Biomechanics of a previously unknown thyroid cartilage fracture in fatal strangulation.

After the death of a 63-year-old woman following pressure against the neck, the injury was assessed forensically and a radiological-preparatory examination of the osseous structure of the larynx was conducted. We used fine preparation and, for further characterization of the fracture, radiological imaging in spiral CT, 3D reconstruction and fine-focus technique (mammography). While a skeletal injury with the basal fractures of the upper horns of the thyroid cartilage was clearly visible in the CT and 3D reconstruction, the radiological visualization of a 3-4mm wide wall-penetrating dehiscence in the upper part of the thyroid cartilage commissure required a higher sensitivity. Using fine-focus technology, we were able to diagnose this fracture as an avulsion of the cartilage from the medial primary ossification center of the thyroid cartilage. Not only has this type of fracture of an insertion avulsion of the median thyrohyoid ligament never been described before, but it must also be considered as the main fracture in dorsocranial traction. In this specific case, it enabled the expert to state in court that strangulation had occurred from behind.

[Autoptical display of the nasopharyngeal space in cases of suspected SARS-Co2 infection]. / Autoptische Darstellung des Nasen-Rachen-Raumes bei Verdacht auf SARS-CoV2-Infektion.

This paper deals with a dissection technique in order to display the nasopharyngeal space. It consists of a parafrontal saw cut through the base of the skull at the level of the sella turcica. In this way the ventral part of the nasopharyngeal space can be separated from the cervical spine and the posterior base of the skull within an anatomically preformed border region. Apart from a comprehensive overview of the nasopharyngeal space, this technique also enables samples to be correctly taken. The time required takes approximately 2-3 min, the external appearance of the deceased is not affected and the preparation of the body is not complicated.

Traumatology of the superior thyroid horns in suicidal hanging--an injury analysis.

It appears still questionable whether fractures to the superior thyroid horns can be used for forensic reconstruction purposes regarding the functional mechanism causing compression of the neck soft tissues. Localisations and types of such fractures were documented in 118 cases of superior thyroid horn fractures caused by suicidal hanging. The placement of the ligature was above the larynx in 109 cases and in the remaining nine cases across the thyroid cartilage. As a secondary parameter the degree of ossification of thyroid cartilages and superior horns was used. Bone densities of typical cases (equidensities) were measured radiologically. Additionally, dummy tests were performed focused on two extreme shapes of superior thyroid horns to assess stress peaks using resin dummies and polarised light. Such peaks were located in the lower thirds of the horns close to their bases. With the larynx still cartilaginous, the base appears a typical location for fractures caused by suicidal hanging. An ossification pattern defined as "type 1" showed broad and osseous superior thyroid horns. If ossification was homogenous, fractures were located at the sites of maximum mechanical stress. In case of inhomogenous ossification, being the more common mode, the horn bases were more resistant to pressure and bending so that no fractures occurred. They were instead located at the sites of the greatest differences in density and distributed in an apparent random pattern. Narrow and deep insertions of the superior thyroid horns at the back surface of the upper thirds of the thyroid cartilages (posterior aspects) were classified as "type 2" ossification. Upon flexion, the long horns came into contact with the upper edges of the dorsal aspect creating a torque. Further flexion from an increasing impact by the ligature extended the long lever arm causing the base of the upper thyroid horn being broadly torn out of the dorsal aspect. The results suggest that localisations of fractures to the superior thyroid horns in connection with ossification patterns may be helpful for the reconstruction in suicidal hanging regarding the mechanics of the ligature in relation to its position around the neck.

Macrophage subsets in mechanical brain injury (MBI)--a contribution to timing of MBI based on immunohistochemical methods: a pilot study.

