Abbreviated Injury Scale Scoring in Traffic Fatalities: Comparison of Computerized Tomography and Autopsy

Evaluation of the cushion effect in blunt abdominal trauma patients: A computerized analysis

BACKGROUND

Obesity may serve as a protective factor in blunt abdominal trauma (BAT) patients due to a "cushion effect". In this study, we aim to use computed tomography (CT) scans to measure abdominal adiposity and its correlation with injury severity in BAT patients.

METHODS

We conducted a retrospective analysis of male BAT patients who had undergone CT scans. Subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were manually measured and height-normalized for analysis at lumbar levels L2 and L3. Statistical methods were used to compare differences in adiposity between patients with and without severe abdominal injuries. For controls, we also compared adipose tissue in patients with and without severe trauma to the chest, where less fat typically accumulates.

RESULTS

We included 361 male participants and conducted a comparative analysis of their demographic and injury characteristics. Patients without severe abdominal injuries had significantly higher SAT and VAT indices at both L2 and L3 (p < 0.05). However, these measures showed no significant differences between patients with and without severe chest trauma. Solid organ injuries, particularly liver injuries, were associated with decreased SAT and VAT.

CONCLUSION

Increase abdominal adiposity was linked to lower abdominal injury severity and solid organ injuries, particularly liver injuries. In addition to conventional BMI for evaluating obesity, either subcutaneous or visceral adipose tissue over lumbar levels L2 and L3 can be used to assess the "cushion effect."

Subject-specific finite element head models for skull fracture evaluation-a new tool in forensic pathology

Post-mortem computed tomography (PMCT) enables the creation of subject-specific 3D head models suitable for quantitative analysis such as finite element analysis (FEA). FEA of proposed traumatic events is an objective and repeatable numerical method for assessing whether an event could cause a skull fracture such as seen at autopsy. FEA of blunt force skull fracture in adults with subject-specific 3D models in forensic pathology remains uninvestigated. This study aimed to assess the feasibility of FEA for skull fracture analysis in routine forensic pathology. Five cases with blunt force skull fracture and sufficient information on the kinematics of the traumatic event to enable numerical reconstruction were chosen. Subject-specific finite element (FE) head models were constructed by mesh morphing based on PMCT 3D models and A Detailed and Personalizable Head Model with Axons for Injury Prediction (ADAPT) FE model. Morphing was successful in maintaining subject-specific 3D geometry and quality of the FE mesh in all cases. In three cases, the simulated fracture patterns were comparable in location and pattern to the fractures seen at autopsy/PMCT. In one case, the simulated fracture was in the parietal bone whereas the fracture seen at autopsy/PMCT was in the occipital bone. In another case, the simulated fracture was a spider-web fracture in the frontal bone, whereas a much smaller fracture was seen at autopsy/PMCT; however, the fracture in the early time steps of the simulation was comparable to autopsy/PMCT. FEA might be feasible in forensic pathology in cases with a single blunt force impact and well-described event circumstances.

Can computed tomography replace or supplement autopsy?

Postmortem computed tomography (PMCT) has been integrated into the practice of many forensic pathologists. To evaluate the utility of PMCT in supplementing and/or supplanting medicolegal autopsy, we conducted a prospective double-blind comparison of abnormal findings reported by the autopsy pathologist with those reported by a radiologist reviewing the PMCT. We reviewed 890 cases: 167 with blunt force injury (BFI), 63 with pediatric trauma (under 5 years), 203 firearm injuries, and 457 drug poisoning deaths. Autopsy and radiology reports were coded using the Abbreviated Injury Scale and abnormal findings and cause of death (COD) were compared for congruence in consensus conferences with novel pathologists and radiologists. Overall sensitivity for recognizing abnormal findings was 71% for PMCT and 74.6% for autopsy. Sensitivities for PMCT/autopsy were 74%/73.1% for BFI, 61.5%/71.4% for pediatric trauma, 84.9%/83.7% for firearm injuries, and 56.5%/66.4% for drug poisoning deaths. COD assigned by reviewing PMCT/autopsy was correct in 88%/95.8% of BFI cases, 99%/99.5% of firearm fatalities, 82.5%/98.5% of pediatric trauma deaths, and 84%/100% of drug poisoning deaths of individuals younger than 50. Both autopsy and PMCT were imperfect in recognizing injuries. However, both methods identified the most important findings and are sufficient to establish COD in cases of BFI, pediatric trauma, firearm injuries and drug poisoning in individuals younger than 50. Ideally, all forensic pathologists would have access to a CT scanner and a consulting radiologist. This would allow a flexible approach that meets the diagnostic needs of each case and best serves decedents' families and other stakeholders.

