INVITED REVIEW

Postmortem Change and its Effect on Evaluation of Fractures

Walter L. Kemp

ABSTRACT
Postmortem changes can both mask and mimic trauma, impairing interpretation of the injuries. Bones, while capable of surviving the
postmortem period relatively intact, are not immune from these effects. Without attached soft tissue to aid an examiner, it can be difficult
to determine the time frame of a fracture’s occurrence (i.e., before death, at death, or after death). Bones are composed of both organic
and inorganic material, each of which contribute to the biomechanical properties of the bones. With the loss of organic material, the bio-
mechanical response of bones to trauma changes; however, the organic material can remain a part of the bone for an extended period
after death. Bone with intact organic material is wet bone, and bone without the organic material is dry bone, and because of this differ-
ence, fractures of wet bone can appear different than fractures of dry bone. Important in distinguishing the two are differential coloration,
various features of the fracture itself (e.g., angle, surface, outline), surrounding flaking of the cortex, and incomplete separation of bone
fragments from the fracture. However, the changes are not absolute, and determination of the two types of fractures can be problematic.
Although the terms antemortem, perimortem, and postmortem have been used to describe the general time frame of fractures in relation
to the time of death of the individual, because of confusion among specialties regarding the definition of “perimortem,” its use may best be
discontinued in favor of a descriptive approach when fractures are identified in skeletal remains. Acad Forensic Pathol. 2016 6(1): 28-44

AUTHOR
Walter L. Kemp MD PhD, Department of Pathology, University of North Dakota School of Medicine and Health Sciences
Roles: Project conception and/or design, data acquisition, analysis and/or interpretation, manuscript creation and/or revision, approved final version for publication,
accountable for all aspects of the work.

CORRESPONDENCE
Walter L. Kemp MD PhD, 501 North Columbia Rd., Mailstop 9037, Rm 5933, Grand Forks ND 58203, wlkemp@gmail.com
ETHICAL APPROVAL
As per Journal Policies, ethical approval was not required for this manuscript
STATEMENT OF HUMAN AND ANIMAL RIGHTS
This article does not contain any studies conducted with animals or on living human subjects
STATEMENT OF INFORMED CONSENT
No identifiable personal data were presented in this manuscsript
DISCLOSURES & DECLARATION OF CONFLICTS OF INTEREST
The author, reviewers, editors, and publication staff do not report any relevant conflicts of interest
FINANCIAL DISCLOSURE
The author has indicated that he does not have financial relationships to disclose that are relevant to this manuscript
KEYWORDS
Forensic pathology, Postmortem changes, Anthropology, Fractures, Perimortem
INFORMATION
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2017 Academic Forensic Pathology International • (ISSN: 1925-3621) • https://doi.org/10.23907/2016.004
Submitted for consideration on 1 Jan 2016. Accepted for publication on 16 Jan 2016

Page 28
 INVITED REVIEW
INTRODUCTION
Postmortem changes introduce artifacts to the body
that a forensic pathologist must distinguish from trau-
ma (1). In addition, these postmortem changes can
mask actual trauma (1). Although it may seem coun-
terintuitive, one area of the body where postmortem
changes affect the accurate assessment of injury is the
skeleton; specifically, the timing of fractures.
Identification of hemorrhage in the surrounding soft
tissue assists a forensic pathologist in helping to de-
termine the time frame for the occurrence of a frac-
ture in relation to the time of death (i.e., antemortem
or postmortem). For example, in general, a fracture
sustained just before the time of death or at the time
of death will have hemorrhage in the surrounding soft
tissue, while a fracture sustained even shortly after
death (e.g., fracture of the hyoid bone caused by re-
moval of the neck organs at autopsy or infant rib frac-
tures caused by cardiopulmonary resuscitation) will
have an absence of hemorrhage (or relative absence
of hemorrhage) in the surrounding soft tissue (2, 3).
However, as the length of time from the death of the
individual to the discovery of the body increases, de-
composition, ultimately with loss of soft tissue, makes
the determination of the timing of skeletal trauma in
relation to the time of death more dependent upon
osteologic features alone, unless microscopic tech-
niques are employed (4). The purpose of this paper is
to assist in the understanding of the use of osteologic
features alone to make a determination of the time of
the fracture in relation to the time of death, and the
inherent difficulties therein.
To describe the relation of an injury to the actual time
of death, both forensic pathologists and forensic an-
thropologists have used the terms antemortem, per-
imortem, and postmortem. However, while the use
of the term antemortem is similar between the two
groups, always referring to injuries sustained prior
to death, the context for the use of the terms peri-
mortem and postmortem has varied between the two
specialities, with fractures determined to be perimor-
tem by the forensic anthropologist having an actual
time range since death that overlaps with the time
range of trauma determined to be postmortem by
the forensic pathologist (5, 6). For example, in one
case, a forensic anthropologist may determine that
a fracture was perimortem based upon their exam-
ination alone, with subsequent history revealing that
the fracture of the bone occurred two months after
death, in what a forensic pathologic would normally
consider the postmortem period. The reason for this
discrepancy is based upon the condition of the re-
mains each group tends to evaluate and the presence
or absence of soft tissue changes to aid in the de-
termination (4, 7). One important point to appreciate
is that while the terms antemortem, perimortem, and
postmortem have been used to indicate time frames,
it is not length of time since death that most affects
the condition of the bone and appearance of resultant
fractures, but instead the environment in which the
body decomposes (5, 8, 9).
For the forensic anthropologist, usually lacking the
contributing information of the surrounding soft tis-
sue to aid in their examination, the distinction between
perimortem fractures and postmortem fractures most
often must be made by examination of the bone alone,
and the difference between a perimortem or postmor-
tem determination is based upon recognition of oste-
ologic features that vary depending upon whether the
fractured bone was wet or dry. Wet bone represents
bone with intact, or relatively intact, organic matrix,
whereas dry bone represents bone with loss of the or-
ganic matrix (5). The fracture patterns produced by
trauma inflicted on wet bone or dry bone can be dif-
ferent because each may respond to trauma in a differ-
ent fashion (5). For example, bowing fractures depend
upon the presence of the organic matrix and should
not occur in dry bone (10).
As such, for a forensic anthropologist, since wet bone
can remain in such a state for a long period of time af-
ter death, what is interpreted as a perimortem fracture
could be from trauma that occurred within a range of
anywhere from days before death to weeks to months
or longer after death (5, 11), whereas for the forensic
pathologist, if they choose to use to term, “perimor-
tem,” the time frame is much more narrow, indicating
the time immediately around death, either just before,

