Legal Medicine 15 (2013) 134–139

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Legal Medicine
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Traumatology of the superior thyroid horns in suicidal hanging – An injury analysis

K.-S. Saternus a, H. Maxeiner b,1, G. Kernbach-Wighton c,⇑, J. Koebke d,1
a
Institute of Legal Medicine Kassel, Germaniastr. 7, D-34119 Kassel, Germany
b
Institute of Forensic Medicine (formerly Free University of Berlin), Hittorfstrasse 18, D-14195 Berlin, Germany
c
Institute of Legal Medicine, University of Bonn, Stiftsplatz 12, D-53111 Bonn, Germany
d
Institute of Anatomy, University of Cologne, Josef-Stelzmann-Str. 9, D-50931 Cologne, Germany

a r t i c l e i n f o a b s t r a c t

Article history: It appears still questionable whether fractures to the superior thyroid horns can be used for forensic
Received 26 May 2012 reconstruction purposes regarding the functional mechanism causing compression of the neck soft tis-
Received in revised form 26 October 2012 sues. Localisations and types of such fractures were documented in 118 cases of superior thyroid horn
Accepted 27 October 2012
fractures caused by suicidal hanging. The placement of the ligature was above the larynx in 109 cases
Available online 20 December 2012
and in the remaining nine cases across the thyroid cartilage. As a secondary parameter the degree of ossi-
fication of thyroid cartilages and superior horns was used.
Keywords:
Bone densities of typical cases (equidensities) were measured radiologically. Additionally, dummy tests
Superior thyroid horns
Fractures
were performed focused on two extreme shapes of superior thyroid horns to assess stress peaks using
Suicidal hanging resin dummies and polarised light. Such peaks were located in the lower thirds of the horns close to their
Ossification bases. With the larynx still cartilaginous, the base appears a typical location for fractures caused by sui-
Photo-elastic experiments cidal hanging.
Gender differences An ossification pattern defined as ‘‘type 1’’ showed broad and osseous superior thyroid horns. If ossi-
Reconstruction fication was homogenous, fractures were located at the sites of maximum mechanical stress. In case of
inhomogenous ossification, being the more common mode, the horn bases were more resistant to pres-
sure and bending so that no fractures occurred. They were instead located at the sites of the greatest dif-
ferences in density and distributed in an apparent random pattern.
Narrow and deep insertions of the superior thyroid horns at the back surface of the upper thirds of the
thyroid cartilages (posterior aspects) were classified as ‘‘type 2’’ ossification. Upon flexion, the long horns
came into contact with the upper edges of the dorsal aspect creating a torque. Further flexion from an
increasing impact by the ligature extended the long lever arm causing the base of the upper thyroid horn
being broadly torn out of the dorsal aspect. The results suggest that localisations of fractures to the supe-
rior thyroid horns in connection with ossification patterns may be helpful for the reconstruction in sui-
cidal hanging regarding the mechanics of the ligature in relation to its position around the neck.
Ó 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction cur prior to onset of ossification, calcification or ‘‘asbestos-like’’

Fractures of the superior thyroid horns are the most common
osseous injuries occurring from suicidal hanging. Their types are
not uniform, although 66% of the fractures are found in the lower
thirds of the bases [1]. Basal fractures can be divided into high
and low dislocations. No explanation has been given so far whether
these represent the same fracture type or whether different frac-
ture types are involved raising the issue whether such fracture
localisations are reliable criteria for reconstruction.
The forensic medical literature from the last two centuries
mentions a close correlation between individual age and fracture
incidence [2–7]. Fractures of the superior horns do typically not oc-
⇑ Corresponding author. Tel.: +49 228 738310; fax: +49 228 738339.
E-mail address: gkwighto@uni-bonn.de (G. Kernbach-Wighton).
1
Deceased.
degeneration of the cartilage. It has been presumed to occur only
rarely in thyroid cartilages still being completely cartilaginous.
Numerous studies have been published concerning the frequency
of superior horn fractures in suicidal hanging, but according to a
newer literature review [8], data tend to vary widely, namely from
75% to 72% [1,9], around 55% [10] and 13–17% [11,12]. Despite an
expected high frequency of upper horn fractures, no systematic
analyses taking into account different types of ossification have
been performed so far.
Our primary objective was to obtain detailed trauma character-
isations based on a large forensic sample with the investigative ap-
proach to examine possible correlations between superior horn
fractures and ossification modes of the thyroid cartilages and
superior horns. Moreover, our investigations aimed to reveal
information about the fracture levels based on dummy tests using
two extreme configurations of upper thyroid horn shapes.

