Cuts to the offender’s own hand—unintentional self-infliction in the course of knife attacks

In a knife attack the perpetrator can unintentionally injure his own hand, if the knife does not have an adequate handguard and the tip of the blade hits a solid, mostly bony structure while being violently thrust into the victims body. The injuries occurring under these conditions are localized on the flexor side of the knife-holding hand and may include the index, middle, ring and little fingers. They are seen particularly often on the little finger at the level of the proximal phalanx and in the skin fold of the proximal interphalangeal joint. The majority of these cuts run transversely to the longitudinal axis of the fingers and can show a step-like arrangement with different distances to the metacarpophalangeal joints, often from ulnar-proximal to radial-distal. In the six cases presented the injuries were most pronounced on the ulnar side of the hand. When the flexor tendons of the fingers are also severed and the tendon stumps are strongly retracted this indicates that the fist was firmly closed at the time of the injury.Dedicated to Prof. Dr. Dr. h. c. B. Brinkmann on the occasion of his 65th birthday.     

指端损伤合并甲床部分缺失的早期处理

目的探讨应用矩形逆推进皮瓣修复手指开放性损伤的方法及疗效。方法全组16例,均用指端背侧逆行矩形推进皮瓣,使甲近端皱襞向近心端推移,在甲近端皱襞下保留0.1~0.2 cm的甲根而将其大部分裸露重建甲床,修复合并指甲部分的手指端损伤。结果经1~4年随访,16例均获得良好的外形及对捏、持物功能。结论皮瓣设计合理,功能恢复良好,外形美观,是手指开放性损伤修复的理想方法。     

A rare case of steering wheel injury causing coronal-plane pancreatic lacerations

The incidence of pancreatic injury after blunt abdominal trauma is extremely low. A timely and accurate diagnosis is important, as a delay could be life-threatening. In this case, a 70-year-old driver crashed a car into a concrete wall at low speed. He was transported to the emergency hospital but died about 9.5 h later with the cause of death unknown. An autopsy revealed that his pancreas was lacerated in the coronal plane and there was mesenteric contusion. Cause of death was determined to be blood loss resulting from pancreatic and mesenteric contusion. The mechanism of the injury was considered to be a very rare “degloving,” caused by the impact from the steering wheel. It is therefore important to keep in mind possible pancreatic damage when examining blunt trauma to the abdomen, especially in traffic accident cases.     

节段毁损性断指（拇）短缩再植的疗效观察

目的：评价手（拇）指节段毁损性断指（拇）再植术后的功能效果。方法我院于2004年3月～2013年3月收治18例22指,男性14例,女性4例;年龄6～56岁,平均33.2岁。其中拇指5指,示指8指,中、环指各4指,小指1指。清创时尽量保留靠近关节侧的组织,对近中节毁损后残留近节基底病例,清创后需保留近节基底至少0.5cm骨质,以保证掌指关节的完整性。拇指清创后其再植后长度需＞2cm,有血管缺损者行自体血管移植,神经缺损者可行二期神经移植,神经自指总神经部撕脱者行神经端侧吻合。结果除1例示、中指离断伤指节毁损严重,行中指异位示指再植,其余均行短缩再植。成活率为90.48％。再植手指较健指平均短2.1cm （1.2～3.5cm）,术后随访18～51个月,优良率为68.42％。结论对掌指关节完整、有一个节段以上的指体相对完整,并可能恢复神经感觉的毁损性断指（拇）,均有再植指征。     

Integrating engineering principles into the medico-legal investigation of a rare fatal rollover car accident involving complex dynamics

Rollover car accidents can be the result of forceful steering or hitting an obstacle that acts like a ramp. Mortality from this type of car accident is particularly high, especially when occupants are thrown out of the vehicle. We report a case of a 67-year‐old man who died after a rollover accident that occurred when he was driving a car equipped with a glass moonroof. He was found inside his car with his safety belt correctly fastened and the roof shattered. At autopsy, a wide avulsion injury of the head was observed, which was associated with an atlanto-axial dislocation and full‐thickness fracture of the cervical body and posterior facet joints of the seventh cervical vertebra. The data collected at the scene of the accident were integrated with the autopsy results to yield a forensic engineering reconstruction. This reconstruction elucidated the dynamics of the event and correctly ascribed the lesions observed at autopsy to the phases of the rollover. Afterward, an analysis of the scientific literature concerning rollover crash tests was conducted to understand why the driver sustained fatal injuries even though his seatbelt was properly fastened.     

Radiogrammetry of the soft tissue at the index finger in acromegaly.