Page 29
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
during, or just after. Determining the time frame for
when fractures were sustained in relation to the time
of death can be of vital importance in the investigation
of a death; however, despite reported differences in
the characteristics of the fractures during each of the
two time periods and supported by statistical analy-
ses of study groups (12-16), reliable determination of
whether a specific fracture is perimortem or postmor-
tem is not necessarily an easy, or even in some cas-
es, an achievable task (12, 13, 17). Highlighting the
difficulties with interpretation of perimortem versus
postmortem fractures, Cappella et al. presented the
results of 210 fractures of known origin reviewed by
two experienced forensic anthropologists, with an er-
ror rate of 16.7% for perimortem fractures of cortical
long bone and an error rate of 15.9% for postmortem
fractures of cortical long bones (18). Of note, the error
rates were much higher (i.e., 83-84%) for interpreta-
tion of perimortem and postmortem fractures of tra-
becular bone or flat bones.
CASE REPORT
A funeral home, when cleaning its facility, identified
a mummified fetus, which was reportedly found in
a trunk that had not been used by the funeral home
in decades. The finding was reported to the coroner,
who requested the assistance of the medical examin-
er. A hospital computed tomography scan obtained
by the coroner prior to transport of the remains to the
medical examiner and read by a hospital radiologist
identified a fracture of the right femur and skull frac-
tures. External examination revealed a completely
mummified body, with a generalized gray to brown-
gray discoloration of the skin (Image 1). There was
brown head hair with an estimated average length of
2.5 cm. Scattered around the body, but prominently
on the buttocks and lower extremities, were variably
sized round defects up to several millimeters, some
of which were confluent, representing postmortem
insect activity. There were female external genitalia
and the foot length was 6.7 cm. The gestational age,

Image 1: Mummified fetus. The white arrow indicates the circular defects in the skin, consistent with prior evidence of insect activity.

Page 30
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
based upon foot length (19), was around 35 weeks,
or, based upon the presence of the ossification cen-
ters for the distal epiphysis of the femora and for the
proximal epiphysis of at least one of the tibia, around
36-40 weeks (20). As the mummified state of the body
would affect measurement of the foot length, but not
the presence of the secondary centers of ossification,
the actual gestational age was most likely around term.
Given the mummified state of the body, the determina-
tion of liveborn versus stillborn was impossible. After
completion of an external examination, the medical
examiner soaked the desiccated remains in water for
several weeks, which rehydrated the soft tissue and
allowed the medical examiner to dissect the remains
and remove each individual skeletal element. There
were fractures of the bones of the cranium (Image 2)
and an incomplete fracture of the right femur, in that
the shaft of the bone was still intact. The defects in the
cranium were fractures and not normal sutures, as the
fracture lines were in locations unoccupied by normal
sutures, and the cranium was fragmented into smaller
pieces of flat bone than would normally be present.
The appearance of the right femoral fracture (i.e., a
butterfly fracture morphology (Image 3) with incom-
plete separation of the shaft at the site of the fracture)
suggested the bone was most likely wet, and not dry,
at the time the fracture occurred, and therefore, the
fracture would not be an artifact of the mummification
and subsequent handling of the body. In addition, the
fracture surface and the surrounding cortical surface
were stained dark red-black, in contrast to the contra-
lateral femur (Image 4). The staining may have repre-

Image 2: Skeletal elements from remains, including cranium. Illustrated are multiple sections of the cranium from the mummified re-
mains. Although normal suture lines (the serrated edges, e.g., the white arrow) are present, there are also sharp lines, where no normal
suture line is present (red arrows), and small fragments of flat bone, not corresponding to normal complete cranial bones or normal
segments of individual cranial bones (double white arrows).

Page 31
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW

Image 3: Fracture of right femur. Note that the fracture of the right femur has a butterfly morphology. The white material on the bone is
adipocere.

Image 4: Left and right femur. The right femur (bottom) has a fracture (white arrow). Note the dark red-black discoloration of the sur-
rounding cortex in contrast to the left femur above.

