Research Articles (Forensic Medicine)

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Stakeholders' perspectives on integrating point-of-care diagnostics into forensic death investigations in South Africa
Ramatsokotla, Sebueng; Soul, Bathabile; Maluleke, Kuhlula; Evert, Lucinda; Jansen van Vurren, Stefan; Chale-Matsau, Bettina; Mabotja, Susan; Duah, Evans; Mashamba-Thompson, Tivani Phosa (Wiley, 2026)
Unnatural and unexplained deaths present critical challenges to the criminal justice, medico-legal, and public health systems. This study explored forensic professionals' perspectives on the integration of point-of-care (POC) diagnostics into unnatural death investigations in South Africa. A Nominal Group Technique (NGT) was conducted with eight key forensic stakeholders to identify and prioritize the potential benefits, facilitators, and barriers associated with POC implementation. Stakeholders ranked guidance for investigation and autopsy, improved turnaround times, and resource efficiency as the most significant POC diagnostic benefits. Scientific validity, quality assurance, and alignment with legal and regulatory frameworks were identified as critical facilitators, whereas technical limitations, quality management gaps, and legal uncertainties emerged as key barriers. Participants emphasized that POC diagnostics could support timely decision-making during death scene investigations and autopsies, reduce laboratory backlogs, and improve family and community outcomes through faster case resolution. However, successful integration requires standardized protocols, validation, and appropriate training to ensure scientific and legal defensibility. These findings provide foundational evidence to inform the responsible integration of POC diagnostics into forensic death investigations, with potential benefits for justice delivery and community health in South Africa. HIGHLIGHTS • The forensic value of POC diagnostics in unnatural death investigation in South Africa was examined. • An expert panel evaluated benefits, facilitators, and barriers associated with POC implementation. • Standardized protocols, validation, and training are crucial for scientific and legal defensibility. • POC diagnostics offer benefits for medicolegal death investigation in resource-limited environments.
The investigation of railway deaths in Pretoria
Blumenthal, Ryan; Makhoba, Musa Aubrey; Hlophe, Samukelisiwe; Muller, Gustav; Hager, Liesl (Lippincott Williams and Wilkins, 2026-09)
This study analyses forensic pathology data on railway-related deaths in Pretoria, South Africa, over a 9-year period (2015 to 2024). A total of 174 cases were identified, of which 138 met the inclusion criteria. The majority of fatalities involved males (93%), with Black individuals comprising 96% of cases. The mean age was 35.86 years, with a peak incidence in the 30 to 40-year age group. Most deaths were classified as accidental (71%), followed by undetermined (19%), suicide (8%), and homicide (2%). The predominant cause of death was multiple blunt force injuries (polytrauma), accounting for 72.5% of cases. A general decline in fatalities was observed after 2017, with a marked reduction from 2019 coinciding with COVID-19-related movement restrictions. Although this study does not assess regulatory or operational factors, it is hoped that these findings will provide important empirical insight into the demographic and injury patterns associated with railway fatalities, which may inform future safety, legal, and policy interventions.