Measurements of the soft-tissue width and phalanx width at the index finger were made in 30 acromegalic patients and compared with values obtained in a large control population. The width of the phalanx, total finger width and soft-tissue thickness are significantly larger than expected and the soft-tissue index values are significantly lower than expected. An important overlap between normal and acromegalic values is found for the soft-tissue index and width of the proximal phalanx. The measurement which best discriminates acromegalics from normal is the total finger width. The soft-tissue thickness parameter is also very sensitive for the detection of acromegalic changes and has the advantage of not being sex and age dependent.     

Finger injuries in extreme rock climbers. Assessment of high-resolution ultrasonography

Dynamic high-resolution ultrasonography findings obtained in 34 extreme rock climbers with finger injuries were compared with those in 20 healthy volunteers. Thicknesses of the flexor tendon and A-2 flexor tendon pulley system were measured at the base of the proximal phalanx. The distance between the tendon and phalanx was evaluated with the finger in extension and in forced flexion as a measure of bowstringing. Gliding ability of the flexor tendons was assessed during active and passive motion. Compared with healthy volunteers, climbers showed a significantly increased thickness of the flexor tendons and the flexor tendon pulley system but no impairment of the gliding mechanism. Only in climbers did the distance between tendon and phalanx increase from 0.14 cm (+/-0.07) during extension to 0.30 cm (+/-0.09) during forced flexion. In three climbers with complete A-2 pulley ruptures this distance was up to 0.51 cm (+/-0.15) during forced flexion. Clinically unsuspected synovial cysts, thickened joint capsules, fibrous tissue, or fluid collection were found only in climbers. We concluded that dynamic ultrasonography is a valuable tool for accurate assessment of early changes in "climber's finger." It provides useful information, especially in cases where clinical evaluation is difficult, and should be performed to select appropriate therapeutic management.     

MEBO治疗手指末节损伤的临床体会

目的：探索保留清创及创面应用湿润烧伤膏治疗手指末节损伤的临床经验。方法：本组38例病人全部应用早期轻柔清创、保留手指皮肤、骨和手指长度、局部应用湿润烧伤膏换药治疗。结果：本组病例应用此方法治疗，局部无感染，痊愈后患指缩短不明显，无明显功能障碍。结论：手指末节保留清创及创面应用湿润烧伤膏外涂的方法可促进患指的愈合及局部再生。     

手指深度烧伤岛状皮瓣修复治疗体会

目的:总结手部岛状皮瓣修复手指深度烧伤的疗效.方法:分析39例71指深度烧伤应用手部岛状皮瓣修复的优、缺点.结果:皮瓣全部成活,应用手部岛状皮瓣能最大限度保留手指长度,掌背皮神经营养血管逆行岛状皮瓣,示指近节背侧岛状皮瓣移位后既有感觉存在,手指质地良好,外观及功能满意.结论:岛状皮瓣血供丰富,安全可靠,是治疗手指远端损伤简便而有效的手术方法.     

Phalangeal microgeodic syndrome: MR appearance

The authors describe the MR features of a case of microgeodic phalangeal syndrome in a 9-year-old boy. Roentgenograms showed multiple small areas of osteolysis in the middle phalanx of the right index finger. T1-weighted MR images showed lesions with diffuse low signal intensity not only in this phalanx but also in other phalanges. These lesions exhibited high signal intensity on T2-weighted images. Contrast- enhanced T1-weighted images showed a wide non-enhancing area in the middle phalanx of the index finger. Received: 26 September 2000 Revision requested: 2 November 2000 Revision received: 25 November 2000 Accepted: 27 November 2000     

Computed tomographic diagnosis of a “midline package” of abdominal trauma: Two illustrative cases

A “midline package” of abdominal injuries may occur when the anterior mid-abdomen suffers direct blunt trauma. This package may include lacerations of the left lobe of the liver, pancreatic lacerations or fractures, and bowel injuries; if high in location, it may also be associated with sternal fractures and cardiac injuries. A common cause is motor vehicle accidents in which the driver suffers anterior abdominal compression from striking the steering wheel or steering column. Two cases are illustrated that were correctly diagnosed by abdominal computed tomography. The authors recommend an awareness of abdominal injury mechanisms and a knowledge of the expected combinations of abdominal injuries that may result.     

