Forensic Science International 159 (2006) 113118

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Sharp force injuries in clinical forensic medicineFindings

in victims and perpetrators
Ulrike Schmidt *, Stefan Pollak
Institute of Legal Medicine, University Hospital of Freiburg, Albertstrasse 9, D-79104 Freiburg, Germany
Received 4 December 2004; received in revised form 15 June 2005; accepted 11 July 2005
Available online 2 September 2005

Abstract

The injury findings in 58 perpetrators and 158 victims surviving bodily injuries due to sharp force are presented here.
Defence injuries were found in 45.9% of the victims without any significant differences between males and females. There was
no clear predominance of defence injuries on the left forearm and hand, as is known from autopsy studies; the right and the left
hands were affected with an almost identical frequency. Regarding other parts of the victims bodies, the topographic
distribution of injuries showed a marked concentration on the left side (63.7%). The thorax, head and neck were frequently
affected (45.9%, 15.3% and 15.3%, respectively), and less often the abdomen (11.1%), the lumbar and gluteal region (6.3%)
and the lower extremities (6.1%). In surviving victims with only one singular stab apart from the upper limbs, the incidence
of additional defence injuries on the hands and/or forearms was significantly higher (28.3%) than in fatalities. When
the perpetrators had unintentionally cut their own hands, the frequency of these injuries on the right and left hands was
almost equal.
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Keywords: Clinical forensic medicine; Sharp force; Knife attack; Defence injury; Injury of offender

1. Introduction settle a fight as an onlooker. In these cases, any knowledge

When evaluating sharp force injuries, the correct inter-
pretation of the individual wound morphology as well as the
total pattern of the findings is of considerable importance
under aspects of crime reconstruction. Inter alia, the differ-
entiation between the accidental, homicidal and suicidal
infliction of injuries helps to distinguish between victims
and offenders [18]. This is of special importance whenever
a suspected person shows sharp force injuries, claiming that
he or she was hurt while trying to ward off an attack or to
* Corresponding author. Tel.: +49 761 203 6830;
fax: +49 761 203 6858.
E-mail address: ulrike.schmidt@uniklinik-freiburg.de
(U. Schmidt).
about the incidence and distribution of sharp force injuries in
victims and perpetrators of knife attacks can be helpful for
verifying the suspects statement or unmasking a defensive
lie.
In the past, comprehensive studies on the findings seen
after sharp force injuries were mostly conducted on autopsy
material [915]. The results obtained from those studies, for
example concerning the frequency, localization and distri-
bution of defence injuries, have so far been applied to
clinical forensic medicine as well. The present study com-
pares data published on autopsy studies [915] with data
collected on victims and perpetrators of non-fatal bodily
injuries due to sharp force. The aim of our study was to
determine whether the patterns of injuries in killed and
surviving victims of knife attacks were different, and if

0379-0738/$ see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.forsciint.2005.07.003
114 U. Schmidt, S. Pollak / Forensic Science International 159 (2006) 113118
so, in what way. Moreover, the question arose as to whether
injuries that perpetrators unintentionally inflicted on them-
selves show any specific characteristics.
2. Material and methods
In a retrospective study, the reports on clinical examina-
tions performed by members of the Freiburg Institute of
Legal Medicine from January 1992 to July 2004 were
analyzed with regard to intentional bodily injuries due to
sharp force. Individuals who could not be clearly distin-
guished as being either a victim or a perpetrator were
excluded. Particularly the cases of knife attacks with several
offenders who had also been injured themselves were not
included in this study. The injuries of a total number of 206
persons (158 victims and 58 perpetrators) involved in 153
offences, documented in written reports and photographs,
were evaluated as to their number, localization and distribu-
Fig. 1. Cumulative diagram of 663 survived stab and cut wounds in 158 surviving victims of sharp force injuries showing the front and back of
the body.
tion. Special importance was attached to cuts and stabs found
on the hands and forearms of the victims. In the following,
these injuries are referred to as defence injuries. Sharp
force injuries on the perpetrators hands are referred to as
unintentionally self-inflicted injuries and were recorded
as well.
As far as possible, the results of the evaluation were
compared with data in the literature. Statistical significance
was determined by means of the x2-test.
3. Results
3.1. Injuries of the victims
In the 158 victims studied (127 males and 31 females
aged 1563) a total of 663 survived stab and cut injuries were
found (Fig. 1). The individuals showed between 1 and 20
single injuries with an average of 3.7 injuries in the male
 U. Schmidt, S. Pollak / Forensic Science International 159 (2006) 113118 115

