Topic 6.

Blunt Force Injury Deaths

One of the most common injury types that result in traumatic death is blunt force injury,
defined as an injury resulting from impact with a blunt object. A blunt object can be considered
a non-sharp object, such as floors, walls, furniture, hammers, baseball bats, fists, the interior
surfaces within an automobile, roadways, trees, and even fluid objects, such as bodies of water.
There are five basic types of blunt force injuries, and each is related to the transfer of force from
the blunt object onto or into the body. It is important to recognize that with many blunt force
injury cases, particularly those that occur in relation to vehicular collisions and falls/jumps from
heights, forces associated with sudden deceleration (or acceleration in certain motor
vehicle-related cases) may significantly contribute to the overall injuries. Consequently, the term
“blunt force injury” should be understood to include deceleration/acceleration forces in some
instances.
Classification of Blunt Force Injuries
As mentioned above, there are five basic types of blunt force injury: abrasions, contusions,
lacerations, fractures, and avulsions.
Abrasions
Abrasions are also known as scrapes or scratches. Actual tissue disruption occurs on the
surface of the epidermis, frequently with injuries extending into the underlying dermis.
Abrasions can be linear, rounded, irregular, or of various specialized types. Very superficial
abrasions (those that do not extend into the dermis) may not bleed. Abrasions only occur at the
site of impact with a blunt object; although they do not occur at every blunt impact site.
Occasionally, the directionality of the applied force can be determined based on the observation
of “peeled-off” superficial layers of epidermis adherent to the skin surface of the abrasion, and
located away from the origin of the force. Friction abrasions (for example, rug burns) are
another type of abrasion. “Road rash” is a term used to describe extensive friction abrasions
that occur when a victim’s body hits a roadway (pedestrian or cycle rider or person ejected from
a vehicle). Certain abrasions may “take on” the shape of the blunt object; these are referred to
as “patterned injuries”.
Fresh abrasions appear red and moist, although postmortem drying frequently causes them
to have a dark, dry appearance. Healing, with scab formation, indicates subacute or remote
(healing) abrasions. Some pathologists refer to scabbed abrasions as “crusted” abrasions.
Microscopically, the presence of healing may reveal that the injury did not immediately
precede death. The proliferation of collagen-producing cells (fibroblasts), excess collagen fibers,
inflammatory cells, and a breakdown product of red blood cell hemoglobin referred to as
“hemosiderin” are all indicators of healing.
 Contusions
Contusions are also known as bruises. Various other terms are sometimes used to describe
contusions, including “ecchymosis.” However, strictly speaking, the term “ecchymosis” refers to
any situation where blood escapes into soft tissues from blood vessels (including various natural
disease processes); whereas the term “contusion” implies a traumatic cause. Unlike abrasions,
which only occur at the site of blunt force impact, contusions can occur at sites of impact , as
well as at sites distant from the impact site. In those that occur at the site of blunt impact, the
contusion may or may not have associated epidermal abrasions and/or lacerations.
Occasionally, a skin contusion may be subtle. Incising the contusion can “prove” that the bruise
is real, as the underlying hemorrhage within the subcutaneous fat will be readily apparent.
Elderly individuals frequently have numerous bruises involving their fragile forearm skin. Classic
examples of contusions occurring away from the site of impact include so-called “raccoon’s
eyes” (bilateral periorbital ecchymosis, or two “black eyes”), occurring as a result of basilar skull
fractures, so-called Battle’s sign (bruising over the “mastoid process,” the skull protrusion
evident behind the ears), also occurring as a result of basilar skull fractures, Grey Turner’s sign
(flank or side of abdomen ecchymosis), occurring with extensive retroperitoneal (behind
abdominal cavity) bleeding, and Cullen’s sign (periumbilical or around the belly button
ecchymosis), occurring when there is extensive internal abdominal hemorrhage. Occasionally,
contusions are patterned.
The appearance of a contusion is not always immediately visible. The color changes that
occur in contusions are not reliable in attempting to determine the age of a bruise. Various
factors play roles in the color of a bruise, including extent of hemorrhage, depth of hemorrhage,
tissue location of hemorrhage, etc. Most forensic pathologists can recall examples of bruises
less than 24 hours old that have a yellow appearance, which, according to some, suggests older
injuries. Consequently, it is not advisable to estimate the age of a contusion based solely on its
color. Microscopically, changes of healing may be seen; however, absolute determinations
regarding the age of such injuries is generally not possible. Contusions may also occur in internal
organs.