Troponin release and mechanism-dependent myocardial injury in a lightning-induced mass casualty incident
Waligóra, Marcin; Sanak, Tomasz; Maciej Mikiewicz,; Blumenthal, Ryan; Zaczyńska, Klaudia; Kosiński, Sylweriusz; Giewont’2019 MCI Review Group (Nature Research, 2026-07)
BACKGROUND : Systematic data on cardiac involvement after lightning strikes are limited and mostly derived from case reports. On 22 August 2019, a cloud-to-ground lightning event on Mt. Giewont (Poland) caused a mass casualty incident, providing a unique opportunity to characterize myocardial injury in a large cohort. This study aimed to quantify high-sensitivity cardiac troponin (hs-cTnT) release after lightning strike and its relationship with injury mechanisms. METHODS : Individuals from the MT Giewont incident with available troponin measurements were analyzed. Injury mechanisms were predefined, and the location on the trail at the time of the strike was determined. Peak hs-cTnT measured in the emergency department was the primary biomarker of myocardial injury. Among 131 exposed hikers, 59 underwent hs-cTnT testing. The cohort comprised 27 (45.8%) females, and median age of individuals was 29.5 years (IQR 23-41). RESULTS : Overall, 27 (45.8%) exceeded the upper reference limit of hs-cTnT (URL; 14 ng/L). Median peak hs-cTnT was 13 ng/L (IQR 7.6–25.6). Individuals with direct strike/side-flash exposure had significantly greater troponin levels (median 25.6 vs 10.7 ng/L; p = 0.004). In multivariable analysis, direct/side flash exposure was the only independent predictor of increased troponin (β = 0.90 p = 0.014; relative change +146%). Contact injury, ground current, and blast injury were not significant. ECG abnormalities were uncommon despite frequent biomarker elevation. Individuals with hs-cTnT above the upper reference limit were more frequently admitted to hospital (63% vs 34.4%; p = 0.03), with a 60% increase in odds of admission per doubling of troponin (95% CI 1.01–2.5; p = 0.048). Discrimination for admission was moderate (AUC 0.66, 95% CI 0.52–0.78); a threshold >16 ng/L provided 53.6% sensitivity and 77.4% specificity. CONCLUSIONS : Among individuals who underwent cardiac troponin testing, nearly half demonstrated elevated hs-cTnT levels. Troponin release was significantly greater in individuals exposed to direct strike/side flash. PLAIN LANGUAGE SUMMARY : Lightning strikes can cause serious injuries, including damage to the heart. However, little is known about how often heart injury occurs after a lightning strike or which individuals are at greatest risk. This study examined people injured during a large lightning strike incident on Mt. Giewont in Poland in 2019. We analyzed blood levels of cardiac troponin, a marker of heart muscle injury, and assessed the likely mechanism of lightning exposure. Almost half of the tested individuals showed elevated troponin levels, suggesting some degree of heart injury. The highest levels were observed in people exposed to direct lightning strikes or side flashes.
Evidence of point-of-care diagnostics in forensic death investigations : a scoping review
Ramatsokotla, Sebueng; Soul, Bathabile; Duah, Evans; Sekwele, Letlhogonolo; Thompson, Gabrielle; Maluleke, Kuhlula; Mbonambi, Linda; Mashamba-Thompson, Tivani Phosa (Elsevier, 2026-02)
BACKGROUND : Point-of-care (POC) diagnostics represent promising health-technology tools capable of providing rapid, on-site analytical support for forensic investigations. This scoping review aimed to systematically map the available evidence on applying POC diagnostics in forensic investigations. The focus is on their potential ability to act as rapid screening and triage tools to assist in determining the cause of death and exploring the challenges and opportunities associated with their implementation on a global scale. METHODS : A comprehensive literature search was conducted across multiple databases, including PubMed, ProQuest Central, Academic Search Complete, Africa Wide, CINAHL, MEDLINE, and Web of Science. Out of the 7603 records screened, four studies met the eligibility criteria and were included in the review. Reporting adhered to the PRISMA-ScR guidelines. RESULTS : These studies demonstrated the expanding role of POC devices in various aspects of forensic investigations, including rapid triage in overdose cases, malaria diagnosis in travel-related deaths, SARS-CoV-2 screening, and hemoglobin testing in child deaths. These studies also highlighted the limitations of POC devices in the postmortem context, emphasizing the need for careful calibration, confirmation, and interpretation of the results. This review identified POC diagnostics as a potential bridge between forensic investigations and public health surveillance, with findings indicating both cause-of-death determination and broader public health strategies. Operational, ethical, and policy considerations for using POC devices in forensic investigations were also discussed. CONCLUSION : This review revealed challenges in ensuring the standardization, accuracy, and integration of POC diagnostics into established forensic practices. Further research is required to evaluate the diagnostic accuracy, cost-effectiveness, and performance of POC tools in forensic settings. Comprehensive guidelines and standardized operating procedures should be developed to ensure the successful implementation of POC diagnostics in forensic investigations. Given the limited and heterogeneous evidence, POC devices in forensic death investigations should be seen as preliminary aids rather than diagnostic instruments. HIGHLIGHTS • POC tools show emerging roles in forensic death investigations, including overdose triage, postmortem malaria, COVID-19, and hemoglobin screening. • POC devices offer rapid on-site insights, but variable postmortem performance requires calibration, confirmatory testing, and expert interpretation. • POC integration into forensic workflows requires standard protocols, accuracy validation, cost-effectiveness review, and ethical oversight.
