Traumatic deaths are a significant public health and forensic problem, and include those due to road traffic, fall, assault, shooting, sharp trauma, burns, or other violent or accidental causes. Injury and violence are responsible for some 4.4 million annual deaths globally, equivalent to nearly 8% of all deaths, with injuries from road traffic accidents, homicide and suicide being significant contributors to deaths among young people [1,2]. Road traffic crashes cause over one million deaths per year, with a disproportionate impact on low and middle-income countries and vulnerable road users including pedestrians, cyclists and motorcyclists [3]. Traumatic deaths are also a contributing part of the medicolegal practice in Pakistan and are also a significant proportion of unnatural deaths investigated by medico-legal autopsy [4]. Victim demographics, cause of injury and trends of fatal trauma can differ significantly depending on age, sex, environment and mechanism, and systematic evaluation of the causes of traumatic deaths is necessary to understand the epidemiological and forensic characteristics [2].

Injury types and locations offer valuable clues to injury mechanism and physiological processes that cause death. Injuries from blunt trauma can present with external wounds and an underlying intracranial, thoracic, abdominal, or skeletal injury; sharp force and gunshot wounds can have characteristic wound morphology, distribution, and associated tissue destruction [5,6]. However, traumatic brain injury is especially relevant to forensic medicine since both blunt and penetrating head trauma can cause death of the brain, and analysis of the lesions may play a role in the cause and manner of death [5]. Likewise, research on road traffic incidents has shown that head and thoracic injuries are common causes of death, and that the type and extent of injury are correlated with the nature of the incident and the biomechanics of the impact [7]. Defensive injuries, associated trauma and location, number and type of wounds may also be useful (but not alone definitive) factors in sharp force deaths when differentiating between homicidal and suicidal deaths [8].

In cases of traumatic death, forensic analysis of these deaths must involve the integration of clinical findings, mode of injury, autopsy findings, ancillary investigations and circumstantial evidence and not just any one of these factors [9]. When several potentially life-threatening injuries occur together, or when pre-existing diseases make an individual vulnerable, or the connection between the traumatic event and the death is complex, determining the cause of death can be difficult [10]. In some forensic cases, a thorough gross examination may not be adequate to determine the mechanism or cause of death, and histopathological examination may be helpful [11]. In addition, recent evidence has shown that injury patterns may not necessarily be sufficient to determine the manner of death and thus should be considered with contextual and investigative data [12]. This holistic approach is especially at the forefront in Pakistan, where documentation and forensic analysis of injuries play a crucial role in the death investigation process [13,14]. The systematic examination of traumatic deaths can therefore give a detailed overview of the mechanisms of injury, the anatomical pattern of injuries, clinical findings, postmortem findings and the post mortem determination of cause of death.

Research Objective

To determine the correlation of injury patterns, mechanisms of trauma, clinical findings, and forensic assessment of the cause of death among traumatic fatalities.

Study Design and Setting The study conducted in a Tertiary care center with vast emergency, clinical and medico-legal facilities, was retrospective analytical cross sectional study. The study was conducted on the traumatic fatality and medico-legal autopsy cases that occurred over a 12-month period from the period of March 2025 to February 2026 Case Selection and Eligibility Criteria The study population consisted of all medico-legal examinations and autopsies of all eligible traumatic fatality cases that were performed during the study period. All cases for both sexes and all ages were included if sufficient clinical, autopsy and forensic documentation were available. Records that were complete, but lacked either injury characteristics or the cause of death were excluded. Records that were complete but missing either injury characteristics or the cause of death were excluded. Case Ascertainment and Sampling Strategy Consecutive sampling was used to select a sample of 300 cases. Medico-legal registers, autopsy records, hospital records and relevant forensic records were used to identify cases. Demographic, circumstantial, clinical, injury-related and forensic data was systematically extracted from each case, which was eligible for review. Characterization of Injury Patterns and Trauma Mechanisms Mechanism of trauma was documented such as blunt, sharp force, firearm, burn, asphyxial, combined or other mechanism. Injury patterns were rated based on anatomical location and nature of injury such as head and neck, upper and lower limbs, chest, abdomen and multiple regions of the body. Additional pathological findings included intracranial injuries, skull fractures, internal haematoma, visceral injuries, and the presence of multiple organ involvement. Clinical, Autopsy, and Forensic Assessment A review of clinical findings, available hospital records, medico-legal examination reports, autopsy findings and forensic laboratory findings was made. Demographic data, cause of death, external and internal injuries, and/or pathological findings were recorded. The results were integrated into determine the most likely sequence and implications of traumatic injury. Determination of Cause and Manner of Death The cause of death was identified on the basis of a comprehensive analysis of the clinical history, circumstances, injury pattern, autopsy, and other forensic evidence. Manner of death was reported as accidental, homicidal, suicidal, or undetermined as appropriate. A special focus was placed on the association between the trauma mechanism, the pattern of anatomic injury, and the certified cause of death. Statistical Analysis SPSS version 26.0 was used to analyse the data. Continuous data was presented as means ± standard deviations or medians (interquartile range), and categorical data was presented as frequencies and percentages. The chi-square test or Fisher’s exact test was used to determine association between categorical variables, and proper parametric or non-parametric tests for continuous variables were used. Where appropriate, factors associated with major outcomes were evaluated using multivariable logistic regression. A p-value <0.05 was considered statistically significant.