Obese Occupant Response in Reclined and Upright Seated Postures in Frontal Impacts

The American population is getting heavier and automated vehicles will accommodate unconventional postures. While studies replicating mid-size and upright fore-aft seated occupants are numerous, experiments with post-mortem human subjects (PMHS) with obese and reclined occupants are sparse. The objective of this study was to compare the kinematics of the head-neck, torso and pelvis, and document injuries and injury patterns in frontal impacts. Six PMHS with a mean body mass index of 38.2 ± 5.3 kg/m2 were equally divided between upright and reclined groups (seatback: 23°, 45°), restrained by a three-point integrated belt, positioned on a semi-rigid seat, and exposed to low and moderate velocities (15, 32 km/h). Data included belt loads, spinal accelerations, kinematics, and injuries from x-rays, computed tomography, and necropsy. At 15 km/h speed, no significant difference in the occupant kinematics and evidence of orthopedic failure was observed. At 32 km/h speed, the primary difference between the cohorts was significantly larger Z displacements in the reclined occupant at the head (190 ± 32 mm, vs. 105 ± 33 mm p < 0.05) and femur (52 ± 18 mm vs. 30 ± 10 mm, p < 0.05). All the moderate-speed tests produced at least one thorax injury. Rib fractures were scattered around the circumference of the rib-cage in the upright, while they were primarily concentrated on the anterior aspect of the rib-cage in two reclined specimens. Although MAIS was the same in both groups, the reclined specimens had more bi-cortical rib fractures, suggesting the potential for pneumothorax. While not statistical, these results suggest enhanced injuries with reclined obese occupants. These results could serve as a data set for validating the response of restrained obese anthropometric test device (ATDs) and computational human body models.

Femoral fractures are an indicator of increased severity of injury for road traffic collision victims: an autopsy-based case-control study on 4895 fatalities

INTRODUCTION

The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs.

PATIENTS AND METHODS

A case-control study based on forensic material from 4895 consecutive RTC-induced fatalities, between 1996 and 2005. Injuries were coded according to the Abbreviated Injury Scale-1990 Revision (AIS-90), and the Injury Severity Score (ISS) was calculated. Victims were divided according to the presence of femoral fractures in all possible anatomic locations or not. Univariate comparisons and logistic regression analysis for probabilities of association as odds ratios (OR) were performed.

RESULTS

The FFx group comprised 788 (16.1%) victims. The remaining 4107 victims constituted the controls. The FFx group demonstrated higher ISS (median 48 vs 36, p < 0.001) and shorter post-injury survival times (median 60 vs 85 min, p < 0.001). Presence of bilateral fractures (15.5%) potentiated this effect (median ISS 50 vs 43, p = 0.006; median survival time 40 vs 65, p = 0.0025; compared to unilateral fractures). Statistically significant associations of FFx were identified with AIS2-5 thoracic trauma (OR 1.43), AIS2-5 abdominal visceral injuries (OR 1.89), AIS1-3 skeletal injuries of the upper (OR 2.7) and lower limbs (OR 3.99) and AIS2-5 of the pelvis (OR 2.75) (p < 0.001). In the FFx group, 218 (27.7%) victims survived past the emergency department and 116 (53.2%) underwent at least one surgical procedure. Complications occurred in 45.4% of hospitalized victims, the most common being pneumonia (34.8%).

CONCLUSION

This study has documented that femoral fractures are associated with increased severity of injury, shorter survival times and higher incidence of associated thoracic, abdominal and skeletal extremity injuries, compared to controls. These findings should be considered for an evidence-based upgrading of trauma care.

Post-Mortem CT Delivers Fast and Accurate Injury Identification in Trauma Patients

Background

Accurate and timely injury identification is critical but difficult to achieve in trauma patients who die shortly after arrival to the hospital. Autopsy has historically been used to detect injuries, but few undergo formal autopsy. This study investigates the utility of post-mortem computed tomography (PMCT) for injury identification in a diverse trauma population.

Methods

Cross-sectional study of adult trauma patients who died within 24 hours of arrival to a Level I trauma center were included. Among patients with PMCT, injury severity score (ISS) and number of injuries (NOI) were calculated either from physical exam alone (pre-PMCT) or exam and imaging (post-PMCT). ISS and NOI before and after PMCT were compared. A cause of death analysis was performed for patients who underwent comprehensive (ie, head, neck, and torso) PMCT. Non-parametric repeated measures tests were used, as appropriate.

Results

7.3% (N = 28) of patients received PMCT. Compared to pre-PMCT, median ISS (21 vs 3.5) and NOI (5 vs 2) were greater post-PMCT ( P < .001, respectively). Autopsy rate was 13.2% overall; 82.5% of autopsies were due to a penetrating mechanism, and median time to autopsy reporting was 38.5 days. Among 17 patients who received comprehensive PMCT, 64.7% had a single cause of death identified, and the remaining were classified as either multiple potential contributors or unknown.