Page 32
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
sented hemorrhage. Of note, as reported by Ubelaker
and Adams (21) and Wheatley (12), butterfly fractures
can be a postmortem occurrence. The presence of the
fractures suggested at least two scenarios for the death
of the fetus: 1) birth followed by inflicted head trauma
and an inflicted injury of the right thigh or 2) intra-
uterine trauma, such as if the mother of this infant was
involved in a severe accident, such as a motor vehicle
collision, and the fetus was stillborn due to the trauma.
DISCUSSION
While not defined in Stedman’s medical dictionary
(22), the term perimortem, derived from the Greek
prefix, “peri,” meaning “around” or “near” and the
Latin base, “mort,” meaning “death” (23), could be
defined as “ around the time of death.” However, as
described above, the boundaries of the time frame
used for this term differ between forensic pathologists
and forensic anthropologists. This difference and the
reason for the difference is important to appreciate, as
forensic pathologists consult forensic anthropologists,
and misunderstanding of the use of the term, “peri-
mortem,” could cause confusion. In fact, because of
confusion with the use of this term and its inconsistent
meaning across forensic specialties, discontinuation
of its use is advocated (6, 16).
The concept of wet bone and dry bone is important
in understanding the distinction between perimortem
fractures and postmortem fractures, as wet bone is
more flexible because of its higher moisture and col-
lagen content (8) and should fracture in a different
manner than dry bone, and thus, exhibit morphologic
differences that can be used to distinguish between the
two time periods when evaluating skeletal trauma (5).
Wet bone is alternatively called fresh or green bone
(8). Perimortem fractures occur in wet bone and post-
mortem fractures occur in dry bone. However, there
are no absolute time frames for the transition from
wet to dry bone, as the state of the bone is very de-
pendent upon the many factors that affect the rate of
decomposition, including the environment in which it
is placed (5). Bodies in wet environments (e.g., under
the water table), bodies with saponification, or bodies
with retention of decompositional fluid may retain wet
bones, and thus, can develop perimortem fractures for
a long period after death (8).
After bone is dried, it is more brittle than wet bone,
fracturing with less deformation due to force (24).
For example, energy delivered to dry bone can cause
crushing of the bone and complete loss of anatomic
relationships, while severe trauma to a wet bone can
still allow for maintenance of anatomic relationships
(25). Wet bone tends to splinter, so fractures tend to
have irregular edges and small fragments of bone that
are attached to the fracture margin, because the peri-
osteum and other soft tissue was still present when
the injury occurred (25, 26). In addition, wet bone can
have flaking of the cortex adjacent to the fracture mar-
gin (8, 27). These described features and others are
used to distinguish perimortem fractures from post-
mortem fractures.
To understand the difference in fracture patterns be-
tween wet and dry bone, it is important to understand
the basic mechanical properties of bone. Bone is a
composite material composed of both organic mate-
rials (collagen and other proteins) and inorganic ma-
terials (hydroxyapatite crystals composed of calcium
and phosphorus) (28). As a composite material, bone
contains both brittle material (minerals) and ductile
material (collagen). This composite nature of bone
contributes to its fracture mechanics.
In a discussion of the biomechanics of bone fractures,
understanding the definition of several terms is neces-
sary: force, load (including stress and strain), elastic
deformation, Young’s modulus, stiffness, yield point,
and plastic deformation. Load is the amount of force
applied to a bone. To provide for a more uniform mea-
surement (i.e., across all sizes of bones), load is relat-
ed to the area. Stress is load (or force) applied per unit
of area and strain is the ratio of change in length to
original length (29-31). Load can be plotted versus de-
gree of deformation to produce the load-deformation
curve, or stress can be plotted versus strain to produce
a stress-strain curve (Figure 1). Examination of the
stress-strain curve can reveal other mechanical prop-
erties of the bone.

Page 33
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
Initially, the stress (y-axis) and strain (x-axis) increase
proportionally (Figure 1). As force is applied, the
bone deforms in proportion to the amount of force;
however, the deformation is not permanent and will
reverse if the force is removed (30-32). This segment
of the stress-strain curve is termed the elastic phase,
the strain produced in the bone is elastic deformation
(Figure 1), and the slope of the line is the elastic mod-
ulus, or Young’s modulus (31). The elastic modulus is
a measure of the stiffness of the bone, with a steeper
slope indicating a stiffer substance (31).
At some level of stress, the bone reaches the yield point
(Figure 1). At this point, the bone enters the plastic
phase. In the plastic phase, the increase in stress is no
longer proportional to the increase in strain. Instead,
for a small increase in stress, there is a large increase
in strain (31-33). The strain produced in the bone is
termed plastic deformation (Figure 1). The yield point
is also referred to as the yield strength (34). Plastic de-
formation, unlike elastic deformation, will not reverse
when the stress is removed. Plastic deformation of the
bone will occur until the level of stress reaches the
ultimate strength of the bone and fracture occurs (31,
34). The amount of strain that can occur in a material
after the yield point and before fracture occurs is a
measure of the ductility of the material (24).
On the stress-strain curve, a pure brittle substance
such as glass has a line that nearly parallels the y-ax-
is, with no change in strain produced with increasing
stress, until failure is reached; whereas a pure ductile
substance such as rubber has a line that nearly paral-
lels the x-axis for a certain length, with an extensive
plastic phase with increase in stress just prior to frac-
ture (31). Brittle material breaks inside or just beyond
the zone of elastic deformation, while ductile material
can undergo much plastic deformation before frac-
ture occurs (24, 29, 30). However, with a viscoelas-
tic material such as bone, which has both brittle and
ductile properties, the rate of application of the stress
also affects the stress-strain curve shape, and thus,

Elastic Plastic
deformation deformation
X
X
Stress
Fracture
Yield point

Strain
Figure 1: Schematic of a stress-strain curve.

