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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.
# 2005 Elsevier Ireland Ltd. All rights reserved.

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


about the incidence and distribution of sharp force injuries in
When evaluating sharp force injuries, the correct inter- victims and perpetrators of knife attacks can be helpful for
pretation of the individual wound morphology as well as the verifying the suspects statement or unmasking a defensive
total pattern of the findings is of considerable importance lie.
under aspects of crime reconstruction. Inter alia, the differ- In the past, comprehensive studies on the findings seen
entiation between the accidental, homicidal and suicidal after sharp force injuries were mostly conducted on autopsy
infliction of injuries helps to distinguish between victims material [915]. The results obtained from those studies, for
and offenders [18]. This is of special importance whenever example concerning the frequency, localization and distri-
a suspected person shows sharp force injuries, claiming that bution of defence injuries, have so far been applied to
he or she was hurt while trying to ward off an attack or to clinical forensic medicine as well. The present study com-
pares data published on autopsy studies [915] with data
* Corresponding author. Tel.: +49 761 203 6830; collected on victims and perpetrators of non-fatal bodily
fax: +49 761 203 6858. injuries due to sharp force. The aim of our study was to
E-mail address: ulrike.schmidt@uniklinik-freiburg.de determine whether the patterns of injuries in killed and
(U. Schmidt). 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 tion. Special importance was attached to cuts and stabs found
injuries that perpetrators unintentionally inflicted on them- on the hands and forearms of the victims. In the following,
selves show any specific characteristics. 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
2. Material and methods as well.
As far as possible, the results of the evaluation were
In a retrospective study, the reports on clinical examina- compared with data in the literature. Statistical significance
tions performed by members of the Freiburg Institute of was determined by means of the x2-test.
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- 3. Results
guished as being either a victim or a perpetrator were
excluded. Particularly the cases of knife attacks with several 3.1. Injuries of the victims
offenders who had also been injured themselves were not
included in this study. The injuries of a total number of 206 In the 158 victims studied (127 males and 31 females
persons (158 victims and 58 perpetrators) involved in 153 aged 1563) a total of 663 survived stab and cut injuries were
offences, documented in written reports and photographs, found (Fig. 1). The individuals showed between 1 and 20
were evaluated as to their number, localization and distribu- single injuries with an average of 3.7 injuries in the male

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.
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 with 24 injuries being localized on the right and 26 on the left
nature. Five of the perpetrators had intentionally inflicted hand (Table 4; Fig. 3).
injuries on themselves after the offence, either with suicidal One of the offenders had inflicted a singular, transverse
intent or to simulate self-defence. Injuries unintentionally cut to the little finger on his right hand located on the flexor
inflicted during the attack were found in 16 offenders. skin fold of the proximal interphalangeal joint. The three
Altogether, the perpetrators hands showed 50 cut wounds 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 117

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

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