fatal free falls from very great heights

Rom J Leg Med [27] 354-360 [2019]DOI: 10.4323/rjlm.2019.354© 2019 Romanian Society of Legal Medicine

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FORENSIC PATHOLOGY

Fatal free falls from very great heights

Elke Doberentz1,*, Julian Geile1, Burkhard Madea1

_________________________________________________________________________________________ Abstract: Falls from great heights are rather rare. Most cases are suicidal or accidental falls. The severity of the injury pattern and the mortality relates to the height of the fall. Two cases of fatal falls from heights from >20 m on non-deformable and deformable surfaces are presented. A 32-year-old man fell from a Ferris wheel in a work accident. Witnesses watched him falling 28 m headlong to the ground. He hit the metallic base of the platform with his head and immediately died from polytrauma with severe traumatic decerebration. In another case, a 19-year-old man died in a 22 m fall from a bridge onto grass. He died from polytrauma with severe cerebral trauma. He was under the influence of alcohol and illicit substances, and the fall was probably accidental. Physical calculations related to falls from heights are presented and the injury patterns of these high-energy traumas and aspects of the blunt force trauma are presented and compared with the literature. Key words: Fall, head trauma, height.

1) University of Bonn, Institute of Legal Medicine, Bonn, Germany* Corresponding author: E-mail: [email protected]

INTRODUCTION

Free falls from >2 m high are called falls from height [1]. Falls from great heights are rather rare cases forensically because it is uncommon for people to be at a great height in their everyday life. The interpretation of injury patterns and the determination of the manner of fall may be difficult. In most cases, suicidal behavior or accidental falls must be considered [2-8]. Accidental falls occur because of carelessness, the influence of alcohol, illicit drugs, and pharmaceutics, or because of acute health problems. Homicidal falls from great heights are quite rare [5, 9-12]. Falls from height are associated with typical injuries of blunt force trauma, which are caused by the abrupt vertical deceleration and impact on a surface. Common injuries from the impact are skeletal fractures. The deceleration of the internal organs causes shear forces, which primarily result in internal organ injuries, including cerebral injury [9].

CASE REPORT 1

On a rainy September day, a 32-year-old man was working on a 50-m high Ferris wheel, which had to be dismantled after the end of a local carnival. He was working on the axis of the Ferris wheel at a height of 28 m. He wore a safety harness and special work shoes. Witnesses stated that his safety rope was fixed to his safety harness, but not to the Ferris wheel. In this way, the man was not protected against falling. He suddenly lost his grip and probably slipped on the wet metal. He then fell to the ground (Fig. 1). Witnesses saw the man in a head-first fall onto the base of the Ferris wheel and hit his head on the edge of the metal platform. During the fall, the witnesses perceived no vocal expressions. Whether there were active body movements is unknown. Finally, the man was found lying in a supine position. Smashed parts of his brain and fragments of the comminuted cranial roof were found in the impact area, with a splash pattern of blood and brain tissues for several meters around (Figs 1–3). Nevertheless, the witnesses immediately started cardiopulmonary resuscitation, which was continued by

Romanian Journal of Legal Medicine Vol. XXVII, No 4(2019)

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the arriving emergency doctor despite the obviously fatal head trauma. The man died immediately from severe open head trauma with decerebration. At autopsy, the man had a weight of about 71 kg and body length of 170 cm. Only sparsely developed livores at the back of the body were found. A few conjunctival petechiae were present in the eyelids. Massive craniocerebral trauma with central rupture of the scalp was present (Fig. 4). The skull was extensively fractured with comminuted fractures of the cranial roof and base. The head appeared to be split into two parts. Cleavage of the anterior cranial fossa and a rupture of the dura mater were observed. The temporal muscles were destroyed. The man had a deep facial skin rupture, especially of the nose and left upper lip region. Multiple fractures of the facial bones, especially of the forehead, were observed. The man was decerebrated with destruction of the brain in several small parts with a total weight of 600 g. The cerebellum and pons cerebri showed contusions. The laryngeal cartilage was vertically fractured.

Blood was found in the trachea and deep bronchi. Multiple fat and muscle hematomas of the thoracic and abdominal wall were found. A massive thoracic trauma with fractures of the sternum and multiple bilateral rib fractures with a left hematothorax (800 mL), an extensive hematoma of the left pleura parietalis and a rupture of the inferior lobe of the left lung was present. The autopsy revealed multiple lacerations of the liver tissue in the abdominal cavity. A bloodless spleen and anemic kidneys with a hilus rupture of the right kidney were found in the bloodless abdominal cavity. Aortic injuries were not present. The man had fractures of all four extremities, including an open wrist fracture of the right arm, an open left forearm fracture (Fig. 5), and left proximal and right distal femoral fractures. The extremities showed diffuse abrasions of the skin. No fractures of the spine were found. Chemico-toxicological analysis and the determination of blood alcohol concentration were inconclusive.

