Death, Trauma,

and the Skeleton

-FAs must be knowledgeable to the
characteristics of trauma to the human
bone
- trauma: pathological category defined as injury caused to
living tissue from an outside source
- many surfaces can cause trauma (including the ground,
chemicals, or extremes in temperature)
- specifics that allow the identification of a medicolegally
significant death:
- (1) trauma that occurred at the time of death (2) the force that
caused the trauma (3) number of wounds (4) sequence of
wounds (in cases of multiple traumas (5) location of wounds

Cause and Manner of Death
- cause of death: same in all humans; person stops breathing
and his or her heart stops beating
- cause here will reference any factor(s) that prompt
these events
- death by trauma is the most likely factor to be
expressed in bone
- manner of death: refers to the way a person died; that is, by
violence, from natural causes, or for other reasons
- the manners of death most relevant to us are
homicide, suicide, or accident
- however, some natural diseases leave skeletal
markers and these can be useful

Basics of Bone Trauma
- fracture: when sufficient force is applied to the bone and a
discontinuity travels completely through the bone
- infraction: the term used when the discontinuity does NOT
travel completely through the bone
- displacement: occurs when surfaces that once were
continuous no longer meet or meet at an unnatural angle
- complete fractures: broken ends are separated from one
another (Figure 11.1)
- hinge fracture: in cases of infraction where part of the
fractured area is still attached to its original bone, the surfaces
meet at an unnatural angle
- green stick fractures: breaks in the bone where separation
does not occur (commonly seen in subadults when trauma
occurs to a long bone, especially the clavicle)
- simple fracture: when a single discontinuity results in a bone
broken into two segments
- comminuted fracture: refers to breaks that result in the
production of multiple fragments of bone (more common in
death by violence, homicide, suicide, accident)
- fracture lines: usually originate near the point of impact, and
help dissipate the contacting force
- radiating lines: most common form of fracture lines that
disperse outward like an irregular sunburst (11.3 B)
- hoop fractures: fracture lines more consistent with projectile
wounds that form concentric rings around the area of impact
(11.4)
- caused by inward and outward bending of the surface
of the bone
- fracture lines will generally not cross suture lines or pre
existing fracture lines
- they can also appear opposite the side where the
force was generated
- pathological fractures: breaks that occur in bones that are
weakened by disease
- stress fractures: breaks caused by overuse
- fatigue fractures: occur in bones that are exposed to
intermittent stress over a long period of time
- most common are stress fractures in the vertebrae in
older persons
- this is the ailment that causes dowagers
hump a condition where the spinal column
is angled so prominently forward that it
appears to form a hump on the back
- after a discontinuity occurs:
- (1) the veins and arteries leak blood and form a pool
over the damaged area
- this pool, called a hematoma, helps to
stabilize the broken pieces, especially after
coagulation
- (2) osteogenic area performs actions
- a. produce connective fibers that span
between the broken surfaces (flexible tissue
infiltrates the hematoma to bridge the gap of
the discontinuity)
- b. a callus then develops of fibrous bone
- these are raised and may be visible
for years after healing (though they
eventually disappear)
- c. this fibrous bone is replaced with much
stronger lamellar bone
- sharp edges of a fracture also become rounded during healing
and often the area of a break will develop pores (in contrast
with the smooth surface of the cortex)

Characteristics of Forces Causing Trauma
- direction: refers to the direction from which the force
contacts the bone
- speed: is either dynamic (sudden impact) or static (slow
build-up)
- focus: refers to the size of the surface on which the force
impacts (wide or narrow)
- Direction
- tension, compression, torsion, bending, shearing
Tension
- force that pulls on bone
- common in accidents
- result in few fracture lines
Compression
- push down on bone
- cause fracture lines
11
- discontinuities can be complete or
incomplete
- fracture lines radiate and are numerous
- common in the skull
Torsion
- twisting forces are most common in
accidents
- common in long bones
Bending
- most common force
- generally do not result in many fracture
lines
- misalignments and discontinuities are
common
- sometimes a triangle of bone is broken off
causing a comminuted fracture
- in subadults, infractions are more common
b/c their bone is more flexible
- parry fracture: of the ulna is caused when
persons hold their arms up, bent at the
elbow, as a form of self defense (Fig. 11 A)
common in many deaths by violence
Shearing
- more consistent with accidents
- results when one part of the bone is
immobilized (like when you fall and hit the
ground)
- Speed of Force
- dynamic force: refers to sudden stress; force
delivered powerfully and at high speed (most
common)
- static force: refers to stress that is applied slowly
(one example is fracturing of hyoid during
strangulation)
- Focus
- narrow focus: the force is applied to a single point
or a thin line
- wide focus: indicates the force is delivered over a
wide area of bone (any mechanism other than cutting
or chopping)