胰腺损伤28例救治体会

目的探讨胰腺损伤的诊断和救治策略。方法回顾性分析我科2000年1月～2009年6月收治胰腺损伤28例的临床资料。胰腺脏器损伤分级(OIS):Ⅰ级13例,Ⅱ级10例,Ⅲ级3例,Ⅳ级1例,Ⅴ级1例。全组均有合并伤,休克15例(53.6%)。均手术治疗,单纯引流14例,清创修补+引流9例,胰尾切除1例,胰体尾切除2例,胰头颈关闭+远端胰空肠Roux-en-Y吻合术1例。并发症8例(28.6%),胰瘘及胰腺脓肿各2例,上消化道出血及胰腺假性囊肿各1例,创伤性胰腺炎2例。结果治愈25例(89.3%),死亡3例,死因为失血性休克、腹膜感染和多器官功能障碍综合征(MODS)。结论选择合理术式能提高救治成功率;对Ⅲ级胰腺伤采用远端胰切除,以及充分可靠引流是减少术后并发症的关键。     

Hand fractures: a study of their site and type in childhood

AIM: The purpose of the study was to document the site and type of fractures of the hand in children up to 16 years of age. MATERIALS AND METHODS: The radiographs of 280 children who were found to have a fracture in Accident and Emergency over a one-year period were reviewed. A total of 293 fractures of the hand and 3 distal interphalangeal joint dislocations without fracture were identified. There were 293 fractures as some children had more than one fracture. RESULTS: Distal tuft fractures were commonest in the 0 to 4-year age-group; fractures of distal phalanx (both transverse and tuft) in the 5 to 8-year age-group; transverse fractures of the proximal phalanx of little finger in the 9 to 12-year age-group and transverse fractures of neck of the fifth metacarpal in the 13 to 16-year age-groups. CONCLUSION: Hand fractures are more common in older children, with a male preponderance in most groups except in the 0-4 age-group. The site of injury is different in the various corresponding age-groups, reflecting the differing mechanisms of injury. The management of hand fractures rely on a correct diagnosis and a knowledge of their common site in each age-group should aid diagnosis.     

Metachronous haemorrhagic epithelioid and spindle cell haemangioma of bone

We present the case of a 7-year-old boy with a haemorrhagic and spindle cell haemangiomas of the ring finger. The lesions appeared in a metachronous fashion initially in the distal phalanx and 16 months later in the proximal phalanx. Radiography revealed expansile lytic lesions of the phalanges. Haemorrhagic epithelioid and spindle cell haemangioma is a benign condition which, due to its unusual morphology, can be confused with more aggressive or malignant endothelial neoplasms. This condition with its possible multifocal presentation should be considered when diagnosing vascular lesions of bone in order that appropriate treatment can be implemented.     

Frostbite of the upper and lower limbs in an expert mountain climber: the value of bone scan in the prediction of amputation level

A 38 year old man was admitted to our hospital 10 days after suffering a frostbite injury in hands and feet while practicing mountain climbing, at 8,100 meters of altitude, while he was trying to reach the top of the K2 mountain. A 99mTc-MDP bone scan performed in aseptic conditions showed: in hands: absence of bone uptake in the 3rd phalanx and distal portion of 2nd phalanx of the 5th finger of the left hand, and multiple areas of increased uptake in the distal portion of both hands. In feet: uptake decreases in the 2nd phalanx of the first toe of the left foot, and absence of bone uptake in the 3rd phalanx of the 2nd toe of the left foot, and in 2nd phalanx of the 1st toe and 3rd phalanx of the 2nd, 3rd and 4th toes of the right foot. As in the hands, there were multiple areas of increased uptake in the distal portion of both feet. The phalanges with absence of bone uptake had to be amputated, while those that presented increased uptake recovered with conservative treatment. Bone scan is indicated in the evaluation of frostbite injuries and helps to establish the prognosis early.     

应用湿性医疗技术治疗手指末节损伤26例总结

目的:探索应用湿性医疗技术治疗手指末节损伤的临床经验.方法:本组26例患者全部进行早期轻柔清创,保留患指皮肤、骨和手指长度,局部应用湿润烧伤膏换药治疗.结果:局部无感染,痊愈后患指缩短不明显,无明显功能障碍.结论:患指末节保留,清创后创面应用湿润烧伤膏外涂治疗可促进患指的愈合及局部再生.     

Soft-tissue measurements at the index finger: age and sex characteristics.

Measurements of the soft-tissue width and phalanx width of the index finger were made in 402 normal individuals (270 women and 132 men, age range 20--89 years) in order to establish age-sex characteristics. Men have a significantly larger total finger and phalanx width than women in all age groups. In both sexes a statistically significant increase with age in phalanx width and total finger width is found. The soft-tissue index and soft-tissue thickness is not influenced by age.     