1344-6223/$ - see front matter Ó 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.legalmed.2012.10.008
 K.-S. Saternus et al. / Legal Medicine 15 (2013) 134–139 135

2. Material and methods

118 upper horn fractures in forensic samples from the Institutes

of Forensic Medicine at the Universities of Cologne (n = 52) and
Berlin (n = 66) were analysed. The laryngeal skeletons had previ-
ously been subject to comprehensive investigations [8,13–18] as
well as the laryngeal soft tissues [19–21]. As far as could be recon-
structed from police files and autopsy findings, the placement of
the ligature was above the larynx in 109 cases, and in the remain-
ing nine cases across the larynx without special positions.
Dissections to expose the horn fractures were performed in two
steps. Firstly, the larynx, left unopened at autopsy, was fixed in for-
malin, followed by dissection of the soft tissues [20]. Secondly,
perichondrium and periosteum were completely removed. In a
number of cases, the periosteum was initially left in place as some
sort of collar for X-ray and only later removed to expose the
fractures.
X-ray was performed by conventional technique, with the thy-
roid cartilages separated in the midline. A density scale was used in
order to obtain semi-quantitative bone densities (equidensities).
Radiological analyses of ossification related to age and gender were
carried out with documentation of the criterion ‘‘variable ossifica-
tion’’. Resin dummies from AralditeÒ were used to simulate ex-
treme variations of superior thyroid horn positions within the
sagittal plane (photo-elastic experiments; Fig. 3). For visualisation
of (isochromatic) distributions of tension, the dummies were sub-
jected to mechanical impacts in polarised light on a ‘‘Zwick’’ testing
machine. Fig. 1. Larynx in the cartilaginous stage. Fracture within the lower third of the
superior thyroid horn.

3. Results
3.1. Degree/type of ossification and fracture location (Table 1)
Five percent of the horn fractures showed the larynx completely
cartilaginous with the fracture levels located in the lower thirds of
the superior horns (Fig. 1). This level corresponded to the load
peaks shown in isotropic material (AralditeÒ) by photo-elastic
experiments. In 11% of the cases, the superior horns were not yet
or only partially ossified with the fractures located at the level of
the ossification front. In 43% the thyroid cartilage was already ossi-
fied up to its upper edge, and completely ossified in 41% of the
cases. Macroscopically, fracture levels initially appeared to follow
a random pattern (Table 1).
3.2. Configuration types of the superior thyroid horns
Especially angles and configurations of the superior thyroid
horns showed wide variations within the sagittal plane ranging
from straight angles off to the dorsal plane to others bending to
the anterior one. Authors who had previously examined the sam-
ple from Cologne [22,23] defined a dorsally tilted, straight horn
as ‘‘male type’’ and anteriorly bent horns as ‘‘female type’’.
3.3. Distribution of mechanical loads
In Fig. 2a and b the isochromatic bands, corresponding to the
locations of equal loads, were shown by polarised light. The stamp
transfers force to the superior thyroid horn, similar the way the lar-
ynx can forcibly be pressed towards the cervical spine by suicidal
hanging. Nevertheless, AralditeÒ resin was not intended to replace
bone in the photo-elastic experiments. It was used to demonstrate
the loading peaks in an object shaped similar to a superior thyroid
horn. Together with X-ray of bone density, this technique is a
widely recognised method in biomechanics [15,24–26].
3.4. Photo-elastic experiments
In addition to the distribution of loads, causation of fractures
was primarily assessed by the degree of ossification. Fig. 2a and
b shows that the maximum number of isochromatic bands (pat-
tern) are not located directly at the base of the horn but in its lower
third close to its base. This observation appeared independent from
the configuration of the horns. If the peak load during force transfer
by suspension occurs close to the base within the lower third of the
horn for both extreme types of shape, this conclusion applies also
to horn shapes between the two extremes. An extensive study
found superior thyroid horns to point dorsally in over 60%, verti-
cally in 48.5% and anteriorly in only 1.5% [8].
Apparently, the number of isochromatic bands depends on the
amount of the applied force. The peak loads observed in the
photo-elastic experiments appear applicable to bone, with the
shape of the superior horn determining the length of the lever
arm although there might be differences between resin dummies
and real bone.

