LECTURE ON MECHANICAL AND LECTURE ON MECHANICAL AND REGIONAL INJURIESREGIONAL INJURIES

DR . SONO MAL RATNANIDR . SONO MAL RATNANIASSISTANT PROFESSORASSISTANT PROFESSOR

DEPARTMENT OF FORENSIC MEDICINE DEPARTMENT OF FORENSIC MEDICINE

JINNAH SINDH MEDICAL UNIVERSITY KARACHI.JINNAH SINDH MEDICAL UNIVERSITY KARACHI.

• DEFINITION OF INJURY   According to Pakistan Penal Code an injury is defined

as any harm what so ever illegally caused to any person in body, mind, reputation or property. The medical profession is concerned with bodily harm which is covered by the term Hurt. 

• HURT: Whoever causes pain, harm, disease infirmity or injury

to any person or impairs, disable or dismembers any organ of the body or part thereof of any person without causing his death, is said to cause hurt.

MECHANICAL INJURIESMECHANICAL INJURIES

Injuries caused by physical violence to the body are known as MECHANICAL INJURIES.

Mechanical Injuries are classified in to: • ABRASIONS.• BRUISES OR CONTUSIONS• WOUNDS: -Theses are of 4 varieties. 

Incised Wounds.Stab or puncture wounds

  Penetrating,

Perforating. Lacerated Wounds.Fire Arm Wounds.

• Abrasions are injuries involving loss of the superficial epithelial layer of the skin and are produced by a blow or a fall on rough surface, by scratching with finger nails, thorns or by teeth bite or by friction and pressure of strings or ropes tied around the neck or other parts of the body. Abrasions vary in size and shape and bleed very little.

ABRASIONSABRASIONS

• Depending up on the manner in which they are caused, abrasions are classified in to:

 

• Scratches.

• Grazes.

• Imprint, pressure or Contact Abrasions.

TYPES:TYPES:

a) SCRATCHES: ARE PRODUCED WHEN OBJECTS LIKE FINGER

NAILS, PIN, THORN, ETC IS DRAWN ON THE SKIN.

CHARACTERISTICS: A CLEAN AREA AT THE COMMENCEMENT

& HEAPING UP OF SURFACE LAYERS OF SKIN AT THE TERMINATION.

b) GRAZE: Graze is an injury which is produced when a broad surface of the skin slides or scraps against a rough surface. It is commonly result of a traffic accident, more particularly when the body has been dragged. The direction of injury is indicated by serrated border initially and heaped up epithelium at the end. This type of abrasions helps a lot in reconstruction of the events in a vehicular accident. Abrasions caused by fall on the ground are generally found over bony prominences such as elbows, front of knees etc.

ARE CAUSED BY CONTACT WITH ROUGH SURFACES LIKE GROUND, ROAD RESULTING IN USUALLY IRREGULAR, REMOVAL OF SKIN SURFACE ALSO CALLED AS BRUSH BURNS IF ACCOMPANIED BY BRUISE.

EXAMPLE SEEN IN: o ROAD TRAFFIC ACCIDENTS (R.T.A).o DRAGGING OF BODY ON A GROUND.o GLANCING KICK WITH A BOOT.

EXAMPLE:EXAMPLE:

• LIGATURE MARKS IN CASES OF HANGING, STRANGULATION.

• BLOWS WITH LASH.

• FRICTION BETWEEN SKIN & EDGES OF GARMENTS.

d) IMPRINT ABRASION: (STAMPED ABRASION)

CAUSED BY IMPACT OF OFFENDING OBJECT

WITH SKIN.

REGISTERING THE IMPRESSION OF THE

OBJECT.

EXAMPLE:

- TYRE MARK.

- IMPRINT OF RADIATOR GRILL.

- TEETH MARKS.

- LIGATURE PATTERN.

- MUZZLE IMPRINT.

MEDICO-LEGAL SIGNIFICANCE:

IDENTIFICATION OF OFFENDING OBJECT.

• Abrasions should be differentiated from post mortem injuries due to ants and insects which commonly attack the moist and exposed parts of the body.

• Water animals such as fishes, which usually attack projecting parts of body such as nose, lips, ears, fingers etc here the edges appear nibbled. 

• In cases of bed sores, which are seen in disabled persons especially over back.

•  In abrasions due to ants, insects, fishes etc the signs of vital reaction are absent.

•  

DEFERENTIAL DIAGNOSIS.

1) POST MORTEM INSECT BITE (ANT BITE)

• NO VITAL REACTION.

• ON EMPOSED PARTS/WET AREAS.

• USUALLY NOT PARALLEL.

• EDGES NIBBLED.

2) EXCORIATION BY EXCRETA.

• INFANTS & DEBILITATED PERSON.

• CONFINED TO PERI-ANAL REGION BUTTOCKS.

3) PRESSURE SORES.

• H / O CONFINEMENT.

• ON PRESSURE POINTS.

DATING AN ABRASION (AGE)OBSERVATION TIME

BRIGHT RED FRESH

RED SCAB

DRIED BLOOD/SERUM

12-24 HOURS.

REDDISH BROWN SCAB 2-3 DAYS.

HEALING FROM PERIPHERY 4-7 DAYS.

COMPLETE HEALING 10-14 DAYS.

