Fatal facial–intracranial impalement injury in an accidental fall from a height: An autopsy case report with a review of the literature

A case of death of purulent meningitis caused by transorbital intracranial penetrating injury due to long-term residual bamboo chopstick

This article reports a case of death caused by purulent meningitis after a long-term transorbital intracranial penetrating injury induced by a bamboo chopstick. A 53-year-old man was pierced with a bamboo chopstick into the left orbit, and the bamboo chopstick broke off. The man remained conscious after the injury but developed paroxysmal headaches. Multiple computed tomography, computed tomography angiography, and rhinoscopy detections revealed that a puncture tract had formed from the left orbit to the right edge of the brainstem through the skull base. However, there was no apparent brain injury or cerebrovascular rupture, thus excluding the possibility of a retained intracranial foreign body by the neurosurgeon. Therefore, the man only received symptomatic and conservative treatments. Unfortunately, the man was found dead one morning, 13 months later. Autopsy and histopathological examinations revealed that he died of purulent meningitis caused by a long-term residual intracranial bamboo chopstick. A review of the relevant literature regarding the diagnosis, including diagnostic values and limitations of different imaging technologies, and treatment of residual intracranial foreign bodies, revealed that this was a case of misdiagnosis, leading to delayed treatment. This case had an indirect causal relationship between the victim's death and medical treatment. This article provides clinical strategies for diagnosing and treating such cases and a forensic perspective for identifying causes of deaths attributed to medical malpractices.

Compound elevated fracture-reconstruction of an unusual skull injury

Our institute of Legal Medicine was asked to examine a 27-year-old patient admitted to the neurosurgical department after a non-fatal accident (non-observed fall from height) at a construction site. Forensic advice was needed because of unexplainable injuries. By example of this case of a near-to-impalement, we would like to highlight an unusual, clinically frequently forgotten, and forensically thus far not discussed type of skull fracture with outward dislocation of bone fragment(s). These so-called compound elevated fractures of the skull are described occasionally in, mainly neurosurgical, case reports. Knowing its entity and its pathomechanism may be of forensic interest, particularly in order of reconstruction purpose. This article provides a brief review of the literature with special regard to the pathomechanism. In addition, it demonstrates the possible pitfall of computed tomography, or more specifically, the 3D reconstruction. To our knowledge, this is the first forensic report describing this kind of fracture.

Non-fatal impalement of the brain: A case report

We present a rare case of a non-fatal impalement injury of the brain. A 13-year-old boy was found in his classroom unconsciously lying on floor. His classmates reported that they had been playing, and throwing building bricks, when suddenly the boy collapsed. The emergency physician did not find significant injuries. Upon admission to a hospital, CT imaging revealed a "blood path" through the brain. After clinical forensic examination, an impalement injury was diagnosed, with the entry wound just below the left eyebrow. Eventually, the police presented a variety of pointers that were suspected to have caused the injury. Forensic trace analysis revealed human blood on one of the pointers, and subsequent STR analysis linked the blood to the injured boy. Confronted with the results of the forensic examination, the classmates admitted that they had been playing "sword fights" using the pointers, and that the boy had been hit during the game. The case illustrates the difficulties of diagnosing impalement injuries, and identifying the exact cause of the injury.

Skeletal fractures resulting from fatal falls: A review of the literature

To investigate what is currently known about skeletal blunt force trauma (BFT) resulting from falls, and how valuable that research is in contributing to forensic anthropology investigations and interpretations of circumstances of death, a comprehensive review of forensic anthropology, forensic pathology and clinical medicine literature was performed. Forensic anthropology literature identified that establishing the type of fall from the analysis of BFT is difficult given the uniqueness of each fall event, the complexities involved with identify BFT and, in particular, the limited available research documenting fracture patterning and morphologies. Comparatively, skeletal BFT resulting from fatal falls is well documented in the forensic pathology and clinical medicine literature. These disciplines cover a wide range of fall types (free falls, falls in juveniles, specific fractures produced from falls, falls down staircases, falls resulting in impalements, and 'other' fall types), provide details on how the nature of the fall influences the skeletal fracturing, and documents the anatomical regions susceptible to fracturing. Whilst these contributions may assist forensic anthropologists, they provide limited details of fracture patterns and morphologies and thus further research investigating the details of skeletal BFT resulting from fatal falls is required.

Primarily unrecognized thoracoabdominal impalement in a motorcyclist

In traffic accidents, fatal impalements are mostly seen in vehicle occupants injured by penetrating blunt-tipped objects such as fence posts or iron bars. Compared with this group of road users, the medical literature lacks reports on impaled motorcyclists. The article presents a case which deserves attention in several respects: 1. Both the impaling object and the victim were moving at the moment of penetration. 2. The lethal impalement trauma remained unrecognized until autopsy, particularly since the causative object did not get stuck in the wound track. 3. Two different body parts (head and trunk) were consecutively affected analogous to re-entry wounds in gunshots and stabs. 4. Due to the tubular shape and the sharp-edged end of the penetrating instrument (stanchion of a broken front-wheel's fork), clothing and soft tissues were punched out along the wound channel and partly remained lodged in the tube's cavity.

Intracranial impalement with entrance site in the mandibular region: postmortem elucidation of an accidental fall on a wooden plant stick

A 78-year-old woman with a history of transient ischemic attacks was found in the doorway of her house in a somnolent and unresponsive condition. In the right mandibular region, a small skin wound was localized, which was surgically treated. Six days after admission to the hospital, an exploratory craniotomy was performed because of abnormal CT findings. Apart from tissue lesions and hemorrhages a small bone fragment was detected in the right cerebral cortex, which was removed. After 11 days in hospital, the patient died from failure of central regulatory functions. At the forensic autopsy, a 15 cm long wound track running upward from the skin wound in the right mandibular region through the bony skull base to the right parietal lobe of the brain was noted. Apparently, the surgically removed bone fragment had been displaced from the right middle cranial fossa. The site of the incident in the deceased's house was inspected again and a bamboo pole used to stabilize a potted plant standing on the floor was found and sent to the trace evidence laboratory. Analysis showed blood and tissue deposits from the victim. On the basis of all the findings and the circumstances of the case, a fatal impalement injury caused by an accidental fall could be assumed.