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COLOUR ATLAS OF FORENSIC TRAUMATOLOGY

Prof. Dinesh Fernando Dr. Sarangi Amarakoon

Faculty of Medicine,
University of Peradeniya,
Sri Lanka

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Copyright reserved by the authors. However, this book can be freely downloaded or reproduced for non-
commercial purposes, since it is meant to be used by medical students and post graduate students in forensic
medicine and pathology. However, if any images or part of the book is used for educational purposes, due
credit should be attributed to the authors.

In case of any questions, comments, suggestions or errors, please mail the authors on
[email protected], [email protected]

ISBN: 978-624-96229-0-6

Uploaded on 05/10/2023

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 FOREWORD
The greatest pleasure I experience as a teacher, is to see my students excel in their chosen careers and
perform even better than myself. The series of e-booklets prepared to better equip medical officers to handle
common conditions likely to be encountered in their day to day forensic practice by Professor Dinesh
Fernando, is a good example of one of my students doing better than me!
Dinesh is the son of Emeritus Professor of Community Medicine, Former Head, Department of Community
Medicine, Former Dean, Faculty of Medicine and Vice Chancellor of the University of Peradeniya,
Malcolm Fernando, who was an illustrious medical academic. Following his father’s footsteps, he joined
the University of Peradeniya in 2003.
Dinesh was one of my post graduate trainees at the Department of Forensic Medicine and Toxicology,
Faculty of Medicine, Colombo, and obtained the doctorate in Forensic Medicine in 2003. He underwent
post-doctoral training at the Victorian Institute of Forensic Medicine, Melbourne, Australia, with my
colleague and contemporary at Guy’s Hospital Medical School, University of London, Professor Stephen
Cordner. During this period, he served as the honorary forensic pathologist of the Disaster Victim
Identification team in Phuket, Thailand following the tsunami, and was awarded an operations medal by
the Australian Federal Police.
He has edited, and contributed chapters to, ‘Lecture Notes in Forensic Medicine’ authored by the former
Chief Judicial Medical Officer, Colombo, Dr. L.B.L. de Alwis and contributed to ‘Notes on Forensic
Medicine and Medical Law' by Dr. Hemamal Jayawardena. He is the editor of the Sri Lanka Journal of
Forensic Medicine, Science and Law. Continuing his writing capabilities, he has compiled an important
and unique set of e-booklets which will be a great asset to undergraduate and post-graduate students of
Forensic Medicine, and also to our colleagues. Its succinct descriptions of complicated medico-legal issues
and clear and educational photographs are excellent. It makes it easy for the students to assimilate the
theoretical knowledge of each topic as they have been augmented with histories, examination findings,
macroscopic and microscopic photographs of actual cases. In some areas, photographs from multiple cases
have been included, so that the students can better appreciate the subtle differences that would be
encountered in their practice.
I sincerely thank my ever so grateful student Dinesh, for giving me this great honour and privilege to write
the foreword.

Professor Ravindra Fernando

Senior Professor of Forensic Medicine, General Sir John Kotelawala Defence University, Ratmalana.
Emeritus Professor of Forensic Medicine and Toxicology, Faculty of Medicine, University of Colombo

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About the authors……...

Dr. Dinesh Fernando is a merit Professor in Forensic Medicine at the Faculty of Medicine,
University of Peradeniya and honorary Judicial Medical Officer, Teaching Hospital Peradeniya.
He obtained his MBBS in 1994 with Second class honours from the North Colombo Medical College, Sri
Lanka, and was board certified as a specialist in Forensic Medicine in 2004. He obtained the postgraduate
Diploma in Medical Jurisprudence in Pathology from London in 2005, and possesses a certificate of
eligibility for specialist registration by the General Medical Council, UK. He underwent post-doctoral
training at the Victorian Institute of Forensic Medicine, Melbourne, Australia. He has also worked at the
Wellington hospital, New Zealand, as a locum Forensic Pathologist and as an Honorary Clinical Senior
Lecturer at the Wellington School of Medicine and Health Sciences, University of Otago, New Zealand.
He was invited to visit and share experiences by the Netherlands Forensic Institute in 2019. He was
conferred a Fellowship by the College of Forensic Pathologists of Sri Lanka in 2021.

Dr. Sarangi Amarakoon is a Temporary Research Assistant at the Department of Forensic Medicine. She
obtained her MBBS in 2023 with Second class honours from the Faculty of Medicine, University of
Peradeniya.

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 PREFACE
Forensic Medicine in Sri Lanka encompasses, both, examination of patients for medico-legal purposes and
conducting autopsies in all unnatural deaths, in addition to those that the cause of death is not known. In
the eyes of the justice system in Sri Lanka, all MBBS qualified medical officers are deemed to be competent
to conduct, report and give evidence on medico-legal examinations of patients and autopsies conducted by
them, as an expert witness. However, during their undergraduate training, they may not get the opportunity
to assist, nor observe, a sufficient variety of representative of cases that may be encountered in the future.