Lacerations
A laceration is a splitting apart of tissues, usually resulting from blunt force (or
deceleration/acceleration) injuries. On the skin surface, lacerations may or may not be
associated with abrasions and/or contusions. Lacerations may be linear, jagged,
irregularly-shaped, or occasionally patterned. Linear lacerations may occasionally be confused
with sharp force injuries. A feature that favors a diagnosis of a laceration versus a sharp force
injury is the presence of “tissue bridging,” which describes the presence of intact nerves, blood
vessels, and other strands of tissue that “bridge the gap” between the two sides of the
laceration, deep to the skin surface. Tissue bridging tends not to occur with sharp force injuries,
as these structures would likely be severed along with the skin and underlying soft tissues.
Other features that tend to occur with lacerations include abrasions and contusions, although
these may also occur with sharp force injuries. If the direction of force that causes a laceration
is angled rather than directly perpendicular to the skin surface, there will frequently be an
abrasion on the side of the laceration from which the force is applied. The opposite side may
demonstrate “undermining,” the presence of a cavity underlying the skin.
Because of the fact that it is sometimes difficult to differentiate a laceration from a sharp
force injury, many persons within healthcare professions misuse the term “laceration,” referring
to true sharp force injuries as lacerations. The term should be reserved for blunt force injuries.
Lacerations frequently occur at sites of blunt force impact; however, they can also be found
away from the site of impact. The classic example occurs in pedestrians struck from behind by a
motor vehicle, where decedent’s frequently have stretch-type lacerations in their inguinal
(groin) regions, related to hyperextension that results from excessive force applied from behind.
Lacerations from blunt force (and acceleration/deceleration) injuries are also common
within internal organs and tissues. They frequently occur in the aorta, the lungs, the liver, and
the spleen, but can occur in virtually any organ or tissue. Lacerations frequently involve the
surface of organs; however, internal lacerations may occur without overlying surface injuries.
Fractures
The breaking of a bone (or cartilage) is referred to as a fracture. There are a variety of
fracture types and several methods of categorizing them. One classification scheme is based on
skin involvement. If the skin overlying a fracture is intact, the fracture is referred to as a “closed
fracture”. In contrast, if the skin overlying the fracture is lacerated, the fracture is referred to as
an “open fracture” or a “compound fracture”. Open fractures are more susceptible to infection.
Another system that can be used to classify fractures describes the characteristics of the
fracture itself. A “simple” or “complete” fracture describes a linear (straight line) fracture that is
relatively perpendicular to the long axis of the bone shaft, and involves both sides (both
cortices) of the bone. An “incomplete” fracture does not involve both sides of the bone shaft.
“Greenstick” fractures are incomplete fractures where the bone, usually in a child, is essentially
“bent.” A “buckle” fracture is an example of an incomplete fracture where one cortex is
essentially collapsed or buckled. A “spiral” fracture has a helical shape, twisting along the long
axis of the bone shaft. Depending on the circumstances, spiral fractures may suggest the
possibility of child abuse. A “comminuted” fracture can be thought of as a fracture with multiple
fragments of bone. Another fracture type occurring in children that suggests the possibility of
child abuse is the epiphyseal plate fracture. Depending on the X-ray view of this type of fracture,
epiphyseal fractures are variably referred to as “bucket-handle” or “corner” fractures.
Rib fractures are common in blunt force injury deaths, as are skull fractures. Skull fractures
can be “linear”, “depressed” (indented inward), or comminuted. “Basilar” skull fractures involve
the base of the skull and have a variety of subtypes (described below). “Diastatic” fractures
represent a splitting apart of a child’s skull suture lines (where the skull plates join each other).
 Fractured bones that are in the process of healing can be differentiated from fractures that
occurred immediately prior to (or coinciding with) death. Evidence of healing can be visualized
by X-ray as well as grossly and microscopically.
Avulsions
An avulsion injury represents a blunt force injury in which a portion of a body part (or
tissue/organ) substantially separates from or totally separates from the body (or tissue/organ).
Amputation injuries are considered a type of avulsion injury in which an entire extremity or
portion thereof is severed from the body. The most extreme example of an avulsion injury is a
decapitation injury, in which the head separates from the body. Not all such injuries are the
result of blunt force (some are due to sharp force injuries); however, a significant percentage of
these types of injuries are related to severe blunt force/deceleration force. Total body
transection may also occur. Internal organ avulsion injuries may also occur, particularly when
severe blunt force/deceleration occurs. Examples include avulsion injuries of portions of organs,
such as the liver, or entire organs, such as the heart and lungs.
