o u
rnalo
fFo
rensicandL
ega
lMedic
ine6
6(20
19)9
5–99
Peri- and post mortem hemorrhages in the anterior neck after chin-collar
application
S.N. Kunza,b,∗ , J.G. Jónassonb,c, R. Rúnarsdóttirc
a
Department of Forensic Pathology, Landspitali University Hospital, Iceland
b
Faculty of Medicine, University of Iceland, Reykjavik, Iceland
c
Department of Pathology, Landspitali University Hospital, Iceland
ARTICLEINFO ABSTRACT
Keywords: Intense blunt compression trauma to the neck can result in subcutaneous, intramuscular or laryngeal mucosa
Forensic medicine bleedings of different intensity. While these findings can easily be detected through a layer-wise dissection of the
Peri mortem injury neck muscles and soft tissue during autopsy, it can be difficult to distinguish between peri-/post- and ante
Post mortem injury mortem hemorrhages solely based on macroscopic findings. Especially when an initial preliminary diagnosis is
Neck injury required, possible artifacts have to be excluded.
Chin-collar
The study at hand examines possible peri- and post mortem hemorrhages in the anterior neck after NorMors™
Compression trauma
chin-collar application.
In routine clinical and forensic autopsy cases, where such a chin-collar has been placed around the neck of the
deceased in close proximity after death, focus was directed to the soft tissue and muscles of the neck.
The results of our analysis could prove that the use of chin-collar shortly within the first 1 ½ hours after death
applies just enough pressure to the neck to be able to cause superficial hemorrhages within the surface of the
sternocleidomastoid muscles, which can mimic vital compression trauma injuries. Based on location, morpho-
logical outlines and intensity of the injuries, it is possible to correlate them with the position of the applied
collar. Together with histological analyses, asphyxia by a second party involvement can be excluded. However,
the application of chin-collars should be prohibited in any case, where an autopsy might be performed.
1. Introduction face without creating facial expression changes. 8 It prevents the mouth
to open and at the same time stabilizes the neck. The collars come in
The differentiation between vital reaction and post mortem artifact two different sizes, L and M and are made of degradable plastic. The
is one of the main research topics in forensic medicine. 1 In order to be device is a thin, bent collar that is put around the anterior half of the
able to verify or falsify a correlation between morphological findings neck and is supported by the collarbone (Fig. 1a). After removal, a thin
and a possible traumatic mechanism of formation, it is primarily es- impression mark can be visible on the skin. If the collar was applied
sential to ensure their vitality. While the best possible estimation of pre- within the region of lividity, corresponding sparing pattern can be seen
mortem formation and age estimation can be established with micro- (Fig. 1b). In the context of post-mortem examination and autopsy, it is
scopic analytical methods, 2–5 it is not always possible to give a pre- important to know whether the applied pressure from the chin-collar is
liminary diagnosis solely based on macroscopic findings during au- enough to cause injuries to the skin and underlying soft and muscle
topsy. When the deceased has been medically treated or its original tissue. The severity, extent and appearance of such possible blunt
status has been changed (e.g. position, clothing, etc.), it is essential for trauma injuries depend on the amount of force delivered, the time over
the forensic examiner to be aware of possible artifacts due to such which the force is delivered, the exact anatomical region, the extent of
treatment.6 Especially the interpretation of potential blunt trauma body surface over which the force is delivered and the nature of the
compression-related injuries to the neck have been a constant chal- device used. The interpretation of such morphological changes always
lenge, even for the experienced forensic pathologist.7 has to be carried out in the context of the case and thus potential peri-
The application of NorMorsT M chin-collars is a common method and post mortem artifacts have to be taken into account. To our
used by funeral personnel to preserve a natural aspect of a deceased's knowledge, there is no scientific research on artifacts caused by
∗
Corresponding author. Department of Forensic Pathology, Landspítali University, Hospital Reykjavik, v/Barónstig 101, Reykjavik, Iceland.
E-mail address: sebastian@landspitali.is (S.N. Kunz).
https://doi.org/10.1016/j.jflm.2019.06.014
Received 18 April 2019; Received in revised form 13 June 2019; Accepted 20 June 2019
Av ailableo nlin
e2 2J un e2 019
17 52 -928X/© 2019E lsevierLtdandF acultyo fForensicandL ega lMedicine.Allrightsrese
rved.