Page 34
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
the mechanical properties of the bone (31). A rapidly
loaded bone has increased stiffness and greater ulti-
mate tensile strength and thus, failure of the bone will
more represent failure of a brittle substance, whereas a
slowly loaded bone has decreased stiffness and lower
ultimate tensile strength and thus, failure will more
represent failure of a ductile substance (29). This vis-
coelastic nature of the bone affects the fracture mor-
phology with slow loading more likely to produce
linear fractures and rapid loading more likely to pro-
duce comminuted fractures (35). For whole bone, the
response to stress depends upon the individual bone
(e.g., the femur is weaker to tension than the tibia) and
whether the bone is wet or dry (30).
Most of the studies to assess the biomechanical behav-
ior of bone involve the use of small segments of bone
(a few centimeters in size) and not the entire bone,
with sizes of the segment sometimes chosen to corre-
spond to specifications for testing of plastics (36-41).
The reason for this use of bone segments instead of
whole bones is that values (e.g., for elastic modulus)
derived from the study of whole bones are only use-
ful for comparison and not for determining material
characteristics (29). These small segments of bone al-
low for testing of a homogenous substance; however,
whole bones themselves are not homogenous, being
composed of both cortical and cancellous bone, and
varying in shape throughout their length.

As stated, bone is a composite material, and each ma-
terial (organic and inorganic) contributes differently
to the overall biomechanical behavior of bone. Con-
ducting experiments on wet unembalmed bone tissue
decalcified to various degrees with hydrochloric acid,
Burstein et al. found that as the mineral content of the
bone decreased, the elastic modulus decreased, the
amount of stress required to enter the zone of plas-
tic deformation decreased, and the ultimate tensile
strength (or point of fracture) decreased (28). There-
fore, bone obtains most of its elastic stiffness from its
mineral content, and the mineral content of bone is
the source of its tensile strength (28). The slope of the
stress/strain curve after the yield point in nondecal-
cified bone and incompletely calcified bone was the
same as the slope of the stress/strain curve for com-
pletely decalcified bone (28). This finding would indi-
cate that the collagen content of the bone is responsi-
ble for its behavior in the zone of plasticity.
The area under the stress-strain curve is the amount of
energy required to cause fracture of the bone and is re-
ferred to as the toughness (24, 30). Toughness occurs
in three stages: diffuse damage (energy absorbed pri-
or to development of a major crack), initiation of the
fracture crack, and progression of the fracture through
the bone (36). Saha and Hayes described the total en-
ergy required to fracture bone as divided into the elas-
tic deformation stage, the plastic deformation stage,
and energy absorbed during fracturing (37).
In general, forensic anthropologists use three terms to
describe timing of skeletal injuries in relation to time
of death: antemortem, perimortem, and postmortem.
Antemortem injuries are those injuries that definitely
occurred before death. Postmortem injuries are those
injuries that definitely occurred after death. Perimor-
tem injuries are those injuries that occurred around the
time of death (25), perhaps a few days or a few hours
before death, or a few hours, few days, a few weeks,
or even possibly a few months or longer after death. In
short, a perimortem fracture is a fracture that cannot
definitively be determined to have occurred prior to
death (i.e., it is not antemortem) or definitively after
death (i.e., it is not postmortem). Correct determina-
tion of the perimortem nature of a fracture is important
because such a fracture indicates trauma that occurred
either at the time of death, and therefore, is potential-
ly indicative of the cause and possibly the manner of
death, or occurred after death, but within a relatively
short time frame and may be unrelated to the cause
and manner of death, but instead may represent post-
mortem handling of the body.
Sauer proposed five steps to distinguish the three time
periods of fracture formation: 1) identification of the
fracture, 2) identification of general mechanism of in-
jury responsible for the fracture (e.g., gunshot wound,
sharp force injury, or blunt force injury) 3) identifi-
cation of any osteogenic response, 4) identification
of animal activity, and 5) identification of differential
staining (26). However, Sauer’s approach does not

Page 35
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
incorporate the features of fractures studied to help
distinguish perimortem fractures from postmortem
fractures, namely fracture angle, fracture surface (i.e.,
fracture edge), and fracture outline, which will be de-
scribed below. Sauer does indicate that more research
is needed to help distinguish the three time periods of
fracture formation.
Antemortem fractures have some form of osteologic
reaction to the injury, which may include a callus (Im-
age 5), fiber-bone periostitis, or an etched line parallel
to the fracture line, which is indicative of periosteal
uplifting (25). In the first few days after a fracture, in-
flammatory cells, red blood cells, and edema are found
at the site. These features would enable the identifica-
tion of an antemortem fracture in a fleshed body; how-
ever, with loss of tissue, inflammatory cells and red
blood cells would also be lost. Thus, these features are
not useful in the evaluation of the defleshed skeleton.
Over the next week, tissue fills the fracture line and,
within the surrounding periosteum, fibrocartilage and
collagen are deposited. Once again, with loss of soft
tissue, the fibrocartilage and collagen would also be
lost, and thus, would not help differentiate the fracture
as an antemortem injury in a skeletonized individual.
Within the next few weeks, the fibrocartilage becomes
calcified, and the fracture site can become visible with
radiography (42). This calcified fibrocartilage may
persist in a defleshed skeletal element. Therefore, for
a fracture to be identified as antemortem in a skele-
tonized (i.e., defleshed) individual, the time frame be-
tween the injury and death would most likely have to
be at least two to three weeks.
Postmortem fractures occur due to burial circumstanc-
es or poor recovery techniques (25-26). In addition to
postmortem breakage, which must be distinguished
from a perimortem fracture, additional postmortem
changes, including postmortem warping, animal ac-
tivity (Image 6), and bone weathering, must also be
distinguished from perimortem trauma (43-44). Post-
mortem warping due to pressure is curvature of the
bone that must be distinguished from plastic deforma-
tion (such as produces a bowing fracture), a condition
occurring in wet bone (8). Bone weathering is crack-
ing, splitting, exfoliation, and fragmentation of bone
exposed to the weather (8, 44).
Distinguishing perimortem from postmortem fractures
is critical, as one fracture type definitely occurred after
death, while the other fracture type may have occurred
at the time of death and therefore, be of importance in
understanding the circumstances of the death. Howev-
er, the distinction is not simple. The study by Cappella
et al. indicated that even experienced forensic anthro-
pologists have a fairly high error rate (around 15%)

Image 5: Callus of rib.

