brand logo

The case of a tree that fell a man

08 Nov 2021

  • Local case report notes need for public awareness on preventing accidental impaling injuries 
BY Ruwan Laknath Jayakody  Public awareness with regard to accidental impaling injuries to both adults and children should focus on the safe manner of chopping trees and the effective covering of redundant stumps, and the guarding of steel bars at construction sites, a case report about the death of an alcoholic following a fall onto an irregularly cut tree stump recommended. The case report was titled “Rare impaling injury to the neck” which was authored by P. Appuhamy, J. Perera, and R. Fernando (attached to the Colombo University’s Medical Faculty’s Forensic Medicine and Toxicology Department) and published in the Medico-Legal Journal of Sri Lanka 3 (1) in January 2015. Impalement or impaling injuries, Appuhamy et al. noted, are uncommon. They occur when a portion of the body is penetrated by a rigid object with a pointed or tapering end (becoming thinner or narrower towards one end). The objects, it is observed, frequently remain in the wound. They are usually caused in the course of falls and traffic accidents. For example, as explained in “Fatal impalement injuries after falls at construction sites” by J. Missliwetz, individuals fall or jump from a structure, onto a pointed object such as a fence, or a pointy metal rod. The US Labour Department’s Occupational Safety and Health Administration added that impalement on unguarded protruding steel reinforcing bars or rebars is a common cause of industrial accidents at construction sites. J.M. Watson and L.J. Goldstein have in “Golf club shaft impalement: Case report of a zone iii neck injury” even reported an impalement on a golf club shaft. In the context of traffic accidents, Appuhamy et al. pointed out that a vehicle might crash onto an obstacle such as a fence, which may then, in part or as a whole, be driven into the car due to the sheer force, thereby impaling the driver or a passenger.  Hence, Appuhamy et al. presented a case report on a death of an alcoholic, following a fall onto an irregularly cut tree stump, thus impaling the neck. Case report  A 65-year-old male had left home to buy an alcoholic drink, and the following day, he was found fallen on the ground, in a prone position, in an area with a lot of bushes. When the body was moved, it was found that the victim was found impaled on a stump of a tree, as there was a thickly bloodstained stump of a tree measuring 45 cm in length. It was sharp, incompletely cut and had a protruding part with a tapering end. The scene examination revealed that this protruding part was in contact with a defect in the shirt and the underlying injury over the neck. There was a large pool of blood on the ground, close to the stump. The scene was undisturbed and there was also an unopened bottle of alcohol. At the autopsy/post-mortem, it was found that there was a v-shaped defect just below the collar on the front of the shirt, on the left side. There were blood stains on it. It measured 6 cm. The upper left half of the shirt was stained with blood and was thickly stained around the defect. There was a gaping, elliptically shaped (oval), penetrative wound over the front of the left lower neck with irregular and abraded (scraped or worn away) margins.  On dissection, contusion (bruising) of the underlying soft tissue and contusion of the sterno-cleido-mastoid muscle (each of a pair of long muscles which connect the breast plate/bone, the clavicle [the bone that connects the breast plate to the shoulder], and the mastoid process [a conical prominence of the temporal bone – either of a pair of bones which form part of the side of the skull on each side and encloses the middle and inner ear – behind the ear, to which neck muscles are attached, and which has air spaces linked to the middle ear] of the temporal bone and serve to turn and nod the neck) was present. The wound was penetrative along the sterno-cleido-mastoid muscle with a through and through perforation. The underlying complete transaction (a cross-section along a long axis or division by cutting across) of the internal jugular vein (any of the several veins of the neck that drain blood from the brain, face, and neck, returning it to the heart) with luminal thrombus formation (the opening inside a tubular body structure with a fibrin structure infiltrated with blood cells, blood proteins and cellular debris) was observed.  