Hey all! Due to the multiple emails I have been receiving, I see you have noticed my Instagram account was deleted! I guess some of my photos were too controversial for some Instagram viewers! I have now changed my username to MrsAngemi, and I’ll still be posting great educational photos! For the photos and themes that are most controversial (ex #forensicfriday) I will have to divert your attention to my blog to view those items. Thank you for your continued support and following my blog and new Instagram account!
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This will be my second year participating in the Philadelphia Science Festival. This year I am doing 2 events, Murder at the Mutter this Friday night, April 26th (http://www.philasciencefestival.org/event/58-murder-at-the-mutter-outbreak) and Discovery Day: Be the Detective this Saturday afternoon, April 27th (http://www.philasciencefestival.org/event/22-discovery-day-be-the-detective). I’m the autopsy expert Come support science and check it out!!!
Lillian Sara Jane Angemi here with her big sister Maria.
Little Italian/Polish baby born on St. Patrick’s day!
Traumatic amputations are one of the more disturbing specimens we receive to the pathology lab. Seeing things that are so recognizably human can be crazy for the mind. Some of these specimens seem rather complicated and trip out many pathology residents and PA students, but they are actually quite simple to handle if you know the proper terminology.
Some gross terms used to describe wounds are just fancy variations of words we learned as children- for example a “scrape” is called an abrasion. These fancy terms are used very frequently during the forensic autopsy to describe trauma associated with accidental, suicide and homicide deaths. We use these same terms in the surgical pathology laboratory when we receive traumatic amputation specimens. Usually these specimens are from accidents, but they can also be from attempted suicides or homicides. Regardless of the traumatic event, most of the specimens are considered medico-legal cases because of either law suits or prosecution.
Abrasion. Abrasion is a fancy word for a “scrape”. This occurs when the skin contacts an opposing surface and the movement of either the skin or the surface results in friction that pulls away the superficial layers of skin. These are commonly seen in amputations involving pedestrians because of the scraping of skin against the road.
Contusion. A contusion is a fancy word for a bruise and occurs when capillaries and large blood vessels tear, resulting in the escape of blood into the extravascular space.
There are 4 terms to describe the gross appearance of contusions. Petechiae, purpura, ecchymoses and hematoma.
Petechiae are small punctate hemorrhages (approximately less than 3mm in diameter). Petechiae are not common in traumatic amputations because of the mechanism in which they occur. They are not caused by blunt trauma. They can be seen in cases of strangulation or other cases of asphyxial death, sepsis and other disease processes. Purpura are hemorrhages that are a little lager than petechiae (3-10mm). These type of hemorrhages are also not present in blunt trauma specimens. They can also occur in cases of sepsis along with other disease processes. If either of these are seen in a trauma specimen, it can be mostly be attributed to the patients underlying health rather than the trauma itself. The photos below show petechiae and purpura.
Ecchymoses. An ecchymosis is larger than a purpura (>1 cm). These are small contusions and in elderly patients (senile ecchymoses) can be caused by minimal trauma or can occur spontaneously. Although these ecchymoses can get quite large they are not to be confused with a hematoma. These collections of blood generally appear to be confined to right below the skin.
Hematoma. A hematoma is what we classically think of as a bruise and occurs when a blunt object tears the vessels causing a blood accumulation in the soft tissue underlying the site of impaction. These are the most likely contusions to be seen on a traumatic amputation specimen. If a true hematoma is incised as seen in the second photo a blood accumulation will be seen in the underlying soft tissue. This is how you can confirm an area of blunt impact compared to the above contusions or livor mortis (post mortem blood pooling).
Incision. An incision is a clean cut on the skin that is made with a sharp object, such as a knife or blade. This hand was traumatically amputated by an electric saw, one clean slice. In the second photo, look closely at the edges of these wounds, the borders are very smooth and clean. This is something you would see if a person is working in an industry with equipment with sharp blades or as defense wounds by a victim getting stabbed with a knife.
Laceration. A laceration differs from an incision. A laceration is not caused by a sharp object, but is caused by the skin and tissue either being twisted, stretched or ripped to the point of it splitting. This first patient had extensive laceration after getting hit by a motor vehicle off of a bicycle. The next 2 photos show a closer exam of lacerations. The borders are irregular, compared to the above incisions. Tissue bridging is a key feature of a laceration. Tissue bridging are the areas seen where there is not a complete tear and strands of of skin are still attached to the edges of the wounds. Lacerations can also be seen in blunt force trauma cases, for example hitting the skin with a baseball bat to the point of it tearing or multiple fractures breaking through the skin in the case of a motor vehicle accident.
Degloving. Degloving is a nasty injury in which the skin (which is referred to as the glove) is literally ripped off the bone leaving the skin completely detached from the underlying bone. Like taking a glove off of your hand. The quality of this first photo is not that good but shows a degloving injury in which the patient had their hand stuck in an elevator shaft. The remnants left are phalangeal finger bones with attached muscle and tendons that extend the length of the forearm. These injuries are usually caused by getting an extremity stuck and pulled off of the body. The second photo shows a partial degloving of the arm. The entire arm skin is removed like a sleeve. This patient was ran over by a train.
One of the most common degloving injuries is caused by patients wearing rings.
Bone trauma. Most of these wounds will coincide with underlying bone fractures. There are many types of fractures, but the main categories are displaced, non-displaced, open, and closed.
In a displaced fracture, the bone snaps into two or more parts and moves so that the two ends are not lined up straight. In a non-displaced fracture, the bone cracks either part or all of the way through, but does move and maintains its proper alignment.
A closed fracture is when the bone breaks but there is no puncture or open wound in the skin. An open fracture is one in which the bone breaks through the skin.
Here is a simple drawing of multiple types of fractures. Multiple types of fractures can be seen depending on the mechanism in which the amputation occurred.
Here is an example of an open fracture. It is common for multiple types of fractures to be seen in one specimen.
Multiple wounds. Some traumatic amputations can have a mixture of wounds going on. This first patient stuck their hand in an industrial size lawn mower to fix a jammed blade. The blades caused multiple incisions while pulling in the hand causing partial degloving, lacerations from tugging and tearing and bone fractures. Also note the blades of grass present. These fingers to the right are from a snow blower accident. Again lacerations, incisions and fractures.
Failed reattachment. I like this lady, even in the worst of times she still maintained her manicures. Sometimes an extremity lost can be reattached. These surgeries are tedious and intense but usually have a high success rate. Reasons for the attachment failing can vary, but most specimens received all have the same appearance- necrotic or dead.
Sometimes it is acceptable for these specimens to be for gross examination only (no microscopic slides). Other times the pathologist would like to see the margins of the specimen under the microscope to prove the tissue still attached to the patient is viable. The margins become more important in cases where an amputation has an attempted reattachment that fails. The most crucial part of the examination of these specimens is documentation of the anatomy present, what wounds and bone fractures can be identified and photographs with multiple views.
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