Therefore, a series of e-booklets has been prepared to better equip medical officers to handle common
conditions that are likely to be encountered in day to day forensic practice. The case histories, macro and
micro images are from cases conducted by Prof. Dinesh Fernando. Ms. Chaya Wickramarathne did a
yeomen service in the initial designing of lay out and formatting the booklet. The compilation of the case
and photographs for publication was initiated by Dr. Deshani Herath, continued by Dr. Shashika
Weerasinghe and finalized by Dr. Sarangi Amarakoon.

The content herein may be used for academic purposes with due credit given.

Any clarifications, suggestions, comments or corrections are welcome.

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Asphyxia
 Asphyxia
Asphyxial deaths are caused by partial or total failure of cells to receive or utilize oxygen.
The "classic signs of asphyxia" include:
 Petechial haemorrhages in the skin of the face and the lining of the eyelids.
 Congestion and oedema of the face.
 Cyanosis (a blue discolouration) of the skin of the face.
 Right heart congestion
 Abnormal fluidity of the blood.
However, these signs are not specific to asphyxia. They can be observed in cases of congestive
cardiac deaths as well. The underlying reason for the first two signs is the raised intravascular
pressure in the blood vessels located in the head and neck. Cyanosis occurs due to increased
amounts of deoxygenated haemoglobin in the blood. Right heart congestion and the fluidity of
the blood may not necessarily point to death by asphyxia. Post-mortem fluidity of blood is not
characteristic of asphyxia or any cause of death, but rather the result of a high rate of fibrinolysis
that occurs in rapid deaths, possibly by high levels of catecholamines.
The abrupt increase in intravascular pressure leading to sudden over-distension and rupture of
small vessels, predominantly small venules can cause pinpoint haemorrhages known as
petechiae. These are most common in visceral pleurae and the epicardium, often referred to as
Tardieu spots. In asphyxial deaths from strangulation, petechiae are classically seen in
conjunctivae and sclera.
For forensic pathologists, petechiae on the face and neck are of paramount importance, as they
indicate a need to understand their origin. It's crucial to investigate if there is any evidence
supporting the idea that pressure was applied to the neck or chest, which might have led to
asphyxia.
Asphyxial deaths can be classified according to the level of mechanical obstruction. Smothering,
overlaying and gagging may occur at the level of the nose and mouth, whereas choking and
drowning occur at the level of air passages. At the level of the neck, manual strangulation, ligature
strangulation, hanging, mugging, and garrotting may occur. Other types of asphyxial deaths are
traumatic asphyxia, postural asphyxia, burking and sexual asphyxia.

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 Asphyxia

Figure 1: Mild petechial haemorrhages seen in a person who died due to manual strangulation

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Figure 2: No petechial haemorrhages seen in a person who died due to hanging

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 Asphyxia

Figure 3: petechial haemorrhages in a person who died due to firearm injury to the head

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Figure 4: Tardieu spots in a person who died due to manual strangulation

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 Asphyxia

Figure 5: Cyanosis around the lips in a person who died due to hanging

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Figure 6(a): Face is congested with petechiae around the eye lids in a person who died of
hanging. The tip of the tongue is clamped between teeth and is cyanosed

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 Asphyxia

Figure 6(b): Face is extremely congested above the ligature; Note the cyanotic right ear and imprint
of the knot on the skin

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Suffocation
Suffocation is a general term used to indicate death from deprivation of oxygen, either from lack
of gas in the breathable environment or from obstruction of the external air passages.
Smothering
The term smothering refers to death from mechanical occlusion of the mouth and nose, usually
using agents like fabric, an impervious sheet or a hand. Occasionally it may be caused by lying
face down in sand, mud, grain or flour. The circumoral and circumnasal pallor caused by passive
pressure of the dependent head after death is difficult to distinguish from the pressure marks of
smothering. Overlaying refers to mechanical obstruction to respiration when part of another
person’s body obstructs the nose and mouth.
Gagging
In gagging, a fabric or adhesive tape occludes the mouth or is thrust into the mouth to prevent
speaking or shouting. While the nasal passages remain patent, air can enter, but later blockage
by mucus or oedema may lead to death, usually, without any petechiae in the face or eyes.
Choking
This term refers to blockage of the internal airways, usually between the pharynx and the
bifurcation of the trachea.
Death can occur due to pure hypoxia caused by occlusion of the airway. In such cases, congestion,
cyanosis and petechiae may be present. But in most cases, death occurs due to neurogenic
cardiac arrest in which the death occurs before any possible hypoxic manifestations.
Drowning
Drowning is a death following immersion or submersion in a fluid medium which is usually water.
It may include any fluid medium. The entire body need not go underwater. Drowning can occur
in shallow water when only the head/ face area goes underwater. This occurs in infants and those
incapacitated due to old age, disease, intoxication and those unconscious.
Manual Strangulation
Manual strangulation is a mechanical obstruction to respiration following the constriction of the
neck using the hands. A common method of homicide is most often encountered when the
physical size and strength of the assailant exceeds that of the victim. It is most commonly seen
in domestic homicides when a husband kills his wife, in sex-related murders when the victim is
again a female, and in child killings when the killer is an adult.