Discussion

PMCT is a readily available method to identify injuries in trauma patients who expire shortly upon presentation. Given the low autopsy rate for blunt trauma and delay in reporting, PMCT is an important adjunct for trauma providers.

The role of PMCT for the assessment of the cause of death in natural disaster (landslide and flood): a Sicilian experience

In this report, the authors provide a contribution of PMCT in assessing the cause of death due to natural disasters. Here, the PMCT findings of 43 subjects who died during both landslide and flood were described. The post-mortem imaging revealed, clearly, traumatic injuries and/or the presence of foreign material in airways allowing to assess the cause of death of each subject, together with external inspection and the collected circumstantial data. Particularly, the PMCT has been helpful for characterization and localization of the clogging substance in airways providing findings on bronchial branches involvement. Moreover, the investigation offered detailed data on skeletal injuries in all anatomic districts and put in evidence both the precise fracturing site and the characteristics of fracture stubs for each bone fracture. This report supports the recommendation of the virtual autopsy in a case with several victims, as in natural disasters, and its role as an alternative diagnostic investigation when the standard autopsy is not feasible.

The usefulness of a trauma probability of survival model for forensic life-threatening danger assessments

Clinical forensic medical examinations constitute an increasing proportion of our institution’s tasks, and, concomitantly, the authorities are now requesting forensic life-threatening danger assessments based on our examinations. The aim of this retrospective study was to assess if a probability of survival (PS) trauma score could be useful for these forensic life-threatening danger assessments and to identify a cut-off PS score as a supporting tool for the forensic practice of assessing life-threatening danger. We compared a forensic database and a trauma database and identified 161 individuals (aged 15 years or older) who had both a forensic life-threatening danger assessment and a PS score. The life-threatening danger assessments comprised the following statements: was not in life-threatening danger (NLD); could have been in life-threatening danger (CLD); or was in life-threatening danger (LD). The inclusion period was 2012–2016. A statistically significant difference was found in the PS scores between NLD, CLD and LD (chi-square test: p < 0.0001). The usefulness of the PS score for categorizing life-threatening danger assessments was determined by a receiver-operator characteristic (ROC) curve. The area under the curve was 0.76 (95% CI, 0.69 to 0.84) and the ROC curve revealed that a cut-off PS score of 95.8 would appropriately identify LD. Therefore, a PS score below 95.8 would indicate life-threatening danger. We propose a further exploration of how the evidence-based PS score, including a cut-off value, might be implemented in clinical forensic medical statements to add to the scientific strength of these statements.

Postmortem CT in Trauma: An Overview

As forensic radiology sees an exponential gain in popularity, postmortem computed tomography (PMCT) is increasingly being used in the appropriate setting, either as preautopsy guidance or as part of complementary virtual autopsy protocol. Many articles have expounded the value it adds to forensic pathology in the general setting and the appropriate technical parameters to be used for optimum benefit. We aim to put forth a concise review on the role of PMCT specifically in trauma and the pitfalls to be aware of. Reviews have shown that presumed cause of death in trauma have been proven by autopsy to be wrong in about 30% cases. Radiology applied to postmortem investigation in unnatural deaths and more specifically in trauma shares many semiotic features with emergency radiology. Therefore, in the near future, emergency radiologists might be required to integrate this type of imaging in their regular practice. Although the predominant drawbacks are time-dependent, PMCT also has some difficulty in differentiating antemortem and postmortem events. However, in many such scenarios, PMCT and autopsy play a complementary role in arriving at conclusions, and we believe understanding the benefits and role in trauma is imperative considering the expanding usage of PMCT.

Role of post-mortem multi-slice computed tomography in the evaluation of single gunshot injuries

Post-mortem multi-slice computed tomography (MSCT) is a new approach in forensic pathology for gunshot injuries. This study determines the role of MSCT in the characterisation of single gunshot injuries. We report three cases. In the first case, an 80-year-old man was found dead in his bedroom with a gun. External examination showed devastating head injuries. In the second case, an 81-year-old man was found dead in his apartment, without a gun. External examination showed gunshot injuries. In the third case, a 56-year-old man was found dead on a road. MSCT and autopsy were performed in all these cases. MSCT not only allowed the determination of entrance and exit wounds but also showed some artefacts. In conclusion, radiology is fundamental for the reconstruction of gunshot injuries, and the manner of death can only be ascertained by autopsy.