Types of Trauma
- blunt: any injury resulting from a blow from wide
instruments that have either a flat or rounded surface
- sharp: caused by an implement with a point or edge
- projectile: have characteristics of blunt and sharp
- miscellaneous trauma also exists
Blunt
- wide area of impact on bone
- compression, bending, and occasionally shearing
- discontinuities and fracture lines
- typically simple but can be comminuted
Sharp
- either compression or shearing applied dynamically
over a narrow focus
- punctures or chop marks can result (Fig. 11.10)
- if it grazes, incisions are visible (Fig. 11.11)
- chopping: complete discontinuity
- cutting: infractions
- fracture lines rare
Projectile
- complete discontinuity with displacement and
fracture lines
- usually compressive, bending also occurs
- focus goes from small to wide
Miscellaneous
- static pressure
- explosions, sawing, chemicals, heat
- not large fracture lines
Timing of Bone Injury
- antemortem trauma: trauma that occurred before death such
that there is partial or complete healing of the injury
- perimortem trauma: injuries that occurred around the time
of death
- postmortem damage: injury occurring after death
Antemortem
- porosity near breaks
- rounding edges of the break (can begin as early as 1
week after break) and can cause fracture lines to
appear as v-shaped grooves
- callus that usually develops by the 6th week covers
the broken bone ends and extends some distance
from the area of the break
- it is irregular in shape
- has a disorganized surface
- raised above the surrounding area
Perimortem
- wont exhibit signs of healing
- recognized by the green bone response (while still
covered in soft tissue and containing the fluids
present in life)
1) sharp edges
2) hinging (bent away from direction of blow (only in
moist bone)
3) fracture lines (Moist bone)
4) broken ends are usually jagged and angled
5) staining from hematoma\

*Osteoblastic: bone formation

Postmortem
- many forces can cause change
- damage can occur during body recovery and
transport (subject of *forensic taphonomy)
- rarely exhibit radiating fracture lines
- more likely to snap
- green stick fractures and hinging are very rare
- long bones break at right angles with ends that are
almost flat
- color of break usually different from rest of bone

Trauma
- injury caused by the action of forces on bones
- can take a variety of forms
- blunt, sharp, projectile
- other injuries to bone that, while not involving forces, might
loosely be considered trauma
- burning, freezing, chemical burning

Why is trauma important?
- type of trauma may provide evidence as to cause and manner
of death
- nature of traumatic lesions may allows ID of weapon used
- number of lesions may provide evidence as to manner of
death
- placement/nature of lesions may provide information about
attacker:
- height, side attacking from, severity

Cause of Death
- same in all cases: person stops breathing, heart stops beating,
brain death occurs
- when we talk about COD, we are talking about the factors that
cause the above
- any number of factors can cause death
- disease, heart failure, exsanguination, etc.
- remember: FA cannot testify as to COD
- however, they can: present evidence of COD to ME; testify
that skeletal evidence is consistent with a certain COD

Manner of Death
- five MODs are recognized forensically
- homicide, suicide, accident, natural causes, unknown
causes
- determining manner of death from skeletal remains may be
difficult because:
- most disease processes dont leave any indication on
the skeleton
- a few that do: TB, treponemal infections,
bone cancers, bone infections
- unless trauma is evident, often nothing to go on
- even with trauma, may be difficult to distinguish
accident from homicide from suicide

Disease and Trauma
- disease processes can lead to skeletal trauma in some cases
(pathological fractures)
- ex. osteoporosis

Bone Trauma
- sufficient force produces a discontinuity (break):
- fracture (breaks completely through)
- infraction (partial break)
- displacement: two surfaces displaced relative to one another;
can occur with either a fracture or infraction
- blunt force trauma
- bludgeons; impact with hard objects (including
ground); collisions
- sharp force trauma
- knives, axes, machetes, cleavers, etc.
- projectile trauma
- bullets, arrows, spears
- miscellaneous trauma
- strangulation, explosion, sawing, burning, etc.

Types of Fractures/Infractions
- complete fracture
- single
- comminuted
- hinge fractures
- green stick fracture

Types of Fracture Lines in Cranial Vault
- radiating lines
- concentric (hoop) fractures

Additional Fractures
- pathological features such as osteopenia, osteogenesis
imperfecta, etc.
- fatigue fractures (which are the same as stress fractures, even
though Byers says they are 2 different kinds)

Fracture Repair
1) hematoma forms
2) cartilagenous callus forms
3) bony callus forms
4) bone remodels

Types of Loads on Bone
- compression
- tension
- shear
- *bending = compression + tension; torsion = shear

Bending and Shearing Fractures
- parry fracture: fracture to ulna or radius from parrying an
attack
- Colles fracture: fracture to wrist from falling

Timing of Trauma
- antemortem
- healing evident
- may be useful in establishing ID
- perimortem
- usually the most forensically germane type of trauma
- postmortem
- taphonomically relevant

Antemortem Injuries
- an antemortem injury to bone occurs long enough before
death that there is evidence of either partial or complete bone
healing
- in U.S. Civil War dead, evidence of bone remodeling has been
noted an average of 13 days after bone injury, with some
skeletal material showing evidence of such as early as 7 days
- porosity in bone near broken ends (increased vascularity) - w/
in a few days of fracture
- rounding or blunting of broken ends, visible macroscopically
w/in 7-13 days
- callus formation, usually begins to form ca. 6 weeks post-
fracture
- healed fracture line: visible macroscopically and/or
radiologically