S.N. Kunz, et al. Journ
alofFo
ren
sican
dLega
lMed
icin
e66(20
19)9–
599
Signs of hemorrhage,
No inflammation
No inflammation
No inflammation
No inflammation
No inflammation
No inflammation
No inflammation
Hemorrhages,
Hemorrhages,
Hemorrhages,
Microscopical
Hemorrhage,
Hemorrhage,
Hemorrhage,
examination
–
–
Medium to high
medium, high)
Intensity (low,
Medium
Medium
High
High
High
Low
–
–
–
Both sides: caudal third, superficial layers of
sternocleidomastoid muscles
Intramuscular hemorrhages
sternocleidomastoid muscle
sternocleidomastoid muscle
Fig. 1a. NorMorsT M chin-collars application around a deceased's neck.
injuries
–
–
–
–
–
application of collar and
Time interval between
122.0 h
105.0 h
autopsy
34.0 h
30.0 h
78.0 h
20.5 h
63.0 h
35.0 h
40.0 h
59.5 h
NorMors™ chin-collars. The objective of this study was to determine
under which circumstances the application of such chin collar could
of death and application of
Time interval between time
< 60 min
< 60 min
< 60 min
Over a time period of one year (April 2018–March 2019), all routine
< 60min
unknown
∼ 90min
∼ 90min
∼ 60min
collar
been placed around the neck of the deceased were included in our
study. There was no exclusion criterion. A standard forensic autopsy
Accidental drug intoxication
MOF subsequent to prostate
Myocardial infarction
Myocardial infarction
Endocarditis, limbic
the body's surface of most of the subjects. Only the patient of case
Cardiac tamponade
pulmonary fibrosis
acute intracerebral
number 4 had signs of putrefaction. His skin showed areas of dark red-
Cause of death
soft tissue and muscle structures of the neck were without decomposi-
tional changes in all cases. As in every forensic autopsy, special focus
was directed to the soft tissue and muscles of the neck. In each of the 8
20.0
26.2
24.7
21.2
27.8
24.1
22.2
23.2
23.1
26.3
were severed horizontally below both clavicles and the neck joints were
78
78
69
31
75
43
73
56
51
76
female
female
female
female
female
of blood from the neck vessels. The hereby created artificial bloodless
male
male
male
male
male
1.
2.
3.
4.
5.
6.
7.
8.
9.
9
6
S.N. Kunz, et al. Journ
alofFo
ren
sican
dLega
lMed
icin
e66(20
19)9–
599
hematoxylin-eosin staining. The intensity of injury was graded low, In each case, the funeral service personnel denied any unusual body
medium and high in correlation to a clearly definable hemorrhage handling. The chin-collars were applied according to NorMorsT M re-
(high), a diffuse hemorrhage (medium) and an indicated hemorrhage commendations.
(low).
In each case, the funeral service was interviewed considering pos-
sible unusual post-mortem body handling or incidents, which could 4. Discussion
explain post mortem injuries to the neck.
Peri- and post mortem injuries can be caused by resuscitation,11
during body recovery,12 postmortem transport,12 the handling of the
3. Results body13 or by the funeral service. It is not unusual, that no detailed in-
formation on post mortem handling of the body is given to the forensic
During the time interval of one year, 13 cases could be identified, pathologist at the time of autopsy. The lack of such information com-
where a NorMorsTM chin-collar has been placed around the neck of the plicates a clear causality assessment of potential injuries. Therefore,
deceased in close proximity before the autopsy. Because of previous detailed information on post mortem body handling is essential in order
placement of a central venous catheter in the neck region of 3 of these to distinguish between an irrelevant artifact and a significant vital re-
patients, diffuse hemorrhages in the neck muscles made a clear as- action. A forensic autopsy is the essential and ultimate investigation
sessment of blunt trauma injuries impossible, which is why those cases tool to verify or falsify the plausibility of information on cause, mode
were excluded. Altogether, 6 clinical and 4 forensic autopsies were and mechanism of death provided by the police, medical personnel
included in our study (Table 1). After removal of the collar, an im- and/or the funeral service.14
pression mark was visible in all cases. No injuries to the skin could be While it is advised to carefully phrase the interpretation of potential
detected in most cases. Only one woman (case nr. 10) showed a yellow- trauma-related morphological findings during autopsy, especially be-
brown discoloration of the skin just below the chin. The skin here was fore a histological analysis is carried out, a preliminary report is often
dried and had a leather like appearance. requested by the police. In such reports, misleading emphasis or mis-
In each case, where the collar was applied shortly after death interpretation of morphological findings can trigger a chain reaction of
(< 30 min), clear hemorrhages could be identified, either next to or unnecessary police action for an irrelevant suspicion of violent death.
within the superficial layers of the sternocleidomastoid muscles (Fig. 2) The neck examinations at hand (Table 1) once again stress the im-
and/or the omohyoid muscles (Fig. 3). Rather slightly developed he- portance of correct interpretation of post mortem artifacts 15,16 and thus
morrhages were in the neck muscles of one man, who received the forensic reserve. Especially in possible trauma-related deaths, further
collar approximately 90 min after his death (case nr. 4). The bleedings analyses of the tissue in question need to be performed in order to verify
were always located within the lower caudal third of the muscles. No its accuracy,2–5,17,18 before a forensic statement can be given.
bleedings were visible in the neck muscles of two women (case nr. 6 In our study, apart from one case (nr. 10), no injuries were de-
and 7), whose collars were applied approximately 90 min and 120 min tectable on the skin of the neck. In this case, the morphological outlines
after death. For one patient (case nr. 8), it was not possible to find out of the injury were typical for a postmortem abrasion mark. All other
the time interval between her death and the collar application. She patients just showed the impression mark from the collar with no in-
showed no traces of bleeding within the neck muscles. juries to the skin.