Table 1
3.5. Ossification patterns and types of upper thyroid horns (Table 2)
Correlation between degree/type of ossification and fracture location.

n % State of larynx/superior horns Location of fracture(s) Examinations of ossification patterns of superior thyroid horns
6 5.1 Completely cartilaginous Lower thirds of superior horns were performed to understand the mechanisms of superior horn
13 11.0 Horns not yet/partially ossified Level of ossification front fractures, but not to present a comprehensive illustration of the
51 43.2 Ossification up to upper edge Random pattern
ossification types of the thyroid cartilage. Ossification of upper
48 40.7 Complete ossification Random pattern
horns shows inhomogeneous patterns, typically starting from their
136 K.-S. Saternus et al. / Legal Medicine 15 (2013) 134–139

Fig. 2. Load distribution (photo-elastic analysis) in resin dummies showing two extreme shapes (a vs. b) of superior thyroid horns in simulated strangulation with load peaks
located in the inferior third/base of the horn.

Table 2
Different types of upper thyroid horns.

Type Morphological characteristics

1 Bone matrix extending to upper border of the thyroid cartilage; larger portion running into the back surface; ossification with an ovoid shape
2 Bone matrix not extending to the upper thyroid cartilage border, reaching the upper to middle third of its dorsal aspect; showing an ovoid ossification pattern
3 Bone matrix of superior thyroid horns with a homogenous transition into the dorsal aspect of the thyroid cartilage; ossification showing frame-like shapes
(hardly any involvement of the upper border)

bases. Traumatologically, ossification of the upper thyroid horns

can be differentiated into three types (Table 2).
In ‘‘type 1’’, the bone matrix extends to the upper border of the
thyroid cartilage with its larger portion running into the back sur-
face of the thyroid cartilage (dorsal aspect; Figs. 3–5). Ossification
of the thyroid cartilage shows an ovoid shape.
In ‘‘type 2’’, the bone matrix does not extend into the upper thy-
roid cartilage border, but reaches the upper to middle third of its
dorsal aspect with the thyroid cartilage also showing an ovoid ossi-
fication pattern (Fig. 6).
In ‘‘type 3’’, the bone matrix of the superior thyroid horn does
similarly not extend into the upper thyroid cartilage border, but
shows a homogenous transition into its dorsal aspect. Ossification
patterns show frame-like shapes, and there is hardly any involve-
ment of the upper border (Fig. 7).

Fig. 4. Radiological bone density distribution (equidensities). Pressure- and flexion-

resistant base of the horn with a fracture in the transitional area to the largest
density differences (No. 1277/82 C).