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 Asphyxia

Figure 7: Florid petechial haemorrhages caused by manual strangulation

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Ligature strangulation
Ligature strangulation is usually homicidal, and involves the application of pressure to the neck
by an item capable of constricting the neck such as scarves, neck-ties, or cables. Typical signs
include, a clear demarcation of congestion, cyanosis, and petechiae above the ligature, as well as
a ligature mark on the neck. This mark may reflect the pattern of the ligature, such as that of a
plaited one, and should be documented carefully with scaled photographs. Broad or soft ligatures
might leave minimal signs on the skin or underlying structures.
Ligature marks usually go around the neck horizontally, but clothing or hair might cause gaps in
the mark. There might be evidence of crossover or knots in the ligature. Unlike hanging, ligature
strangulation does not show signs of a suspension point. Post-mortem, these marks often appear
as brown parchment bands due to the drying of abraded skin. Even though accidental and suicidal
ligature strangulation can happen, it is vital to approach such cases with caution until homicide
is ruled out after a thorough investigation.
Hanging
Hanging is a form of ligature strangulation in which the force applied to the neck is derived from
the gravitational drag of the weight of the body or part of the body.
Mugging
Originally, the term "mugging" referred specifically to a form of assault where an attacker would
wrap their arm around the victim's neck from behind, applying pressure. The same arm-lock
technique has been adopted by law enforcement officers as a restraining method. Unfortunately,
in some cases, this method has resulted in fatal outcomes for the individual being restrained.
Garrotting
It is a method of execution or assassination, historically used in various cultures, that involves
strangulation with a wire, rope, cord, or other similar tools. The wire or cord is tightened around
the victim's neck, leading to death either by strangulation or severing of the spinal cord. The
garrotte has been used as a method of execution in some countries, and it was notably used in
Spain until the late 20th century hence it is also known as “Spanish windlass.”

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 Asphyxia

Traumatic asphyxia
It is caused by mechanical fixation of the chest, (therefore, also called mechanical asphyxia) and
is important, both, because of its frequency in accidents and because it provides the most
extreme demonstration of the ‘classic signs’ of asphyxia. Whereas other types of mechanical
asphyxia may obstruct air entry into the lungs, ‘traumatic asphyxia’ acts by restricting respiratory
movements, and thus, prevents inspiration. It was termed ‘traumatic’ because gross mechanical
forces are usually the reason for the fixation of the thoracic cage.
Traumatic asphyxia occurs in two main conditions:

1. The chest and usually the abdomen are compressed by an unyielding substance or object
so that chest expansion and diaphragmatic lowering are prevented.
2. Crushing in crowds or falling and being trampled in stampedes also leads to traumatic
asphyxia.
Postural asphyxia
When a person remains in a certain position for an extended time, either due to being trapped
or being in a drunken or drugged state, there may be a mechanical impediment to adequate
respiratory movements. In addition, the normal venous return to the heart may be impaired.
Burking
Burk and Hare killed 16 people to sell the bodies to a medical faculty. Burk sits on the chest of a
feeble person or one incapacitated by alcohol and closes the nose and mouth with both hands.
One hand is over the nose/ mouth and the other over the chin/ upper neck. Death occurs due to
a combination of traumatic asphyxia, smothering and may be palmer strangulation.
Sexual asphyxia
Autoerotic asphyxia refers to fatalities that occur during solitary sexual activity, where individuals
intentionally restrict oxygen to the brain to enhance sexual arousal. The basic premise is that
partial cerebral ischaemia can produce erotic hallucinations. This act is known by various names
like sexual asphyxia, asphyxiophilia, and hypoxyphilia, among others. It typically involves the use
of a device or restraint around the neck, leading to cerebral hypoxia. While predominantly
occurring in men, there are reports of females engaging in this high-risk behaviour. Key indicators
for identifying such cases include evidence of solo sexual activity, a private setting, and no signs
of suicidal intent, use of unique props such as ligatures and pornography, and a malfunctioning
safety device that results in death.

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4. Dolinak D, Matshes EW, Lew EO. Forensic Pathology Principles and Practice.1st ed. London: Elsevier
Academic Press; 2005

5. Gosink PD. Autoerotic asphyxiation in a female. Am J forensic Med Pathol.2000 jun;21(2):114-8

6. Richard H, Andrew L, Kim KY. Autoerotic asphyxiation: A case report. The primary care companion
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