The penetrative injury had gone through the thoracic (longest region of the spine) inlet and terminated at the upper part of the left chest cavity, causing a 400 ml haemothorax (collection of blood within the pleural [space between the two pleura –  visceral and parietal – of the lung] cavity). Small broken parts of the tree stump were found at the end of the wound. There were no injuries to the rest of the body. All organs were pale. The blood alcohol level was 116 mg per decilitre. There was no natural disease pathology which could have caused or contributed to the death. According to E.R. Thal and D.M. Meyer’s “Penetrating neck trauma”, a penetrative injury with a sharp pointed weapon such as a knife would result in an injury that has regular margins. In the present case, Appuhamy et al. added, a blunt object with a tapering end would be the cause, owing to the abraded, irregular margins of the injury and the underlying soft tissue and muscle bruising while the transection of the jugular vein would have led to severe bleeding as evidenced by the pool of blood at the site with the 400 ml haemothorax also being a contributory factor as far as the death is concerned.  As pointed out by Thal and Meyer, and J. Bostwick the Third, W.J. Schneider, M.J. Jurkiewicz, and H.H. Stone’s “Penetrating injuries of the face and neck”, penetrative neck and facial trauma represent roughly 5-10% of all trauma cases that present to emergency departments, with a mortality rate of 1-6%. However, other than knife or gunshot wounds, per J.C. Markey, J.L. Hines, and F.C. Nance’s “Penetrating neck wounds: A review of 218 cases”, other causes of penetrating head and neck injuries, in particular – impalements, are uncommon. They are however, commonly seen in falls onto iron bars erected on the ground, the latter which are frequently found at construction sites. As explained earlier, passengers who are ejected from automobiles onto wooden or metal post fences could also sustain such injuries. Furthermore, impalement injuries can occur, M.R. Hyde, C.A. Schmidt, J.G. Jacobson, E.E. Vyhmeister, and L.L. Laughlin’s “Impalement injuries to the thorax (chest) as a result of motor vehicle accidents”, when a moving object penetrates a stationary body, a situation which usually occurs in the context of motor traffic accidents, where the victim can be impaled by a multitude of objects such as the windshield wiper, the metal guard rail, the wooden rail fences, and steel rods.  That said, Appuhamy et al. maintained that impalement injuries to the neck as a result of falling onto a stump of a tree are extremely rare. For example, S.M. Wijeyaratne, C. Weerasinghe, and M.R.N. Cassim reported in “Blunt carotid (the two main arteries which carry blood to the head and neck, and their two main branches) injury from a penetrating stick: An unexpected injury”, a case of a man falling off a tree and being impaled upon a pointy stick, thus injuring the internal jugular vein. Moreover, Appuhamy et al. argued that there are no published reports of a fatality occurring due to impalement upon a tree stump. They explain that had the victim in the instant case died due to slow bleeding (the period of survival thus being longer), there is a possibility that at the time of impalement, he would have had a higher blood alcohol level than 116%, a concentration which would have sufficiently incapacitated him enough to not be capable of extricating himself from the tree stump upon being impaled upon it. Also, due to the weight of the body acting upon the neck, the stump would have sunk deeper and deeper into the injury. On a different note, Appuhamy et al. observed that, in a similar event where such an injury is sustained, if the victim walked a significant distance away from the tree stump, the latter (tree stump) would not be discovered at the scene, and therefore, a strong suspicion of foul play may arise with regard to explaining the injury. Therefore, Appuhamy et al. emphasised that when such penetrating injuries due to blunt pointed objects are detected, the scene should be thoroughly searched for any offending agent, prior to reaching any conclusion as to whether a crime has occurred.  In conclusion, they reiterated that the public should be made aware regarding the safe chopping of trees and the effective covering of such redundant tree stumps because children run the risk of facing the same accidental circumstances when they play. Also, with regard to steel bars found at construction sites, Appuhamy et al. recommended the guarding of such with special caps (also suggested by the US Labour Department’s Occupational Safety and Health Administration in dealing with construction tools) designed to afford protection and prevent hazards such as impalement.


More News..