Limited diagnostic agreement of quantitative sonography of the radius and phalanges with dual-energy x-ray absorptiometry of the spine, femur, and radius for diagnosis of osteoporosis

OBJECTIVE: The aim of our study was to evaluate the diagnostic agreement of quantitative sonography of the radius and proximal phalanx and dual-energy X-ray absorptiometry (DXA) of the radius, lumbar spine, and femoral neck for the detection of osteoporosis. MATERIALS AND METHODS: In 95 women (mean age, 53 +/- 13 years) and 26 men (mean age, 53 +/- 13 years), DXA measurements of the lumbar spine (posterior-anterior, L1-L4) and the femoral neck, as well as quantitative sonography of the radius and proximal phalanx of the third finger were obtained. The percentage of patients below a given threshold was calculated for each imaging technique. A T score of less than -2.5 indicated presence of osteoporosis. Diagnostic agreement in identifying individuals with osteoporosis was assessed using kappa scores. RESULTS: Between 14% and 22% of the patients were classified as osteoporotic after DXA of the various regions of interest of the radius, 31% after DXA of the spine, 43% after DXA of the femoral neck, 32% after quantitative sonography of the distal radius, and 34% after quantitative sonography of the phalanx of the third finger. Correlation coefficients between T values for quantitative sonography and those for DXA varied between not significant and 0.54 at the different regions. Kappa analysis showed the diagnostic agreement among quantitative sonography and DXA to be fair to moderate (kappa = 0.38-0.48). The highest agreement was between quantitative sonography of the proximal phalanx of the third finger and DXA of the total radius (kappa 0.48; p < 0.05). CONCLUSION: Considerable diagnostic disagreement exists between quantitative sonography and DXA of the forearm, as is true for most quantitative techniques in the assessment of skeletal status. The lack of correlation makes quantitative sonography impractical for routine diagnostic use but might characterize different parameters related to bone quality.     

Fatal cardiovascular injuries to the unbelted occupant associated with airbag deployment: two case-reports

We present two forensic autopsy cases of unbelted occupants associated with the airbag deployment in motor vehicle collisions. Both victims suffered from cardiovascular injuries which were the cause of death. Case 1: A 50-year-old man sustained a contusion on the left anterior chest with rib fractures and laceration of the intrapericardial inferior vena cava, the right ventricle, and the right pleuropericardium. Case 2: A 40-year-old man sustained multiple rib fractures, sternal fracture, and the rupture of the right ventricle. Autopsies and vehicle examinations revealed that both victims' chest seemed to strike the steering wheel through the deployed airbag. Therefore, we determined that the source of blunt impact force is the steering wheel through the airbag rather than airbag deployment only. In light of these two cases, we learned that the steering wheel should be considered as the blunt impact force inducing cardiovascular injuries even in cases in which the airbag has been deployed.     

Reproducibility of phalanx osteosonography and relation with forearm peripheral quantitative computed tomography: single finger versus average measurement on the last four fingers

The aim of this study was to evaluate the in vivo short-term reproducibility of amplitude-dependent speed of sound (AD-SOS) measured at the proximal phalanx, using an Igea DBM Sonic 1200 device, as well as its relationship with bone mineral density of the ultradistal radius, assessed using peripheral quantitative computed tomography (pQCT). In particular, the authors wished to evaluate whether average measurements on the last four fingers, as recommended by the manufacturer, yielded or not more information than measurements on one single finger. For the precision study, the authors carried out phalanx osteosonography ten times once every other day in ten healthy young women. To compare with pQCT of the radius, 37 women referred for screening of osteoporosis (mean age 60 years) were studied. AD-SOS was reported for each finger separately, as well as an average; pQCT (XCT 960 Stratec) yielded trabecular (BMD_t); cortical (BMD_c); and total (BMD_tot) bone mineral densities, as well as the cortical area (A_c). The reproducibility of AD-SOS was significantly higher for the middle finger (mean coefficient of variation (CV) 1.1%) and the index than for the ring and small (mean CV 2.7%) finger. The middle finger consistently showed the best correlations with pQCT variables; the relationships involving BMD_c (r=0.54), BMD_tot (r=0.62) and A_c (r=0.61) were stronger than that with BMD_t (r=0.34). The authors conclude that phalanx AD-SOS is moderately correlated with BMD of the ultradistal radius—at least when it includes the cortical component—and that reporting AD-SOS for the middle finger—instead of an average value—improves the reproducibility and possibly the relevance of phalanx osteosonography.