Forces associated with nonaccidental injury often affect multiple bones in separate regions of the body. A good example is the violent shaking of an infant, which gen- erates compression and posterior levering of the chest as well as flailing of the limbs. Figure 6.27 shows the distri- bution of healing fractures observed in a 3-month-old female. A total of 25 rib fractures and 15 long bone frac- tures were found on the decedent. All fractures were healing. Based on the healing stages observed in the ribs, a minimum of two traumatic episodes were identi- fied (Fig. 6.28). The type and distribution of the rib fractures – posterior, posterolateral, and at the chondro- osseous junction – and CMLs of nearly every long bone are consistent with constriction and posterior levering of the chest and uniform flailing of the limbs. The fracture distribution suggests violent shaking.
Figures 6.29–6.32 show rib and scapular fractures observed on a 21-month-old female. A total of 51 frac- tures were observed on the decedent. The more severe
rib fractures were located in the posterior and postero- lateral regions. At the fracture sites, the ribs were buckled or splayed apart. The fractures in the anterior and anter- olateral regions of the ribs were simple, consisting pri- marily of incomplete failure in compression. The right and left scapulae were fractured along the medial border at the level of the scapular spine. The infraspinous processes along the medial margin of the right and left scapulae were buckled, and the internal and external surfaces of the medial border of the right scapula were splayed apart. The fractures observed in the decedent were in two stages of healing: soft callus formation with minimal SPNBF and acute with sharp margins and no bony reac- tion. The types and distribution pattern of the fractures were consistent with a posterior-to-anterior-directed force applied while the anterior chest was supported by a broad surface. The uniformity of the fracture types and the healing stages suggest a similar force was applied on two separate occasions within a relatively short period.
Figure 6-27. Distribution pattern of fractures of a 3-month-old female. The blue dots mark the location of the fractures. The
Figure 6-28. Posterior rib fractures demonstrating two stages of healing. The fractures were observed in the same individual represented in Fig. 6.25. (a) Fracture in the soft callus formation stage. Note that the fracture is open, with minimal SPNBF.
Figure 6-29. Posterior and posterolateral rib fractures. (a–c) Posterior and posterolateral rib fractures of a 21-month-old female. Note the splaying apart of the bone, especially in panel (b), and the buckling, most notable in panel (c). The fracture types were observed bilaterally in all ribs except right and left rib 12. The fracture types and distribution are consistent with a posterior-to-anterior impact. The cause of death was classified as blunt trauma of the torso and head with bilateral rib and scapular fractures, visceral lacerations, and multiple contusions; the manner was classified as homicide.
Figure 6-30. Lateral rib fracture of the individual pictured in Fig. 6.29. Note the buckling of the cortical bone, resulting from a force directed parallel to the anterior/posterior plane of the bone.
Figure 6-31. Incomplete compression fractures observed in the anterior region of the rib of the individual pictured in Fig. 6.27.
Note the subtle fracture with SPNBF (right arrow) in comparison with the absence of a healing response at the fracture site, indicated by the left arrow.
Figure 6-32. Scapular fractures observed in the individual pic- tured in Fig. 6.29. (a) Note the bilateral uniformity (arrows), sug- gesting that a single impact caused both fractures. (b) Also note the splaying apart of the bone, most notable at the arrow.
Summary
Recognition of various stages of healing and fracture distribution patterns is critical to the successful recon- struction of the traumatic event(s). Providing an estima- tion of the minimum number of traumatic episodes and a timeline based on the stage(s) of healing can
contribute significantly to the investigation of the case.
Identifying the trauma vector of each fracture and then, when appropriate, associating the individual forces with a single action enable a comprehensive reconstruction of the inflicted injury.
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