Cortical hemorrhages as a consequence of closed mechanical brain injury (MBI) trigger an inflammatory response including a distinct increase of macrophages. According to published data this reactive macrophage population is heterogenous as to their immunological properties. The expression of certain immunohistochemically detectable epitopes of macrophages, however, may correlate with the posttraumatic interval (PTI). In a pilot study, 50 selected cases of cortical hemorrhages with 1 min to 1.5 years PTI were examined by light microscopy and macrophages were labeled with CD68-, HLA-D-, HAM-56-, LN-5-, and 25F9-antibodies, while hemosiderin was detected by a Prussian-blue reaction. Qualitative and semiquantitative investigations were performed. The semiquantitative study included 5 different classes. The results of the study revealed a distinct timetable of the appearance of macrophages labeled with certain antibodies. While HLA-D immunoreactivity was detected after a PTI of 6h in the cortex and white matter bordering the traumatic hemorrhage, CD68 immunopositive macrophages were present after 12h, LN-5 and HAM-56 after 48h, and 25F9 within 10d. Hemosiderin-containing macrophages were detectable within 100h in the same region. Within the hemorrhage itself a certain immunoreactivity of macrophages starts several hours before: CD68 after 3h, LN-5 after 24h, HAM-56 after 31h, hemosiderin after 76h, and 25F9 after 4d. For forensic purposes these observations are of crucial importance because the time course of the appearance of certain immunopositive macrophages labeled with different antibodies allows a differentiated timing of contusional injuries; however, the cause of this different immunopositive reaction remains unexplained. The observed time dependency of different macrophage antigen expressions in cortical hemorrhages after closed head injury is a suitable method to estimate the PTI and will allow a forensic reliable estimation if future investigations are extended on higher numbers of cases and/or additional markers.

The mobile Condylus tertius occipitalis and fractures of the hypochordal clasp.

The Condylus tertius is defined as a small bony hunch on the anterior surface of the clivus. Its presence means an enormous functional impairment of the upper head joint, looking at the 3-point-contact between the skull base and the upper cervical vertebrae. In 10 of the 2000 forensic examined bodies, analyses of neck vertebra + skull base revealed this feature. The origin of these findings is discussed, as stated in the literature of embryology, to be a suboccipital hypochordal plate. So in one of the cases the condylus was found at the hypochordal plate itself whereas the so-called socket was lying at the margin of the clivus. In three cases there was found a free body between the apex of the Dens and the Clivus forming a mobile Condylus tertius. In our opinion its position varies over the anterior arch of the atlas and the apex of the dens as a result of rotatory forces between the atlas and axis and physiological strain. Examples are given to elucidate this. There is a difference in the differentiation of the deposited material according to functional demand. A pressure bed (i.e. a Condylus tertius) is formed when a bony structure is deposited on the clivus. This functional prospect relativises the hypothesis of a purely constitutional genesis of the Condylus tertius. A fracture of the hypochordal clasp being joined with a bony connection to the anterior atlantic arch is described for the first time.

Care of relatives following sudden infant death.

This paper deals with 301 families who have been offered a consultation for managing bereavement following sudden infant death. Eighty-eight percent of the parents (269 families) accepted and 36 more families out with Lower Saxony wished to be cared for. Without a previous autopsy 1.172 contacts happened from 1989 to 2003 comprising primary crisis intervention and long-term care, the latter including saying farewell before and after autopsy. One main aim was a close linking with the international self-help organization of parents (GEPS). Single cases conferences were carried out for more than five years according to the Sheffield model. There is given the methodical basis and many details of the care project.

Some medicolegally important aspects of symphyseal injuries due to trauma.

A total of 58 cases of fatal trauma (forensic autopsies) were investigated for lesions of the pelvic girdle, the pubic symphysis, and for injuries distant from the pelvis. Traumata of the pubic symphysis were present in 30% (n = 17) of the cases. The symphyses were examined by x-ray and macroscopically related to the main violence (Abbreviated Injury Scale [AIS]). A correlation between the latter and the severity of the resulting injuries could be deducted. Characteristic patterns of symphyseal injuries included small hemorrhages, partial and complete ruptures, and also ruptures of the ligamentary insertions, which have not yet been described. The kind and severity of these lesions related to the intensity/direction of the violence are demonstrated and discussed.

Fall or shaken: traumatic brain injury in children caused by falls or abuse at home - a review on biomechanics and diagnosis.