3.6. Features of different types of ossification (types 1–3)

Ossification of ‘‘type 1’’ (Figs. 3–5) show common features such

Fig. 3. Configuration of horns resulting in bases resistant to pressure and flexion.
Photo-elastic analysis: the fracture is located in the centre of the impact peak with
the superior thyroid horn showing homogenous ossification (729/82).
as broad horn bases with high compressive and tensile resistances
resulting from bone architecture, but with superior horn fractures
not being uniform. Fig. 3 shows the bone matrix not only extending
widely into the superior thyroid cartilage border but also into its
dorsal aspect. In such homogenously ossified horns showed, frac-
ture levels in the lower horn thirds correspond to those of the car-
tilaginous larynges.
 K.-S. Saternus et al. / Legal Medicine 15 (2013) 134–139
Fig. 5. Pressure- and flexion-resistant horn (equidensities). Horn fracture within
the transitional region to the largest density differences (221/79).
Fig. 6. Narrow and deep insertion of the superior thyroid horn. Early contact of the
horn with the ossified thyroid cartilage margin (torque) upon anterior flexion.
Flexion of the longer lever arm has caused a deep bilateral dislocation of the horn
base (358/83).
Fig. 7. Osseous smooth transition from the superior thyroid horn extending into
the dorsal aspect of the thyroid cartilage. On anterior flexion, the horn had early
contact with the non-ossified cartilage border (torque). Deep bilateral dislocation
from the dorsal aspect has occurred by flexion via the long lever arm.
Accordingly, the fracture of Fig. 4 is consistent with ‘‘type 1’’
ossification with the basal horn parts showing a high degree of
bending resulting from impact with a subsequent fracture within
137
the ossification front. Bone density has also been shown in a grey
scale (equidensity pattern) with the bright structures representing
higher densities and dark ones those of lower density. A fracture
(dislocation) is located in the transitional zone between higher
and lower bone densities with the fragment showing dorsal
ossification.
Fig. 5 shows ‘‘type 1’’ ossification with superior horn fractures.
The ossification line is located more cranially compared to Fig. 4
and the dislocated horn can be seen exactly at this level.
A ‘‘type 2’’ ossification shows an insertion of the superior horn
in the upper to middle third of its dorsal aspect. The bone matrix
forms part of the lower oval and extends along the orientation of
the inferior thyroid tubercle. The matrix may be intersected by
bony extensions originating from the lower horn (Fig. 6). Such
superior horns should be regarded as much longer lever arms than
‘‘type 1’’ horns. In suicidal hanging, flexion of the horn within the
sagittal plane is caused by being moved towards the cervical spine
leading to anterior excursion to a contact point. Mostly the upper
part of the thyroid cartilage’s ovoid ossification where a torque
develops shows broad dislocation of the horn out of the dorsal as-
pect (via the long upper lever arm).
In a ‘‘type 3’’ ossification, the abutting bed for the anteriorly
flexed horn is not osseous but cartilaginous. Fig. 7 demonstrates
a torque occurring upon contact with a regressively altered carti-
lage. The superior part of the dorsal part is torn out via the long le-
ver arm created by this process.
4. Discussion
Numerous studies [2–4,7,27] have shown that superior horn
fractures in hanging are caused indirectly. Cranio-dorsal traction
of the ligature moves larynx and hyoid bone towards the cervical
spine. Therefore, fractures of the superior thyroid horns and of
the hyoid bone are effects of flexion resulting from compression ef-
fects by the ligature between larynx and hyoid bone at the level of
the thyro-hyoid membrane.
The bending impact is presumed to originate from tilting effects
to larynx and hyoid bone with this theory prevailing until the mid-
dle of the last century. Recent authors agree that hanging causes
larynx and hyoid bone being pressed towards the cervical spine
[23]. However, bending is considered already causing fractures of
the superior thyroid horns and the hyoid bone [28–30].
However, other morphological findings support different views.
Previous experimental studies on neck compression revealed that
the thyro-hyoid membrane often represents not the final position
of the ligature [2]. An explanation for this may be the topography
of the larynx not providing enough space to accommodate a con-
ventional ligature [31]. This applies especially if the hyoid bone
is not separated from the larynx via a wide stretched-out mem-
brane, but slides over the anterior edge of the larynx via a synovial
bursa.
Conclusions about the types of loads and impacts in suicidal
hanging can also be drawn from injuries of the hyoid bone. Among
