Nilesh Keshav Tumram 1, Vipul Namdeorao Ambade *,1

Department of Forensic Medicine, G

Received 9 February 2013; revised

Available online 14 June 2013

Cervical vertebra fracture;

Chunnissociated with a long drop, it is not reported in ligature strangulation. In the present case, a

15 year-old female was accidentally strangled when her chunni was caught in a rear wheel of a

from the ligature mark around the neck. Fracture and dislocation of the cervical vertebra in

2013 Production and hosting by Elsevier B.V. on behalf of Forensic Medicine Authority.

1. Introduction

cle of clothing, a neck band, a cord or a chain gets entangled in

almost instantaneous in strangulation and a delayed death is

very rare.2 While it is recognized that fracture and dislocation

of a chunni (long scarf worn around the neck by Indian wo-

2. Case report

The death of a 15-year-old girl was reported to the local inves-

tigating ofcer following an apparent accidental ligature stran-gulation. As per the investigating ofcer, the deceased wasriding along with her father on a Rajdoot, a two-wheeler mo-

torcycle. The girl was a pillion rider, dressed in the conven-tional Indian dress with a chunni worn around her neck. Theloose end of the chunni got entangled in the rear wheel and be-

* Corresponding author. Tel.: +91 9422159573.

E-mail address: vipulambade@rediffmail.com (V.N. Ambade).1 Tel.: +91 712 2743588; fax: +91 712 2740832.

Peer review under responsibility of Forensic Medicine Authority.

Production and hosting by Elsevier

Egyptian Journal of Forensic Sciences (2013) 3, 9698

Contents lists available a

Egyptian Journal of

journal homepaga moving machine and is tightly drawn around the neck all of a

sudden, as occasionally seen in a mill workers.1 The death is

men) in the rear wheel of a moving motorcycle is presented.Strangulations at their face value are homicidal in nature.Accidental ligature strangulation is rare and usually occursat the extremes of life or in otherwise healthy adults, usually

under the inuence of alcohol or drugs. It occurs when an arti-

of the cervical vertebra are seen in judicial hangings or hang-ings associated with long drop3, it is not reported in ligaturestrangulation. A case of fracture and dislocation of the cervical

vertebra in accidental ligature strangulation due to entrapmentaccidental ligature strangulation by chunni are very rare and has not been reported previously.motorcycle while sitting on the pillion. She was immediately taken to the nearest hospital in an

unconscious condition. She died after a period of 4 days. The autopsy revealed a fracture the

dislocation of the 5th cervical vertebra with extensive bruising of the deep muscles of the neck apart20

htKEYWORDS

Ligature strangulation;

Accidental;90-536X 2013 Productiontp://dx.doi.org/10.1016/j.ejfs.o

aand host

2013.05.0overnment Medical College, Nagpur 440 003, Maharashtra State, India

10 April 2013; accepted 6 May 2013

Abstract Accidental ligature strangulation though rare, is occasionally reported and circumstan-

tial evidence alone can sufciently indicate the accidental nature of the occurrence. While it is rec-

gnized that fracture and dislocation of the cervical vertebra are seen in judicial hanging or hangingCASE REPORT

Fractured cervical vertebra inchunniing by Elsevier B.V. on behalf of F

01accidental strangulation by

t SciVerse ScienceDirect

Forensic Sciences

e: www.ejfs.orgorensic Medicine Authority.

came twisted around her neck. As the vehicle was still in mo-tion, the rotating wheel caused the chunni to tighten aroundher neck and resulted in her falling off and being knocked

unconscious. She was immediately rushed to the governmenthospital in an unconscious condition with a history of acciden-tal strangulation. Radiograph of the neck showed the fracture

and dislocation of the 5th cervical vertebra (Fig. 1). She wasclinically diagnosed as accidental strangulation with fractureand dislocation of C5 with quadriplegia and bowelbladder

involvement. The patient died after a period of 4 days ofadmission. Her body was sent to the mortuary for autopsyafter preliminary police investigations. Before sending thebody for autopsy, the police prepared the inquest and made

other investigations including the statements of eye witnessesregarding the reasons and manner of death.

2.1. Autopsy ndings

On external examination, the skin was pale and dried and therewas no petechia or ecchymosis. Postmortem lividity was pres-

ent on the back of the body except over pressure points. Herface was cyanosed with blood-tinged mucus oozing from nos-trils and blood from the mouth. An intravenous injection mark

was present over both cubital fossae. Ligature mark was pres-

chea and fractured cervical vertebra (Fig. 3). There was an

associated injury to the spinal cord corresponding to the frac-tured cervical vertebra with evidence of massive oedema, soft-ening and surrounding hematoma. Hyoid bone and thyroidcartilage were intact. Mucosa of the respiratory tract was con-

gested and showed a showers of petechiae in the larynx andepiglottis. Visceral organs were congested. Lungs were con-gested and oedematous with subpleural petechiae. The brain

was congested and oedematous. The victim died due to injuryto the spinal cord as a result of a fractured cervical vertebra inligature strangulation.