They provide valuable information depending up their.

 • Site.• Nature of object used.• Purpose of injury.• Direction of injury.• Time of injury. 

MEDICO LEGAL IMPORTANCE MEDICO LEGAL IMPORTANCE OF ABRASIONSOF ABRASIONS

• SITE:  In cases of fall on rough surface the

abrasions are mostly found over the bony prominences such as elbows, front of knees, hands etc.

 • NATURE OF OBJECT USED:  e.g. ligature mark in cases of hanging

strangulation, nail marks over the neck in throttling, teeth bite in defense or struggle.

 

• PURPOSE OF INJURY:  Site of an abrasion helps to determine purpose of

injury e.g. around the neck in throttling, over nose and mouth in smothering, on the inner aspects of thighs and genitilia in rape, around the anus in sodomy, and over bony prominences in cases of fall.

 • DIRECTION OF INJURY:  Serrated border initially and heaped up epithelium

at the end.

• TIME OF INJURY:  This can be determined from the process of

healing.

BRUSIE (CONTUSION)BRUSIE (CONTUSION)

DEFINITION: AREAS OF DISCOLORATION FORMED DUE TO COLLECTION OF BLOOD IN SUB-EPIDERMAL LAYERS OF SKIN OR COVERING OF AN ORGAN AS A RESULT OF RUPTURE OF CAPILLARIES OR VENULES WITH0UT BREACH IN THE INTEGRITY OF COVERING TISSUE (SKIN OR

CAPSULE), AS A RESULT OF APPLICATION OF BLUNT OBJECT.

DIAGNOSTIC FEATURES:DIAGNOSTIC FEATURES:

= ROUNDED IN SHAPE. SHAPE MAY CORRESPOND THE SHAPE OF CAUSATIVE OBJECT.

= REDDENED AREA WHEN FRESH.

= PAIN WITH TENDERNESS.

= SWELLING.

= EPIDERMIS MAY / MAY NOT SHOW DAMAGE.

= SIZE VARIES FROM PINHEAD TO AN EXTENSIVE HAEMATOMA.

TERMINOLOGY USED FOR EXTRA TERMINOLOGY USED FOR EXTRA VASCULAR COLLECTION OF BLOOD. VASCULAR COLLECTION OF BLOOD.

RATIONALE IS SIZE.RATIONALE IS SIZE.

a) PETECHIAL HAEMORRHAGE: SIZE OF PINHEAD.

b) ECCHYMOSIS: MORE THAN PIN HEAD, SMALLER THAN BRUISE.

c) BRUISE: LARGER THAN 5 mm IN DIAMETER.

d) HAEMATOMA: REMARKABLE COLLECTION OF BLOOD.

CAUSES:CAUSES: 1. SPONTANEOUS (DUE TO DISEASE):

DISEASE OF BLOOD, PURPURA, SCURVY, LEUKAEMIA.

2. TRAUMATIC:

BLOWS WITH CLUB, LATHI, FIST, KICKS, STONE & BRICKS.

FIRM GRIPING (IN WEAK DEBILITATED PERSONS)

TYPE OF BRUISE:TYPE OF BRUISE: DEPENDING UPON DEPENDING UPON DEPTH OF THE TISSUE DEPTH OF THE TISSUE

INVOLVEDINVOLVED1. SUPERFICIAL:

INTRADERMAL BRUISE:

1. DEEP:

DELAYED BRUISE

VISCERAL BRUISE

OR CONTUSION.

DEEP BRUISE MAY BECOME EVIDENT AFTER THE LAPSE OF SOME TIME (2-3 DAYS).

INVOLVING VASCULATURE OF MUSCLES, ORGANS & DEEP ADIPOSE TISSUE.

BELOW THE EPIDERMAL LAYERS. VISIBLE, EASILY PALPABLE.

MECHANISM:MECHANISM:

SUDDEN PRESSURE DUE TO MECHANICAL IMPACT CAUSES CAPILLARIES & VEINS TO RUPTURE RESULTING IN ACCUMULATION OF BLOOD BENEATH THE SKIN. SKIN POSSESSING ELASTICITY & PLASTICITY OFFER GREATER RESISTANCE, SO DO NOT BREAK.

FACTORS MODIFYING THE FACTORS MODIFYING THE APPEARANCE OF BRUISE.APPEARANCE OF BRUISE.

1) CONDITION & TYPE OF TISSUE:

BRUISE OCCUR MORE READILY, EASILY & EXTENSIVELY IN LAX TISSUE (EYE LIDS) AND WHERE EXCESSIVE. S/C FAT IS PRESENT. (FACE, BREAST) CONVERSELY WHERE SKIN IS STRONGLY SUPPORTED BY FIBROUS TISSUE (SCALP, PALMS OR SOLE) OR WHERE MUSCLE TONE IS STRONG (BOXERS, ATHLETES) BRUISE IS NOT FORMED OR LESS MARKED.

2) ECTOPIC BRUISE:2) ECTOPIC BRUISE:

A BRUISE MAY NOT BE PRESENT NECESSARILY AT THE SITE OF

IMPACT.

THE EXTRAVASATED BLOOD MAY MOVE ALONG TISSUE PLANES UNDER GRAVITY INFLUENCE AND GETS COLLECTED AT A DISTANT PLACE (GRAVITY SHIFTING).