Head Injuries
Many deaths due to blunt force trauma are caused by head and brain injuries.
Craniocerebral trauma can be used as a collective term to describe injuries to the head,
including the skull, and the brain. If there are no skull fractures, brain injuries are sometimes
referred to as ‘‘closed head injuries.’’ If there are significant neck and upper spinal cord injuries,
the terms craniocerebral and cervical trauma can be applied. Blunt trauma injuries to the head
may involve the following (commencing with the outermost layers): skin, subcutaneous and
subgaleal tissues, skull (cranium) and facial bones, dura, subdural space, subarachnoid space,
and, finally, the brain.
Neck, Spinal Cord, and Vertebral Artery Injuries
The neck is vulnerable to blunt trauma which may compromise blood flow to the brain or
damage the integrity of the spinal cord. A broken neck may result from blunt force injury with
fracture of the cervical vertebral column, causing contusion, laceration, or transaction of the
cord. Disruption of the atlanto-occipital joint, where the occiput, or base of the skull, connects
to the first cervical vertebrae, may result in similar injuries. A blow to the side of the head or
face, with abrupt twisting or sideways flexion of the neck, may cause laceration of the vertebral
artery with resultant lethal basilar subarachnoid hemorrhage.
Mechanisms of Death in Blunt Force Trauma
A number of mechanisms of death can be involved in blunt force injury deaths. The
following discussion will be divided into acute (quick) deaths and delayed deaths.
Regarding acute deaths related to blunt force injuries, a general description of blood loss
will be followed by specific comments about certain organ systems. One of the most common
mechanisms of death involves the acute loss of blood. Exsanguination (blood loss) can occur
externally or internally. For blood loss to occur, vascular (blood vessel) trauma must be present.
When there is an insufficient amount of blood within the circulatory system (heart and blood
vessels), oxygen is not able to be delivered to the tissues of the body. This lack of “tissue
perfusion” (lack of blood delivery to tissues) is referred to as “shock,” and eventually becomes
irreversible, and death occurs. Deaths related to traumatic blood loss can involve virtually any
organ or tissue. Particularly common sites of injuries where blood loss causes death include the
aorta, heart, lungs, liver and spleen. In order for death to be attributed to acute blood loss,
approximately 33% of the blood volume must be lost.
It is important to note that, in certain situations, death can also occur from bleeding even
when there is a relatively small amount of blood involved. If blood accumulates within the
pericardial cavity (“cardiac tamponade.”), the condition is referred to as a “hemopericardium.”
When this occurs, the accumulating blood can compress the heart to such an extent that it is no
longer able to beat. In a similar way, if there is a traumatic hemorrhage within or around the
brain, the compressive effect of the blood can cause death, even though the total amount of
blood is not sufficient to cause death from blood loss alone.
Physical disruption of the central nervous system is another very common mechanism of
death involved in blunt force injury deaths. Transection or injury of a vital CNS structure, such as
the brainstem or upper cervical spinal cord, represent examples of grossly-evident CNS
disruption. Diffuse axonal injury, represents a type of physical disruption that typically cannot
be seen grossly, but may be evident microscopically, so long as an individual survives long
enough for it to become evident. The term “commotio cerebri” refers to a death that occurs
following a sudden blow to the head wherein autopsy fails to reveal any lethal trauma or
markers/indicators of trauma (subdural and/or subarachnoid hemorrhage). Such cases probably
represent deaths related to severe traumatic diffuse axonal injury. Another rare occurrence,
“malignant cerebral edema,” is similar to commotio cerebri in that there is no intracranial
hemorrhage, but there is severe diffuse cerebral edema (swelling).
Injuries around and/or involving the lungs can result in the inability of air exchange to occur.
