In sharp force injury cases, the presence of hesitation marks or defense wounds figures among useful characteristics in the distinction of suicide and homicide. However, there are very few systematic comparative studies of hesitation marks and defense wounds in the forensic literature. This study was thus undertaken to systematically compare features of hesitation marks and defense wounds, with a particular emphasis on dispersion patterns. Over a 5-year period, all suicidal and homicidal sharp force cases were retrospectively reviewed for hesitation marks and defense wounds. A total of 58 suicides (7 women; 51 men) and 149 homicides (59 women; 60 men) were found, of which 74% (n = 43) were positive for hesitation marks and 61% (n = 91) for defense wounds. On the upper limbs, hesitations marks were more often observed on the anterior aspect of the limb, while defense wounds were equally distributed on the anterior and posterior aspect. For hand lesions, hesitation marks were generally located on one side only, while defense wounds more commonly involved both sides. No left or right predominance was observed in hesitations marks or defense wounds. Defense wounds were more widely distributed on the upper limbs than hesitation marks.

Deaths in a head-down position, mostly accidental events, are rare deaths in which a victim is found in an inverted body posture, with marked congestion of dependent body parts and no definite pathoanatomical cause of death. Such an exclusion diagnosis can only be put forward after elimination of other possible causes of death, following a scene investigation, medical record review, complete autopsy, and toxicological analysis. Particular attention should be taken not to confuse deaths by head-down position from the more usual positional asphyxia. We here report the case of an 82-year-old woman found stuck in the railings of the staircase leading to her house, her body freely suspended downward below the stairs. Death was finally attributed to a head-down position when correlating the autopsy findings with elements from the scene. Case reports of death by head-down position in the literature are reviewed. Furthermore, results from human experimental studies of head-down tilt are compiled. This systematic review allows an interesting insight into the physiopathology of those deaths, pointing more toward heart failure than to an asphyxial phenomenon per se.