EXAMPLE:EXAMPLE:

- BLOW ON FOREHEAD OR FALL ON VERTEX: BLACK EYE.

- FACTURE HEAD OF FEMUR

LATERAL ASPECT OF LOWER THIGH.

- BLOW ON OUTER PART OF THIGH

BRUISE AROUND KNEE.

3) AGE:3) AGE:

CHILDREN (DUE TO LOOSENING OF SKIN) & OLD (DUE TO LOSS OF FLESH & CHANGES IN BLOOD VESSELS) BRUISE EASILY.

4) SEX: FEMALES (OBESE) BRUISE EASILY.

5) VASCULARITY OF PART: BRUISING IS DIRECTLY PROPORTIONAL TO VASCULARITY OF AFFECTED PART.

6) COMPLEXION: VISIBILITY BETTER AND CLEAR IN FAIR SKINNED PEOPLE.

7) PRESENCE OF DISEASE. 7) PRESENCE OF DISEASE.

• COAGULATION FACTOR DEFICIENCY.• DISEASE OF BLOOD VESSELS.• DIMINISHED PLATELETS.

8) SITE TO INJURY: BRUISING IS MORE MARKED IN TISSUE OVERLYING BONES WITHOUT INTERVENTION OF FIBROUS TISSUE OVER SKIN.

BRUISE EASILY

MEDICO-LEGAL SIGNIFICANCEMEDICO-LEGAL SIGNIFICANCE• INDICATES OFFENDING OBJECT (BLUNT). • GIVES IDEA ABOUT DEGREE OF VIOLENCE.• TIME OF INJURY.• MOTIVE/PURPOSE OF INJURY.• IN THROTTLING, PRESSURE OF PADS OF

FINGER (SIX PENNY BRUISE) – HOMICIDE.• BRUISE ON BACK OF FINGERS, HAND &

FOREARMS. ( DEFENSIVE ACT).• MULTIPLE SMALL BRUISE ON ARMS JUST

BELOW SHOULDERS.

(FORCE FULL GRASPING DURING STRUGGLE)

• NUMEROUS BRUISE OF DIFFERENT AGE LOCATED AT JOINTS & OTHER AREAS IN.

• ADULTS: ALCOHOLICS, DRUG DEPENDENT.

• IN CHILDREN: BATTERED BABY SYNDROME.

• TRAM TRACK BRUISE: RESULTS FROM BLOW WITH ROD, STICK OR WHIP & ANY FLEXIBLE OBJECT. (TORTURE). CENTRAL DEPRESSED PALE AREA WITH MARGINS SHOWING BLOOD & SWELLING.

• SUCTION PETECHIE: BRUISING ON THE CHEEKS & BREAST. (SEXUAL INTERCOURSE),(LOVE BITES)

• BRUISE ON THE MEDIAL ASPECT OF THIGH, VULVA & AROUND ANUS INDICATE FORCEFUL SEXUAL INTERCOURSE.

• BRUISING OF CERVIX SHOWS DILATATION CERVIX.

• BRUISING OF BUTTOCKS INDICATE TORTURE• HOMICIDAL BRUISE: STILL COMMON IN OUR

SOCIETY. • MULTIPLE & MASSIVE CONTUSIONS MAY LEAD

TO REDUCTION OF EFFECTIVE CIRCULATING BLOOD VOLUME LEADING TO SHOCK THAT MAY PROVE FATAL.

• DUE TO SUDDEN COMPRESSION OF SUBCUTANEOUS TISSUES, FAT MAY BE DISPLACED AND ENTERS INTO INJURED VESSELS LEAD INTO FAT EMBOLISM.

• ACCIDENTAL: COMMON OCCURRENCE. • SUICIDAL: NOT COMMON SUICIDAL

FALL DO OCCUR.

• SELF INFLICTED: ARTIFICIAL BRUISED AREA PRODUCED BY RUBBING MARKING

NUT JUICE OVER SKIN.

DATING A BRUISE (AGE OF BRUISE)DATING A BRUISE (AGE OF BRUISE) DONE BY:

- MACROSCOPIC EXAMINATION (COLOR CHANGES).- MICROSCOPIC EXAMINATION (BLOOD PIGMENTS).

MECHANISM:BLOOD, DUE TO DISINTEGRATION OF RBC

BY HAEMOLYSIS, RELEASES HAEMOGLOBIN THAT BREAKS DOWN INTO HAEMOSIDRIN, HAEMOTOIDIN & BILIRUBIN BY THE ACTION OF HISTIOCYTES & TISSUE ENZYMES.

MACROSCOPIC CHANGES:MACROSCOPIC CHANGES: CHANGES ARE SEEN FROM PERIPHERY TO CENTER.

CHANGES OBSERVED TIME REQUIRED

RED 1ST DAY.

VOILET 2ND DAY.

BLUISH-BLACK 3RD DAY.

BROWN OR LIVID RED 4TH DAY.

GREENISH& THEN GREEN

5TH -6TH DAY.

YELLOWISH & THEN YELLOW

7TH-12TH DAY.

NORMAL 13TH -15TH DAY

MICROSCOPIC CHANGES:MICROSCOPIC CHANGES:

HEMOSIDIRIN WITHIN MACROPHAGES: NOT LESS THAN

24-48 HOURS.

