Autopsy report

For an autopsy report, what is the proper format, specifically when reporting broken/missing bones?

Also, what vocabulary would be used for fingers? Would I say "appendages" or "phalanges" or be specific in what section of the digit?

 

Obvious answer is obvious

I think I was deterred to do that with anything that can pop up on Google, especially images. I do NOT need to see bodies before bed.

 

Can also depend on whence the autopsy report originates. I do tons of translations for autopsy reports that originate from the Forensic Sciences Institute of Puerto Rico. They do not use a template form. They instead create a report that is actually simple block-text, but the report itself is exhaustively detailed.

Always in the following order:

• External Exam - This is general and gives details of identification of the body: apparent age, ethnicity, gender, height and weight, eye color, hair color, hair texture, clothing (if any), etc.
• External Evidence of Trauma - This will be highly, highly detailed. Some parts of the body will be made reference in common terms (eye, shoulder, arm), other parts will be indicated in precise medical terms (your missing finger would be indicated in very precise medical terms, indicating exactly which bones are missing, the joint at which the trauma appears, the kind of trauma (tear, laceration, contusion, burn) etc.) Points of trauma are given coordinates in their given area that include the size or length of the area of trauma, and are nearly always measured from the distance of the midline of the body to the area of trauma, and another measurement from another known point on the body in that area, up or down to the point of trauma. Each point of trauma is usually given its own numbered paragraph in this section unless it is part of a grouping.

Example from actual report:

Contusion with laceration and a thick abraded area in a rectangular pattern located in the posterior region of the head at the level of the right parietal. The contusion is located 3” below the top of the head and 1 ½” to the right of the posterior medial line. There is a contusion that measures 2 ½” and also an irregular laceration of 1 ¾” associated with an abrasion that measures 2” X 1”.​

• Internal Evidence of Trauma - Same as above. Expect very, very technical terms. Another example from same report as above:

1. There is a depressed fracture with separation and displacement of the frontal bone of the left frontal region with affectation of the parietal in a round, interrupted pattern that measures 3” x 2 ½” and the lower region of the fracture is irregular, depressed, and affects the anterior right and left fossa and the crista galli.
2. There is also a frontal subgaleal hemorrhage of 4" X 2 1/2" and parietal subgaleal hemorrhage of 4” X 2 ½”
3. There is a fracture to the base of the cranium involving the anterior fossa, medial, right and left anterior fossa, crista galli and extends toward the right and left posterior fossa.
4. Diffuse subarachnoid hemorrhage.
5. Cerebral Edema

​

• Internal Exam - Organs are described and weighed. Expect metric measurements, even in America. Sometimes there will be further description of trauma in this part of the report.
• Toxicological Analysis - This part nearly always says "See attached report".
• Autopsy Findings - This part gives a repeat of the major areas of trauma that are the basis for the Cause of Death, which is also mentioned in this part of the report. In the case of the report I have referenced above:

The footnote indicated by the 1 next to the word "homicide" says: Term used without implying its legal meaning.​

 

Findings, yes, that was what I had trouble with.

Here's an excerpt from a chapter I have:

Right tibia fractured, comminuted; ribs 3, 7, 9 fractured, comminuted; ribs 5, 6, 8 missing; multiple phalanges missing…

I was wondering if this was how it should be written. I wasn't sure if the ribs were numbered as teeth are (like when you go to the dentist and you hear them rattle off numbers, like "Number 34 is sealed, etc.").

 

That fracture to the tibia would be more detailed. You mention that it's comminuted, so where does the fracture start and stop, length of area affected. That kind of break is not a simple, clean, transverse break. Same with the ribs. Yes, they are numbered, 1 -12, top to bottom, left and right, but you haven't mentioned the side of the missing ribs or the side of the fractured ribs. That detail would defo be in the report. The missing phalanges would be detailed as well, like: Apparent blunt force trauma to index finger of left hand, distal and middle phalanges of the index finger of left hand are missing, also portion of proximal phalange. (that's just an example)

 

Haha That's where non-disclosure agreements come into play, and I have signed my fair share of those. But the situation you mentioned would be more likely to happen when the translator is working on the Scene Findings Report (in common parlance, the Crime Scene Report). The concern the OP had over running across photo images of headless torsos is a feature of that report. And yes, I translate those too, all day long.

 

Almost. Un cuerpo sin cabeza.