Table 1 Table 3
Distribution of 663 sharp force injuries on the one or other side Frequency of defence injuries in surviving victims of sharp force
found in 158 surviving victims of knife attacks. Statistical signifi- injuries in relation to the number of stabs and/or cuts inflicted on the
cance is indicated trunk
Anatomical region Number of Left Right p Number of Number of Frequency
injuries (%) (%) injuries to cases of defence
Body (excluding 425 63.7 36.3 <0.001 the trunk injuries (%)
upper limbs) 0 5a 100.0
Upper arms 36 75.0 25.0 <0.005 1 60 28.3
Forearms 64 56.2 43.8 n.s. 25 76 46.1
Hands 138 50.7 49.3 n.s. 610 12 91.7
>10 4 100.0
Total a 157 45.9
victims and 6.4 injuries in the female. In 33.0% of the a
One case with a singular cut to the left upper arm was excluded.
victims examined, injuries due to blunt force were evident
as well. 63.4% of the sharp force injuries were localized on
the front of the body, and 36.6% on the back. The left half of injuries were equally frequent (in two out of 14 cases) and
the body accounted for 63.7% of the stabs and cuts, and the more frequent in singular stabs to the chest (in six out of 16
right half for 36.3%. The injuries were predominantly cases). Most of the defence injuries were located on the
localized on the thorax (45.9%) and in the region of the flexor sides of the victims hands (Table 4; Fig. 2), but results
head and the neck (30.6%). The abdomen (11.1%), the did not show any statistical significance.
lumbar and gluteal regions (6.3%) and the lower extremities In five individuals, defence injuries were present with-
(6.1%) were less often affected. out any concomitant sharp force injury to the remaining
Injuries to the upper arms were mostly found on the left parts of the body (Table 3). According to the investigation
side. This preferential distribution was less pronounced on results, knives were primarily used for threatening the
the forearms and absent on the hands (Table 1). Ambulatory victim in four of these cases (two sexual offences, one
treatment was required in 64 out of 158 victims (40.5%), and domestic argument and one fight in a disco). In these
77 out of 158 victims (54.6%) had to be admitted to hospital victims, the majority of defence injuries (superficial cuts)
due to penetrating injuries of the thorax and abdomen and was localized on the flexor sides of the fingers. In another
injuries to the internal organs as shown in Table 2. No further case, the victim who was sitting on the passenger seat of a
medical treatment was needed by 17 individuals. parked car, was assaulted through the open side window
Regarding the total number of victims, defence injuries suffering three superficial cuts on the left hand and left
were present in 45.9% (Table 3). There was no significant forearm.
difference in frequency between males and females. Among
60 victims who had sustained only one singular stab or cut 3.2. Injuries of the perpetrators
injury on their body apart from the upper limbs, 17 showed at
least one additional defence injury on the hands and/or Among the 58 perpetrators of knife attacks (50 males and
forearms. In singular stabs to the abdomen or back, defence 8 females aged 1772), there were 21 individuals showing

Table 2
Traumatological consequences of sharp force injuries in victims of knife attacks that underwent ambulatory (n = 64) or clinical (n = 77)
treatment after the offence. Multiple diagnoses were possible. The actual number of the cases is indicated
Number of injuries to Total number Number of cases with
the trunk of cases a Ambulatory treatment Clinical treatment
Injuries of soft tissues only Total Involvement of the Involvement of the Other
thoracic cavities abdominal cavity injuriesb
(of thoracic organs) (of abdominal organs)
1 60 28 32 15 (8) 15 (12) 4
25 67 30 37 23 (6) 17 (16) 4
610 12 5 7 6 (0) 1 (1) 1
>10 2 1 1 1 (0) 0 (0) 0
141 64 77 45 (14) 33 (29) 9
a
No further medical treatment was needed by 17 out of the 158 victims.
b
Other injuries were injuries to the spinal cord, retroperitoneal organs and major (arterial) blood vessels.
116 U. Schmidt, S. Pollak / Forensic Science International 159 (2006) 113118