Among 300 traumatic fatalities, most victims were aged 21–30 years (24.33%), followed by 31–40 years (21.33%), and 77.33% were male (table 1). Blunt trauma was the most common mechanism (46.33%), while head and neck injuries were the predominant anatomical pattern (53.00%). Major external soft-tissue injuries (58.00%) and internal hemorrhage (47.67%) were the most frequent clinical/autopsy findings. Road traffic collisions accounted for 40.33% of deaths, with accidental deaths comprising 58.00%. Hemorrhagic shock/exsanguination was the leading cause of death (33.67%), followed by traumatic brain injury (27.67%).

Table 1. Sociodemographic, trauma-related, clinical, circumstantial, and cause-of-death characteristics of traumatic fatality cases (N=300)

A significant association was observed between mechanism of trauma and manner of death (χ²=178.36, p<0.001), shown in table 2. Blunt trauma was predominantly associated with accidental deaths (86.33%), whereas sharp-force injuries were mainly homicidal (51.02%) or suicidal (34.69%). Firearm injuries were predominantly homicidal (62.50%).

Table 2. Association between mechanism of trauma and manner of death (N=300)

Note: Pearson’s chi-square test was used to assess the association between mechanism of trauma and manner of death.

Anatomical injury patterns were significantly associated with cause of death (p<0.001), shown in table 3. Head and neck injuries were predominantly associated with traumatic brain injury (47.80%), whereas cases without head and neck injury more frequently had hemorrhagic shock (47.52%). Chest and abdominal injuries were also predominantly associated with hemorrhagic shock, while multiple-region injuries showed a greater proportion of multiple traumatic causes.

Table 3. Association between anatomical injury patterns and cause of death (N=300)

Note: Pearson’s chi-square test was used to assess associations between anatomical injury patterns and primary cause of death.

Major clinical and autopsy findings demonstrated significant associations with cause of death (p<0.001), shown in table 4. Intracranial injury and skull fracture were strongly associated with traumatic brain injury, while internal hemorrhage was predominantly associated with hemorrhagic shock. Visceral/organ injury was more frequently observed among cases attributed to hemorrhagic shock and multiple traumatic injuries.

Table 4. Association between clinical/autopsy findings and cause of death (N=300)

Note: Pearson’s chi-square test was used for categorical associations. Fisher’s exact test was used where expected cell frequencies were <5.

Multivariable logistic regression identified blunt trauma (AOR=3.84, p<0.001), head/neck injury (AOR=8.17, p<0.001), skull fracture (AOR=4.26, p<0.001), and multiple-region injury (AOR=1.67, p=0.041) as significant predictors of traumatic brain injury as the primary cause of death. Age, male sex, and internal hemorrhage were not independently significant (table 5).

Table 5. Multivariable logistic regression analysis of factors associated with traumatic brain injury as cause of death

Note: Multivariable binary logistic regression was used to identify independent predictors of traumatic brain injury as the primary cause of death. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