In cases of traumatic brain injuries in children it may be difficult to differentiate between physical abuse and accidental occurrence. This review will shed light on discriminating epidemiological as well as biomechanical data, morphological findings, and clinical features. As a basic principle, simple injuries are caused by simple mechanisms like falls whereas life-threatening injuries should be attributed to abuse until proven otherwise. Implausibilities between reported events and mechanisms by caregivers as well as more than one explanation of injury indicate suspicion of child abuse. From reviewing the literature, it can be stated that falls from less than 1.5 m lead only in few cases to severe brain injuries. Children who experienced a fall at home seldom exhibit fractures of the skull but just minor intracranial injuries without neurological deficits. Regarding biomechanical aspects, multiple or complex skull fractures, depression fractures, additional fractures of the body, and intracranial hemorrhages as a consequence of an impact are the most important findings in child abuse. Moreover, additional specific morphological criteria give evidence of clinical and/or post-mortem diagnosis of the shaken baby syndrome. These include subdural hemorrhage and laceration of the brain and retinal bleeding, epidural hemorrhage of the cervical cord, gripping marks (bruises) on chest and/or shoulders, and tearing injuries of the throat and neck muscles. Post-mortem signs of recurrent shaken baby syndrome are indicated by iron-positive cells or microglial cells in neuronal or retinal tissue. A clinical diagnosis will be dependent on the one hand on the exclusion of coagulation diseases, on the other hand on the demonstration of a subdural hemorrhage by means of neuroimaging techniques, i.e., CT and MRI, as well as retinal hemorrhage. The shaken baby syndrome will usually be observed within the first year of life. The doctor has to manifest his diagnosis to the caregivers and - before informing the caregivers - he must be sure of his diagnosis.

Sudden infant death--focus subject of medico-legal research.

The compilation of research activities concerning SID in the field of legal medicine could only choose those out of a great abundance of high-quality examinations which represent applied research. By this they have contributed either to the clarifying of the aetiology which has not been cleared up or to the prophylaxis. For this looking through in a widest sense the basic approach was to consider SID being the result of an intrinsic and/or extrinsic disturbance of the modulation of respiratory regulation of the infant. This namely means a metabolic disturbance of respiratory neurons. One must not share this opinion even if it is given a certain plausibility by newer physiological examinations. But this also means that some examinations did not receive the acknowledgement which they would have received if there had been an immunological approach. The compilation was completely done without a presentation of the primary crisis intervention and the long-term care as being a fundamental medico-legal approach. Altogether may be summarized that legal medicine has completely fulfilled its duty to take care of the problem SID and that the examinations did not remain without success.

Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants.

Alterations in the heart rate were monitored before, during and after the application of a unilateral mechanical impulse to the high cervical spinal cord region which was administered strictly in connection with the so called manual therapy (diagnosis= KISS). The investigation is based on a survey of 695 infants between the ages of 1 and 12 months. A notable change in the heart rate was evident in 47.2% of all examined infants (n= 695). In 40.1% of these infants, the change in heart rate was characterized by heart rate decrease of 15-83% compared to control conditions. Infants in their first 3 months of life responded more often with a severe bradycardia (50-83% decrease), older infants (7-12 months) more often with a mild bradycardia (15-49.9% decrease). This comparison revealed a significantly increased occurrence of severe bradycardia in the younger age group compared to the group of children >3 months (significance 0.0017). In 12.1% (n= 84) of the infants, the bradycardia was accompanied by an apnea. We discuss the hypothesis that mechanical irritation of the high-cervical region serves as a trigger that may be involved in sudden infant death (SID).

[Psychosocial management of a new pregnancy after sudden infant death (SID)--results of a long-term study of 115 families]. / Psychosoziale Betreuung einer erneuten Schwangerschaft nach Plötzlichem Säuglingstod (SID)--Ergebnisse einer Langzeitstudie in 115 Familien.

BACKGROUND: Every subsequent pregnancy after the loss of a child due to Sudden Infant Death (SID) causes highly anxious parents. The aim of this investigation was to point out which feelings and experiences have to be considered as influencing factors for a following pregnancy--besides being afraid of a repeated loss. The overlapping fixing of our aim was to develop some proposals and recommendations for a capable accompanying during a subsequent pregnancy. MATERIALS: The base of the evaluation were 789 consultations during long-term cares of 115 families affected by Sudden Infant Death (SID). When their children died because of SID 9 of all the mothers were pregnant again. In the families which were cared for half-a-year or longer (n = 80), 47 (58.7%) subsequent pregnancies became known. All gravidities occurred within one year after SID except two cases. RESULTS: We found a strong exigency for information, structure and protection during the whole pregnancy. This fact can be deducted from a high potential of anxiety and fear within the parents. Furthermore, our investigation revealed considerable doubts of the mothers about their parental competence and altered, but still intensive affects of grief yet confidence and great joy as well. Besides, we also observed problematic social experiences, as e.g. hushing up of the dead child or a lacking acceptance of grief by the social environment. CONCLUSIONS: A supporting and reliefing accompanying during a subsequent pregnancy comprises a continuous enlightenment of parents by being honest and open even in giving unpleasant and burdensome informations. It is recommended to show understanding for the exceeding anxieties of the parents, to offer them more possibilities of examinations and conversations as usually appropriate and to talk to them about their dead child and grief. Often the arrangement of contact to a parent-self-help association is the essential offer of support.