Table 4
Distribution and localization of sharp force injuries found on the hands of 71 victims and 16 perpetrators. The results were not statistically
significant
Localization Injuries of victims hands Injuries of perpetrators hands
Left (%) Right (%) Left (%) Right (%)
Flexor side of the hand 29.0 25.3 24.0 30.0
Extensor side of the hand 16.6 13.9 10.0 6.0
Radial and ulnar sides of palm and digits 5.1 10.1 18.0 12.0
Total 50.7 49.3 52.0 48.0

sharp force injuries which were mainly of a superficial
nature. Five of the perpetrators had intentionally inflicted
injuries on themselves after the offence, either with suicidal
intent or to simulate self-defence. Injuries unintentionally
inflicted during the attack were found in 16 offenders.
Altogether, the perpetrators hands showed 50 cut wounds
with 24 injuries being localized on the right and 26 on the left
hand (Table 4; Fig. 3).
One of the offenders had inflicted a singular, transverse
cut to the little finger on his right hand located on the flexor
skin fold of the proximal interphalangeal joint. The three
relevant victims whom he had attacked from behind, showed

Fig. 2. Cumulative diagram of 138 sharp force injuries found on the Fig. 3. Cumulative diagram of 50 sharp force injuries found on the
hands of 71 victims of knife attacks. Dotted lines indicate that a hands of 16 perpetrators of knife attacks. Dotted lines indicate that a
lesion continues on the reverse side. lesion continues on the reverse side.
 U. Schmidt, S. Pollak / Forensic Science International 159 (2006) 113118
two to three stab wounds each, mostly in the scapular region.
The weapon used was a knife with a 10 cm long, stable, fixed
blade, but no handguard.
4. Discussion
Compared to studies on autopsy material [915], the
surviving victims with sharp force injuries showed both
corresponding and differing findings. In surviving as well
as in killed victims the majority of injuries are localized on
the left half of the body and on the thorax, respectively
[9,11,1315]. The total frequency of defence injuries was
comparably high both in the victims who survived and those
who were killed. However, surviving victims with singular
stab or cut wounds of the trunk, which accounted for about
the same percentage of our study material as in the studies on
fatalities [10,12,13], showed additional defence injuries in a
disproportionately high number of cases (x2 = 16.25; 3 d.f.;
p < 0.01). In that group, there were also two victims with
one singular stab in the back. Consequently, it can be
deducted that a singular stab to the back does not generally
exclude the presence of defence injuries in surviving victims
of knife attacks [13]. The higher percentage of defence
injuries in female versus male victims [10,12,14] that is
often described and discussed was also observed in our study
material, but was not statistically significant (x2 = 1.335;
1 d.f.; p = 0.125).
With regard to the localization of defence injuries, the
survivors showed one significant difference: whereas in the
fatally injured stab victims up to 69.0% of the defence
injuries were found on the left hand and left forearm
[12,13], the surviving victims of our study material showed
defence injuries on the left in 52.5% and on the right in
47.5% (x2 = 25.01; 1 d.f.; p < 0.01). The frequency of
injuries on the left and right hand was almost identical,
although injuries of the upper arms were found more often
on the left side; the same applied to injuries on the trunk. The
widely held opinion that the victims left hand is nearer to the
knife used by the perpetrator who is mostly right-handed,
and is thus injured more often [13] could not be confirmed in
our study of the surviving stab victims. On the basis of their
post-mortem study, Bajanowski et al. [9] stated that defence
injuries were not predominantly localized on the left side,
but their case number was very small (14 fatalities).
A special feature in surviving victims is the presence of
defence injuries without any stab or cut wounds on the other
parts of the body. In our study, there were five cases of this
type, in four of which the knife had been used primarily to
threaten the victim and the offender may not have had the
intention to injure or even kill him/her. In the fifth case, it had
in fact been intended to injure the victim, but the offender
was severely handicapped in his ability to act due to the
limited space available (attack through the window of a car).
As Bauer et al. [16] demonstrated, the perpetrators motiva-
tion or intention may actually influence the victims pattern
117
of injury. It is very difficult, however, to evaluate these
influences objectively. Thus, it is not possible to give a definite