In the present study, a predominance of young and male population was observed in the traumatic deaths with a mean age of 40.1 ± 18.4 years and a male ratio of 77.33%. The largest age group was 21–30 years (24.33%), followed by 31–40 years (21.33%). The main mechanism of injury was blunt trauma (46.33%) and the most common circumstance was road traffic collisions (40.33%). This is similar to more recent Pakistani trauma-related literature which has demonstrated significant predomination of males, and significant involvement of younger adults. A large trauma registry study from Pakistan reported 79.82% male patients and a recent study in Peshawar revealed that 72% of trauma cases were male and about half were due to road traffic accidents [15,16]. The fact that there was a higher proportion of males than females in the current fatal series of injuries, and of younger males than females, could be attributed to increased exposure to road traffic, occupational and outdoor traumatic hazards. The most common anatomical pattern from our study was head and neck injury (53.00%), multiple-region (38.67%), and chest injuries (33.00%). Forty out of 100 patients (40.33%) had intracranial injuries, and 28 out of 100 patients (28.67%) had skull fractures. These results are similar to the autopsy study conducted in Karachi, where head injury was responsible for 64.6% of the deaths in road traffic accidents and skull fractures were found in 53% of the cases [17]. An autopsy study of all blunting road traffic deaths also found that the most commonly injured areas were the head and chest [18]. This may be because our overall population included non-road-traffic head injury cases such as sharp-force, firearms, burns, and asphyxial injuries, which are more likely to result in fatal injury. This correlation between the manner of death and trauma mechanism was especially strong. Most of the accidental deaths were caused by blunt trauma (86.33%), while sharp force deaths were mainly homicidal (51.02%) or suicidal (34.69%). Most firearm injuries were from homicide (62.50%). This overall association was statistically significant (χ²=178.36, p<0.001). These results are corroborated by the forensic literature, which is able to demonstrate that the type of weapon and the nature of the injuries will yield valuable data in the differentiation of the manner of death. Autopsy research on homicides has revealed a recent trend toward blunt instruments as the most common cause of death and that head trauma is the most common pathomechanism in homicide [19]. For example, forensics examinations of gunshot deaths highlights that the distribution of gunshot wounds and autopsy findings aid in distinguishing homicide from suicide [20]. A further finding was the strong correlation between anatomical injury distribution and cause of death that was seen in the present findings. Traumatic brain injury (47.80%) was associated with head and neck injury, while hemorrhagic shock was associated with cases without head and neck injury (47.52%). Chest and abdominal injuries also were more likely to be associated with hemorrhagic shock, and multiple region injuries exhibited a higher percentage of multiple traumatic causes. These trends are consistent with the accepted physiopathology of the difference between fatal neurological injury and exsanguinating trauma. A recent study in a cohort of patients in Peshawar found that severe TBI was significantly more common in those who died than in survivors, and hypotension and low Glasgow Coma score scores were independent risk factors for death [16]. Trauma death studies from around the world also confirm that hemorrhage and traumatic brain injury are the major causes of trauma-related death [21]. This relationship was supported by clinical and autopsy data. Of the traumatic brain injury deaths, 64.46% had intracranial injury and 70.93% had skull fracture. On the other hand, multiple traumatic injuries (34.04%) and hemorrhagic shock (44.68%) were common associations with visceral/organ injury, while hemorrhagic shock (53.15%) was common with internal hemorrhage. Such observations are supported by evidence that skull fractures are associated with more severe traumatic brain injury and are associated with increased mortality [22]. It is also a finding that highlights the importance of integrated autopsy evaluation as the external injury may not be enough to indicate the internal pathological process that caused death. Finally, multivariable analysis showed that blunt trauma, head/neck injury, skull fracture and multiple-region injury independently predicted traumatic brain injury as the primary cause of death (AOR=3.84, 8.17, 4.26 and 1.67, respectively). Although the association was weak, head/neck injury was the most prominent, suggesting that cranial trauma plays a major part in fatal injury patterns. Age >40 years, male sex and internal hemorrhage were not significant risk factors. Overall, the results suggest that the cause and manner of traumatic death should be considered together when evaluating mechanism, anatomical distribution and specific pathological findings. Systematic injury characterization is supported by Pakistani and international evidence, and this demonstrates the need for better trauma prevention and earlier management of severe head and hemorrhagic injuries [15-22]. Strengths and Limitations One of the most significant features of this study was the systematic analysis of traumatic deaths by recognizing demographic factors, trauma mechanism, anatomical injury pattern, clinical and autopsy findings, circumstances of death and forensic determination of cause and manner, which enabled an integrated evaluation of fatal trauma. By including consecutive cases over a specific 12-month period, selective case inclusion was limited and a representative sample of traumatic medico-legal deaths presenting to a tertiary healthcare centre was obtained. Multivariable analysis was also performed to determine factors independently associated with TBI as a cause of death. The retrospective single centre design may not be generalizable to other regions, however, and reliance on existing clinical, autopsy and medico-legal records may have resulted in information and documentation bias. The study also did not have a longitudinal follow-up and there was not a uniform data collection at various institutions, caution should be used in drawing causal inferences.

The relationships between the mechanism of the injury, anatomical injury patterns, clinical findings and autopsy findings and the final cause and manner of death were clearly illustrated in the case of traumatic deaths. Blunt trauma, cranial injury and hemorrhagic injury were important patterns in the fatal trauma spectrum, as was multiple-region trauma. Diagnosing cause and manner of death requires a thorough clinical history, circumstances, study of the distribution of injuries, autopsy and forensic evidence as an integrated whole. The results highlight the need for a systematic forensic assessment and preventative and management approaches.