Callus Recognition
- irregular in shape
- disorganized surface
- raised above surrounding surface

Woven Bone
- recognize callus by woven bone
- called such because it looks like fabric
- very vascular (richly supplied with blood vessels)
- woven bone can appear without a break (if you slam your shin
for example)
- signals some sort of periosteal reaction (insult to periosteum
or callus surface)

Healed Fractures/Infractions
- without medical intervention, bones may not be aligned
properly and may ossify improperly

Perimortem Trauma
- recognized by green bone response:
- sharp edges, hinging, fracture lines, angular/jagged
surfaces, discoloration (possibly)
- broken bone edges usually sharp, and may be jagged
- bone may not be completely fractured, but infracted instead
(like a hinge); sharp wounds to ribs may lever a piece of
cortical bone away from body of rib
- in skull especially, radial and concentric fracture lines may be
seen (not seen in dried bone, based on experiments using both
empty and gelatin-filled crania)
- dry bone is too brittle to withstand forces
- brain is also able to spread out the force
- recent fracture ends may be stained by heme portion of
hemoglobin from red blood cells (ferruginous staining)

Postmortem Injuries
- if injury to bone occurs fairly soon after death, bone may not
have dried out (still be green) and may still behave similarly
to living bone - may be difficult to discern from perimortem
trauma
- often seen secondary to recovery and transportation damage to
bone
- recognized by dry bone response
- hinging is rare
- fracture lines rare
- right angle fractures, flat surfaces
- differences in coloration (if broken post-
depositionally)
- fractured surfaces are granular in texture
- no radiating or concentric fracture lines are seen, as
skull is empty (or brain has shrunk considerably, by
decomposition or dehydration), and there is no
substance to conduct cavitational shock waves to
skull

CASE STUDY 15: DOCUMENTING CHILD ABUSE
Purpose:
- to examine a case in which an understanding of the timing of
trauma to the skeleton was important in securing a conviction
- to explore a case in which the tools available to the ME
(autopsy and radiographic analysis) were inadequate for the
investigation

- child abuse leads to ca. 1200 cases of non-accidental death in
infants and children every year
- in some cases, offending parent may claim accidental death.
skeletal evidence of past abuse may be critical to document
pattern of abuse
- in other cases child is reported kidnapped, and remains may
not be found until skeletonized. Healed trauma in skeleton
may document pattern of abuse
- if you can document a history of trauma, accidental death is
not probable

- police investigating child disappearance: 3 yr old child
missing five years
- after evidence points to parents, they claim child had died
after slipping and hitting head in bath, after which they buried
him without alerting the authorities
- police discover partially skeltonized remains of a small child
in trunk of family car
- likely the kid had been in the trunk the entire time; there was
still a bit of soft tissue; probably was in an air tight plastic bag
- considerable amount of soft tissue, but autopsy produced no
indications of COD or MOD
- radiographic analysis failed to detect evidence of trauma
- remains given to Phil Walker (UCSB) for forensic
anthropological analysis
- dental development/eruption and diaphyseal lengths indicate
age between 3 and 4
- histological examination of teeth
- striae of Retzius (7 day periodicity) indicate age of 3
years, 7 months
- need to have a tooth where the crown is still
forming
- physiological insults had arrested development at
times, the last episode being 2 months before death
- teeth had periodically stopped growing and then
started again
- defect in enamel
- periods of physiological insult that
prevented his body from growing (latest
was 2 months before death)
- after maceration, linear fracture of occipital observed running
from foramen magnum to lambdoid suture
- 2 stages of healing evident along fracture; one representing ca.
1 month healing post-fracture, the other about 1 week healing
- disruption of healing is common in cases of repetitive abuse
- abuse cases also generally do not show evidence of medical
intervention since parents fear being detected
- child had fractures to both maxillary and mandibular
deciduous incisors
- occlusal wear to broken incisal surfaces indicated trauma
before death
- damage to teeth occurs accidentally, but also occurs with high
frequency in abuse cases
- healed trauma evident in right lateral clavicular shaft, left
radius and left ulna
- amount of healing consistent with trauma one month prior to
death
- fairly thin layer of woven bone... probably a bone bruise
- lesions to forearm bones represented periosteal reactions
resulting in < 1mm of new bone formation on diaphyseal
surface, hence not visible radiographically. However, porous
appearance of subperiosteal lesions immediately evident on
gross exam of defleshed bones
- radiographic analysis did reveal multiple Harris lines (growth
arrest lines) in long bones
- reflect systemic stress when skeletal growth ceased
and then resumed
- stressors can include illness, starvation, trauma, or
psychological stress
- there were 15 periods in this case
- multiple injuries at different stages of healing = abuse
- accidental explanation of trauma becomes increasingly less
likely as more healed/partially healed traumatic lesions
become evident
- parents plead to 2nd degree murder

Take Home Messages:
- it is not only imperative that the FA be able to differentiate
antemortem from perimortem from postmortem trauma, but
that he/she must be able to make defensible inferences about
the timing of antemortem injuries
- documenting a history of abuse is the primary prosecutorial
tool in cases of child abuse