Page 36
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
when attempting to distinguish known perimortem
and postmortem fractures (18). Ubelaker and Adams
reinforce the difficulty in that the authors found three
butterfly fractures, fractures they indicate are normal-
ly associated with the perimortem period, but, in their
case, were obviously postmortem in nature (21). They
determined that the butterfly fractures were postmor-
tem and not perimortem based upon 1) differential
coloration of the fracture edge and the adjacent cor-
tex and 2) the observation that the direction of forces
producing the butterfly fractures on the left tibia and
left fibula were in opposite directions, and therefore,
could not have occurred in a living individual or even
in articulated human remains.
As discussed above, color differences are one feature
that can help distinguish perimortem fractures from
postmortem fractures (Image 7), with perimortem
fractures having the same color of bone at the fracture
surface as at the adjacent cortical surface (8, 11, 16,
21, 25, 26, 45). The concept being that if the bone is
fractured prior to decomposition and skeletonization,
both the fracture surface and the adjacent un-fractured
cortical surface are exposed to the same conditions
and thereby have the same coloration; however, if the
fracture occurs postmortem and after the cortex of the
bone is discolored, the now exposed fracture surface
will not have the same coloration as the adjacent cor-
tex. However, color differences are not an absolute

Image 6: Rodent gnawing. Note the side-by-side parallel linear defects in the bone. Although the rodent gnawing is present throughout
the specimen, the white arrow specifically indicates one example.

Page 37
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
indicator of postmortem fractures as differential stain-
ing of the cortical surface and fracture margin can be
due to various environmental and postmortem factors
such as decompositional fluids, soil, foliage (such as
leaves), and dirty water, but could also be due to more
perimortem phenomena such as hemorrhage; there-
fore, this feature as a marker for postmortem versus
perimortem fracture should be used cautiously (8, 46).
Also, postmortem handling of the bones could affect
the distribution of color changes. For example, if a
body is buried in the ground for a long enough period
for skeletonization to occur, the outer surface of the
bones may be brown discolored from contact with the
soil. If these bones are removed from the ground and
fractures occur during the process, the color differen-
tial between the outer cortical surface (i.e., brown) and
the fracture surface (i.e., white, or yellow-white) will
assist in the determination that the fractures are post-
mortem. However, if the bones are then reburied and
exhumed at a later time, the fracture surface would
then potentially appear brown and the postmortem
fractures could be misinterpreted as perimortem frac-
tures. Scene investigation and historical information
would be especially important to assist in the correct
evaluation of the nature of the fractures in this second
situation.

Image 7: Postmortem cranial defect. This defect in the bone was identified in a cranium that was inadvertently found while an individ-
ual was digging in the ground. Note that the bone, for the most part, is brown-discolored from the soil; however, the rim of the defect
is more white-tan discolored. The appearance of this fracture is consistent with the history, with trauma caused to the bone during the
digging.

Page 38
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
In addition to a color differential between the frac-
ture surface and adjacent cortical surface, the appear-
ance of the fracture angle, the fracture surface, and
the fracture outline may help distinguish perimortem
and postmortem fractures (16). The fracture angle (the
angle formed by the surface of the fracture and the
surface of the cortical bone) is obtuse or acute in wet
bones, whereas those in dry bones are at or nearly at
right angles (8, 14, 47). Thus, a perimortem fracture
should have an obtuse or acute angle, while a post-
mortem fracture should have a right angle (Image 8,
Figure 2). The fracture surface (i.e., fracture edge)
is the surface of the fractured end of the bone and is
usually smooth, sharp, and sometimes beveled in wet
bone, and irregular (Image 9) or jagged in dry bone
(8, 14, 15, 45). However, this texture of the fracture
surface may also depend upon the source of the load,
with low-energy force producing a rough fracture sur-
face as a result of spread around vascular spaces and
high-energy force producing a smooth fracture sur-
face as a result of propagation through vascular spac-
es (48). Therefore, a low-energy force could produce
a fracture surface that mimics a postmortem fracture,
while a high-energy force could produce a fracture
surface that is consistent with a perimortem fracture.
The fracture outline is the general shape of the frac-
tured end of the bone. Designation of fracture outline
includes 1) transverse, 2) curved, and 3) intermediate
(47) (Images 10 and 11). Intermediate fracture out-
lines are those fracture outlines that are straight but
oblique or those with a stepped outline. Postmortem
fractures tend to be transverse while perimortem frac-
tures tend to be curved (47).
In support of these fracture features being used to
help separate perimortem from postmortem fractures,

Image 8: Fracture of dry bone, example of fracture angle. The white arrow indicates a fracture angle that is right angled. See also
Figure 2. Also note the color difference between the fracture surface (which is lighter in color) and the surrounding cortical surface.

