Forensic Science, Medicine and Pathology

https://doi.org/10.1007/s12024-024-00896-3

IMAGES IN FORENSICS

Postmortem CT and autopsy findings in an elevator-related death: a

case report
Giovanni Aulino1 · Michele Rega1 · Vittoria Rossi1 · Massimo Zedda1 · Antonio Oliva1

Accepted: 9 September 2024

© The Author(s) 2024

Abstract
Elevator-related fatalities and injuries are rarely discussed. Falls have been identified as the first cause of mortality in the
majority of these accidents. Evidence suggests that many elevator accidents may be attributed to inadequate equipment
maintenance or malfunctions of the devices. This study examines a case involving an elevator maintenance worker found
within an elevator shaft, using postmortem computed tomography (PMCT) along with a full autopsy. The autopsy revealed
that the cause of death was severe polytrauma resulting from dragging, compression, and crushing mechanisms, which
resulted in a dislocated skull and multiple thoraco-abdominal injuries, including exposed organs and viscera. Detailed
examination identified a cranio-encephalic crush, leading to a significant alteration in the physiognomy of the facial struc-
tures. Additionally, PMCT revealed complex spinal fractures, such as a Jefferson fracture and a complete Chance fracture
at the D6 vertebra, accompanied by spinal deviation proximal to the fracture site. Autopsy findings corroborated these
PMCT results. A multidisciplinary approach, including PMCT, is proposed as a strategic method for the comprehensive
reconstruction of such accidents, facilitating the collection of extensive data.

Keywords Virtopsy · Forensic radiology · Elevator accident · PMCT · Fracture

Introduction to assess a workplace accident involving an elevator, in

which the victim was found motionless within the eleva-
Elevator-related fatalities and injuries are infrequently tor shaft [5–9]. The injuries sustained from the precipitat-
addressed in literature. Between 1992 and 2009, there ing event were significantly overshadowed by the presence
were 443 reported fatalities associated with elevators in the of severe polytrauma, which led to cranio-encephalic dis-
United States [1]. Conversely, injuries attributed to eleva- placement and multiple thoracic and abdominal injuries,
tors are believed to occur more frequently within the United including exposed organs and viscera. Consequently, this
States, impacting both children and the elderly [2, 3]. In study aims to provide a comprehensive description of the
cases involving fall-related trauma, PMCT has facilitated a fractures sustained, integrating evidence from the accident
more accurate reconstruction of the accident and provided scene with radiological and autopsy findings.
a detailed characterization of the injuries sustained, as cor-
roborated by subsequent autopsy examinations [4].
In our institution, PMCT is utilized in specific forensic Case report
cases, including those involving extensive carbonization,
gunshot wounds, and drowning. This technique was applied Case presentation

A 35-year-old elevator maintenance worker was discovered

in a prone position at the base of the elevator shaft where
Giovanni Aulino he had conducted maintenance the preceding day. He had
aulinogiovanni@gmail.com been reported missing since the previous evening. The indi-
1
Department of Health Surveillance and Bioethics, Section vidual was found wearing a bloodstained shirt and trousers
of Legal Medicine, Università Cattolica del Sacro Cuore, that were partially lowered to just above the knees, along
Fondazione Policlinico Universitario A. Gemelli IRCCS, with work shoes, of which only the left shoe was worn.
Largo Francesco Vito, 1, Rome 00168, Italy

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
 Forensic Science, Medicine and Pathology

Additionally, longitudinal streaks of blood were noted on and leakage of lung parenchyma. A similarly sized injury
the walls of the upper compartment at the scene. was found on the left flank, with exposure of the abdominal
viscera (Fig. 2b, c). Finally, a full-thickness fracture of the
External examination thoracic vertebra was documented (Fig. 3a).

Upon examination of the head, a cranio-encephalic crush Post-mortem CT

was identified, characterized by significant disruption of the
facial structure, including disrupted eyes and destruction of Prior to the autopsy, and following the external examination
the bony elements of the cranial vault. Comminuted frag- of the decedent, PMCT was conducted using a Somatom
ments of cerebral parenchyma were also present (Fig. 1a-c). Sensation 16 CT scanner (Siemens®, Munich, Germany).
Two parallel ecchymotic and excoriated bands were The examination settings included 140 kVp, 160 mAs,
observed: one in the mid-sternal region and another later- 24-mm feed/rotation, 1-mm slice collimation, 1-mm slice
ally adjacent, each approximately 1 cm thick and diffusely width, and reconstruction kernels of 10, 30, 40, 70, and 80.
over the anterior thorax and abdomen. Additionally, lacer- Subsequent to data processing, axial, coronal, and sagittal
ated and contused wounds affecting the anterior trunk were two-dimensional (2D) reconstructions, along with a three-
observed (Fig. 2a). dimensional (3D) volume rendering (VR) and shaded sur-
In the right thoracic region, a lacerated contusion was face display (SSD), were performed. The resultant images
identified, associated with multiple dislodged rib fractures were reviewed by a board-certified radiologist with over 10