HEMOTOIDIN WITHIN

MACROPHAGES: NOT LESS THAN 3 DAYS.

BILIRUBIN EXTRA CELLULAR: NOT LESS THAN 7

DAYS.

INCISED WOUNDS:INCISED WOUNDS:

• 1. SYNONYMS: CUT, SLASH, SLICE. • 2. DEFINITION: WOUNDS CAUSED BY IMPACT

OF SHARP EDGE OBJECT, EDGE MAY BE LINEAR OR POINTED.

• 3. CAUSATIVE WEAPONS: • - INSTRUMENTS: KNIVES, RAZOR, BLADES

DAGGERS, SWORDS, AXE. • - FRAGMENTS OF: CHINA GLASS, METAL. • - EDGES OF: PAPERS, GRASS. • 4. MECHANISM: PRESSURE (CONCENTRATION OF

FORCE) + MOVEMENT OF INSTRUMENT+ SHARP NESS.

APPEARANCE & SEVERITY DEPENDS UPON:- SHAPE OF WEAPON. - SHARPNESS OF EDGE. - MANNER OF INFLICTION.- TISSUE INVOLVED.

DIAGNOSTIC FEATURES: a) SHAPE: USUALLY SPINDLE SHAPED &

GAPING.b) MARGINS: CLEAN & REGULARLY CUT IF THE

SKIN IS FIRM OR TAUT, IRREGULAR MARGINS ARE SEEN IF SKIN IS LOOSE OR LAX.

EXAMPLE: SCROTUM, NECK (OLD PERSON).

c) EDGES: SHARP, EVENLY DIVIDED, EVERTED, SMOOTH.

RETRACTION OF SKIN & UNDERLYING MUSCULATURE CAUSES EVERSION OF MARGINS & GAPING OF WOUND.

d) ANGLES: SHARP , ACUTE.

e) BASE: INTERVENING DEEPER TISSUES ARE CLEANLY & EVENLY DIVIDED.

f) DIMENSIONS: LENGTH IS GREATER THAN DEPTH. WIDTH OF WOUND IS

GREATER THAN THE EDGE OF WEAPON CAUSING IT.

g) BLEEDING: BLEED FREELY & PROFUSELY (VESSELS ARE CUT).

h) TAILING: GRADUAL DECREASE IN DEPTH OF WOUND IS SEEN TOWARDS

TERMINAL END. SO A SUPERFICIAL WOUND INVOLVING ONLY SKIN IS SEEN. THIS IS CALLED “ TAILING OF THE WOUND”. TAILING INDICATES DIRECTION OF FORCE.

i) CLOTHES: CUTS ON CLOTHES MAY CORRESPOND WITH THE WOUND BUT IF THE CLOTHES ARE LOOSE, FOLDED OR DRAWN UP DURING STRUGGLE, CUTS IN CLOTHES MAY NOT COINCIDE WITH THE WOUNDS.

CLASSIFICATION OF INCISED WOUND CLASSIFICATION OF INCISED WOUND (BASED ON THE MOTIVES / INTENTION / (BASED ON THE MOTIVES / INTENTION /

MANNER).MANNER).

1. THERAPEUTIC (INFLICTED IN GOOD FAITH): CAUSED BY SURGEON AS A

PART OF TREATMENT. THEY ARE FOUND AT CERTAIN ELECTIVE, DEFINITE ANATOMICAL SITES.

2. ACCIDENTAL:

a) FROM FALLING UPON A SHARP OBJECT.

b) IMPACT BY A SHATTERED OBJECT LIKE GLASS, OCCUR ON ANY PART OF BODY.

3. HOMICIDAL TO PUNISH:

CAUSED WITH 3 MOTIVES.

TO MAIM OR DISFIGURE OR TO KILL: • FOUND ON FACE (CROSS SLASH). • FOUND ON NECK REGION. • ADDITIONALLY DEFENSE WOUND ON HAND

&

ARMS ARE FOUND, IF VICTIM WAS CONSCIOUS.

HOMICIDAL WOUNDS VARY CONSIDERABLY IN:

- DIRECTION.

- DEPTH.

- LOCATION.

4. SUICIDAL: FOUND ON CERTAIN ELECTIVE SITES.

= SIDES + FRONT OF NECK.

= FRONT OF WRIST (RADIAL ARTERY).

= FRONT OF THIGH (FEMORAL).

= FRONT OF CHEST (HEART).

FEATURES: MULTIPLE, SUPER IMPOSED, PARALLEL OF VARYING DEPTHS FOUND ON OPPOSITE SIDE OF THE WORKING HAND OF THE DECEASED, SHOW HESITATION OR TENTATIVE CUTS.

CHARACTERISTICS OF HESITATION OR TENTATIVE CUTS.

PRELIMINARY CUTS, SMALL, SUPERFICIAL,MULTIPLE FOUND AT THE COMMENCEMENT OF DEEP WOUND & MERGING IN DEEP CUT.

DIFFERENTIATION B/W SUICIDAL & HOMICIDAL CUT THROAT.DIFFERENTIATION B/W SUICIDAL & HOMICIDAL CUT THROAT. 1.CIRCUMSTANTIAL EVIDENCE (EXTRA 1.CIRCUMSTANTIAL EVIDENCE (EXTRA CORPORAL EVIDENCE).CORPORAL EVIDENCE).