A five-year review of pesticide deaths in Pretoria, South Africa
Lubbe, Gareth; Van Deventer, Barbara Stroh; Blumenthal, Ryan (Lippincott, Williams and Wilkins, 2026-06)
Pesticide poisoning remains a major global health concern, with low and middle-income countries like South Africa bearing a disproportionate burden. This retrospective, cross-sectional study analyzed 173 suspected pesticide poisoning deaths investigated at the Pretoria Medico-Legal Laboratory from January 2016 to December 2020. Most decedents were male (69.9%), with a mean age of 31 years; 85% were between 18 and 65. Foreign nationals comprised 12% of cases, and deaths peaked during winter (31% from June to August). Over half were referred from health care facilities, and 95% died within 24 hours of admission. Common autopsy findings included black, pepper-like granules in the gastrointestinal tract (89%), pulmonary froth (63%), and fecal soiling (14%). Toxicology was requested in 170 cases, but 86% remained pending; among 24 completed reports, 71% were positive for Terbufos. Pseudocholinesterase was measured in 39 cases, with levels reduced in 98% (mean = 1493 U/L). Histology most often showed intra-alveolar edema (83%) and pulmonary venous congestion (60%). The findings suggest that a combination of gross autopsy features, depressed pseudocholinesterase levels, and supportive histology may reliably indicate pesticide poisoning, even in the absence of timely toxicology results. The recent ban on Terbufos provides a key opportunity for future public health evaluation.
Kounis syndrome following a wasp sting
Blumenthal, Ryan; Troskie, Paula; Mabotja, Seduma Suzan (Lippincott, Williams and Wilkins, 2025-12)
At 2:00 pm, a middle-aged man with no previously documented medical history experienced an insect sting on his right foot (Fig. 1). The sting resulted in redness and itching of the skin, accompanied by swelling of his tongue. In response, he took amoxicillin and chlorpheniramine maleate tablets. By 3:30 pm, he visited a pharmacy, where he was given 2 Betadexamine tablets and was referred to his family physician. At 4:30 pm, his family physician administered promethazine and betamethasone via intramuscular injection. Shortly after returning home at 5:00 pm, he began to feel nauseous, vomited several times, and experienced chest pain. He passed away shortly thereafter.
The investigation of an agile mobile quadruped robot in forensic death scenes
Blumenthal, Ryan; Siyenga, Similo; Mostert, Jordan; Steyn, Wynand Jacobus Van der Merwe; Rossouw, Servaas Hofmeyr (Lippincott, Williams and Wilkins, 2026-03)
The Fourth Industrial Revolution has accelerated the integration of robotics and artificial intelligence (AI) into workplaces, creating opportunities to merge technology with real-world practice. In forensic pathology, workforce shortages and the dangers of investigating hazardous death scenes highlight the need for innovation. This study explored the use of a mobile, agile quadruped robot to investigate hanging death scenes, assessing its ability to navigate, capture evidence, and reduce human risk. The research focused on low-risk hanging death scenes as a starting point, with the aim of later extending to more hazardous environments such as chemical-related scenes, fire deaths, and mass disasters. The quadruped robot demonstrated advanced mobility, allowing routine inspection tasks and the collection of visual and environmental data with accuracy, safety, and frequency. The study reviewed existing literature on robotic applications in forensic investigations, developed an initial procedure for scene evaluation, and tested the approach on selected hanging cases. The findings discuss advantages, limitations, and lessons learned, offering insight into the potential role of robotics in forensic death scene work. While promising, technical and operational challenges remain before robotics can be fully integrated into routine forensic practice.
Streamlining the forensic autopsy
Blumenthal, Ryan (Academy of Science of South Africa, 2026-01)
SIGNIFICANCE : The forensic autopsy, in many respects, remains rooted in medieval practice. In today’s world of escalating caseloads, human resource shortages and increasing demands on forensic pathology services, this traditional model has become unsustainable. Forensic pathologists now face mounting fatigue and burnout, while institutions struggle with staff shortages and growing backlogs. In resource-constrained and resource-depleted environments, the challenge is not only to keep up with the workload but to preserve the integrity and quality of the forensic system itself. All this must be done while upholding standards and ensuring that the forensic autopsy is adequate.
Next generation sequencing : a possible answer to sudden unexplained deaths in a young South African cohort?