Figure 1. Base of the Ferris wheel. The corpse is covered with a grey blanket. White arrow: brain tissue.

Figure 2. End position after the fatal fall with destroyed skull. Black arrow: point of first impact with smashed brain tissue. White arrow: fragment of the cranial roof.

Figure 3. Corpse covered with a grey blanket. In front of the corpse is the point of the first impact of the head (black arrow). From here, a splash pattern of blood and smashed brain tissue extend towards upper edge and right upper corner of the image.

Figure 4. Destroyed head with a disrupted scalp, fragmental fracture of the cranial roof, ruptured dura mater and missing brain.

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Doberentz E. et al. Fatal free falls from very great heights

The cause of death was polytrauma, including severe traumatic decerebration.

CASE REPORT 2

A 19-year-old man was out with his friends on a warm June night. They drank alcohol and took drugs. It was reported that he had used methylenedioxymethamphetamine (MDMA, or ecstasy) after a long period of abstinence. After midnight, the young man walked towards his home alone in the dark in a rural area, but he unfortunately never arrived. After 2 days of intensive searching, he was found dead

lying under a 22-m high railway bridge (Fig. 6). It was assumed that the young man had used it as a short cut on his way home. The bridge was for high-speed trains and pedestrian traffic was prohibited. The bridge had a waist-high handrail. The man was lying in a right lateral prone position in the grass below the bridge (Fig. 7). At autopsy, the man had a weight of about 58 kg and body length of 174 cm. He had strongly developed

Figure 5. Open fracture of the left upper arm.

Figure 6. View from the ground up to the railway bridge.

Figure 7. Position of the body discovered under the bridge.

Figure 8. Vertical fissures of the anterior cerebral fossae.

Figure 9. Small horizontal laceration of the intima (white arch) of the thoracic aorta.


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livores at the front of the body. There was an area of skin abrasions with direction of skin tags towards the feet on the flank of the right lower abdomen. The right temporal muscles showed small hemorrhages. The left temporal muscle and the scalp presented hemorrhage. The skull showed transverses fissures of the anterior cranial fossae (Fig. 8). Subdural and subarachnoid hemorrhage over both cerebral hemispheres was present. The left hemisphere showed contusions of the cerebral cortex and hemorrhage in the subcortical tissue. The tissue of the brainstem was extremely softened, showed hemorrhages and was ruptured above the pons. The right clavicle was fractured and dislocated. On the right side of the thorax, serial fractures of all ribs, with hemorrhage and rupture of the pleura, were found. The back muscles of the right thorax showed extensive hemorrhage. Both hili of the lung presented hemorrhage in the pulmonary tissue and the right hilus was ruptured with about 100 mL blood in the thoracic cavity. The pulmonary tissue had contusions with areas of blood aspiration, with blood in the trachea and deep bronchi. The intima of the thoracic aorta showed a horizontal laceration (Fig. 9) and the abdominal aorta had a transmural vertical laceration. In the abdominal cavity, 200 mL blood was found with lacerations of the liver. Hemorrhage into the adipose capsule of the kidney was found, with 300 mL blood in the right capsule. Hemorrhages around the renal pelvis and in the left psoas muscle were present. Chemico-toxicological analysis and the determination of the blood alcohol concentration in femoral blood revealed:

THC 4.2 ng/mLTHC-OH 3.7 ng/mLTHC-COOH 13.2 ng/mLMDMA 618 ng/mLMDA 29.3 ng/mLAlcohol 0.69 ‰

The cause of death was polytrauma with severe cerebral trauma.

DISCUSSION

The major factor of the severity of the injury pattern in vertical free falls from height is the velocity of the body at the moment of landing, which in turn depends on the height of the fall [13]. The calculation of the velocity at the moment of the impact in a free fall is demonstrated here. The potential energy (Wpot), or position energy, is the energy held by a person (or an object), which is determined by the person’s (object’s) position during the fall, and it depends on the body mass, gravitational force

and height. The construction worker in case 1, with a body mass of 71 kg, and starting from a point 28 m above the ground, had a potential energy of:

Wpot = m ∙ g ∙ h Wpot Potential energy (Nm) m mass (kg) g gravitational force (9.81 m/s2) h fall height (m) Wpot= 71 kg ∙ 9.81 m/s2 ∙ 28 m Wpot = 19,502.28 kg m2/s2 (Nm).