INDICATOR SUICIDAL CUT THROAT

HOMICIDAL CUT THROAT.

PLACE SOLITARY, SEGREGATED LONELY.

NOT NECESSARY.

SCENE. UNDISTURBED. DISTURBED.

SELECTION OF WEAPON

LIGHT, SHARP EDGE. HEAVY WITH SHARP EDGE.

PRESENCE OF WEAPON AT THE SCENE.

PRESENT. USUALLY ABSENT MAY BE PRESENT.

CLOTHES. ORDERLY. BLOOD STAINED ON ANTERIOR PORTIONS OF CLOTHES.

DERANGED SUGGESTING SCUFFLE. BLOOD STAINS ON BACK OF NECK AND GROUND.

FARWELL LETTERS. MOSTLY PRESENT. ABSENT. IF PRESENT, COMPARE HAND WRITING.

PERSONALITY TRAIT.

DEPRESSED. NORMAL.

II. CORPORAL EVIDENCE:II. CORPORAL EVIDENCE:

CADAVERIC SPASM. HANDS CLENCHED HOLING INSTRUMENT.

HANDS MAY BE CLENCHED, CONTAINS BELONGING OF THE ASSAILANT.

DEFENCE WOUNDS. ABSENT. PRESENT.

DISTRIBUTION OF INJURIES.

CONFINED TO CERTAIN ELECTIVE SITE (NECK).

ADDITIONAL INJURIES OVER THE BODY.

WOUND COMPLEX.

SITE. LEFT SIDE OF NECK IN RIGHT-HANDED PERSON OR VIE VERSA.

BOTH SIDE & MID LINE.

LEVEL. HIGHER LEVEL ABOVE THE THYROID CARTILAGE.

LOWER LEVEL BELOW THE THYROID CARTILAGE.

TENTATIVE CUTS. PRESENT AT THE COMMENCEMENT.

NIL.

DIRECTION OF WOUND OBLIQUELY DOWN WARDS & MEDIALLY.

TRANSVERSE, UPWARDS & LATERALLY.

DEPTH OF WOUND GRADUAL DEEPENING, SHALLOWING WITH TAILING.

B0LD DEEP CUT WITHOUT TAILING.

NECK STRUCTURES. SUPERFICIAL STRUCTURES ARE CUT AT HIGHER LEVEL THAN DEEPER ONE.

SUPERFICIAL STRUCTURES ARE CUT AT LOWER LEVEL THAN THE DEEP ONE.

DEFENSE WOUNDS.DEFENSE WOUNDS. WOUNDS CAUSED AS A RESULT OF IMMEDIATE &

INSTINCTIVE REACTION OF VICTIM TO SAVE HIM FROM THE ATTACKING WEAPON, EITHER BY RAISING THE ARM OR BY GRASPING THE WEAPON.

SITES:

MEDICO LEGAL IMPORTANCE: 1. INDICATIVE HOMICIDE.2. VICTIM WAS ALIVE & CONSCIOUS.

WEAPON TYPE LOCATION BLUNT BRUISE DORSUM OF HANDS,

FORE ARMS

SHARP EDGES.

INCISED WOUNDS PALM OF HANDS ULNER BORDER OF FOREARM.

FABRICATED (FICTITIOUS. FORGED FABRICATED (FICTITIOUS. FORGED SELF-INFLICTED INJURIES.SELF-INFLICTED INJURIES.

DEFINITION: THE WOUNDS INFLICTED ON THE BODY, BY THE PERSON HIMSELF OR BY ANOTHER PERSON TO MISGUIDE THE INVESTIGATORS, WITH SOME MALAFIDE INTENTIONS OR ULTERIOR MOTIVES.

MOTIVES: 1. TO BRING A CHARGE AGAINST A PERSON OR TO

IMPLICATE AN INNOCENT PERSON IN A FALSE CASE. 2. TO ACCUSE POLICE OF MALTREATMENT DURING

CUSTODY. 3. POLICE/WATCHMAN/GUARDS CLAIM EFFICIENCY

DURING CATCHING/ENCOUNTERS WITH CRIMINALS. 4. MURDERER MISGUIDING THE INVESTIGATORS, THAT

KILLING WAS IN SELF-DEFENSE.

WEAPONS USED:

1. SHARP EDGE LIGHT CUTTING WEAPON_____ COMMONLY USED.

2. FIRE ARMS (SHOT GUN)______ RARELY USED

3. CHEMICALS _______ MARKING NUT JUICE VERY RARELY USED.

4. BLUNT WEAPONS_______ VERY RARELY USES

o INJURIES SUSTAINED DUE TO FALL ARE CLAIMED TO BE CAUSED BY BLOWS.

o TOOTH SHED DUE TO DISEASE IS CLAIMED TO CAUSED BY BLUNT TRAUMA.

ELECTIVE SITES: 1. ACCESSIBLE/NON VITAL AREAS. TOP OF

HEAD/FORE HEAD OUTER SIDE OF LEFT ARM. FRONT OF LEFT FOREARM. FRONT OF CHEST/ABDOMEN. FRONT & OUTER PART OF THIGH.