Transverse process fractures of the thoracic vertebrae-the significance of this injury in the context of medicolegal opinions on high-energy trauma cases

Thoracic transverse process fractures (TTPFs) are injuries that go unnoticed during traditional autopsies, as demonstrated by a lack of medicolegal publications regarding TTPFs. However, postmortem computed tomography (PMCT) has made detection of this type of injury easy. Thus, the goal of our study was to analyze the significance of TTPFs in the context of medicolegal opinions. Forensic autopsy reports and PMCT scans of 116 people who had died from high-energy trauma were analyzed. TTPFs were found in 34.48% (n = 40) of the total test group. The highest proportions of TTPFs were found in drivers (50%, n = 8) and in victims of falls from heights (41%, n = 14). Among seven car passengers, only one victim had suffered TTPFs. In comparison with persons without TTPFs, persons with TTPFs demonstrated more severe general injuries, especially to the chest and abdomen, and more often (in 90% of cases) died at the scene of injury (all these differences were statistically significant; p < 0.0001). Pedestrian TTPFs were present only in victims struck from their front or back. TTPFs in victims of falls were found only in those cases in which the height of the fall was at least 9 m. The presence of TTPFs indicates that the application of a very strong force leads to injuries that, in most cases, result in death at the scene of the event. Detecting TTPFs provides additional information about the mechanism of trauma, especially in pedestrians, drivers, passengers, and victims of falls from heights.

Predictive capability of the injury severity score versus the new injury severity score in the categorization of the severity of trauma patients: a cross-sectional observational study

PURPOSE

The AIS scale is a measurement tool for single injuries. The ISS is considered the gold standard for determining the severity of injured patients, and the NISS was developed to improve the ISS with respect to loss of information, as well as to facilitate its calculation. The aim of this study was to analyse what injury severity measure, calculated according to the Abbreviated Injury Scale (AIS), 1998 and 2005 (update 2008) versions, performs better with mortality, cost and hospital length of stay healthcare indicators.

METHODS

This cross-sectional observational study was carried out between February 1st 2012 and February 1st 2013. Inclusion criteria were injured patients due to external causes admitted to trauma service through the emergency department. Manual coding of all injuries was performed and ISS and NISS scores were calculated for both versions of the AIS scale. Severity was then compared to mortality (in-hospital and at 30 days), healthcare cost, and length of hospital stay.

RESULTS

The index with the best predictive capability for in-hospital mortality was NISS 05 (AUC = 0.811). There was a significant increase in hospital stay and healthcare cost in the most severe patients in all indexes, except for ISS 05.

CONCLUSIONS

NISS is found to be an index with higher predictive capability for in-hospital mortality and correlates better to length of hospital stay and healthcare cost.

A Practical Guide to Virtual Autopsy: Why, When and How

Postmortem imaging is considered a routine investigative modality in many forensic institutions worldwide. Because of its ability to provide a quick and complete documentation of skeletal system and major parenchymal alterations, postmortem computed tomography (PMCT) is the imaging technique most frequently applied in postmortem forensic investigations. Also postmortem magnetic resonance has been implemented in postmortem setting, but its use is mostly limited to focused analysis (eg, study of the heart and brain). PMCT presents some limits in investigating "natural" deaths, particularly related to its poor ability in differentiating soft tissue interfaces and in depicting vascular lesions. For this reason, PMCT angiography has been introduced. A major limitation of these postmortem imaging techniques is the absence of body samples for histopathologic, toxicologic, or microbiological analysis. This limit has been overcome by the introduction of postmortem percutaneous biopsies. The aim of this review is to provide a practical guide for virtual autopsy, with the intent of facilitating standardization and augmenting its quality. In particular, the indications of virtual autopsy as well protocols in PMCT examinations and its ancillary techniques will be discussed. Finally, the workflow of a typical virtual autopsy and its main steps will be described.

Quality of head injury coding from autopsy reports with AIS © 2005 update 2008

ABSTACT Objective: Coding injuries from autopsy reports of traffic accident victims according to Abbreviated Injury Scale AIS © 2005 update 2008 [1] is quite time consuming. The suspicion arose, that many issues leading to discussion between coder and control reader were based on information required by the AIS that was not documented in the autopsy reports.

METHODS

To quantify this suspicion, we introduced an AIS-detail-indicator (AIS-DI). To each injury in the AIS Codebook one letter from A to N was assigned indicating the level of detail. Rules were formulated to receive repeatable assignments. This scheme was applied to a selection of 149 multiply injured traffic fatalities. The frequencies of "not A" codes were calculated for each body region and it was analysed, why the most detailed level A had not been coded. As a first finding, the results of the head region are presented.

RESULTS

747 AIS head injury codes were found in 137 traffic fatalities, and 60% of these injuries were coded with an AIS-DI of level A. There are three different explanations for codes of AIS-DI "not A": Group 1 "Missing information in autopsy report" (5%), Group 2 "Clinical data required by AIS" (20%), and Group 3 "AIS system determined" (15%). Groups 1 and 2 show consequences for the ISS in 25 cases. Other body regions might perform differently.