The construction worker fell and his potential energy of 19,502.28 Nm was transformed into kinetic energy, which was transmitted to his falling body at the moment of impact. The kinetic energy itself results from the body mass and the velocity. In this way, the velocity of the impact can be calculated as:

Wkin = ½ ∙ m∙v2

Wkin kinetic energy (Nm) m mass (kg) v speed (m/s) Wkin = ½ ∙m∙v2

v = √ 2 ∙ Wkin m v = √ 2 ∙ 19502.28 kg m2/s2

71 kg v = 23.43 m/s 1 m/s = 3.6 m/h v = 84.34 km/h.

Body mass is negligible in determining the velocity of a vertically falling body from an initial resting position. The velocity depends on the constant acceleration of the gravitational attraction (gravitational force) of 9.81 m/s2, which induces a uniform acceleration. The mass and shape of an object can affect the velocity because of air drag. A vertical fall of a body with a smaller profile has been shown to result in a faster impact due to the increased velocity [14]. However, big objects generally fall faster than small objects. In calculating the velocity of the impact, the velocity–distance law, gravitational force and fall height are the main parameters:

v = √ 2 ∙ g ∙ h g gravitational force (9.81 m/s2) h fall height v speed (m/s) v = √ 2 ∙ 9.81 m/s2 ∙ 28 m v = 23.43 m/s 1 m/s = 3.6 m/h v = 84.34 km/h. In this way, the duration of the fall can also be calculated:

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t = √ 2 ∙ h g t = √ 2 ∙ 28 m 9.81 m/s2

t = 2.38 s.

In conclusion, the velocity of the construction worker who fell from a Ferris wheel was 84.34 km/h at the moment of impact. This free fall had a duration of 2.38 s. The young man in case 2 who fell from a bridge had a velocity 74.79 km/h at the moment of impact. This free fall had a duration of 2.11 s. The fall height is proportional to the severity of the suffered injuries, which are the result of the kinetic energy transmitted to the body at the time of impact [15]. The higher the fall and the greater the body mass, the more kinetic energy the body has at the moment of impact. These variables affect the severity of the impact. A fall of >3 m [8] with a velocity of 7.6 km/h at the moment of impact, or a fall of >5 m with a velocity of impact of 35.6 km/h on non-deformable surfaces can cause fatal injuries [16]. Intermediate impacts during the fall might also cause severe and even fatal injuries and can reduce the final velocity of impact as well as the kinetic energy [11, 14, 17]. The autopsies of the two men revealed polytrauma due to extensive blunt force trauma in falls from 22 and 28 m, with injuries to the head, thorax, abdomen and the skeletal system. These are typical findings in fatal falls from great heights [3-5, 7, 10, 11, 14, 16-25]. As already mentioned, the landing surface is another major factor in falls from height. Hard (non-deformable) surfaces cause a maximum of force effects and a maximum of blunt force trauma in contrast to soft (deformable) surfaces, i.e., soil or water. Thus, higher falls on deformable surfaces can be survived [6, 15]. In impacts on soft surfaces, the time of rapid deceleration is longer due to the deformation of the soft surface. In this way, part of the kinetic energy can be transferred to the deformable surface; therefore, less energy is consequently transmitted to the body. Thus, fewer fractures, which mainly result from direct forces, can occur [15]. Of the two cases presented, only the construction worker, who fell on a non-deformable surface, presented fractures of the extremities. Skull fractures were present in both cases. In case 1, the skull showed comminuted fractures with burst fractures due to a global deformation, but also bending fractures due to local deformations. Witnesses saw the man in a head-first fall and saw his head impact the ground. The brain tissue and skull fragments spread around several meters from the area of the primary body impact due to the extensive kinetic energy. Gyomarch et al. reported an exceptional decerebration in a head-first fall from stairs with a height of only 2.1 m [26]. In their case report, they presented the calculation of the velocity of the impact in a non-vertical fall.