The histological analyses of the soft and muscle tissues showed ac- The majority of patients showed visible hemorrhages within their
cumulation of erythrocytes between muscle cells (Fig. 4). No disk-like neck muscles. These injuries were located at pressure points of the
fragmentation of muscle fibers and no loss of sarcoplasmic cross-stria- NorMorsTM chin-collar. From their size, intensity and morphological
tion could be identified. Within the erythrocytes, a few individual outlines, it is possible to match these bleedings with the accurately
neutrophils could be detected. However, no accumulation of these cells applied plastic collar. None of the cases presented alternative me-
was seen, which would correlate to an inflammatory cell reaction. chanisms of formation. In the case of hanging (case nr. 4), the position
9
7
S.N. Kunz, et al. Journ
alofFo
ren
sican
dLega
lMed
icin
e66(20
19)9–
599
of the body. A slightly bent or twisted head-neck relation could alter the
correct placement of the collar, reduce the pressure to the neck and thus
not leave any visible damages to the underlying soft tissue and muscles.
Such uneven distribution of force could also lead to irregular hemor-
rhages on varying sides of the neck.
Independently from these variables, our results could corroborate
that post mortem application of NorMorsT M chin-collars can generally
produce artifacts within the neck muscles. In order to be able to cor-
relate the use of such devices to morphological findings, knowledge on
any peri- or post mortal activity by second party involvement is im-
portant.
5. Limitation
9
8
S.N. Kunz, et al. Journ
alofFo
ren
sican
dLega
lMed
icin
e66(20
19)9–
599
Conflicts of interest 9. Peterson GF, Clark SC. National association of medical examiners. Am J Forensic
Pathol. 2006;27:200–225.
10. Richter M. Gerichtsärztliche Diagnostik und Technik. Leipzig: Hirtze; 1905.
This article is a result of forensic routine work, which was done for 11. Friberg N, Schmidbauer S, Walther C, Englund E. Skeletal and soft tissue injuries
the police and prosecution. The research was not funded and there is no after manual mechanical chest compression. Eur Heart J Qual Care Clin Outcomes.
actual or potential conflict of interest in relation to this article. 2019 Jan 11. https://doi.org/10.1093/ehjqcco/qcy062.
12. Zollinger U, Pollak S. Vortäuschung von Strangulationsbefunden durch postmortale
Bergungs- und Transportmaßnahmen. Beitr Gerichtl Med. 1989;47:479–486.
References 13. Kunz SN, Brandtner H, Meyer H. Putrefaction in a mortuary cold room? Unusual
progression of postmortem decomposition processes. Arch Kriminol.
2013;231:130–135.
1. Sharma G, Singh H, Mittal S, Chawla R, Sandhu R. Dilemma for autopsy surgeon.
14. Kunz SN, Bergsdóttir þ, Jónasson JG. Autopsy rates in Iceland. Scand J Publ Health.
JIAFM. 2007;29:971–973.
2019 Jan 11. https://doi.org/10.1177/1403494818820748.
2. Betz P. Histological parameters for the age-estimation of human skin wounds.
15. Mirza FH, Makhdoom PA. Importance of correct interpretation of post mortem ar-
Rechtsmedizin. 1999;9:163–169.
tifacts in medicolegal autopsies. J Park Med Assoc. 1998;48:49–50.
3. Betz P, Hausmann R. Practical wound age estimation. Rechtsmedizin. 2007;17:55–66.
16. Abdullah F. Artifacts in Forensic Pathology. Hand Book of Forensic Pathology. J.B
4. Madea B, Grellner W. Vitale reaktionen. Teil 1. Rechtsmedizin. 2002;12:378–394.
Lippincott Company; 1973:235–253.
5. Madea B, Grellner W. Vitale reaktionen. Teil 2. Rechtsmedizin. 2003;13:32–48.
17. Kibayashi K, Higashi T, Tsunenari S. A differential study between antemortem
6. Hädrich C, Banaschak S, Dreβler. Perimortal artifacts. Differential diagnosis during
bleeding and a postmortem infiltration of hemoglobin. Nihon Hoigaku Zasshi.
external examination of the corpse and autopsy. Rechtsmedizin. 2012;22:17–23.
1991;45:227–232.
7. Pollanen MS. Pitifalls and artifacts in the neck at autopsy. Acad Forensic Pathol.
18. Burke MP, Olumbe AK, Opeskin K. Postmortem extravasation of blood potentially
2016;6:45–62.
simulating antemortem bruising. Am J Forensic Med Pathol. 1998;19:46–49.
8. NorMorsTM chin collar. available at: http://www.normors.no/text2_2.html, Accessed
date: 22 August 2018.
9
9