different hyoid bone types [15], the hyperbola-shaped one appears
to be most informative in this respect. There can be found capsular
lesions on its inner surface in suicidal hanging, but only if the junc-
tion between body and major horn is not yet ossified [14]. This
means that the hyperbola-shaped hyoid bone is bent open by a
blunt impact. Strangulation causes the major horns bending
inwardly.
Fig. 8a and b shows impacts resulting in dorsal dislocation of a
broad lamella and anterior compression of the fractured horn into
the upper margin of the thyroid cartilage (fulcrum). This effect
does not only depend on the position of the superior thyroid horn
within its sagittal direction, but also in its actual position within
138 K.-S. Saternus et al. / Legal Medicine 15 (2013) 134–139
Fig. 8. Basal superior horn dislocation within the sagittal plane, dorsally (a) with
deep dislocation of a lamella and anteriorly showing (b) impingement on the upper
border of the thyroid cartilage (fulcrum; 156/85).
Fig. 9. Medio-anterior and inward bending of the superior thyroid horn. Lateral (a)
dislocation of a lamella from the border of the thyroid cartilage, medial (b)
impression resulting in a release fracture (156/85).
the frontal plane. In 85 specimens selected by age and gender,
horns were tilted laterally in none of the cases [32]. The deviation
from the sagittal plane to the medial one had a minimum of 5°, a
maximum of 46.5°, and a mean of 27°, with no correlations to
age or gender.
Therefore, it appears that fractures of the superior thyroid horns
with fragments shifting anteriorly and inwardly are rather com-
mon with an example pictured in Fig. 9a and b. The dislocation
of an osseous lamella can be identified on the outer aspect
(Fig. 9a) and some impingement is seen on the inner side of the
thyroid cartilage edge forming a slightly compressed fragment
(Fig. 9b).
Other research revealed that superior thyroid horns in males
were age-dependently aligned slightly laterally [33]. In suicidal
hanging lateral bending of superior horns occurred less frequently
than shifting into the sagittal plane. This may be linked to the horn
configuration showing a wide range of variants in a right–left com-
parison [17,22,32,34]. Thus, the throat skeleton can also be subject
to an off-centre impact even if the ligature is positioned
symmetrically.
Possible slight sagittal alignments of the superior thyroid horns
and bending loads within the sagittal plane have also to be taken
into account. Some deviations of the directions of the vectors can
be identified due to this effect. Our results show that the high fre-
quency of fractures within lower third and base of superior horns
does not provide any supportive information which might help
to reconstruct the injury mechanism [1]. Rather, despite their dif-
ferent levels, fractures can indeed be classified into a uniform in-
jury mode linked to superior horn ‘‘type 1’’. This is due to the
fact that the base of the superior horn forms part of the thyroid car-
tilage so that it is resistant to pressure and bending. In case of a
homogenous ossification, fractures occur at the sites of peak loads
within the lower horn thirds. If the superior thyroid horns have
ossified only inhomogeneously with bending-resistant bases, frac-
tures occur at the boundary to the largest differences in mechani-
cal tolerance to mechanical impacts.
Lesions of ‘‘types 2 and 3’’ are characterised by the upper thy-
roid horn acting more like a long lever arm. Suicidal hanging
causes its flexion by forceful compression towards the cervical
spine. The long lever arm is bent to its maximum elasticity towards
the osseous or cartilaginous dorsal border of the thyroid cartilage.
This mechanical constellation produces a torque consisting of a rel-
atively long lever arm fixed to the cervical spine and a short lever
arm, which has its position between the insertions of the upper
thyroid horn and the fulcrum of the entire system. If the impact
continues, the long lever arm is likely to tear the insertion of the
horn broadly out of the dorsal aspect involving adjacent areas.
5. Final conclusions
The type of injury analysis performed for this study requires a
combination of both dissection and X-ray. An important issue to
ascertain whether a superior horn fracture resulted from the horn
being pressed towards the cervical spine by a blunt impact is a
thorough knowledge about its ossification pattern. This traumatic
mechanism appears typical for suicidal hanging. Hence, this study
may have taken us a little step closer towards an answer to the old
forensic question what effect, if any, the ossification of the larynx
can have on the causation of superior horn fractures.
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