answer to this question, i.e. whether the different findings in
surviving and killed victims of knife attacks, as described in
this paper, are actually attributable to a generally different
dynamic in bodily injuries and in completed homicides.
As to the outcome of sharp force injuries in surviving
victims, no consistent correlation between the number of
injuries suffered and the severity of the bodily harm could
be determined (Table 2). Among the 141 victims admitted to
ambulatory or clinical treatment, 45.4% showed only injuries
of the skin and soft tissue with up to 12 individual injuries to
the trunk. Considering the high proportion of cuts and stabs to
the thorax (45.9%), the number of injuries involving the
thoracic organs, i.e. the lungs or the heart, was relatively
small. Whereas 87.9% of the cases with penetrating injuries of
the abdominal cavity also showed injuries to the abdominal
organs, injuries to the thoracic organs were recorded in only
31.1% of the cases with penetrating injuries of the thorax
(Table 2). This may be due to the fact that in most cases a
(hemo-) pneumothorax which is frequently observed after
stabs to the back or chest, can be sufficiently treated by
drainage. Thoracotomy will not be performed unless other-
wise indicated, and thus minor lesions, e.g. of the lungs will
not be diagnostically confirmed. Compared to post mortem
examinations, the extent of injury to internaland especially
thoracicorgans seems to be underestimated in surviving
victims of sharp force injuries.
It has been pointed out that the cultural background of
perpetrators and victims may be an influencing factor in
knife attacks [9,17]. Due to the very heterogeneous data, this
assumption could not be verified in this study (data not
given). It can be stated though that out of 95 offences in
which the cultural background of the persons involved was
known, the victim and the offender were of different nation-
alities in 29 cases (30.5%).
Unintentional, self-inflicted injuries suffered by the
offenders in the course of knife attacks have rarely been
discussed in literature [18,19]. In our study, cut wounds on
the perpetrators hand showed a slight preference for the left
hand. They were mostly seen on the flexor side of the fingers,
whereas cuts to the palms were rare. However, the small total
number of injuries did not enable any preferential regions to
be determined. Defence injuries of the skin fold between the
first and the second metacarpal bone typically found in
victims grasping the weapon were not observed in the
perpetrators examined. The investigation material described
in this study included only one case in which the perpetrator
had sustained an injury to the hand holding the knife
(transverse cut wound on the flexor side of the right little
finger at the level of the proximal interphalangeal joint) by
slipping off the hilt. It is possible for the perpetrators hand to
slide onto the blade of the knife causing an injury, if the knife
used does not have an adequate handguard and the tip of the
blade hits a solid resistance, and is thus abruptly decelerated.
This may cause characteristic lesions predominantly affect-
118 U. Schmidt, S. Pollak / Forensic Science International 159 (2006) 113118
ing the little finger when the stab is effected with the blade
protruding on the ulnar side of the fist [18]. When the knife is
held with the blade protruding on the radial side, injuries
may occur to the thumb or index finger, and even to both,
especially if a double-edged blade is used [19]. Accordingly,
such specific injuries on the perpetrators hand can contrib-
ute to the reconstruction of an offence and the elucidation of
the course of events. Nevertheless, the majority of injuries
found in the perpetrators investigated in this study show that
general statements on pathognomonic lesions of the perpe-
trators hand cannot be made.
5. Conclusions
The preponderance of defence injuries on the left forearm
and hand, as found in autopsy cases, could not be demon-
strated in the surviving victims of knife attacks presented in
this study. The distribution of injuries affecting other parts of
the body was comparable in killed and surviving victims.
Special features in the group of surviving victims were: (1)
defence injuries without concomitant injuries of the trunk,
and (2) additional defence injuries in individuals who sus-
tained singular stabs to the back.
Perpetrators of knife attacks may also show sharp force
injuries on their hands which they unintentionally inflict
upon themselves in the dynamics of the offence. The major-
ity of these injuries do not permit any conclusions as to the
suspects kind of involvement.
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