DIAGNOSTIC FEATURES:1. HISTORY. EXAGGERATION WITH REFERENCE TO:o WEAPON.o NUMBER OF ATTACKERS. o METHOD OF INFLICTION.o NUMBER OF BLOWS.

EXAMINATION OF CLOTHES: o CLOTHES ARE SPARED USUALLY. o IF CLOTHES ARE INVOLVED THEY ARE DAMAGED, THEY

ARE CUT IN A WAY INCOMPATIBLE, WITH THE NUMBER, LENGTH DIRECTION & NATURE OF WOUND.

THE WOUND:o SUPERFICIAL, MULTIPLE, MADE HALF HEARTEDLY. o SEEN ON ACCESSIBLE, NON-VITAL LESS FUNCTIONING

AREAS. o CAUSED BY LIGHT, CUTTING INSTRUMENTS. o FIREARMS ARE ALSO USED IN OUR AREAS. o SHOT GUNS ARE USED. o CARTRIDGE DISCHARGING SMALL PALLETS IS USED. o SEEN SUPERFICIALLY BELOW THE SKIN OR ON

MUSCULAR AREA. o WOUND MAY BE INCISED & PELLETS ARE KEPT

MANUALLY.o AFTER X-RAY (CERTIFICATE) THEY ARE REMOVED.

STAB WOUND:DEFINITION: WOUND CAUSED BY A SHARP POINTED

WEAPON DRIVEN IN THE BODY, THE DEPTH OF WOUND BEING THE GREATEST DIMENSION.

SUBSTITUTING WORDS: PENETRATING WOUND: WHEN THE WEAPON AFTER

PASSING THROUGH TISSUES OPEN IN TO SOME PART OF THE BODY i.e. WOUND OF ENTRY BUT NO WOUND OF EXIT.

PERFORATING WOUND: WHEN THE WEAPON PASSES THROUGH & THROUGH THE BODY MAKING TWO WOUNDS i.e. WOUND OF ENTRANCE, WOUND OF EXIT, CAUSATIVE WEAPON.

- FLAT, POINTED OBJECTS_____ KNIFE, DAGGER, .

- SHARP, ROUNDED OBJECTS____NEEDLES, ICE PICKS. - ELONGATED, BLUNT ENDED ____ SCISSOR, FENCE.

DIAGNOSTIC FEATURES: HAVING ALL THE FEATURES OF INCISED WOUND, BUT DEPTH IS MORE THAN OTHER DIMENSIONS.

HOW TO ASCERTAIN DEPTH OF WOUND:

IN CASE OF PENETRATING WOUNDS:

IN LIVING:

NEVER INSERT ANY INSTRUMENTS/PROBE IN THE SUSPECTED STAB WOUND BECAUSE, CLOT ALREADY FORMED BY BODY RESPONSE CAN BE DISLODGED, CAUSING FRESH BLEEDING WITH FATAL RESULT. SHIFT THE INJURED TO OPERATION THEATRE, UNDER ANESTHESIA & ASEPTIC CONDITIONS EXPLORATION OF WOUND IS DONE, DEPTH IS OBSERVED.

IN CASE THE PERSON IS DEAD: AUTOPSY IS DONE & DEPTH IS GAUGED IN CASES OF PERFORATING WOUNDS: THE WOUND OF EXIT IS THE GUIDING PRINCIPLE.

CHARACTERISTICS OF WOUND OF ENTRY & WOUND OF EXIT CAUSED BY PERFORATING WEAPON WOUND OF ENTRY.

- GENERALLY BIGGER THAN THE WOUND OF EXIT. - PIECES OF CLOTH/FIBERS DIRECTED TOWARDS

WOUND. - MARGINS ARE CLEAN CUT & INVERTED.- ABRASION/BRUISING OF EDGES/MARGINS DUE

TO EFFECT OF HILT OF WEAPON MAY BE SEEN. - SHAPE OF WOUND MAY CORRESPONDS THE

SHAPE OF WEAPON.

EXAMPLE:

WOUND OF EXIT: SMALLER WITH EVERTED MARGINS. CLOTH FIBERS ARE DIRECTED OUT WARDS.

WEAPON SHAPE OF WOUND

SINGLE SHARP

EDGED WEAPON.

WEDGE SHAPE

DOUBLE SHARP EDGED WEAPON ELLIPTICAL SHAPE

ROUNDED POINTED CIRCULAR

POINTED SQUARE CRUCIATE

DOUBLE EDGED BLUNT CIRCULAR WITH BRUISING

INSTRUMENT TWISTED BEFORE WITH DRAWL.

TRIANGULAR OR CRUCIATE.

LACERATED WOUNDSLACERATED WOUNDS

• Lacerated wounds are the wounds in which the tissues are torn as a result of application of blunt force to the body; the force may be produced by some moving weapon or object or by a fall. Localized portions of tissues are displaced by the impact of blunt force. This displacement sets up traction forces and tearing or rupture of the tissues.

The characteristic features of The characteristic features of lacerated wounds are:lacerated wounds are:

 • The edges are irregular, ragged and frequently bruised.• The margins are commonly abraded and abraded area

corresponds to the surface of impact.• Deeper tissues are unevenly divided.• Hair bulbs if present are crushed.• Blood vessels are crushed unevenly so external hemorrhage is

less.• Foreign material usually found in the wound.• No relation ship between wound and weapon causing it is seen.• Usually accompanied by internal injuries.• Fat embolism is the chief complication.