On the contamination of ambient air by preparations carried out with a band-saw.

The aim was to evaluate contamination by bone-dust and formaldehyde when using a band-saw for preparations of the base of the skull and the cervical vertebral spine (stationary band-saw, 1400 upm, saw blade with 160 saw teeth/m; distances 19-26 cm, time intervals 55-90 s). The asservation of bone particles was done with adhesive microscopic slides and calcium-specific staining by alizarin-red. The quantification of air contamination was carried out with micrometry and a particle-counter. Dräger-tubes 0.2/9 were utilized for estimation of formaldehyde. The band-saw did not produce high amounts of bone-dust with suspension power. Nevertheless, 75% of the particles ranged below 5 microns in size and were respirable. Contamination decreased with an increasing height above the floor. A massive flow of particles was observed during the first minutes of sawing. The bone-dust spread some metres away. The formaldehyde levels ranged throughout between 0.5 and also over 5 ppm (MAK = 0.5 ppm). This fact makes clear an intensive contamination of the air. Therefore, a ventilation directed to the floor is necessary when a band-saw is used, as well as breathing masks and safety-goggles.

[The evaluation of experimentally induced injuries to the upper cervical spine with a digital x-ray technic, computed tomography and magnetic resonance tomography]. / Evaluation experimentell erzeugter Verletzungen der oberen Halswirbelsäule mit digitaler Röntgentechnik, Computertomographie und Magnetresonanztomographie.

PURPOSE: To compare digital X-ray, CT, and MRI in the evaluation of ligamentous and osseous lesions in upper cervical spine specimens after artificial craniocervical injury with the findings of macroscopic preparation. MATERIALS AND METHODS: A rotation trauma of defined severity was applied to 19 human corpses. After dissection of the neck specimens, digital X-ray (DIMA Soft P41, Feinfocus), conventional and helical CT (CTi, High Speed, GE, collimation 1 mm; pitch 1.0), and MRI were performed from the skull base to C3. The findings were correlated with the macroscopic results of preparation. MR (Magnetom Vision, Siemens) imaging was obtained with a 1.5 T system using 2D- and 3D-sequences. RESULTS: Preparation revealed 6 fractures of the vertebral bodies, 5 fractures of the dens axis, 1 fracture of the arcus anterior of the atlas, 4 osseous flakes at the occipital condylus, and 6 lesions of the alar ligaments. Digital radiography showed all fractures and 4 osseous flakes at the occipital condylus. With conventional and helical CT, all fractures and all ruptured alar ligaments could be detected. 2D MRI depicted 9 of the fractures and 3D MRI showed fractures. With 2D MRI, 2 of the 4 osseous flakes at the condylus could be detected and with 3D MRI one occipital condylus fracture could be depicted. Ligamentous injuries were visualized by 2D MRI in 2 of 6 cases and by 3D MRI in one case. CONCLUSIONS: In post-mortem studies, CT was superior to MRI in the visualization of osseous and ligamentous injuries after trauma of the upper cervical spine. However, these results are not transferable to patients with rotation injury in general.

High cervical stress and apnoea.

The aim of this study was to investigate vegetative reactions in infants after mechanical irritation of the suboccipital region. The investigation is based on 199 infants who were observed while being treated with a suboccipital impulse (manual therapy). The results revealed vegetative reactions in more than half of all cases (52.8%, n = 105). The frequency of such vegetative reactions observed was at follows: flush 48.7% (n = 97), apnoea 22.1% (n = 44), hyperextension 13% (n = 26), and sweating 7.5% (n = 15). It is pointed out that approximately 25% of all the infants examined reacted by apnoea due to a mechanical irritation of the suboccipital region. This symptom was part of an extensive vegetative reaction. This method of inducing an apnoea has not yet been described; from this it follows that there are close relations to sudden infant death.

[Sawdust in autopsies: production, spreading, and contamination]. / Knochenstäube bei der Autopsie. Entstehung, Ausbreitung, Kontamination.