CONCLUSIONS

The AIS-DI can indicate the quality of the underlying data basis and, depending on the aims of different AIS users it can be a helpful tool for quality checks.

Virtual animation of victim-specific 3D models obtained from CT scans for forensic reconstructions: Living and dead subjects

Post-mortem CT scanning (PMCT) has been introduced at several forensic medical institutions many years ago and has proved to be a useful tool. 3D models of bones, skin, internal organs and bullet paths can rapidly be generated using post-processing software. These 3D models reflect the individual physiognomics and can be used to create whole-body 3D virtual animations. In such way, virtual reconstructions of the probable ante-mortem postures of victims can be constructed and contribute to understand the sequence of events. This procedure is demonstrated in two victims of gunshot injuries. Case #1 was a man showing three perforating gunshot wounds, who died due to the injuries of the incident. Whole-body PMCT was performed and 3D reconstructions of bones, relevant internal organs and bullet paths were generated. Using 3ds Max software and a human anatomy 3D model, a virtual animated body was built and probable ante-mortem postures visualized. Case #2 was a man presenting three perforating gunshot wounds, who survived the incident: one in the left arm and two in the thorax. Only CT scans of the thorax, abdomen and the injured arm were provided by the hospital. Therefore, a whole-body 3D model reflecting the anatomical proportions of the patient was made combining the actual bones of the victim with those obtained from the human anatomy 3D model. The resulted 3D model was used for the animation process. Several probable postures were also visualized in this case. It has be shown that in Case #1 the lesions and the bullet path were not consistent with an upright standing position; instead, the victim was slightly bent forward, i.e. he was sitting or running when he was shot. In Case #2, one of the bullets could have passed through the arm and continued into the thorax. In conclusion, specialized 3D modelling and animation techniques allow for the reconstruction of ante-mortem postures based on both PMCT and clinical CT.

What are the differences in injury patterns of young and elderly traffic accident fatalities considering death on scene and death in hospital?

Older traffic participants have higher risks of injury than the population up to 65 years in case of comparable road traffic accidents and further, higher mortality rates at comparable injury severities. Rib fractures as risk factors are currently discussed. However, death on scene is associated with hardly survivable injuries and might not be a matter of neither rib fractures nor age. As 60% of traffic accident fatalities are estimated to die on scene, they are not captured in hospital-based trauma registries and injury patterns remain unknown. Our database comprises 309 road traffic fatalities, autopsied at the Institute of Legal Medicine Munich in 2004 and 2005. Injuries are coded according to Abbreviated Injury Scale, AIS© 2005 update 2008 [1]. Data used for this analysis are age, sex, site of death, site of accident, traffic participation mode, measures of injury severity, and rib fractures. The injury patterns of elderly, aged 65+ years, are compared to the younger ones divided by their site of death. Elderly with death on scene more often show serious thorax injuries and pelvic fractures than the younger. Some hints point towards older fatalities showing less frequently serious abdominal injuries. In hospital, elderly fatalities show lower Injury Severity Scores (ISSs) compared to the younger. The number of rib fractures is significantly higher for the elderly but is not the reason for death. Results show that young and old fatalities have different injury patterns and reveal first hints towards the need to analyze death on scene more in-depth.

Early neurological deterioration in older adults with traumatic brain injury

INTRODUCTION

Traumatic brain injuries (TBIs) and resulting fatalities among older adults increased considerably in recent years. Neurological deterioration often goes unrecognized at the injury scene and patients arrive at emergency departments with near-normal Glasgow Coma Scale (GCS) scores. This study examined the proportion of older adults experiencing early neurological deterioration (prehospital to emergency department), associated factors, and association of the magnitude of neurological deterioration with TBI severity.

METHODS

This secondary analysis of National Trauma Data Bank Research Datasets included patients who were age ⩾65, sustained a TBI, and transported from the injury scene to an emergency department. Data analysis included chi-square analysis, t-tests, and logistic regression. Long-term anticoagulant/antiplatelet therapy was not associated with deterioration.

RESULTS

Of the sample of 91,886 patients, 13,913 (15.1%) experienced early neurological deterioration. Adjusting for covariates, age, gender, head AIS_max injury severity, and probability of death were associated with early deterioration. Patients with severe and critical head injuries had the highest odds of early neurological deterioration (OR=1.41 [CI=1.22-1.63] and OR=1.98 [CI=1.63-2.40], p<0.001).

DISCUSSION/CONCLUSIONS

Prehospital providers, nurses, physicians, and other providers have opportunities to optimize outcomes from older adult TBI through early recognition of neurological deterioration, rapid transport to facilities for definitive treatment, and targeted rehabilitation.

