5.24 6 54
(2012) 5 data 2.6% 43 18.6% 5 2.2% 23.4% m ─

A
no no
42 Saisudhee r no no no dat dat 8 n

M
r (2012) s a 200 200 data 0.47 data data ─ a ─ a ─ 4.0% m ─
Abd-
Elwahab no no
43 s r a 118 118 2.68 23 50
Hassan ED data data 12.7 10.2 n
(2013) 19.5% 15 % 12 % 42.4% m ─
Kurtulus 41. 1.1 25.5 21.6
44 s r a 102 102 2.52 21 20.6% 26 22 67.6% 0.0%
(2013) 0 3 % % 69 0
Naimo 34. no no n
PT
45
(2013) s r a, ct 25 25 0 data data 0 0.0% 6 24.0% 2 8.0% 8 32.0% m ─
Sumińska no no
no
46 -Ziemann r no no no dat dat n
data
E

(2013) s a 477 477 data 7.83 data data ─ a ─ a ─ ─ m ─

no no
CC

Ambade no no no
47 s r a 127 127 5.35 dat dat 17 n
(2015) data data data
─ a ─ a ─ 13.4% m ─
Naimo 27. no no n
48 s r a, ct 25 25 4
(2015) 1 data data 16.0% 0 0.0% 2 8.0% 6 24.0% m ─
A

Taktak 450 450 37. no 13.5 235 n

49 s r a 2.73 762 984 610 52.3%
(2015) 2 2 8 data 16.9% 21.9% % 6 m ─
no
50 no no no no dat 17.4% n
Ma (2016) s r a 141 46 data data data data ─ a ─ 1 2.2% 8 m ─
no no
Russo no no no no
51 s r a 260 199 3.66 dat dat n
(2016) data data data data
─ a ─ a ─ ─ m ─

35
 R I
SC
Tugaleva 39. no
52 m r a 632 632 4.36 30 4.7% 10 1.6% 3 0.5% 46 7.3% 0.5%
(2016) 8 data 3
no no

U
Tulapunt 37. no no
53 s r a 244 244 4.19 dat dat 2 n
(2017) 2 data data
─ a ─ a ─ 0.8% m ─

N
no no
54 Schulze r 39. no no dat dat 21 2.9

A
(2018) s a, ct 35 35 8 2.18 data data ─ a ─ a ─ 60.0% 1 %

M
ED
E PT
CC
A

36