SN6 SHORT NOTE 5M ★ High-yield

Describe the injuries sustained in a fall from a height.

Forensic Medicine · 2nd Professional — Para-Clinical

Mechanism and Determinants

The injury depends on — the height of the fall; the nature of the surface struck (concrete against soft earth or water); the part of the body striking first; the posture and whether the person was relaxed or rigid; whether the fall was broken by projections, awnings or vegetation on the way down; the age and build of the person; and whether the person jumped or was dropped
The energy is absorbed by deceleration, and the injuries are characteristically internal and out OF proportion to the external findings — which is the single most important point about falls
Falls onto water behave like falls onto a hard surface above about 20 to 25 metres, since water does not yield at that velocity

Landing position	Characteristic injuries
Landing on the feet	Fractures of the calcaneus ("lover’s fracture"); fractures of the tibia and femur; ring fracture of the base of the skull, where the cervical spine is driven upward into the skull; compression fractures of the lumbar and thoracic vertebrae; and rupture of the aorta and the thoracic and abdominal viscera from deceleration
Landing on the buttocks	Fractures of the pelvis, sacrum and coccyx; vertebral compression; and again a ring fracture
Landing on the head	Severe skull fractures, often comminuted or with a ring fracture; cervical spine fracture-dislocation; extensive brain injury; and death is usually instantaneous
Landing on the side or flat	Multiple rib fractures, rupture of the liver, spleen and kidney, and pelvic fracture
Any position — deceleration injuries	Transection of the aorta at the ligamentum arteriosum, where the mobile arch meets the fixed descending aorta; laceration of the liver and spleen at their attachments; avulsion of the renal pedicle; tearing of the mesentery and bowel; and contrecoup brain injury

CLINICAL PEARL

A fall kills from the inside, and the outside may look almost untouched. The body decelerates over a few centimetres while the organs continue moving, so the aorta tears at the ligamentum arteriosum, the liver and spleen split at their attachments and the renal pedicles avulse — all with little more than an abrasion on the skin. The rule is therefore that the external injuries never predict the internal ones in a fall, and a full internal examination is mandatory however trivial the surface findings.

Manner of the Fall

Feature	Suggests accident / suicide (jumped)	Suggests homicide (pushed)
Distance of the body from the base of the building	A person who jumps lands further out, having pushed off; a person who simply falls or is dropped lands closer to the wall	A pushed person may land further out than a simple fall but the distance is not by itself decisive — and calculations from it must be treated with caution
Defence injuries and signs of struggle	Absent	Present — injuries on the hands and forearms, grip bruises on the arms, and disturbance at the site of departure
Other injuries not explained by the fall	Absent	Present — strangulation marks, stab or firearm wounds, or head injury of a pattern inconsistent with the impact, all indicating the person was assaulted or already dead
Toxicology	Alcohol or drugs support accident; a sedative overdose may support suicide	A high level may also indicate the victim was incapacitated first, so it cuts both ways
Circumstances	A note, a psychiatric history, financial or personal crisis; or an occupational fall with an obvious mechanism	Recent quarrel, motive, a witness, and disturbance at the scene

The medical evidence alone rarely distinguishes jumped from pushed, and the doctor should say so; the value of the autopsy lies in excluding injuries not attributable to the fall and in establishing whether the person was alive when they fell
Always exclude a preceding assault — a person may be killed and then thrown from a height to simulate suicide, and the finding of strangulation marks, a stab wound or an incompatible head injury settles the case
Always exclude natural disease as the cause of the fall — a cardiac event, epilepsy, stroke or hypoglycaemia

Applied Aspects

Open all three cavities in every fall; the internal injuries are disproportionate to the external and a partial examination will miss the cause of death
Look specifically at the aorta at the ligamentum arteriosum, and at the attachments of the liver, spleen and kidneys; these deceleration injuries are characteristic and are missed if not sought
Examine the base of the skull for a ring fracture and the calcaneus and spine, which together establish that the person landed feet-first from a height
Record the height, the surface and the distance of the body from the wall, and obtain photographs of the scene; these facts cannot be reconstructed later and bear on the manner
Search for injuries the fall cannot explain — ligature marks, defence wounds, grip bruises, stab or firearm injury — which is the principal contribution the autopsy makes to the question of manner
Take blood for alcohol and drugs in every case with fluoride preservative; intoxication is a common contributor to accidental falls and is relevant to both civil and criminal proceedings

All questions in Mechanical Injuries

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