Page 39
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
Wieberg and Wescott, based upon their study of 60 curved outlines to transverse angles, rough surfaces,
porcine long bones each fractured after a variable and fewer curved outlines; however, some groups of
postmortem interval, determined that, in general with bones with the same postmortem interval had both
increasing postmortem interval, fracture morpholo- perimortem and postmortem features (13). In support
gy changes from acute angles, smooth surfaces, and of this finding, Wheatley (12) found characteristics of

Fracture angle

Medullary cavity
Wet bone Dry bone
Figure 2: Schematic of fracture angles. Figure 2 illustrates two segments of bone, wet bone on the left side and dry bone on the right
side. Each segment has a fracture at the top. The figure illustrates the difference between an acute angle, which are associated with
wet bone and the right angle, which are associated with dry bone.

Page 40
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW

Image 9: Fracture of dry bone, example of fracture surface. The white arrow indicates the fracture surface. Note that it is irregular and
not smooth.

Image 10: Fracture of wet bone, example of fracture outline. Note the curved appearance of the fracture outline (contrast this image
with Image 11).

Page 41
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
wet bone (i.e., acute fracture angle, smooth fracture
surface, and curved outlines) in bones that were one
year postmortem.
Although studies may show that perimortem and post-
mortem fractures may present osteologic features that
are different from each other, Cappella et al. indicat-
ed that perimortem fractures can acquire postmortem
features (7). The authors examined seven individuals
who had been autopsied, and then exhumed 15 years
later, stored in an ossuary for five years, and then ex-
amined. They indicated that additional postmortem
fractures can mask perimortem fractures, that warping
and abrasion of the bone can modify fractured edges,
and that taphonomic variables (e.g., environmental
conditions) can alter the color or outline of the frac-
ture.
CONCLUSION
With increasing postmortem interval, the ability of a
forensic pathologist to identify and interpret injuries
becomes more difficult. In the case of decomposi-
tion, and especially skeletonization, forensic pathol-
ogists will often consult with forensic anthropologists
to assist in the identification of and interpretation of
skeletal trauma, because determining when a skeletal
injury occurred in relation to the time of death can be
of importance to a death investigation.
When only the skeletal elements are available for
examination, forensic anthropologists can use cer-
tain features of the fracture to assist in determining
whether or not an injury was sustained prior to death
or is postmortem, with those injuries sustained prior

Image 11: Fracture of dry bone, example of fracture outline. Note the transverse appearance of the fracture outline. At the white arrow
is postmortem animal activity, with puncture of the cortex of the bone.

Page 42
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
 INVITED REVIEW
to death exhibiting some form of osteologic reaction
to the injury (e.g., callus formation). However, for a
variable length of time after death, depending upon
the environment in which the body decomposes, the
biomechanical behavior of bone in response to load is
the same as if the bone were still in a living individu-
al. It is considered wet bone. Once sufficient time has
elapsed and the correct conditions exist and the bone
has lost its organic matrix, its biomechanical behavior
in response to load is no longer the same as if it were
in a living individual and it is now considered dry
bone. Thus, in the true postmortem period (i.e., the
time following the death of the individual), fractures
of a bone, depending upon the state of the bone, either
wet or dry, can appear differently. A fracture bearing
the features of one occurring in wet bone could have
happened at the time of death, or up to several weeks
or months after death. Obviously, each of these time
frames has a different connotation for a death investi-
gation. The term, “perimortem” has been used in the
past and currently by some authors to describe a frac-
ture that was not definitely antemortem or definitely
postmortem; however, the use of this term, and the
range of time around the actual death of the individu-
al that it encompasses, varies between specialties and
thereby, the use of the term, “perimortem” has led to
potential confusion.
The features of a fracture commonly associated with
wet bone include an acute angle, a smooth fracture
surface and a curved outline, which differ from the
features of a fracture commonly associated with dry
bone, which include a right angle, a rough fracture
surface, and a transverse outline; however, the distinc-
tion is not absolute. Also, the transition from wet bone
to dry bone is gradual, and thus, it could be expected
that during that transition, a bone may respond to trau-
ma as neither a bone within a living individual nor as
a bone that has been without soft tissue for five years
and buried in dry soil. Other features such as attached
fragments of bone and chipping of the surrounding
cortex in wet bone and differential coloration between
the fracture surface and adjacent cortical surface in
dry bone can also assist in the determination of the
time frame of the fracture. Although the term is used
in the literature, avoidance of the confusion associated
Page 43
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion
with the use of the word “perimortem” is preferable,
and Symes et al. advocate a descriptive approach to
skeletal trauma, and an interpretation based upon wet
versus dry bone, instead of perimortem versus post-
mortem (16).
REFERENCES
1) Lew E, Matshes E. Forensic pathology: principles and practice. 1st
ed. Amsterdam: Elsevier Press; c2005. Chapter 24, Postmortem
changes; p. 527-54.
2) Dolinak D, Matshes E. Forensic pathology: principles and practice.
1st ed. Amsterdam: Elsevier Press; c2005. Chapter 17, Child abuse;
p. 369-412.
3) Dolinak D. Forensic pathology: principles and practice. 1st ed.
Amsterdam: Elsevier Press; c2005. Matshes E. Chapter 8, Asphyxia;
p. 201-25.
4) Cattaneo C, Andreola S, Marinelli E, et al. The detection of micro-
scopic markers of hemorrhaging and wound age on dry bone: a
pilot study. Am J Forensic Med Pathol. 2010 Mar; 31(1):22-6.
PMID: 19935396. http://dx.doi.org/10.1097/paf.0b013e3181c15d74.
5) Symes SA, L’Abbé EN, Chapman EN, et al. A companion to forensic
anthropology. West Sussex (UK): Wiley-Blackwell; c2012. Chapter
17, Interpreting traumatic injury to bone in medicolegal investiga-
tions; p. 340-89.
6) Bunch AW. National Academy of Sciences “standardization”: on
what terms? J Forensic Sci. 2014 Jul;59(4):1041-5. PMID: 24854677.
http://dx.doi.org/10.1111/1556-4029.12496.
7) Cappella A, Castoldi E, Sforza C, Catteneo C. An osteological
revisitation of autopsies: comparing anthropological findings on
exhumed skeletons to their respective autopsy reports in seven cases.
Forensic Sci Int. 2014 Nov; 244:315.e1-10. PMID: 25315679.
http://dx.doi.org/10.1016/j.forsciint.2014.09.003.
8) Moraitis K, Spiliopoulou C. Identification and differential diagnosis
of perimortem blunt force trauma in tubular long bones. Forensic
Sci Med Pathol. 2006 Dec; 2(4):221-9. PMID: 25868767.
http://dx.doi.org/10.1385/fsmp:2:4:221.
9) Coelho L, Cardoso FV. Timing of blunt force injuries in long bones:
the effects of the environment, PMI length and human surrogate
model. Forensic Sci Int. 2013 Dec 10; 233(1-3):230-7.
PMID: 24314524. http://dx.doi.org/10.1016/j.forsciint.2013.09.022.
10) Matshes E, Lew E. Forensic pathology: principles and practice. 1st ed.
Amsterdam: Elsevier Press; c2005. Chapter 26, Forensic osteology;
p. 563-604.
11) Galloway A, Symes S, Haglund WD, France DL. Broken bones:
anthropological analysis of blunt force trauma. 1st ed. Springfield
(IL): Charles C. Thomas; 1999. Chapter 1, The role of forensic
anthropology in trauma analysis; p. 5-31.
12) Wheatley BP. Perimortem or postmortem bone fractures? An exper-
imental study of fracture patterns in deer femora. J Forensic Sci. 2008
Jan; 53(1):69-72. PMID: 18005007.
http://dx.doi.org/10.1111/j.1556-4029.2008.00593.x.
13) Wieberg DA, Wescott DJ. Estimating the timing of long bone
fractures: correlation between the postmortem interval, bone moisture
content, and blunt force trauma fracture characteristics. J Foren-
sic Sci. 2008 Sep; 53(5):1028-34. PMID: 18624891.
http://dx.doi.org/10.1111/j.1556-4029.2008.00801.x.