Van Deventer, Barbara Stroh; Du Toit-Prinsloo, Lorraine; Van Niekerk, Chantal (Springer, 2025-09)
Sudden cardiac death (SCD) is a major public health concern. In sub-Saharan Africa (SSA), including South Africa, there is a lack of reliable statistics on the incidence of SCD, even though there has been a fourfold increase in noncommunicable diseases (NCD), particularly cardiovascular diseases (CVD). Sudden cardiac death contributes to an estimated 50% of all cardiovascular deaths, which highlights South Africa’s need for research into better detection, treatment and prevention. This study aimed to identify an inherited cardiac arrhythmogenic disorder, linked to variants in cardiomyopathy- and arrhythmia-related genes, as a potential contributing factor to sudden cardiac deaths. DNA was extracted from blood samples collected at autopsy of 51 sudden unexpected death (SUD) cases, and subjected to next-generation sequencing (NGS) of 49 genes linked to inherited cardiac arrhythmogenic disorders. Variants were annotated and interpretated for clinical significance using the Galaxy bioinformatic platform. In total, 175 different missense variants were identified in the study population (n = 51). Of these, 92.5% (162/175) were known, documented variants, and the remaining 7.4% (13/175) were considered novel. Of the known variants, 78.4% (127/162) were of benign/likely benign significance, 20.4% (33/162) were variants of unknown significance (VUS), and 1.2% (2/162) was pathogenic. The 13 novel variants were analysed using online prediction software, with 92.3% (12/13) predicted to be likely benign and 7.7% (1/13) grouped into the VUS category. Post-mortem genetic testing provided evidence of a genetic arrhythmic/cardiac conduction disorder as the probable pathogenic basis for approximately 4% (2/51) of sudden unexpected death (SUD) cases.
Illustrated forensic pathology : necklacing
Blumenthal, Ryan; Maximilian, Robert (Lippincott Williams and Wilkins, 2025-09)
In July 2024, we examined the charred remains of an unidentified adult male. Remnants of a burned tire were found to be wrapped around the neck and torso. According to the available history, the deceased had been “necklaced.”
Suicidal iron and paracetamol overdose : a case report
Vandoorne, Carmen Zenda (Lippincott Williams and Wilkins, 2025-03)
A woman presented to a hospital complaining of drowsiness and body weakness. The patient reported intentionally ingesting about 30 ferrous sulfate tablets and about 10 paracetamol tablets after an argument with a loved one. The ingestion occurred within 24 hours of presentation to hospital. Blood samples taken before any treatment was given demonstrated severe metabolic acidosis, leukocytosis, and liver impairment with raised aspartate transaminase (244 U/L), alanine transaminase (140 U/L), alkaline phosphatase (130 U/L) and conjugated bilirubin (9 μmol/L), and an international normalized ratio of 4.61 seconds. Serum paracetamol levels more than 12 hours after ingestion confirmed paracetamol toxicity at 433 μmol/L (reference range, >264 μmol/L). Serum iron studies showed raised transferrin at 5.07 g/L (reference range, 2.50–3.80 g/L) and normal ferritin at 58 μg/L (reference range, 10–291 μg/L); however, serum iron testing was rejected due to insufficient specimens. The patient underwent treatment including iron chelation therapy with desferrioxamine and acetylcysteine therapy for paracetamol overdose. Later, an upper gastrointestinal bleed was suspected due to a rapid drop in hemoglobin level from 10.5 g/dL to 5.1 g/dL. Despite appropriate medical treatment and cardiopulmonary resuscitation, the patient died approximately 24 hours after admission.
Penetrating crossbow injury to the head : a case of suicide
Joubert, Dorethea Maria (Lippincott Williams and Wilkins, 2025-03)
We present here the case of a 42-year-old male with a history of mental illness. There had been a previous attempt at suicide by similar means, using a firearm. He currently resided with family and was confined to bed for most of the day due to complications of abdominal injuries sustained during the previous suicide attempt; however, mobility was still possible. On the day of his demise, his mother looked in on him and found him dead on his bed with a bolt in his head and a crossbow in close proximity—next to his bed.