Changing threshold for AIS scores of thoracolumbar compression fractures

BACKGROUND

The Abbreviated Injury Scale (AIS) is an anatomical-based coding system created by the Association for the Advancement of Automotive Medicine, utilized to classify and code injuries resulting from trauma, in order of severity. According to the latest version, all Thoraco-Lumbar Compression Fractures (TLCF), even without injury to other spine components and with >20% loss of height, were branded AIS 3 injuries, reflecting a serious threat to life or permanent disability. Advances in spine imaging, recent biomechanical studies, and long-term outcomes research offer the opportunity to consider these injuries differently.

OBJECTIVE

To re-evaluate the percent compression threshold of TLCF of the spine from motor vehicle crashes (MVC) for serious risk to life identified as surgical treatment, delineating a reliable cut-off for fracture severity and morbidity. Little national data considers degree of compression and provides adequate followup imaging to determine degree of compression, justifying this effort.

METHODS

Charts and radiographs of patients admitted to our institution due to vehicle crashes with isolated (vertebral body only) TLCF between 2008 and 2015 were reviewed. Data were collected on degree of compression, treatment, and long-term outcomes to determine the threshold of permanent injury. Vertebral bodies at the level of fracture were measured both anteriorly and posteriorly, and compared to adjacent segments; percentage compression was calculated.

RESULTS

1470 patient records with diagnoses of spine trauma were reviewed; 695 isolated compression fractures were identified, of which 194 were in vehicle crashes and had adequate imaging and follow-up. Ages ranged from 19 to 82, with a male: female ratio of 60:40. No patient with vertebral body compression of less than 30% underwent surgery unless presenting with a neurological deficit. All 22 surgical patients demonstrated significant retropulsion of bone into the spinal canal. Five surgical patients suffered eight complications; there were no adverse outcomes in the nonsurgical group.

CONCLUSIONS

These results are consistent with evolving clinical thinking, resulting in decreasing surgical incidence and orthosis use. Our data strongly suggests that isolated compression fractures in the absence of neurologic deficit or severe cord compression due to retropulsed bone are self-limiting. Therefore, the AIS scores for these common injuries could be reconsidered and reflect their relatively benign outlook.

Understanding traffic crash under-reporting: Linking police and medical records to individual and crash characteristics

OBJECTIVE

This study aligns to the body of research dedicated to estimating the underreporting of road crash injuries and adds the perspective of understanding individual and crash factors contributing to the decision to report a crash to the police, the hospital, or both.

METHOD

This study focuses on road crash injuries that occurred in the province of Funen, Denmark, between 2003 and 2007 and were registered in the police, the hospital, or both authorities. Underreporting rates are computed with the capture-recapture method, and the probability for road crash injuries in police records to appear in hospital records (and vice versa) is estimated with joint binary logit models.

RESULTS

The capture-recapture analysis shows high underreporting rates of road crash injuries in Denmark and the growth of underreporting not only with the decrease in injury severity but also with the involvement of cyclists (reporting rates of about 14% for serious injuries and 7% for slight injuries) and motorcyclists (reporting rates of about 35% for serious injuries and 10% for slight injuries). Model estimates show that the likelihood of appearing in both data sets is positively related to helmet and seat belt use, number of motor vehicles involved, alcohol involvement, higher speed limit, and females being injured.

CONCLUSIONS

This study adds significantly to the literature about underreporting by recognizing that understanding the heterogeneity in the reporting rate of road crashes may lead to devising policy measures aimed at increasing the reporting rate by targeting specific road user groups (e.g., males, young road users) or specific situational factors (e.g., slight injuries, arm injuries, leg injuries, weekend).

Analysis of death in major trauma: value of prompt post mortem computed tomography (pmCT) in comparison to office hour autopsy

Background

To analyze diagnostic accuracy of prompt post mortem Computed Tomography (pmCT) in determining causes of death in patients who died during trauma room management and to compare the results to gold standard autopsy during office hours.

Methods

Multiple injured patients who died during trauma room care were enrolled. PmCT was performed immediately followed by autopsy during office hours. PmCT and autopsy were analyzed primarily regarding pmCT ability to find causes of death and secondarily to define exact causes of death including accurate anatomic localizations. For the secondary analysis data was divided in group-I with equal results of pmCT and autopsy, group-II with autopsy providing superior results and group-III with pmCT providing superior information contributing to but not majorly causing death.

Results

Seventeen multiple trauma patients were enrolled. Since multiple trauma patients were enrolled more injuries than patients are provided. Eight patients sustained deadly head injuries (47.1 %), 11 chest (64.7 %), 4 skeletal system (23.5 %) injuries and one patient drowned (5.8 %). Primary analysis revealed in 16/17 patients (94.1 %) causes of death in accordance with autopsy. Secondary analysis revealed in 9/17 cases (group-I) good agreement of autopsy and pmCT. In seven cases autopsy provided superior results (group-II) whereas in 1 case pmCT found more information (group-III).