This leads to the lack of blood oxygenation, which ultimately leads to lack of tissue oxygenation
and death. Injuries of the lungs themselves can result in the air spaces (alveoli) filling with
blood, thus preventing air from getting into the air spaces. If the surface of the lung is injured,
or if the chest wall is injured (a “sucking chest wound”), air can enter the pleural cavity (chest
cavity) surrounding the lung, resulting in a “pneumothorax.” If air can enter the pleural cavity
but cannot get out, then a “tension pneumothorax” can result, wherein the accumulating air
compresses the lung (and sometimes the heart and other lung), such that air can no longer
enter the lungs. In a similar fashion, the lung can be compressed by accumulating blood
(“hemothorax”). In each of these situations, the lack of air exchange within the lung acts as a
mechanism of death. If a pneumothorax is suspected, the pathologist can create a “pocket”
between the reflected chest and the side of the rib cage prior to removing the anterior chest
plate. This pocket can be filled with water, and then an incision can be made between the ribs,
so that the incision connects the pleural cavity with the water. If a pneumothorax is present, air
bubbles will escape into the water. The bubbles can be collected in an inverted, water-filled
graduated cylinder in order to measure the amount of air. A final lung-related finding that can
occasionally be encountered in blunt force, as well as other types of injuries, is aspiration
(breathing in) of blood. Aspirated blood has a characteristic gross appearance at autopsy.
A relatively rare cardiac mechanism of death that occurs in certain blunt force injury cases is
“commotio cordis.” A lethal arrhythmia can be induced by a blow to the chest that occurs at a
very specific time within the electrical cycle (electrocardiogram tracing) of the heart. There may
be evidence of anterior chest wall injury, but not always. By strict definition, there should be no
trauma of the heart itself, although some have argued that this definition is too limiting, and
cases with cardiac injury that do not lead to exsanguination or cardiac tamponade should be
included in the definition of commotio cordis.
Traumatic disruption of a pre-existing natural disease process (or even a preexisting injury
that was previously not severe enough to be lethal) with subsequent hemorrhage and death is
also known to occur. An example is a person who has a cerebral artery berry aneurysm that
ruptures when someone punches the person in the face. In such a case, the blunt force trauma
and underlying natural disease process should be included in the cause of death statement. The
manner of death should be determined based on the circumstances of the blunt trauma. In the
example case provided, homicide is an appropriate ruling.
Delayed Deaths Related to Blunt Force Injury
Death does not have to occur immediately when blunt trauma is the underlying cause of
death. Such delayed deaths may occur several hours, days, weeks, months, or even years after
the initial traumatic event. As long as an uninterrupted chain of events can link the underlying
trauma to the eventual death, it is appropriate to rule the underlying trauma as the underlying
cause of death.
A frequent example of a delayed death following blunt trauma is a situation where the
victim initially survives the trauma as a result of valiant efforts by emergency medical services
and hospital personnel. Despite these efforts, the massive stress associated with severe
traumatic injuries can be too much for the victim to overcome. Various complications related to
shock, trauma, inflammation, and stress can ultimately lead to death despite all efforts to avoid
such complications.
A variety of other situations can cause death in persons who have survived the initial effects
of blunt trauma, the most frequent being pulmonary embolism. Persons who are bedridden for
whatever reason have an increased risk of developing thrombi (blood clots) within the deep
veins of their legs and the risk is increased even more if there are also injuries of the legs. Many
trauma victims are in such a situation. If the clots within the leg veins break free and travel
upward into the inferior vena cava and ultimately through the right side of heart into the
pulmonary arteries, they can cause a massive “pulmonary embolism” which results in an abrupt
stopping of all blood flow to the lungs and sudden death.
Another complication that can occur following any type of injury is infection. As with any
infection, a localized infection can spread to involve the entire body (“sepsis”) which is a
life-threatening event and can rapidly lead to death.
The fat embolism syndrome is a relatively rare complication, and usually occurs several days
after severe trauma, typically including skeletal trauma. Clinically, it is characterized by the
sudden onset of respiratory distress, with or without neurological symptoms. At autopsy, gross
examination of the brain can reveal numerous small hemorrhagic areas within the white matter.
Microscopically, fat and bone marrow emboli can be visualized within blood vessels of the brain,
as well as blood vessels within the lungs and evaluation of frozen brain and lung tissue can aid
pathologists in their identification. It should also be noted that the microscopic identification of
fat and bone marrow emboli within lung tissue is frequently seen in cases of blunt trauma, in
absence of the clinical scenario associated with the fat embolism syndrome as described above.
Clothing Examination
As with many other injury types, the examination of a decedent’s clothing in cases of blunt
force injury death can provide important information. Clothing defects or other markings may
correlate with injuries on the skin surface. Transfer of trace evidence from the blunt object that
caused trauma can sometimes be identified and collected for subsequent examination in the
crime laboratory.