Fig. 1 External examination and PMCT findings of the craniofacial bony components of the cranial vault. d, e: PMCT 3D-rendered images
region. a, b, c: Cranio-encephalic injury characterized by significant depicting the bone structure of the craniofacial area
loss of facial structure, including ocular rupture and destruction of the

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Forensic Science, Medicine and Pathology

Fig. 2 External examination findings of the thoraco-abdominal region. skeletal tissue and homolateral lung parenchyma in the right thoracic
a: Two parallel ecchymotic and excoriated bands measuring 1 cm in region. c: A lacerated-contused wound with a longer transverse axis,
thickness, located in the mid-sternal region and adjacent laterally. b: exposing abdominal viscera in the left flank
A lacerated-contused wound with exposure of underlying musculo-

years of experience in forensic imaging. The findings from sectioning, pronounced pallor of the organs was observed.
the external examination were communicated to the radiolo- Moreover, no significant findings identified that would sug-
gist prior to the review. gest the presence of underlying pathologies capable of con-
PMCT confirmed fractures in the craniofacial region tributing to the determination of death.
(Fig. 1d, e) and revealed complex fractures of the spine,
including a Jefferson fracture and a complete Chance frac-
ture at the D6 level, with spinal deviation proximal to the Discussion
fracture (Fig. 3b, c). Numerous fractures were also identified
in all four limbs as well as in the thoracic cage. Additionally, Elevator accidents, while infrequent, can lead to fatalities
a diaphragmatic rupture and mediastinal dislocation were and severe injuries [10]. Despite being one of the safest
noted. forms of transportation, the high volume of elevator traf-
fic can contribute to serious incidents [2]. According to
Autopsy findings McCann, 20.5% of elevator passengers were not engaged
in work at the time of their accidents, while 20.1% were
All radiological findings were corroborated by the foren- performing work-related duties, such as clerical, stock han-
sic autopsy. The macroscopic examination revealed mul- dling, and janitorial tasks. Notably, the remaining cases
tiple lacerations of the thoracic and abdominal viscera. On

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
 Forensic Science, Medicine and Pathology

Fig. 3 External examination and PMCT findings of the spinal column. a: Full-thickness fracture of the thoracic spine demonstrated. b: PMCT
3D-rendered image of the spinal column’s bone tissue. c: Frontal view of the spine as observed on the PMCT scan

(59.4%) involved construction workers who were in or near The nature of injuries sustained in elevator incidents varies
elevator shafts [1]. according to the specific circumstances surrounding each
Reconstructing elevator-related accidents is crucial case. Prahlow et al. highlighted that falls from heights were
for both safety improvement and legal accountability [4]. the leading cause of elevator-related fatalities, followed
The majority of these accidents can often be attributed to closely by severe asphyxia, crushing injuries, and pressure-
inadequate maintenance or malfunctioning equipment [6]. related injuries, which placed third [11].

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Forensic Science, Medicine and Pathology

