[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Forensic medicine](https://durgical.com/en/forensic-medicine/) › [Asphyxia and physical agents](https://durgical.com/en/forensic-medicine/areas/asphyxia-physical/) › Manual strangulation (throttling) # Manual strangulation (throttling) - Finding In manual strangulation hands squeeze the neck: it leaves finger and nail marks, but many living victims show nothing at all. Updated Nov 5, 2026 ## Key points - Round bruises (fingertips) and crescent abrasions (nails) on the front and sides of the neck. - About half of living victims have no visible injuries: the absence of marks does not rule out strangulation. - Autopsy: neck muscle haemorrhages and sometimes fracture of the superior thyroid horns or the hyoid, more in older people. - Petechiae of the face and conjunctivae: support venous compression but are non-specific. - Non-fatal strangulation by a partner is a strong predictor of future homicide. ## What it is Manual strangulation is compression of the neck with the hands, forearm or knee. It is almost always homicide or assault, because a person loses consciousness before being able to kill themselves this way. It is common in intimate-partner and sexual violence, and non-fatal strangulation is a strong predictor of later violence and homicide. It leaves round fingertip bruises, crescent-shaped nail abrasions, petechiae above the compression and, at autopsy, haemorrhages in the neck muscles and sometimes fractures of the hyoid or thyroid cartilage. About half of living victims have no visible injuries. ## How to tell it apart - Versus ligature strangulation: there is no continuous furrow; the marks are discontinuous and round. - Versus hanging: there is no oblique furrow and no suspension point. - Resuscitation or intubation injuries on the neck and face can be confused with strangulation injuries: record resuscitation attempts. - Hypostatic haemorrhages or poor dissection technique mimic neck injuries. ## How to recognise it - Small round bruises on the neck, sometimes grouped by the position of the fingers and thumb. - Linear or crescent-shaped nail abrasions, from the assailant or from the victim trying to defend themselves. - Petechiae in the conjunctivae, eyelids, face and oral mucosa; facial congestion. - Symptoms in the living victim: hoarseness, painful swallowing, difficulty breathing, loss of consciousness, incontinence. - At autopsy: haemorrhages in the muscle layers, laryngeal or hyoid fractures, defence injuries elsewhere. ## How it forms - Hand pressure occludes the jugular veins and the carotids; loss of consciousness can come within a few seconds. - Uneven, repeated pressure explains the asymmetric spread of bruises and abrasions. - Ossified laryngeal cartilages fracture more easily; in young people they tend to bend without breaking. ## Next step: what to do and document - Ask directly and without judgement about strangulation in every victim of partner or sexual violence. - Document symptoms (voice, swallowing, loss of consciousness, incontinence) and signs, with scaled photographs even if there are no marks. - Refer urgently for airway and neck artery assessment if there was loss of consciousness, neurological symptoms or breathing difficulty. - Activate the care pathway for victims of violence, assess risk and report to the surveillance system; notify the authorities as the law requires. - Take nail samples and swabs of the neck skin for the assailant's material, with a chain of custody. ## Common mistakes - Ruling out strangulation because there are no visible marks on the living victim. - Discharging without assessing laryngeal or neck artery injury when there was loss of consciousness or symptoms. - Not asking directly about strangulation in an intimate-partner violence consultation. - Treating petechiae as sufficient proof of strangulation. ## Test yourself Think of the answer, then tap the question to see it. ## Which external injuries suggest manual strangulation? Round fingertip bruises, crescent-shaped nail abrasions on the neck and petechiae of the face and conjunctivae. ## Does the absence of visible injuries in a living victim rule out strangulation? No. About half of victims of non-fatal strangulation have no visible injuries. ## Why are hyoid fractures more frequent in older people? Because their laryngeal cartilages and hyoid are ossified and break instead of bending. ## Why does non-fatal strangulation matter in intimate-partner violence? It is a strong predictor of later violence and homicide: it calls for a risk assessment and activation of the protection pathway. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/forensic-medicine/manual-strangulation/) ## Elsewhere in DurgiPedia - [Mandatory reporting: public health, violence and abuse](https://durgical.com/en/medical-ethics/mandatory-reporting-public-health-violence-and-abuse/) - [The limits of confidentiality: duty to warn and legal disclosure](https://durgical.com/en/medical-ethics/the-limits-of-confidentiality-duty-to-warn-and-legal-disclosure/) ## Connections ## Related 7 - [Intimate-partner and gender-based violence](https://durgical.com/en/forensic-medicine/intimate-partner-and-gender-based-violence/) - [Ligature strangulation](https://durgical.com/en/forensic-medicine/ligature-strangulation/) - [Hanging](https://durgical.com/en/forensic-medicine/hanging/) - [The forensic exam after sexual violence](https://durgical.com/en/forensic-medicine/the-forensic-exam-after-sexual-violence/) - [Bruises and haematomas: recognising them, and why colour cannot date them](https://durgical.com/en/forensic-medicine/bruises-and-haematomas-recognising-them-and-why-colour-cannot-date-them/) - [Abrasions](https://durgical.com/en/forensic-medicine/abrasions/) - [Chain of custody (cadena de custodia) in the hospital or rural post](https://durgical.com/en/forensic-medicine/chain-of-custody-in-the-hospital-or-rural-post/) ## Related conditions 2 - [Intimate partner and sexual violence (mental-health care)](https://durgical.com/en/conditions/intimate-partner-and-sexual-violence/) - [Sexual violence (care of the survivor)](https://durgical.com/en/conditions/sexual-violence/) [← All of forensic medicine](https://durgical.com/en/forensic-medicine/) 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: [Approach considerations for the management of strangulation in the emergency department](https://pmc.ncbi.nlm.nih.gov/articles/PMC9013263/) (JACEP Open, PubMed Central, 2022); [Strangulation Injuries](https://www.ncbi.nlm.nih.gov/books/NBK459192/) (StatPearls, NCBI Bookshelf, 2023); [Ligature Mark: Crime or Suicide?](https://pmc.ncbi.nlm.nih.gov/articles/PMC9655629/) (International Journal of Environmental Research and Public Health, PubMed Central, 2022). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/forensic-medicine/manual-strangulation/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). 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