Airborne infections are well known in clinical medicine (transport of bacteria by aerosols). During autopsies floating, respirable kinds of bone dust are produced, depending on the type of saw. Experiments were carried out with oscillating saws (without/with exhauster) and manual saws (autopsy of cranial cavity). The intention was to characterize and quantify the sawdust produced by the different saws. Furthermore, we wanted to find out whether bacteria are transported by these aerosols. Bone dust was collected with adhesive microscopic slides. Alizarin red was used for solid histochemistry of bone particles. Quantification was carried out by an eyepiece micrometer. Airborne particles and bacteria were identified macroscopically per unit of time. The oscillating saw without exhauster produced sawdust in large quantities. This dust was respirable and had suspension power for hours. There was a remarkable reduction of sawdust by an integrated exhauster. Spreading of particles carrying bacteria/saccharomycetes was seen over 6-8 m. There is a very low risk of an airborne infection when utilizing a manual saw (production of particles similar to chippings, absence of suspended sawdust). It is necessary to take every precaution against airborne infections by wearing breathing masks and safety goggles when using an oscillating saw.

Axonal injury--a diagnostic tool in forensic neuropathology? A review.

We used beta-amyloid precursor protein (beta-APP) to investigate our own forensic neuropathological case material (n = 252) in light of the current literature on the phenomenon "axonal injury" (AI) to determine the incidence, specificity and biomechanical significance of AI and its significance for determining vitality and survival time. The case material consisted of cases of fatal nonmissile closed-head injury (n = 119), gunshot injury (n = 30), fatal cerebral ischemia/hypoxia (n = 51), brain death caused by mechanical trauma (n = 14) or nonmechanical injury (n = 18), and acute hemorrhagic shock (n = 20). AI was observed in 65% to 100% of cases of closed-head injury, fatal cerebral ischemia/hypoxia, and brain death with a survival time of more than 3 h; AI could not be detected in the cases of acute hemorrhagic shock. A statistically significant difference between traumatically and nontraumatically induced (nondisruptive) AI was not found. There was no statistical evidence of a correlation between AI and the different types of external force, since AI could be demonstrated after both acceleration/deceleration injuries and traumatic impact. Therefore, biomechanical inferences for reconstruction purposes are not possible. On the other hand, beta-APP was found to be a definite marker of vitality. In our material, cases with a posttraumatic interval of under 180 min did not express beta-APP. Moreover, the literature shows that the posttraumatic interval can be determined by other methods for demonstration of AI such as by ubiquitin immunostaining (360 min), silver staining (15-18 h), hematoxylin and eosin staining (about 24 h), or by demonstration of a microglial reaction (about 4 to 10 days) or of a few remaining isolated bulbs, without accompanying fibers, which can be detected after a survival time of up to 17 months.

[Heavy metal incorporation as an unusual self-injury]. / Schwermetall-Inkorporation als ungewöhnliche Selbst(be)schädigung.

A 19-year-old man was admitted to hospital because of uncharacteristic neurologic symptoms. During the first examination morphologic alterations due to an injection of mercury into the left arm and the left side of the trunk were found. The dose and the manner of application were doubtful and suspected to be a case of self-infliction. The man informed the police only 7 months later because his relatives had finally persuaded him to do so. The description of the infliction by unknown perpetrators was full of contradictions. Initially the patient gave only an indistinct description. But later on, the number of details increased. At the same time there was a change in the characteristics of the perpetrator(s). Other differences existed concerning a loss of consciousness which should have been caused by a single stroke on an arm. Furthermore, the patient told about a swelling as big as an egg, provoked by an injection of liquid mercury. It could be shown by experiments that mercury can be injected into soft-tissue very simply and that it spreaded widely. Arguments for a self-injection were e.g. the technical possibility, the topography of the injection marks, and an easy handling of the syringe. A psychiatric examination furthermore revealed, that the patient had had periods of restriction of thinking, sometimes combined with a lack of appreciation.

["I have killed my child". Experiences with severe depression in mothers after sudden infant death from the psychiatric and legal medicine viewpoint]. / "Ich habe mein Kind getötet". Erfahrungen mit schweren Depressionen bei Mütten nach Plötzlichem Kindstod aus psychiatrischer und rechtsmedizinischer Sicht.

Grief and depressive syndrome belong to normal reaction by parents after a sudden infant death (SID). In the following we report on two cases from the point of view of psychiatry and forensic medicine in which, subsequent to SID, mothers reacted with extremely grave depression and accused themselves of having killed the child. Furthermore, some recommendations are given for the care of parents affected.