PMCT images for this study. Her expertise and meticulous attention to
In this case, the cause of death was determined to be detail significantly enhanced the quality of our analysis. We appreciate
severe polytrauma resulting from dragging, compression, her collaborative spirit and contributions, which were invaluable to the
and crushing injuries that led to a dislocated skull and mul- success of our research.
tiple thoraco-abdominal injuries, exposing internal organs
Author contributions Giovanni Aulino: Conceptualization, Method-
and viscera. The most plausible scenario suggests that the
ology, Writing -original draft; Michele Rega: Writing -original draft;
victim experienced compression between the elevator shaft Writing – review & editing. Vittoria Rossi: Writing -original draft;
wall and the elevator, followed by a fall that resulted in fur- Writing – review & editing. Massimo Zedda: Writing -original draft;
ther crushing as the elevator descended. Writing – review & editing. Antonio Oliva: Conceptualization, Writing
-original draft; Writing – review & editing; All authors approved the
Evidence supporting this hypothesis includes blood
final version of the manuscript.
found on the wall adjacent to the elevator, facial lacerations,
longitudinal bruising on the anterior chest, and multiple Funding Open access funding provided by Università Cattolica del
fractures identified through PMCT. It has demonstrated not Sacro Cuore within the CRUI-CARE Agreement. This research re-
only exceptional sensitivity and specificity in recognizing ceived no specific grant from any funding agency in the public, com-
mercial, or not-for-profit sectors.
and classifying various types of fractures, but it also allows
for the identification of injuries to soft tissues and organs Data availability My manuscript has associated data in a data reposi-
[12–16]. tory.
A systematic review of 15 studies comparing PMCT
and autopsy findings in cases of traumatic death indicated Declarations
an agreement rate ranging from 50 to 100% in determin-
ing the cause of death, with enhanced concordance noted Competing interests The authors declare they have no conflict of in-
specifically in gunshot-related fatalities [17]. Additionally, terest.
a subsequent large-scale study revealed an almost perfect
Article classification 10: Forensics.
correlation between PMCT and autopsy results in the detec- 10.010: Pathology.
tion of craniofacial injuries and gunshot-related deaths [18]. 10.190: Autopsy.
Thus, PMCT was instrumental in characterizing fractures
that would have been challenging to analyze during a stan- Ethical approval and consent to participate This article does not con-
tain any studies with animals. Informed consent is not necessary in
dard autopsy, thereby providing critical insights into the
this work because it was a judicial autopsy case. The report does not
dynamics of the accident [19]. Indeed, PMCT has enabled contain personal data. In any case, all data are covered by the Italian
the description and reconstruction of fractures in the cra- Law—Data Protection Authority (Official Gazette no. 72 of March 26,
niofacial region and has revealed complex spinal fractures, 2012)—for scientific research purposes.
including a Jefferson fracture and a complete Chance frac-
Open Access This article is licensed under a Creative Commons
ture at the D6 level, along with spinal deviation proximal to Attribution 4.0 International License, which permits use, sharing,
the fracture. adaptation, distribution and reproduction in any medium or format,
The autopsy further confirmed the absence of any pre- as long as you give appropriate credit to the original author(s) and the
existing pathological conditions that could have contrib- source, provide a link to the Creative Commons licence, and indicate
if changes were made. The images or other third party material in this
uted to the victim’s injuries. To maximize data collection, a article are included in the article’s Creative Commons licence, unless
multidisciplinary approach incorporating PMCT is essential indicated otherwise in a credit line to the material. If material is not
[20]. Nevertheless, the autopsy remains a key component in included in the article’s Creative Commons licence and your intended
establishing the cause of death and ruling out any underly- use is not permitted by statutory regulation or exceeds the permitted
use, you will need to obtain permission directly from the copyright
ing health issues that may have played a role in the injuries holder. To view a copy of this licence, visit http://creativecommons.
sustained. org/licenses/by/4.0/.
In conclusion, the circumstances of the accident and the
height of the fall significantly influence the severity of inju-
ries and the likelihood of a fatal outcome in elevator inci- References
dents. Precise reconstruction of these accidents is essential
for forensic investigations, as it aids in understanding the 1. McCann M. Deaths and injuries involving elevators and escala-
dynamics involved, especially in industrial contexts. Addi- tors (2013). https://www.cpwr.com/sites/default/files/publica-
tions/elevator_escalator_BLSapproved_2.pdf (accessed 17 Aug
tionally, PMCT has proven to be a valuable, rapid, and non- 2019).
invasive tool for the documentation and reconstruction of 2. O’Neil J, Steele GK, Huisingh C, Smith GA. Elevator-
traumatic injuries, enhancing the overall forensic analysis. related injuries to children in the United States, 1990 through
2004. Clin Pediatr (Phila). 2007;46(7):619–25. https://doi.
Acknowledgements We would like to extend our heartfelt gratitude org/10.1177/0009922807300232.
to Dr. Valentina Masini for her exceptional work in reconstructing the

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
 Forensic Science, Medicine and Pathology