Discussion

The presented work studied the diagnostic value of pmCT in defining causes of death in comparison to standard autopsy. Primary analysis revealed that in 94.1% of cases pmCT was able to define causes of death even if only indirect signs were present. Secondary analysis showed that pmCT and autopsy showed equal results regarding causes of death in 52.9%.

Conclusions

PmCT is useful in traumatic death allowing for an immediate identification of causes of death and providing detailed information on bony lesions, brain injuries and gas formations. It is advisable to conduct pmCT especially in cases without consent to autopsy to gain information about possible causes of death and to rule out possible clinical errors.

Value of monoenergetic dual-energy CT (DECT) for artefact reduction from metallic orthopedic implants in post-mortem studies

OBJECTIVES

The aim of this ex vivo study was to assess the performance of monoenergetic dual-energy CT (DECT) reconstructions to reduce metal artefacts in bodies with orthopedic devices in comparison with standard single-energy CT (SECT) examinations in forensic imaging. Forensic and clinical impacts of this study are also discussed.

MATERIALS AND METHODS

Thirty metallic implants in 20 consecutive cadavers with metallic implants underwent both SECT and DECT with a clinically suitable scanning protocol. Extrapolated monoenergetic DECT images at 64, 69, 88, 105, 120, and 130 keV and individually adjusted monoenergy for optimized image quality (OPTkeV) were generated. Image quality of the seven monoenergetic images and of the corresponding SECT image was assessed qualitatively and quantitatively by visual rating and measurements of attenuation changes induced by streak artefact.

RESULTS

Qualitative and quantitative analyses showed statistically significant differences between monoenergetic DECT extrapolated images and SECT, with improvements in diagnostic assessment in monoenergetic DECT at higher monoenergies. The mean value of OPTkeV was 137.6 ± 4.9 with a range of 130 to 148 keV.

CONCLUSIONS

This study demonstrates that monoenergetic DECT images extrapolated at high energy levels significantly reduce metallic artefacts from orthopedic implants and improve image quality compared to SECT examination in forensic imaging.

Post-mortem imaging compared with autopsy in trauma victims--A systematic review

BACKGROUND

Post-mortem imaging or virtual autopsy is a rapidly advancing field of post-mortem investigations of trauma victims. In this review we evaluate the feasibility of complementation or replacement of conventional autopsy by post-mortem imaging in trauma victims.

MATERIALS AND METHODS

A systematic review was performed in compliance with the PRISMA guidelines. MEDLINE, Embase and Cochrane databases were systematically searched for studies published between January 2008 and January 2014, in which post-mortem imaging was compared to conventional autopsy in trauma victims. Studies were included when two or more trauma victims were investigated.

RESULTS

Twenty-six studies were included, with a total number of 563 trauma victims. Post-mortem computer tomography (PMCT) was performed in 22 studies, post-mortem magnetic resonance imaging (PMMRI) in five studies and conventional radiography in two studies. PMCT and PMMRI both demonstrate moderate to high-grade injuries and cause of death accurately. PMCT is more sensitive than conventional autopsy or PMMRI in detecting skeletal injuries. For detecting minor organ and soft tissue injuries, autopsy remains superior to imaging. Aortic injuries are missed frequently by PMCT and PMMRI and form their main limitation.

CONCLUSION

PMCT should be considered as an essential supplement to conventional autopsy in trauma victims since it detects many additional injuries. Despite some major limitations, PMCT could be used as an alternative for conventional autopsy in situations where conventional autopsy is rejected or unavailable.

A new tool for coding and interpreting injuries in fatal airplane crashes: the crash injury pattern assessment tool application to the Air France Flight AF447 disaster (Rio de Janeiro-Paris), 1st of June 2009

For investigation of air disasters, crash reconstruction is obtained using data from flight recorders, physical evidence from the site, and injuries patterns of the victims. This article describes a new software, Crash Injury Pattern Assessment Tool (CIPAT), to code and analyze injuries. The coding system was derived from the Abbreviated Injury Score (AIS). Scores were created corresponding to the amount of energy required causing the trauma (ER), and the software was developed to compute summary variables related to the position (assigned seat) of victims. A dataset was built from the postmortem examination of 154/228 victims of the Air France disaster (June 2009), recovered from the Atlantic Ocean after a complex and difficult task at a depth of 12790 ft. The use of CIPAT allowed to precise cause and circumstances of deaths and confirmed major dynamics parameters of the crash event established by the French Civil Aviation Safety Investigation Authority.