• Depending upon the manner in which they are produced, they are classified in to.

•  SPLIT LACERATIONS: (Blunt perpendicular impact).

• STRETCH LACERATIONS ( Tangential impact )

• AVULSION ( Horizontal crushing impact )

• TEARS ( Irregularly directed impact )

DIAGNOSTIC FEATURES: - MARGINS : FREQUENTLY ABRADED.- EDGES : IRREGULAR, JAGGED,

INVERTED, SWOLLEN, BRUISED.- ANGLES : TORN, IRREGULAR.- DEPTH (BASE) : UNEVEN, NON UNIFORM DEPTH,

STRAND OF TISSUE FOUND, BRIDGING/ CROSSING

OVER AT THE VARYING DEPTHS. - HAIRS BULBS: CRUSHED. - B. VESSELS : CRUSHED.- SKIN : FLAPPING. - EXTERNOUS : COMMONLY FOUND.- MATERIAL :

MECHANISM OF CAUSATION OR TYPES: ON THE BASIS OF MECHANISM OF CAUSATION

LACERATION ARE DIVIDED INTO 4 TYPES.

a) SPLIT / SLIT LACERATION.

SPLITTING OF SKIN AND UNDERLYING TISSUES OCCUR, WHEN THERE IS COMPRESSION/ CRUSHING OF THE AFFECTED TISSUE BETWEEN TWO HARD OBJECTS THAT IS BONE & BLUNT INSTRUMENT OR GROUND. IMPACT IS PERPENDICULAR.

EXAMPLE: COMMONLY SEEN OVER SCALP, CHEEK (ZYGOMATIC ARCHES)

CHIN, EYE BROW ETC.

RESEMBLANCE: APPARENTLY OR ON CURSORY EXAMINATION THEY ARE CONFUSED WITH INCISED

WOUNDS.

SOLUTION: CAREFUL EXAMINATION WITH HAND LENS, SHOWS, DENUDATION OF HAIRS NOT CUTTING, IRREGULAR EDGES WITH BRUISING.

b) OVER STRETCHING OF SKIN:

THERE IS LOCALIZED PRESSURE WITH PULL, WHICH INCREASES UNTIL TEARING

OCCURS PRODUCING A FLAP INDICATING DIRECTION OF THE OFFENDING OBJECT, IMPACT IS TANGENTIAL.

EXAMPLES:-LACERATION OF SCALP WHEN HEAD STRIKES WITH WINDSCREEN.

- GLANCING KICKS WITH A BOOT.

- DEFORMITY OF BONE OCCURRING AFTER FRACTURE CAUSING

OVERLYING TISSUES AND SKIN TO TEAR.

c) AVULSION/GRINDING COMPRESSION OF SKIN

LOCALIZED PRESSURE DUE TO HEAVY WEIGHT CAUSES TEARING OF SKIN, CRUSHING OF MUSCLES & SEPARATION OF SKIN FROM THE UNDERLYING TISSUES, FORMING A SPACE. THERE WILL BE EXTRAVASATION OF BLOOD, FAT, FOREIGN BODIES IN THE POTENTIAL SPACE. IMPACT IS HORIZONTAL.

EXAMPLE: RUN OVER BY A LORRY WHEEL.

COMPLICATION: CRUSH SYNDROME LEADS TO FAT EMBOLI RESULTING IN DEATH.

CRUSH RELEASE OF FAT ENTRY IN THE BLOOD.

CIRCULATION FAT EMBOLI DEATH.

d) TEARING OF THE SKIN: CAUSED BY IMPACT BY OR AGAINST IRREGULAR OR SHARP PROJECTING OBJECT. THIS IS ANOTHER FORM OF OVER STRETCHING.

EXAMPLE: MOTOR CAR / DOOR / HANDLES.

e) CUT LACERATION: WHEN A HEAVY AND SHARP EDGED WEAPON IS USED SKIN IS CUT WITH BRUISING AT EDGES, HAIRS ARE FORCED INTO WOUND.

EXAMPLE: HATCHET OR CHOPPER WOUND. MEDICOLEGAL ASPECTS: I) IDENTIFICATION OF OBJECT:

a) BLUNT ROUND END (POCKER HEAD) GIVES A STELLATE SHAPE WOUND

b) HAMMERHEAD GIVES A CRESENTRIC SHAPED WOUND. c) LINEAR ROUND OBJECT SUCH AS IRON BAR GIVES A LINEAR, Y – SHAPED

END WOUND (SWALLOW’S TAIL).d) LINEAR WITH EDGE (SQUARE JACK

HANDLE) GIVES A GROOVED TEAR.

II) DIFFERENTIATION B/W FALL & BLOW WITH STICKS. a) SHALVING OR MERGENCE: ONE MARGIN

OVER RIDING THE OTHER.b) FOREIGN BODIES/MATERIAL: INDICATE

THE FALL. III) INDICATION OF DIRECTION OF FORCE

THE MORE UNDERMINED EDGE IS THE SIDE TOWARDS WHICH THE FORCE OF STRIKING OBJECT IS DIRECTED. THE SIDE SHOWING ADJACENT CONTUSION IS THE SIDE FROM WHICH FORCE IS DIRECTED.