The effect of the COVID-19 pandemic on suicide trends in Pretoria, South Africa
Robinson, Kay-Leigh; Pretorius, Candice; Blumenthal, Ryan; Meyer, Pieter Willem Adriaan (Lippincott Williams and Wilkins, 2024-09)
Suicide is one of the worldwide leading causes of unnatural death. Pretoria is a capital city of South Africa and is the fourth most populated city in South Africa. Between 16 and 22 suicide cases are recorded daily in South Africa. Case files from the Pretoria Medico-Legal Laboratory were reviewed between 1 January 2015 to 31 December 2021, which spanned the COVID-19 pandemic. All cases of possible and probable suicides were included. One-way analysis of variance and Pearson chi tests were conducted to determine statistical significance in the observed trends. A total of 1820 possible and probable suicide cases were identified. The year following the outbreak of the COVID-19 pandemic accounted for the largest number of suicides. White males were the most heavily represented population, followed by Black males. Hanging was the most common method for males, whereas poisoning via ingestion and/or overdose was more commonly used by females. Suicides in Pretoria have increased since previous studies from 9.74% and 10.2% to 13.32%. Methods used have changed among various population groups over the past two decades. This paper examined changes in suicide trends in Pretoria compared to previous studies and highlighted correlations between suicide trends and COVID-19 lockdown measures.
A 15-year review of lightning deaths in Germany-with a focus on pathognomonic findings
Bingert, Rebecca; Bremer, Larissa; Buettner, Andreas; Nigbur, Stefan; Blumenthal, Ryan; Zack, Fred (Springer, 2024-07)
Lethal accidents caused by lightning are divided into observed and unobserved events. Pathognomonic or characteristic findings are often overlooked during external postmortem examination. Classical mistakes may be made which may often lead to an incorrect diagnosis. An analysis of 270 fatalities was performed on a historical collection of the Committee for Lightning Conductor Construction for the United Economic Area e. V. (ABBW) on lethal accidents due to lightning that occurred in Germany for the period 1951–1965. Furthermore, a selective literature research was carried out. The aim of the study was to analyze the death scene, the clothing, and the victim. The authors focused on chief findings which were relevant to the correct diagnosis of “death by lightning.” Both Lichtenberg figures and singed body hair were considered pathognomonic for a lightning strike. The question arose as to whether Lichtenberg figures, for example, represented the finding that most often led to the correct diagnosis. Of the 270 lightning-struck victims from the case collection, 129 (47.8%) had singed body hair and 25 (9.3%) had Lichtenberg figures. A comparison of the frequency of the two reported findings, singed body hair versus Lichtenberg figures, has only been performed in the literature for case numbers below 40. This study is the first evaluation of a relatively large number of lethal accidents due to lightning. Singed body hair was reported more frequently in lightning-struck victims than Lichtenberg figures. This study showed that singed body hair is probably more diagnostically important than Lichtenberg figures.
Full-metal jacket mild steel core ammunition : a case report
Blumenthal, Ryan; Rossouw, Servaas Hofmeyr (Lippincott, Williams & Wilkins, 2023-12)
The deceased was a 26-year-old man who was killed in a multiple shooting incident while sitting alone in his car. This individual was shot by multiple individuals, with different types of ammunition, from different angles. It is beyond the scope of this article to describe all the gunshot wounds. It is the intention of the authors to merely focus on the pathology of trauma of full-metal jacket ammunition with a penetrator (mild steel core in this presentation). The authors describe what was found at autopsy.
The added value of molecular-based diagnostics in the African forensic medical setting
Van Deventer, Barbara Stroh; Makhoba, Aubrey Musa; Du Toit-Prinsloo, L.; Van Niekerk, Chantal (Clinics Cardive Publishing, 2022-09)
Sudden unexpected infant death (SUDI) is reported to be an extraordinarily high burden in sub-Saharan Africa, with the incidence rate in South Africa among the highest in the world. It is common for the cause of many such infant deaths to remain unexplained even after a full medico-legal death investigation, and then to be categorised as a sudden unexplained infant death (SUID). Fortunately, advances in molecular-based diagnostics allow researchers to identify numerous underlying inherited cardiac arrhythmogenic disorders in many SUDI cases, with a predominance of variants identified in the SCN5A gene. Such cardiac arrhythmogenic-related sudden deaths generally present with no structural alterations of the heart that are macroscopically identifiable at autopsy, therefore highlighting the importance of post mortem genetic testing. We report on a significant genetic finding that was made on a SUDI case in which the cause was ascribed to an acute bacterial pneumonia but it was still subjected to post mortem genetic testing of the SCN5A gene. The literature shows that many SUDI cases diagnosed with inherited cardiac arrhythmogenic disorders have demonstrated a viral prodrome within days of their death. It is therefore not uncommon for these cardiac disorders in infants to be mistaken for flu, viral upper respiratory tract infection or pneumonia, and without the incorporation of post mortem genetic testing, any other contributory causes of these deaths are often disregarded. This study highlights the need for research reporting on the genetics of inherited cardiac disorders in Africa.