Comparison of whole-body post mortem 3D CT and autopsy evaluation in accidental blunt force traumatic death using the abbreviated injury scale classification

Although 3D CT imaging data are available on survivors of accidental blunt trauma, little similar data has been collected and classified on major injuries in victims of fatal injuries. This study compared the sensitivity of post mortem computed tomography (PMCT) with that of conventional autopsy for major trauma findings classified according to the trauma Abbreviated Injury Scale (AIS). Whole-body 3D PMCT imaging data and full autopsy findings were analyzed on 21 victims of accidental blunt force trauma death. All major injuries were classified on the AIS scale with ratings from 3 (serious) to 6 (unsurvivable). Agreement between sensitivity of autopsy and PMCT for major injuries was determined. A total of 195 major injuries were detected (mean per fatality, 9.3; range, 1-14). Skeletal injuries by AIS grade included 37 grade 3, 45 grade 4, 12 grade 5, and 2 grade 6 major findings. Soft tissue injuries included 10 grade 3, 68 grade 4, 16 grade 5, and 5 grade 6 major findings. Of these, PMCT detected 165 (88 skeletal, 77 soft tissue), and autopsy detected 127 (59 skeletal, 68 soft tissue). PMCT agreed with autopsy in 86% and 76% of skeletal and soft tissue injuries, respectively. PMCT detected an additional 37 skeletal and 31 soft tissue injuries that were not identified at autopsy. Autopsy detected 8 skeletal and 22 soft tissue injuries that were not detected by PMCT. PMCT was more sensitive for skeletal (P=0.05) and head and neck region injury (P=0.043) detection. PMCT showed a trend for greater sensitivity than autopsy, but this did not reach statistical significance (P=0.083). 3D PMCT detected significantly more skeletal injuries than autopsy and a similar number of soft tissue injuries to autopsy and promises to be a sensitive tool for detection and classification of skeletal injuries in fatal blunt force accidental trauma. Use of the AIS scale allows standardized categorization and quantification of injuries that contribute to death in such cases and allows more objective comparison between autopsy and PMCT.

Interobserver agreement of the injury diagnoses obtained by postmortem computed tomography of traffic fatality victims and a comparison with autopsy results

The present study investigated the interobserver variation between a radiologist and a forensic pathologist in 994 injury diagnoses obtained by postmortem computed tomography (CT) of 67 traffic fatality victims, and the results were compared with diagnoses obtained by autopsy. The injuries were coded according to the abbreviated injury scale (AIS). We found a low interobserver variability for postmortem CT injury diagnoses, and the variability was the lowest for injuries with a high AIS severity score. The radiologist diagnosed more injuries than the pathologist, especially in the skeletal system, but the pathologist diagnosed more organ injuries. We recommend the use of a radiologist as a consultant for the evaluation of postmortem CT images. Training in radiology should be included in forensic medicine postgraduate training. CT was superior to autopsy in detecting abnormal air accumulations, but autopsy was superior to CT in the detection of organ injuries and aortic ruptures. We recommend a combination of CT and autopsy for the postmortem investigation of traffic fatality victims.

Investigation of a fatal airplane crash: autopsy, computed tomography, and injury pattern analysis used to determine who was steering the plane at the time of the accident. A case report

A fatal accident is reported in which a small single-engine light airplane crashed. The airplane carried two persons in the front seats, both of whom possessed valid pilot certificates. Both victims were subject to autopsy, including post-mortem computed tomography scanning (PMCT) prior to the autopsy. The autopsies showed massive destruction to the bodies of the two victims but did not identify any signs of acute or chronic medical conditions that could explain loss of control of the airplane. PMCT, histological examination, and forensic chemical analysis also failed to identify an explanation for the crash. A detailed review of an airplane identical to the crashed airplane was performed in collaboration with the Danish Accident Investigation Board and the Danish National Police, National Centre of Forensic Services. The injuries were described using the abbreviated injury scale, the injury severity score, 3-dimensional reconstructions of the PMCT, and an injury pattern analysis. We describe how, on basis of these data, we reached a conclusion about which of the two victims was the most likely to have been in control of the airplane at the time of accident. Furthermore, we argue that all victims of fatal airplane crashes should be subject to forensic autopsy, including PMCT and forensic chemical analysis. The continuous accumulation of knowledge about injury patterns from "simple" accidents is the foundation for the correct analysis of "difficult" accidents.

Postmortem magnetic resonance imaging dealing with low temperature objects

In Japan, the medical examiner system is not widespread, the rate of autopsy is low, and many medical institutions therefore perform postmortem imaging using clinical equipment. Postmortem imaging is performed to clarify cause of death, select candidates for autopsy, make a guide map for autopsy, or provide additional information for autopsy. Findings are classified into 3 categories: cause of death and associated changes, changes induced by cardiopulmonary resuscitation, and postmortem changes. Postmortem magnetic resonance imaging shows characteristic changes in signal intensity related to low body temperature after death; they are low temperature images.