Also, it's so much more gruesome when it's partial rather than total, as is often the case with GSW's to the head.

 

The last thing I need is seeing certain body parts maimed or detached before I go to bed. That's the stuff of nightmares. And lost lunches.

 

Eh, I've done worse.

 

I agree, have not doubt, but since few translators want to look at that stuff for the obvious reasons - let alone spend the time to do high resolution screen-grabs from the original documents to include in the translated versions - it's one way of securing my niche in a highly competitive field.

 

If you didn't want to know about such things, then perhaps you should not
ask for such things. Read one of the Scarpetta series. She is a forensics
coroner, and gets some pretty grisly victims on her slab.

Way to take the fun out of it for me.

 

Jesus, I don't know what any of those medical terms mean but even I know that from the sound of it... that person did not have a pleasant death.

 

That is your basic blunt force trauma to the head.

A blow that drove part of the skull inwards, compressing the brain and causing blood vessels to rupture.

 

'Ow' would be the understatement of the century...

 

Its ok, at least we know to a certain extent that the skull is
bulletproof to some small caliber bullets. Given the density
of the bone, and the round shape helps to deflect them.
However it is strongly advised against testing this one
at home.
There are plenty of cases involving people surviving
a gunshot to the head with minor cranial damage.
Pretty surprising just how hard the top frontal part
of your skull is one tough cookie.

 

It is the curve, not so much the density, that saves you from a bullet. Tank designers in WW2 discovered that the angle of a shot to the armor was more important than the thickness of the armor, which is why, for example, German tanks went from squared to angled armor. Mossad's favorite tool for assassination in the 70s and 80s was a .22 long rifle with a reduced powder charge (to cut noise) fired into the skull at very close range at a right andle.

Bullets, like most things, follow the path of least resistance. I worked a case where a stray .22 clipped a guy on the downward side of its trajectory. It flattened against the skull, but the transfer of kinetic engery ruptured a blood vessel in the brain. The guy was walking around asking who hit him with a rock, and then keeled over dead. Took forever to figure out what caused the injury.

But I grow pedantic, as is my nature.

 

Yeah, that is true. I read an article last night about how
bullets affect different parts of the body, and it was
quite interesting. The stats for mortally killing some one
with a min. 9mm shot to the head without penetration,
was 80% they would die from the impact damage of the
brain through the kinetic transfer energy.

Actually was an interesting read, which is quite useful for
someone like me writing a war story. So far my ballistics
have been fairly consistent based upon whether it was
gas-powered or energy fired projectile. Though it is in
the future so you can get a bullet with a bit more velocity
for your buck.

 

On a related note: Often - as part of the packages of documents mentioned above that I am tasked to translate - there are drawings that are referred to as croquis in Spanish. It means sketch, though they are often significantly more detailed and precise than the word sketch would imply. Regardless, they are used to map out where items of evidence are found at crime scenes and to show possible locations from where shots may have been fired. It's all very intriguing as regards the way the events of a crime are pieced together after the fact.

 

That is kinda why I skipped Crime Thriller, and jumped to War. I am bad at those
fine details that are needed to make a good Crime scene. Little bit easier to point out
a direction when the bullets are still coming.

Though I use to enjoy those crime shows that tried to piece the puzzle together.
Putting fiberglass rods at the wound sites to determine trajectory, and angle of
the shooter. Just don't have much of knack for making it believable. so to speak.

That is kinda cool and also a bit dark, that you get to learn all that stuff though.
Must test your limits at times as far as dealing with such gruesome stuff in the
real world. Them again as a species we are intrigued with the macabre elements
of our own, and try to figure out how another could do such vicious things to another.

 

Yep. I've done translations for some pretty gruesome documents, but the worst thing I have ever had to do was the transcription (and later translation) of a video made on a cellphone.

Long story short:

In Puerto Rico, the place where you go to buy illegal drugs is called "el punto" (the point). A mule for a drug punto was caught "skimming the till", so to speak. The owner of the punto recorded the beat-down that was given to the mule. One minute he was being beaten, the next minute he was kicked in the head so hard that you heard the snap and he was dead.

What made it exceptionally horrible for me was that I had to watch it over and over and over again to get down all the dialogue from all the parties that could be heard in the recording. It has to be as exact as humanly possible.

I put myself on a little week-long vacation after that project, but the image and the sound of that guy dying is burned into my memory forever.