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American Journal of Forensic Medicine & Pathology:
doi: 10.1097/PAF.0b013e318219c832
Case Reports

Three Different Mechanisms of Death: An Unusual Form of a Child Murder by Asphyxia

Miziara, Ivan Dieb MD, PhD; Bertaccini, Flavio MD

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From the Hospital das Clínicas-São Paulo University School of Medicine; and Legal Medicine Institute, São Paulo, Brazil.

Manuscript received April 28, 2008; accepted November 13, 2008.

Reprints: Ivan Dieb Miziara, MD, PhD, Hospital das Clínicas-São Paulo University School of Medicine, Teodoro Sampaio, 352-22, São Paulo, Brazil 05406000l. E-mail:

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We report a very unusual case of murder of a 4-year-old male white child who died of asphyxiation. Asphyxia occurred due to 3 factors: manual strangulation, hyperextension of the neck, and atlantoaxial subluxation. The offenses were carried out by a single assailant (the stepfather of the child) who strangled the child with his right hand, using his left hand to pull the hair of the child, forcing the head back and causing hyperextension of the neck, thereby dislocating the first and second cervical vertebrae.

Manual strangulation is a method of homicide that is primarily used when there is a great difference in physical size and strength between the assailant and the victim,1 such as between an adult man and a child. Death by asphyxiation is a common finding in forensic practice and requires elucidation concerning the manner in which the death occurred. In some cases, the victim dies as a result of a combination of different mechanisms of asphyxia.2 There have been few reports implicating multiple forms of asphyxia in the death of the same individual.3,4 Atlantoaxial subluxation rarely occurs as a consequence of manual strangulation. Here, we report a rare case: the murder of a child involving 3 forms of asphyxia, one of which was atlantoaxial subluxation.

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A 4-year-old male white child was found dead in the backyard of his house by his mother. A forensic autopsy was performed 6 hours later on the same day at the Franco da Rocha Medical Examiner's Office, located in the city of Franco da Rocha, Brazil. At the time of death, the child measured 100 cm and weighed 10.5 kg. The external examination revealed cyanosis of the face, lips, and nails, together with conjunctival petechiae. There were no defense injuries and no signs of sexual violence. On the anterior neck, there were 2 crescent-shaped hematomas measuring 1.5 × 1 cm (Fig. 1). In addition, there was abnormal, exaggerated mobility of the cervical spine (Fig. 2). In the internal examination, we observed an area of blackish hemorrhagic infiltration, measuring 2.5 × 2 cm, in the paravertebral muscles (Fig. 3), with disruption of the anterior and posterior longitudinal ligaments, as well as of the interspinous ligaments, at C1-C2. In addition, the first and second cervical vertebrae were dislocated, without signs of fracture. There was meningeal and cerebral congestion, together with brain edema, principally in the region of the brainstem. During the dissection of the neck, we observed a blackish hematoma located in the right and left sternothyroideus muscles (Fig. 4). There was also hemorrhaging in the cervical musculature. There was hemorrhagic infiltration underlying the perichondrium of the right superior thyroid horn and 3 small (0.5 cm) submucosal hematomas within the larynx. In the lungs, we observed congestion and subpleural petechiae. Histological examination under microscopy revealed hemorrhagic infiltration of the brainstem and alveolar hyperinflation.

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This case is interesting because it describes a common form of child abuse by parents or caregivers: grabbing a child by the neck. It also describes a quite rare combination of 3 mechanisms of death.

The assailant (the stepfather of the boy) squeezed the neck with his right hand, grabbed the hair with his left hand and pulled the head back. These sequential movements were so violent that the articulation between the first and second vertebrae was dislocated, thereby putting pressure on the brainstem.

To our knowledge, there are no similar cases in the literature. Lupascu et al4 described a case of a 75-year-old woman killed by asphyxiation involving 3 mechanisms: suffocation, strangulation, and chest compression. In our case, manual strangulation was confirmed based on external evidence (bruises on the cervical skin) and internal evidence (laryngeal and perilaryngeal lesions) consistent with the method. However, we found no fractures of the larynx, which might be explained by the young age of the victim and the consequent elasticity of the laryngeal cartilages.

Dislocation of the C1-C2 joint was confirmed through direct examination, and hyperextension of the neck was evidenced by rupture of the ligaments surrounding the C1-C2 joint. In attempting to describe the mechanism involved, it must be borne in mind that the hyoid bone and laryngeal cartilage form an anatomic and functional whole, relatively strongly connected to each other and to the skull base, transmitting force from one structure to another.5 In all tissues, the hemorrhagic infiltrations were of medium intensity, suggesting that they occurred simultaneously.

All forms of strangulation put pressure on the air passages, blood vessels, and nervous structures of the neck.5 However, the exact pathophysiological mechanism that leads to death in strangulation is not completely clear, although narrowing of the airway most probably plays a less important role than does obstruction of the blood vessels.

Regarding the mechanism of death in the present case, we concluded that the victim died as a result of the combination of different mechanisms of asphyxia.2 The concentration of oxygen in the blood dropped sharply due to the mechanical compression of the neck, which reduced the supply of oxygen. Airflow was impaired by constriction of the laryngeal lumen (by the hematomas and congestion of the mucous membranes). In addition, the extreme hyperextension of the neck might have caused narrowing of the upper airways.

Conjunctival petechiae, as was seen in this case, should be considered a strong indicator of uninterrupted venous compression (for at least 10 seconds).5,6 In addition, the dislocation of the C1-C2 joint resulted in brainstem compression.

As stated by Püschel et al,7 injuries of the cervical spinal column and brainstem are quite rare in cases of strangulation. In a study of 821 hanging deaths, the authors found fractures of the cervical spinal column in only 6 cases, in which the fractures occurred between the segments C5 and C6.

In the present case, the aggressor, the stepfather of the child, was arrested within 24 hours. He confessed to the murder but denied that the killing was intentional. He stated that he simply wanted to "teach the child a lesson."

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1. Knight B. Fatal pressure on the neck. In: Knight B, ed. Forensic Pathology. London, PA: Edward Arnold; 1991:334-359.

2. Azmak D. Asphyxial deaths. a retrospective study and review of the literature. Am J Forensic Med Pathol. 2006;27:134-144.

3. Blanco Pampin J, Garcia Varela L. Suicidal choking by a bizarre combination of inhalation to the bronchi and external neck compression. J Leg Med. 2001;3:119-122.

4. Lupascu C, Lupascu C, Beldiman D. Mechanical asphyxia by three different mechanisms. Leg Med. 2003;5:110-111.

5. Nikolic S, Micic J, Atanasijevic T, et al. Analysis of neck injuries in hanging. Am J Forensic Med Pathol. 2003;24:179-182.

6. Plattner T, Bolliger S, Zollinger U. Forensic assessment of survived strangulation. Forensic Sci Int. 2005;153:202-207.

7. Püschel K, Türk E, Lach H. Asphyxia-related deaths. Forensic Sci Int. 2004;144:211-214.


manual strangulation; traumatic asphyxia; neck hyperextension; homicide

© 2011 Lippincott Williams & Wilkins, Inc.


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