14) Wright CS. Perimortem and postmortem fracture patterns in deer
femora [master’s thesis]. Tuscaloosa (AB): University of Alabama;
2009 [cited 2016 Jan 1]. 64 p. Available from: 128(6):981-4. PMID: 414566.
http://acumen.lib.ua.edu/content/u0015/0000001/0000030/
u0015_0000001_0000030.pdf.
15) Shattuck RE. Perimortem fracture patterns in south-central Texas: a
preliminary investigation into the perimortem interval [master’s
thesis]. San Marcos (TX): Texas State University-San Marcos; 2010
[cited 2016 Jan 1]. 59 p. Available from: https://digital.library.txstate.
edu/bitstream/handle/10877/4066/fulltext.pdf.
16) Symes SA, L’Abbé EN, Stull KE, et al. Manual of forensic tapho-
nomy. Boca Raton: CRC Press; c2014. Chapter 13, Taphonomy and
the timing of bone fractures in trauma analysis; p. 341-66.
17) Kroman AM, Symes SA. Research methods in human skeletal biol-
ogy. Waltham (MA): Academic Press; c2013. Chapter 8, Investiga-
tion of skeletal trauma; p. 219-39.
18) Cappella A, Amadasi A, Castoldi E, et al. The difficult task of assess-
ing perimortem and postmortem fractures on the skeleton: a blind
text on 210 fractures of known origin. J Forensic Sci. 2014 Nov;
59(6):1598-601. PMID: 24990801. PMID: 9437514. http://dx.doi.org/10.1016/s8756-3282(97)00228-7.
http://dx.doi.org/10.1111/1556-4029.12539.
19) Ludwig J. Handbook of autopsy practice. 3rd ed. Totowa (NJ):
Humana Press; 2002. 592 p.
20) Scheuer L, Black S. Developmental juvenile osteology. San Diego:
Elsevier Academic Press; 2000. 587 p.
21) Ubelaker DH and Adams BJ. Differentiation of perimortem and
postmortem trauma using taphonomic indicators. J Forensic Sci.
1995 May; 40(3):509-12. PMID: 7782760.
22) Stedman TL. Stedman’s medical dictionary. 25th ed. Baltimore: Will-
iams and Wilkins; 1990. 1784 p.
23) Ayers DM. Bioscientific terminology: words from Latin and Greek
stems. Tucson: University of Arizona Press; 1972. 325 p.
24) Turner CH, Burr DB. Basic biomechanical measurements of bone:
a tutorial. Bone. 1993 Jul-Aug; 14(4):595-608. PMID: 8274302.
http://dx.doi.org/10.1016/8756-3282(93)90081-k.
25) Rodríguez-Martín C. Forensic anthropology and medicine: comple-
mentary sciences from recovery to cause of death. Totowa (NJ):
Human Press; c2006. Chapter 8, Identification and differential diag-
nosis of traumatic lesions of the skeleton; p. 197-224.
26) Sauer NJ. Forensic osteology: advances in the identification of
human remains. 2nd ed. Springfield (IL): Charles C Thomas; c1998.
Chapter 15, The timing of injuries and manner of death: distinguish-
ing among antemortem, perimortem, and postmortem trauma; p. 321-
32.
27) Jordana F, Colat-Parros J, Bénézech M. Diagnosis of skull fractures
according to postmortem interval: an experimental approach in a
porcine model. J Forensic Sci. 2013 Jan; 58 Suppl 1:S156-62. perimortem trauma in skeletal material. Internet J Biol Anthropol.
PMID: 23106527. http://dx.doi.org/10.1111/1556-4029.12012.
28) Burstein AH, Zika JM, Heiple KG, Klein L. Contribution of collagen
and mineral to the elastic-plastic properties of bone. J Bone Joint
Surg Am. 1975 Oct; 57(7):956-61. PMID: 1184645.
29) Reilly DT, Burstein AH. Review article: the mechanical properties
of cortical bone. J Bone Joint Surg Am. 1974 Jul; 56(5):1001-22.
PMID: 4603167.
30) Rogers LF. Radiology of skeletal trauma. New York: Churchill-
Livingstone; 1982. 939 p.
31) Porta DJ. Forensic medicine of the lower extremity. Totowa (NJ):
Humana Press; c2005. Chapter 9, Biomechanics of impact injury;