An atypical asphyxial death : a case study
Blumenthal, Ryan; Ferraris, Stefanie Claudia (Lippincott Williams and Wilkins, 2023-09)
An atypical asphyxial death is presented. The deceased was found wrapped like a mummy with multiple layers of plastic and adhesive tape, lying face down on the floor of his home. The death scene was in the lounge area of a large, poorly-kempt, free-standing house. No obvious evidence of illicit drugs or other medications were identified. There was no pornographic material or other paraphernalia of a sexual nature in proximity to the body. According to the brother, the deceased had attempted similar incidents like this in the past, where someone was available to release him. Because of the similar behaviour in the past, the background psychiatric history, and statements from the girlfriend and relatives, the authors propose that this represents an atypical asphyxia death.
Practical tips to using formalin-fixed paraffin-embedded tissue archives for molecular diagnostics in a South African setting
Van Deventer, Barbara Stroh; Du Toit-Prinsloo, L.; Van Niekerk, Chantal (AOSIS, 2022-06-23)
BACKGROUND : Formalin-fixed paraffin-embedded (FFPE) tissue archives in hospitals, biobanks, and others offer a vast collection of extensive, readily available specimens for molecular testing. Unfortunately, the use of tissue samples for molecular diagnostic applications is challenging; thus, the forensic pathology FFPE tissue archives in Africa have been a largely unexploited genetic resource, with the usability of DNA obtainable from these samples being unknown. INTERVENTION : The study, conducted from January 2015 to August 2016, determined the usefulness of FFPE tissue as a reliable source of genetic material for successful post-mortem molecular applications and diagnostics. Formalin-fixed paraffin-embedded tissue samples were collected and archived from autopsies conducted over 13 years in the forensic medicine department of the University of Pretoria (Pretoria, South Africa). Deoxyribonucleic acid from FFPE tissue samples and control blood samples was amplified by high-resolution melt realtime polymerase chain reaction before sequencing. The procurement parameters and fixation times were compared with the quantity and quality of the extracted DNA and the efficiency of its subsequent molecular applications. LESSONS LEARNT : This study has shown that FFPE samples are still usable in molecular forensics, despite inadequate sample preparation, and offer immense value to forensic molecular diagnostics. RECOMMENDATIONS : FFPE samples fixed in formalin for more than 24 h should still be used in molecular diagnostics or research, as long as the primer design targets amplicons not exceeding 300 base pairs.
The “hypopigmented” bitemark : a clinical and histologic appraisal
Robinson, Liam; Bunn, Belinda Kathleen; Blumenthal, Ryan; Bernitz, Herman (Springer, 2023-01)
So-called “hypopigmented” bitemark patterns, commonly seen but not limited to dark skinned individuals, can be of value in forensic investigations. The process of aging bitemarks observed on skin is controversial and without guidelines. This report analyzes tissue obtained from the site of a hypopigmented bitemark using special histochemical stains for the identification of melanin pigment, and a panel of immunohistochemical markers to aid in the aging process. Histologic evaluation clearly showed that cellular changes in the hypopigmented area were indicative of wound healing that had taken place over a period of time. This validates the hypothesis that a hypopigmented bitemark is an indication of a wound inflicted some days previously. These findings have value in forensic investigations, particularly in cases of suspected long-term physical abuse.
Glass penetrating skull injury mimicking projectile injury
Blumenthal, Ryan (Lippincott, Williams & Wilkins, 2022-06)
A 29-year-old man was involved in a motor vehicle accident as a driver in May 2021. According to the available history, his car overturned and hit a wall. Death was due to head injury. Diffuse brain injury was present. A small piece of glass penetrated the left occipital bone of the skull. What was remarkable was that this wound mimicked a projectile injury. Were it not for the small fragment of glass lodged within the central aspect of the bony wound defect, this wound could have been construed as that of a projectile injury.

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