3. Discussion

This is an unusual case of accidental ligature strangulation

with fracture and dislocation of the cervical vertebra. Whilstit is recognized that consciousness is lost within 1015 secondsand death is immediate,2 the delayed death in ligature strangu-

lation is very rare. Accidental strangulation though rare, isoccasionally reported and the circumstantial evidence alonecan sufciently indicate the accidental nature of the occur-rence.2 The rst reported case of accidental strangulation

was that of the world famous dancer Isadora Duncan who diedon 14 September 1929. The long scarf, which she was wearing,was caught in the wire wheels of her Buggati car, stopping the

vehicle. Isadora died on the spot and was later found to havesustained a fractured larynx and carotid artery injury.4 Bhullaret al.,5 Aggarwal et al.,6 Kohli et al.,7 Agrawal et al.8 and Gup-

Figure 3 Showing fracture dislocation of 5th cervical vertebra

with surrounding extravasation.

Fractured cervical vertebra in accidental strangulation by chunni 97ent around the neck as abrasion with a brownish scab of size35 2 cm with evidence of slippage of ligature on the right lat-eral aspect and back of the neck (Fig. 2). The mark was trans-

versely placed and completely encircled around the neck at thelevel 1 cm below thyroid cartilage. It was situated 7 cm belowmastoid tip on both sides, 9 cm below tip of chin and 15 cm be-

low occipital protuberance. Crescentric scratch abrasions werepresent on the anterior aspect of the neck. Multiple abrasionswere present over upper half of the chest, the right leg and both

feet. Internally, hematoma of size 6 3 cm was present in theright sternocleidomastoid muscle of the neck correspondingto the ligature mark. There was a fracture and dislocation of

the 5th cervical vertebra with extensive bruising of the deepmuscles of the neck and extravasation around the larynx, tra-

Figure 1 Radiograph showing fracture of 5th cervical vertebra.Figure 2 Showing transverse ligature mark of strangulation over

neck with evidence of slippage of ligature.

ta et al.9 also reported a few cases of accidental ligature stran-gulation due to entanglement of the chunni while moving in avehicle like a rickshaw, motorcycle and bicycle. Thus, all re-

ported cases of accidental strangulation involved a vehicleand chunni/scarf; all occurred on the road and the victims diedimmediately due to asphyxiation but without cervical spine in-

jury except Gupta et al.9 in which there was only a dislocationbetween the 2nd and 3rd cervical vertebrae. In the present caseof accidental ligature strangulation, the victim was hospital-

ized in an unconscious condition and survived for 4 days,and had a fracture and dislocation of the cervical vertebra

brain compressed the vital centres causing respiratory paralysis

Funding

None.

Conict of interest

None declared.

Ethical approval

ethics committee.

98 N.K. Tumram, V.N. Ambadeas a terminal event. A few more cases of accidental ligaturestrangulation have been reported, in which the article of cloth-

ing was caught in the moving machine, such as a shawl in thecrop thrasher in the agriculture eld,3 a chunni in a movingelectrical grinder at home10 and a head scarf in an ironing ma-

chine in the hospital laundry room.11 But none of these caseshad a cervical spine injury. There was only a fracture of thehyoid bone and cricoid cartilage in accidental ligature strangu-

lation by the ironing machine.Usually in strangulation, there is a fracture of the superior

horn of the thyroid cartilage and hyoid bone. There may alsobe a fracture of the cricoid cartilage and tracheal rings if more

force is applied.3 Fracture and dislocation of the cervicalvertebra is seen in judicial hangings or in hangings associatedwith a long drop3; but it is not reported in ligature strangula-

tion. Jain et al.12 reported 12 cases of cervical spine injury outof the total 25 cases of accidental strangulation due to entan-glement of dupatta/scarf in a moving part of machinery. In 10

out of 12 cases, there was subluxation of the cervical spine, andin two cases there was a dislocation of the cervical vertebrawith complete ligamentous disruption. Most of these injuries

involved the lower cervical spine unlike Hangmans fracture.This is due to the fact that the dupatta is worn on the lowerpart of the neck. However, fracture of the cervical vertebrawas not noticed in any of these cases. In the present case of

accidental ligature strangulation, there was a fracture disloca-tion of the lower cervical vertebra. This is due to a sudden jerkon the neck leading to hyper-extension injury to the neck as the

head is being snapped back due to the entangled chunni andthe motorcycle continues to move forward. This is followedby a rotational movement of the neck due to the fall of the

victim from the moving vehicle. Fracture of the cervical verte-bra in a case of accidental ligature strangulation is extremelyuncommon and not reported previously.References

1. Subrahmanyam BV, editor. Modis medical jurisprudence and

toxicology. 22nd ed. New Delhi: Butterworths; 1999, p. 26172.

2. Ambade VN, Godbole HV, Dixit PG, Kukde HG. Accidental

ligature strangulation due to crop thrasher. J Forensic Leg Med

2008;15:2635.

3. Pillay VV, editor. Textbook of forensic medicine and toxicology.

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Survival from accidental strangulation from a scarf resulting in

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females. Injury Int J Care Injured 2008;39:3348.associated with spinal cord injury. It manifested clinically asquadriplegia. Also, the progressive oedema of the cord and

Necessary ethical approval was obtained from the institute

Fractured cervical vertebra in accidental strangulation by chunni1 Introduction2 Case report2.1 Autopsy findings

3 DiscussionFundingConflict of interestEthical approvalReferences