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A keyhole gunshot wound to the head: an autopsy case

Considering the high incidence of deaths caused by firearms, forensic pathologists must possess a thorough understanding of the patterns of injuries caused by these weapons. Occasionally, distinguishing between entrance and exit gunshot wounds can be difficult. In our case, a 61-year-old man was killed by a 9 mm calibre gunshot wound to the head during a robbery. At the post-mortem examination the calvarium exhibited an atypical injury that showed both entrance and exit wound characteristics, compatible with a ‘keyhole’ defect of the skull. Keyhole fractures occur when a projectile strikes the cranium tangentially, owing to the vertical and horizontal forces usually generated by the fragmentation of the bullet. Atypically, in our case the bullet showed no fragmentation after the impact with the cranial bones and was still able to result in a keyhole defect. An accurate evaluation of the pattern of atypical lesions found in the post-mortem examination is necessary in order to evaluate the cause and the manner of death.