During the impact of a head on a non-deformable surface, bouncing can typically occur, which can cause comminuted fractures as secondary fractures [8, 15, 27, 28]. Comminuted fractures are more frequent in falls from greater heights [17, 29]. In these falls, more frontal and facial fractures occur, as opposed to falls from lower heights that commonly occur with parietal, temporal and occipital fractures [30, 31]. In case 2, following a fall on a deformable surface, the young man was found in a right-side prone position. Regarding this position and especially the skeletal injury pattern, a prone impact on the right side of the body was likely. The base of the skull presented fissures in the frontal parts without fracture of the cranial roof. The deceleration of the brain and the extensive shear forces caused a rupture of the brainstem.The construction worker’s impact on the hard metal surface and sudden deceleration caused a maximum of over-flexion or overextension of the head with a vertical fracture of larynx. As mentioned by von Hofmann >100 years ago, fractures of the laryngeal cartilage can occur in cases of head trauma due to falls [31, 32]. In addition, fractures of the hyoid bone occur [5, 33]. Interestingly, the construction worker also had petechial hemorrhage in the eyelids due to the extensive blunt force injury of the head [33]. Obviously, the intravascular pressure rising at the moment of impact is sufficient to cause petechial hemorrhages before internal hemorrhage develops due to organ rupture. These findings must be distinguished from injuries due to suicide or to homicidal neck compression before a fall [5, 34]. In the two presented cases, the influence of other people could be excluded based on the circumstances. Several studies have focused on the correlation of height and injuries. In addition, the number of injured regions of the body correlates with the height [29]. In this way, researchers have reported on a correlation between falling height and head trauma [17, 29]. In other studies, a correlation was not confirmed (e.g., 35). Petaros et al. investigated 176 fatal falls from height and the most affected body regions were the thorax (73%) and head (55%) [29]. In the present case 1, after the head impact, the trunk and the extremities secondarily hit the ground with high kinetic energy and were injured from the resulting pressure and traction forces. The skeletal injuries included bilateral thoracic fractures and fractures of the arms and legs. Bilateral thoracic fractures increase significantly with height [17] and are associated with pleural lacerations and pulmonary injuries [14, 17]. Bruno et al. could not confirm a relationship between rib fractures and the height of the fall [25]. Bilateral rib fractures were not observed in the present case 2. The thorax had extensive rib fractures on the side of impact. The fall height correlates to the extent of injuries to the internal organs [14, 17, 36]. Indirect forces due to the deceleration of the organ tissues [28] cause organ


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ruptures with typical traction injuries. Türk and Tsokos reported on cardiac injuries in fatal falls from >6 m height in 33 of 68 cases [23]. Casali et al. reported on cardiac trauma in 53% of the 309 investigated cases [4]. Cardiac injuries were not present in both our cases. The liver is the most affected abdominal organ in falls from great heights [17, 25], but spleen ruptures are also typical for falls from >24 m [21, 37]. Typical deceleration injuries of the internal organs were observed in the present cases: i.e., liver lacerations in both cases, injuries of the renal hili in both cases, spleen laceration in one case, injuries of the pulmonary hili in one case, brainstem rupture in one case. In general, the reconstruction of falls can be difficult because of insufficient information from the scene or because of a lack of witnesses [38]. The orientation of the body and the landing position may relate to the cause of the fall because the body position at the moment of impact influences the injury pattern [11, 14, 15, 17, 28, 29]. In an initial impact of the feet, the legs must absorb the kinetic energy. Typical injuries due to axial compression are fractures of the lower extremities, spine fractures, and fractures of the skull base [16, 24, 29, 39], which are indicators of suicide. Accidental falls are rather undirected and craniocerebral injuries, thoracic injuries and fractures of the arms might be more frequent than in suicidal falls [24]. It must be considered that in cases of falls from great height, multiple rotations of the body due to the acceleration and active body movements are possible [40]. It might be problematic or even impossible to determine the location of the first impact because of the enormous kinetic energy and the blunt force trauma of several parts of the body. In case 1, the reconstruction of the course of the fall was possible because there were witnesses and the police investigated the scene thoroughly. The

location of first impact was the head because of the vertical fall. This correlates to the autopsy findings and findings at the scene. Head-first falls can be a sign [29] of unconsciousness. Because of the missing myotonia and absence of movement, the body enters a vertical position. The influence of alcohol, illicit drugs, medication or acute impairment of health could be excluded. The man was working alone and it seemed to be an accident due to a lack of protection against falls. The man wore a safety harness, but this was not fixed to the structure. Thus, he probably slipped because of the bad weather conditions. Fischer and Eisenmenger reported on accidental falls from up to 23 m of male construction workers with an average age of 38.8 years [16]. Most of the men died from severe head trauma. The local prosecution initiated official investigations into whether safety standards had been ignored. In case 2, the young man walked alone in the dark while under the acute influence of alcohol and illicit substances (cannabis and MDMA). Especially, the designer drug MDMA was found in a very high concentration. MDMA has euphoric and mood-brightening effects and can cause disorientation, confusion and hallucinations. The skin abrasions on the man’s right upper abdomen were probably caused by leaning on the handrail, which could have caused the fall. The injury pattern points to an undirected fall rather than the typical feet-first injury pattern of suicide. The circumstances of this case led to the conclusion of an accidental fall. In conclusion, in investigations of falls from height, autopsy findings, further analysis and the results of the police investigation must be considered to clarify the circumstances of the fall.

Conflict of interest. The authors declare that there is no conflict of interest.

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fatal free falls from very great heights

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