Background: Free fatal falls (FFF) represent a distinct form of blunt force trauma (BFT) that is frequently encountered in forensic practice. Distinguishing FFF injuries from other forms of BFT, such as motor vehicle accidents (MVAs), can pose challenges. Despite its growing usage, the role of postmortem computed tomography (PMCT) in diagnosing FFF and its comparison with autopsy remains underexplored. Purpose: This review synthesizes fracture patterns in FFF, examining both extrinsic and intrinsic variables that influence skeletal injuries. It also compares PMCT and autopsy findings to establish a replicable database for forensic analysis. Methods: PubMed and Google Scholar were systematically searched by three independent reviewers. The inclusion criteria required studies to be published in English, report at least 10 cases, focus on fatal falls, and provide precise data on skeletal injuries. Studies lacking detailed descriptions, focusing on survivors, or involving non-free falls were excluded. Data extraction tables facilitated synthesis and analysis. Key Findings: FFF are characterized mainly by axial skeletal fractures, particularly of the chest, skull, and pelvis. A history of intoxication and psychiatric disorders often correlates with the manner of death. Fracture patterns vary by fall height, impact surface, and cause: accidental falls show greater chest and skull involvement, whereas suicidal falls present more pelvic and skull fractures. PMCT detects fractures more frequently than traditional autopsy. Conclusions: Distinct fracture patterns aid in differentiating suicidal from accidental FFF, shaped by extrinsic and intrinsic factors. Given its superior fracture detection capabilities, PMCT should be integrated into forensic protocols for FFF investigations.

Background: Free fatal falls (FFF) are a frequent occurrence in forensic medicine. Many variables, such as the victim’s sex, BMI, intoxication, height of the fall, and mental illness, can influence injury patterns. Previous studies identified fracture patterns and frequencies mostly with general anatomical detail, focusing on broad areas. As specific fractures might be roots for new statistical connections, this leaves a gap in our understanding. Using postmortem computed tomography, we aim to establish fracture frequencies and identify possible new statistical connections. Methods: In total, we retrospectively analyzed seventy-nine cases of confirmed deaths due to falls using the database of the Department and Institute of Forensic Medicine in Lublin. Our inclusion criteria were death due to free fall onto hard, non-deformable surfaces. We excluded cases of ground-level falls. All victims must have undergone postmortem computed tomography. Furthermore, each analyzed case documented individual intrinsic variables (sex, age, body mass, height, pre-existing mental conditions, and drug or alcohol use) and extrinsic variables (fall height, landing surface, time between the fall and death, and known cause of the fall). Results: Injuries in free fatal falls tend to focus on the axial skeleton. Suicides experience more severe, bilateral fractures, often involving the pelvis and limbs, while accidents tend to have unilateral injuries with rare limb involvement. We established new correlations with the height of the fall for the maxilla, mandible, anterior and posterior regions of the occipital bone, and the temporal bone. Moreover, our research confirmed previously noted correlations between the height of the fall and fractures of the limbs (and their individual bones), the lumbar vertebrae, and the chest. Conclusions: Our findings highlight that free fatal falls are characterized by distinct skeletal injury patterns that differ between accidents and suicides, with bilateral pelvic and limb fractures being particularly indicative of intentional falls. The integration of PMCT with autopsy improves the detection of these patterns. It provides valuable diagnostic and medico-legal insights, supporting a more precise determination of the cause and manner of death.

Fatal free falls (FFF) represent a distinct form of blunt force trauma and pose a significant challenge in forensic investigations, particularly in estimating fall height and differentiating between accidental and suicidal events. Postmortem computed tomography (PMCT) enables detailed assessment of skeletal injuries, including quantitative evaluation of skull fracture patterns. Total Cranial Fracture Length (TCFL), derived from three-dimensional CT skull fracture scoring (3D-CT-SF), has been proposed as an objective indicator of impact severity; however, available evidence remains limited. This study aimed to assess the relationship between TCFL and fall height in fatal free falls and to evaluate the influence of selected anthropometric and biomechanical variables on cranial fracture severity. A retrospective analysis of 76 fatal free-fall cases examined between 2016 and 2024 was conducted using PMCT and autopsy data. TCFL was measured on three-dimensional volume-rendered CT reconstructions of calvarial fractures. Statistical analyses were performed for the entire cohort and separately for accidental and suicidal falls. No significant correlation between TCFL and fall height was observed in the overall cohort or among suicide cases. In contrast, a significant negative correlation between TCFL and fall height category was identified in accidental falls. TCFL showed significant positive correlations with body mass, body mass index (BMI), and kinetic energy, particularly in the suicide subgroup. TCFL is a promising objective parameter for assessing the severity of cranial injury in fatal free-fall cases. While its utility in estimating fall height appears limited in suicidal falls, TCFL may support forensic interpretation of fall dynamics and contribute to distinguishing the manner of death, especially in accidental cases. Further studies in larger, more diverse populations are warranted.