CASE REPORT

A Self-Inflicted Gunshot Wound With an Unusual Hand Injury

Matthew J. Cecchini, MD, PhD and Michael J. Shkrum, MD

Abstract: Self-inflicted gunshot wounds are a common cause of firearm-

related deaths. The appearance and location of the entry wound, other
concomitant findings at autopsy, and correlation with the scene and cir-
cumstances are critical in determining the manner of death. A case of a
72-year-old man with a self-inflicted gunshot wound with an unusual
injury pattern is described. There was a contact range gunshot entry in
the right temple, and an exit wound was seen in the left parietal region.
There was a re-entry with an associated exit wound on the left hand.
Downloaded from http://journals.lww.com/amjforensicmedicine by BhDMf5ePHKbH4TTImqenVMwtnSTRWRk8F61/zO02b2IgXUZsswY6zxVEM1KBZySH on 02/06/2019

Key Words: forensic pathology, gunshot, suicide, injury pattern

(Am J Forensic Med Pathol 2019;40: 47–48)

S elf-inflicted gunshot wounds are a common cause of death in

forensic pathology practice.1 There are cases described in the
literature in which self-inflicted gunshot wounds have suggested a
criminal offense or homicide.2,3 The circumstances preceding
death, the deceased's medical history, scene findings, and features
of the gunshot injury and associated findings at autopsy assist in
differentiating self-inflicted gunshot wounds from those caused
by other individuals.
Defensive wounds are often seen in the context of homicidal
sharp-force wounds in which the deceased can have superficial
wounds on the hands or forearms from attempts at blocking in-
coming attacks from a sharp object.4–6 Defensive entry wounds
from gunshots are less common but have been reported to involve
a hand of the victim who tries to block or move a gun fired by the
perpetrator.4 If fired at close range, the entry wound on the hand
can show soot deposition or stippling with or without soot deposi-
tion from the muzzle discharge.
We report a case with a unique hand injury associated with a
self-inflicted gunshot wound.

CASE REPORT
The deceased was a 72-year-old man who had a recent diagno-
sis of metastatic lung cancer. He lived alone. His wife had died
8 years previously. A neighbor became concerned about his welfare
and alerted the deceased's brother. He found him dead fully clothed
in an empty bathtub (Fig. 1A). There was a bloody towel folded on
his groin. The towel was not available for examination at the time of
the autopsy. There were no photographs of the towel taken by the
police when it was removed from the deceased's body. The police
investigators did note that there was a circumscribed blood stain
around a hole in the towel. It showed no soot deposition. When
the outer fold of the towel was lifted, the deceased's left hand was

Manuscript received June 6, 2018; accepted June 30, 2018.

From the Department of Pathology and Laboratory Medicine, London Health
Sciences Centre; and Schulich School of Medicine and Dentistry, Western
University, London, Ontario, Canada.
The authors received no funding for this article and report no conflict of interest.
Reprints: Michael J. Shkrum, MD, Department of Pathology and Laboratory
Medicine, London Health Sciences Centre–University Hospital, Room
FIGURE 1. Scene photos. A, Decreased in unfilled bathtub with
A3-140, 339 Windermere Rd, London, Ontario, Canada, N6A 5A5.
E-mail: mike.shkrum@lhsc.on.ca. limited blood pooling over the edge of the tub (bullet on floor,
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. arrow). B, .38 special revolver and partly blood-stained towel on the
ISSN: 0195-7910/19/4001–0047 groin of the deceased (C) bullet impact site (arrow) on the wall
DOI: 10.1097/PAF.0000000000000427 opposite the bathtub.

Am J Forensic Med Pathol • Volume 40, Number 1, March 2019 www.amjforensicmedicine.com 47

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cecchin and Shkrum
FIGURE 2. External injuries. A, Entry wound with soot deposition and abrasion ring on right temple. B, Exit wound with beveled out bone
fragments involving the left parietal bone. C, Re-entry wound on the palm of the hand; D, exit wound on the dorsum of the hand.
seen on the rest of the towel, which was on his left thigh. His right
hand was between his thighs near a .38 special revolver, which was
on the floor of the tub (Fig. 1B).
The revolver was loaded with 6 cartridges. A single fired car-
tridge was aligned with the barrel. A bullet was found beside the tub
(Fig. 1A, arrow). There was an indentation in the upper wall near a
mirror opposite the bathtub (Fig. 1C, arrow). There was a note
found on the kitchen table stating that he was ending his life
because he did not want people to see him suffer. The residence
was observed by the police to be tidy.
The postmortem examination confirmed that the deceased
died of a contact gunshot wound that entered the right temple
(Fig. 2A). The entry was 8 cm from the top of the head, 7 cm
from the midline, and 1.3 cm above the right ear. It was oval and
1.1  0.5 cm. There was an eccentric abrasion ring that was up to
0.7 cm on the inferior edge of the wound. Soot deposition was
seen particularly at the 3 o'clock (anterior) and 6 o'clock (inferior)
sides of the wound. The wound track passed through the right
temporal bone and exited the left lateral parietal scalp. The exit
was 4.5 cm from the top of the head and 7 cm from the midline.
The wound was irregular, and its edges were not abraded to
suggest shoring (Fig. 2B). The direction of the wound track, in
relation to the deceased, was left, up and back.
The right (firing) hand did not show any blood spatter in the
photograph taken of the body at the scene. Wounds were noted on
the nonfiring hand. There was an irregular hole, 1.5  0.4 cm, on
the left palm and a 3.5  1.0-cm hole on the dorsum of the hand
(Fig. 2, C and D). Neither of these wounds showed soot deposition
or stippling. Photographs of the left hand at the scene showed
blood staining limited to the wound on the palm.
The deceased had metastatic adenocarcinoma originating in
the right upper lobe of the lung (Figs. 1, 2).
DISCUSSION
To our knowledge, this is the first report of a perforating
wound through a hand placed over the exit site in a case of a
self-inflicted gunshot wound.
The deceased had terminal lung cancer. He left a note indi-
cating his intent to kill himself. The entry wound was contact
range and on the temple, a common site for self-infliction.5,6 The
48 www.amjforensicmedicine.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Am J Forensic Med Pathol • Volume 40, Number 1, March 2019
upward trajectory was consistent with the deceased seated in the
bathtub. There were no other signs of trauma on the body.
There was no soot deposition or stippling on the hand
wounds indicating that the deceased interposed his hand between
the muzzle of the revolver and his temple. On occasion, the
nonfiring hand will be inadvertently positioned over the muzzle
and result in a perforating wound to the hand and re-entry into
the head.5 In this case, the injuries on the left hand were caused
by the deceased placing his palm over the left side of his scalp
where he anticipated the bullet exiting. How the deceased posi-
tioned the towel at the time of shooting cannot be definitively
determined because it was not available at the time of the postmor-
tem examination; however, it was likely held by his left hand be-
cause it was seen inside the folded towel resting on his left
thigh. After the bullet perforated the hand, it traveled up to hit
the opposite wall from where it bounced to the floor landing be-
side the bathtub.
In conclusion, this case report describes a rare hand injury as-
sociated with a self-inflicted gunshot wound to the head. The per-
forating wounds through the nonfiring hand raised the possibility
of a defensive type wound. The circumstances, scene, and autopsy
findings are consistent with an injury pattern arising from the vic-
tim placing his nonfiring hand over the exit site on his head.
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