p 279-310.
INVITED REVIEW
32) Crowe JE, Swischuk LE. Acute bowing fractures of the forearm in
children: a frequently missed injury. AJR Am J Roentgenol. 1977 Jun;
http://dx.doi.org/10.2214/ajr.128.6.981.
33) Pierce MC, Bertocci GE, Vogeley E, Moreland MS. Evaluating long
bone fractures in children: a biomechanical approach with illustra-
tive cases. Child Abuse Negl. 2004 May; 28(5):505-24.
PMID: 15206413. http://dx.doi.org/10.1016/j.chiabu.2003.01.001.
34) Daegling DJ, Warren MW, Hotzman JL, Self CJ. Structural analysis
of human rib fractures and implications for forensic interpretation.
J Forensic Sci. 2008 Nov; 53(6):1301-7. PMID: 18798775.
http://dx.doi.org/10.1111/j.1556-4029.2008.00876.x.
35) Smith OC, Peters CE. Biomechanics and the bone. In: Symes SA,
editor. Bones: bullets, burns, bludgeons, blunders and why. Proceed-
ings of the 48th Annual Meeting of the American Academy of
Forensic Sciences; 1996 Feb 19-24; Nashville, TN. Nashville:
University of Tennessee; 1996. p. 6-14.
36) Zioupos P, Currey JD. Changes in the stiffness, strength, and tough-
ness of human cortical bone with age. Bone. 1998 Jan; 22(1):57-66.
37) Saha S, Hayes WC. Tensile impact properties of human compact
bone. J Biomech. 1976; 9(4):243-51. PMID: 1262359.
http://dx.doi.org/10.1016/0021-9290(76)90010-5.
38) Bayraktar HH, Morgan EF, Niebur GL, et al. Comparison of the
elastic and yield properties of human femoral trabecular and cortical
bone tissue. J Biomech. 2004 Jan; 37(1):27-35. PMID: 14672565.
http://dx.doi.org/10.1016/s0021-9290(03)00257-4.
39) Norman TL, Vashishth D, Burr DB. Fracture toughness of human
bone under tension. J Biomech. 1995 Mar; 28(3):309-20.
PMID: 7730389. http://dx.doi.org/10.1016/0021-9290(94)00069-g.
40) Laird GW, Kingsbury HB. Complex viscoelastic moduli of bovine
bone. J Biomech. 1973 Jan; 6(1):59-67. PMID: 4735081.
http://dx.doi.org/10.1016/0021-9290(73)90038-9.
41) Reilly DT, Burstein AH, Frankel VH. The elastic modulus for bone.
J Biomech. 1974 May; 7(3):271-5. PMID: 4846264.
http://dx.doi.org/10.1016/0021-9290(74)90018-9.
42) Calmar EA, Vinci RJ. The anatomy and physiology of bone fracture
and healing. Clin Ped Emerg Med. 2002; 3(2):85-93.
http://dx.doi.org/10.1053/epem.2002.127037.
43) Quatrehomme G, Ïşcan MY. Postmortem skeletal lesions. Forensic
Sci Int. 1997 Oct 6; 89(3):155-65. PMID: 9363624.
http://dx.doi.org/10.1016/s0379-0738(97)00113-8.
44) Marden K, Sorg MH, Haglund WD. Research methods in human
skeletal biology. Waltham (MA): Academic Press; c2013. Chapter 9,
Taphonomy; p. 241-62.
45) K Moraitis, C Eliopoulos, C Spiliopoulou. Fracture characteristics of
2008; 3(2):[8 p.]. http://dx.doi.org/10.5580/20a2.
46) Dupras TL, Schultz JJ. Manual of forensic taphonomy. Boca Raton:
CRC Press; c2013. Chapter 12, Taphonomic bone staining and color
changes in forensic contexts; p. 315-40.
47) Villa P, Mahieu E. Breakage patterns of human long bones. J Hum
Evol. 1991 Jul; 21(1):27-48.
http://dx.doi.org/10.1016/0047-2484(91)90034-s.
48) Herrmann NP, Bennett JL. The differentiation of traumatic and heat-
related fractures in burned bone. J Forensic Sci. 1999 May; 44(3):
461-9. PMID: 10408102.

Page 44
Kemp • Postmortem Fracture Evaluation
ACADEMIC FORENSIC PATHOLOGY: THE OFFICIAL PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS
©2016 Academic Forensic Pathology Incorporated
Downloaded from www.afpjournal.com by an AFP Journal subscriber
This article is for personal use only and may not be shared or distributed in any fashion