Chest injuries, aortic rupture and resuscitation artefacts
- Finding
Chest injuries kill by bleeding, air and heart damage; the doctor must also tell injuries from violence apart from those caused by resuscitation.
What it is
Blunt chest trauma breaks ribs and sternum, bruises and tears the lungs, bruises the heart and can tear the aorta. Sudden deceleration, as in a car crash or fall from height, tears the aorta just beyond the left subclavian artery (the isthmus), where the mobile arch meets the fixed descending aorta; most victims die at the scene. A blow over the heart at a precise moment of the beat can stop it without visible damage (commotio cordis). Penetrating wounds kill through bleeding and cardiac tamponade. In forensic practice, chest compressions during resuscitation also break ribs and the sternum: in a large review, more than half of resuscitated patients had rib fractures and about a quarter had sternal fractures. The doctor must record resuscitation so that its injuries are not taken for assault.
How to tell it apart
- Resuscitation fractures usually show little bleeding because circulation was poor; marked bleeding suggests they happened with a heartbeat.
- Old people with brittle bones break more ribs during resuscitation; children rarely do, so rib fractures in an infant need careful study.
- A small intimal tear of the aorta may lead to a later dissection or rupture; causation then depends on the records.
- Penetrating wounds of the heart may close and leave a small skin wound; the pericardium reveals the tamponade.
How to recognise it
- Rib fractures: site, number, side; flail segment; bleeding into the chest wall (vital reaction).
- Lungs: contusion, laceration by rib ends, haemothorax, pneumothorax.
- Heart: contusion, rupture, haemopericardium; valve or septal tears.
- Aorta: transverse tear of the intima or full thickness at the isthmus; mediastinal haematoma.
How it forms
- Deceleration: the heart and arch keep moving while the descending aorta is fixed, and the wall tears at the junction.
- Compression: the chest is squeezed between objects, as when run over or crushed.
- Chest compressions push the sternum down and bend the ribs at the front.
- Death comes from bleeding, tension pneumothorax, tamponade, arrhythmia or lack of oxygen.
Step by step
- Before the autopsy, find out whether resuscitation was attempted, by whom and for how long.
- Test for pneumothorax before opening the chest when suspected.
- Record each rib fracture by side, rib number and position (front, side, back) and its bleeding.
- Open the aorta along its length and examine the isthmus; measure blood in each cavity and the pericardium.
Resuscitation injuries versus inflicted injuries (orientation, not proof)
| Feature | Usually resuscitation | Raises concern for inflicted injury |
|---|---|---|
| Rib fracture site | Front and front-side, often both sides | Back of the ribs, near the spine, or a single side from a blow |
| Bleeding at fractures | Little | Marked, with chest wall bruising |
| Age of fractures | All recent and the same | Different ages, healing callus |
| Skin | Compression marks on the sternum, defibrillator marks | Patterned bruises, grip marks, injuries elsewhere |
Next step: what to do and document
- Record in the notes every resuscitation attempt: who, when, how long, compressions, devices, drains, punctures and intubation.
- Describe chest injuries present on arrival before any procedure, with their site and side.
- Keep chest imaging: the first radiograph or CT shows fractures and air before resuscitation changed them.
- In a death with chest injuries, send the full record of resuscitation to the medico-legal autopsy.
- In an infant with rib fractures, do not attribute them to resuscitation without study; follow the child-protection route.
Common mistakes
- Calling resuscitation fractures signs of assault.
- Not testing for pneumothorax before opening the chest.
- Explaining posterior rib fractures in an infant as resuscitation.
- Missing a small aortic tear because the arch was not opened.
Test yourself
Think of the answer, then tap the question to see it.
Where does the aorta usually tear in a deceleration injury, and why?
At the isthmus, just beyond the left subclavian artery, where the mobile arch meets the fixed descending aorta.
Which rib fractures are typical of chest compressions?
Anterior and front-lateral fractures, often on both sides, with a transverse sternal fracture and little bleeding.
What is commotio cordis?
Cardiac arrest caused by a blow over the heart at a vulnerable moment of the beat, without structural damage.
Why do posterior rib fractures in an infant raise concern?
Resuscitation rarely breaks infant ribs, and posterior fractures fit squeezing of the chest, typical of abuse.
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Educational content on forensic and legal medicine; not legal advice and no substitute for the technical guides of Colombia's National Institute of Legal Medicine and Forensic Sciences. Laws change: each page links the official text and says when it was last checked. For a real case, follow the guide in force and ask the competent authority.
Sources: Thoracic Trauma (StatPearls Publishing (NCBI Bookshelf), 2026); Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis (European Journal of Trauma and Emergency Surgery (PMC), 2024); Delayed occurrence of traumatic aortic dissection? Biomechanical considerations and literature (International Journal of Legal Medicine (PMC), 2023); Blunt Cardiac Injury (StatPearls Publishing (NCBI Bookshelf), 2024); Commotio Cordis (StatPearls Publishing (NCBI Bookshelf), 2023).
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