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Japan. A 59-year-old male was driving a car on the road. The back of his car was hit by a tanker and the collision forced his car into the opposite lane, where it collided with another big lorry. His car rotated clockwise and hit the tanker again. The man was wearing a seat belt but in an unconventional manner; that is, not over his right shoulder, but through the right axilla. Both airbags were inflated upon the impact of the vehicles. The windscreen of his car was destroyed and there was a marked deformation of the right bonnet and right front door.

Fig.1 Laceration of the right upper lip extending to the right nostril. Note some small lacerations and abrasions around the nostril.

When the ambulance arrived at the scene, the man was in a state of cardiopulmonary arrest with his head lying on the passenger’s seat, and he was bleeding profusely from his right nostril. He was confirmed dead at the hospital. The victim was brought to the Hamamatsu University School of Medicine for an autopsy.

Fig.2 Base of the victim’s skull, showing the perforation in the area of the ethmoid bone. A metal sound had been inserted into the perforated part.

The victim was 59 years old, 170 cm tall, and weighed 69.5 kg. As external findings, the face was ischemic and showed a marked laceration of the right upper lip extending to the right nostril. There were small lacerations, discolorations, and abrasions around the right nostril. Slight bone fractures were palpable at the right nasal and facial parts. Slight discolorations were observed in the right chest; they were probably caused by the seat belt. There was no bleeding from either external acoustic meatus. Except for the above injuries, only slight abrasions, discolorations and lacerations were evident on the rest of his body, in contrast to the severity of the traffic accident.

Fig.3 Basal view of the victim’s brain. The white arrows show the locations of contusion injuries of the brain stem and the cerebellum.

As internal findings, in the base of the skull, there were notable perforated fractures of both the ethmoid bone and the central part of the sphenoid bone, including the sella turcica; the perforated area with bone fractures was small stone-sized. In accordance with the basal skull fractures, there were contusion injuries in the midbrain, the left rostral part of the pons, and also the right part of the cerebellum. There were slight subarachnoid hemorrhages at both latero-parietal regions of the cerebrum. Bone fractures were found in the right fifth and sixth ribs. Except for the above injuries, there were no notable injuries to any other organ inside the chest and the abdomen, and no fractures were found in the extremities.

Fig.4 Lateral view showing with a metal sound that a stick-like item had penetrated through the right nostril and the base of the skull.

It was evident that a stick-like item had become impaled in his right nostril, passing through the nasal cavity and the basal skull bones into the basal part of the brain, resulting in the fatal brain injury, as demonstrated in Figure 4, using a metal sound. The length from the nostril to the brain stem was measured at 9.6 cm. Blood and urine alcohol levels were measured and found to be negative. The presence of amphetamines and psychotropic drugs in the urine was also screened with Triage1 and they were all negative.

Fig.5 Gear stick being fixed to the column of steering wheel, which probably caused the impalement from the nostril to the basal part of the brain.

Since the victim had not been ejected from his car during the collisions with both the tanker and the big lorry, a stick-like item that was responsible for the above impaling injury was looked for inside the front of the car. The gear stick that was attached to the steering wheel column was considered the most likely, because of its length, thickness, hardness, and immobility. It was, therefore, concluded that the gear stick had become impaled in the victim’s right nostril and then had passed into the basal part of the brain through the nasal cavity and the basal skull bones.

This was an unusual type of fatal injury resulting from a road traffic accident. The victim’s car collided three times with two big vehicles. Because of such strong impacts and the rotatory movement of his car during the accident, the body of the victim was probably flung across the car in an unusual way, resulting in the penetration of the gear stick into his right nostril. The detailed movements of the victim before the impalement are not clear.

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