3. Steele GK, O’Neil J, Huisingh C, Smith GA. Elevator- 13. Henningsen MJ, Larsen ST, Jacobsen C, Villa C. Sensitivity
related injuries to older adults in the United States, 1990 to and specificity of post-mortem computed tomography in skull
2006. J Trauma. 2010;68(1):188–92. https://doi.org/10.1097/ fracture detection-a systematic review and meta-analysis. Int
TA.0b013e3181b2302b. J Legal Med. 2022;136(5):1363–77. https://doi.org/10.1007/
4. Jacobsen C, Schön CA, Kneubuehl B, Thali MJ, Aghayev E. s00414-022-02803-3.
Unusually extensive head trauma in a hydraulic elevator acci- 14. Mondello C, Baldino G, Bottari A, Sapienza D, Perri F, Argo
dent: post-mortem MSCT findings, autopsy results and scene A, Asmundo A, Ventura Spagnolo E. The role of PMCT for the
reconstruction. J Forensic Leg Med. 2008;15(7):462–6. https:// assessment of the cause of death in natural disaster (landslide and
doi.org/10.1016/j.jflm.2008.03.006. flood): a sicilian experience. Int J Legal Med. 2022;136(1):237–
5. Cascini F, Polacco M, Cittadini F, Paliani GB, Oliva A, Rossi 44. https://doi.org/10.1007/s00414-021-02683-z.
R. Post-mortem computed tomography for forensic applica- 15. Ampanozi G, Halbheer D, Ebert LC, Thali MJ, Held U. Postmor-
tions: a systematic review of gunshot deaths. Med Sci Law. tem imaging findings and cause of death determination compared
2020;60(1):54–62. https://doi.org/10.1177/0025802419883164. with autopsy: a systematic review of diagnostic test accuracy and
6. Coty JB, Nedelcu C, Yahya S, Dupont V, Rougé-Maillart C, meta-analysis. Int J Legal Med. 2020;134(1):321–37. https://doi.
Verschoore M, Ridereau Zins C, Aubé C. Burned bodies: post- org/10.1007/s00414-019-02140-y.
mortem computed tomography, an essential tool for modern 16. Kranioti EF, Nathena D, Spanakis K, Karantanas A, Bouhaidar
forensic medicine. Insights Imaging. 2018;9(5):731–43. https:// R, McLaughlin S, Thali MJ, Ampanozi G. Unenhanced PMCT
doi.org/10.1007/s13244-018-0633-2. in the diagnosis of fatal traumatic brain injury in a charred body.
7. Hourscht C, Christe A, Diers S, Thali MJ, Ruder TD. Learn- J Forensic Leg Med. 2021;77:102093. https://doi.org/10.1016/j.
ing from the living to diagnose the dead - parallels between CT jflm.2020.102093.
findings after survived drowning and fatal drowning. Forensic 17. Scholing M, Saltzherr TP, Fung Kon Jin PH, Ponsen KJ, Reitsma
Sci Med Pathol. 2019;15(2):249–51. https://doi.org/10.1007/ JB, Lameris JS, Goslings JC. The value of postmortem computed
s12024-018-0081-9. tomography as an alternative for autopsy in trauma victims: a
8. Cittadini F, Polacco M, D’Alessio P, Tartaglione T, De Gior- systematic review. Eur Radiol. 2009;19(10):2333–41. https://doi.
gio F, Oliva A, Zobel B, Pascali VL. Virtual autopsy with mul- org/10.1007/s00330-009-1440-4.
tidetector computed tomography of three cases of charred 18. Le Blanc-Louvry I, Thureau S, Duval C, Papin-Lefebvre F, Thie-
bodies. Med Sci Law. 2010;50(4):211–6. https://doi.org/10.1258/ bot J, Dacher JN, Gricourt C, Touré E, Proust B. Post-mortem
msl.2010.010116. computed tomography compared to forensic autopsy findings: a
9. Oliva A, Grassi S, Zedda M, Calistri L, Cazzato F, Masini V, French experience. Eur Radiol. 2013;23(7):1829–35. https://doi.
Polacco M, Maiolatesi F, Bianchi I, Defraia B, Grifoni R, Filo- org/10.1007/s00330-013-2779-0.
grana L, Natale L, Focardi M, Pinchi V. Forensic significance 19. Filograna L, Manenti G, Grassi S, Zedda M, Ryan Collen P,
and inferential value of PMCT features in charred bodies: a Floris R, Oliva A. Health Technology Assessment (HTA) of
bicentric study. Forensic Imaging. 2024;37:200590. https://doi. virtual autopsy through PMCT with particular focus on Italy.
org/10.1016/j.fri.2024.200590. Forensic Imaging. 2022;30:200516. https://doi.org/10.1016/j.
10. Khaji A, Ghodsi SM. Trend of elevator-related accidents in Teh- fri.2022.200516.
ran. Arch Bone Jt Surg. 2014;2(2):117–20. 20. Filograna L, Manenti G, Micillo A, Chirico F, Carini A, Gigliotti
11. Prahlow JA, Ashraf Z, Plaza N, Rogers C, Ferreira P, Fowler PE, Floris R, Malizia A, Oliva A. Post-mortem imaging: a tool
DR, Blessing MM, Wolf DA, Graham MA, Sandberg K, to improve post-mortem analysis and case management during
Brown TT, Lantz PE. Elevator-related deaths. J Forensic Sci. terrorist attacks. Forensic Imaging. 2023;34:200551. https://doi.
2020;65(3):823–32. https://doi.org/10.1111/1556-4029.14235. org/10.1016/j.fri.2023.200551.
12. Di Paolo M, Maiese A, dell’Aquila M, Filomena C, Turco S, Gia-
coni C, Turillazzi E. Role of post mortem CT (PMCT) in high Publisher’s note Springer Nature remains neutral with regard to juris-
energy traumatic deaths. Clin Ter. 2020;171(6):e490–500. https:// dictional claims in published maps and institutional affiliations.
doi.org/10.7417/CT.2020.2263.

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:

1. use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
2. use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
3. falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
4. use bots or other automated methods to access the content or redirect messages
5. override any security feature or exclusionary protocol; or
6. share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at

onlineservice@springernature.com