IV) INDICATES PLACE OF INCIDENCE: THE FOREIGN BODIES FOUND IN THE

DEPTH OF WOUND INDICATES PLACE OF INCIDENCE.

V) MANNER OF INJURY: ACCIDENTAL: COMMON, ESPECIALLY IN

THE URBAN AREA. INVOLVES THE EXPOSED PARTS OF THE BODY.

HOMICIDAL: COMMON IN RURAL AREA WHERE PRIMITIVE INSTRUMENTS ARE USED FOR ASSAULT.

SUICIDAL: VERY RARE.

VI) COMPICATIONS:

a) LACERATION MAY BE A SOURCE OF SEVERE, EVEN FATAL INTERNAL OR EXTERNAL BLEEDING.

b) BECOMES A PORTAL OF ENTRY FOR THE BACTERIA.

c) PULMONARY OR SYSTEMIC FAT EMBOLISM.

M.L. IMPORTANCEM.L. IMPORTANCE 

• Mostly seen in vehicular accidents or building collapse.

• Homicidal, when hit with some hard, blunt, heavy weapon of Assault.

• Suicidal when jumping on rough ground from a height to commit suicide.

•  

REGIONAL INJURIES

HEAD INJURIES

HEAD INJURYHEAD INJURY

• Head injury is the leading cause of death in road traffic accidents. It may be caused by other accidents such as fall from height or may be due to homicidal attack with blunt weapons. Fire arm injuries of head are another common cause of death, mostly homicidal.

For an easy understanding the head injuries are studied under three heads

• Scalp Injuries

• Skull Injuries

• Brain Injuries

a) SCALP INJURYa) SCALP INJURY

• Majority of injuries in Pakistan are accidental or homicidal.

ANATOMY-• S- skin• C- connective tissue• A - aponeurosis• L - loose connective tissue• P- periosteum

Majority of injuries in Pakistan are accidental or homicidal. Very rarely , scalp injuries are suicidal in nature mostly seen in lunatics.

Accidental scalp injuries mostly seen in vehicular accidents , fall from height or an object falling on the head. Most of the homicidal injuries are caused by hitting by a blunt weapon like lathi or sharp weapon like axe, hatchet, chopper,sword , gandasa , etc.

Scalp injuries may be contusion , incised or lacerated wound. In scalp lacerated wound may look like incised wound. It is essential that edges of wounds should be carefully noted as in incised wound the margins would be clean cut and hair bulb clear cut while in lacerated wound , the edges would be irregular and hair bulb crushed. Scalp injuries sometimes go unnoticed being hidden under the hair. Since scalp is dense tissue , less signs of bleeding , swelling and other signs of inflammation are observed.

Injuries of the scalp which have a special medicolegal significance are .

• ContusionBLACK EYE : this is a condition due to the bleeding in the

soft tissue around the eye owing to blunt trauma of the forehead rupturing the blood vessels and the blood tracks along the facial attachment around the lower margin of the orbits.

SPECTACLE HEMATOMA : This is a condition in which blood is collected in the soft tissue around the eyes , due to the fracture of the base of the skull.

BATTLE’S SIGN : A Bluish discoloration of the skin behind the ear that occurs from the blood leaking under the scalp after a skull fracture

Following are the types of fractures of skull• Depressed Fracture : It is due to direct impact of

weapon on the skull where bone is depressed to the extent of the force used. Since , the depression may resemble the weapon , the fracture is also called as Signature fracture or fracture ala signature.

• Comminuted Fracture : It is a case of depressed fracture where bone on fracture site gets broken into multiple pieces. The fragmented parts may get driven into underlying brain tissue. If there is no displacement of comminuted fragments , the area looks like spider’s web of mosaic.

B. SKULL FRACTURESB. SKULL FRACTURES

• Pond or Indented Fracture : it may be seen in small infants and children where skull is elastic. It may be produced by obstetric forceps during childbirth or hit by a blunt object. There may be indentation or simple buckling of skull.

• Gutter Fracture : It is due to Flanking or grazing by the bullet which produces a furrow in outer table of the skull.

• Linear or fissured fractures: They are linear cracks without any displacement of fragments of skull bones. The line of linear crack is very thin. They are usually caused by a blunt impact with broad resisting force like fall on the ground or in road traffic accidents.

• Diastatic Fracture: Separation of sutures or diastatic fracture is called when fracture line involves separation of sutures. They are commonly seen in children. There are caused due to broad impact of blunt force like fall from height , road traffic accidents , train accidents , etc.

• Contre-coup Fractures: there Fractures occur when head is not supported and is moving. In this fracture is seen on diagonally opposite side of the skull. It may be depressed fissured or crushed. Such fractures are common in road traffic accidents.

• Basilar Fracture : Basilar fractures are fractures of base of the skull ranging from linear to complex one. Basilar fractures are produced by heavy blunt force like fall , road accidents , etc.

Fractures of Base of the SkullFractures of Base of the SkullFollowing are types of fractures of base of skull:Following are types of fractures of base of skull:•Fracture of the anterior cranial fossaFracture of the anterior cranial fossa : is due to direct impact : is due to direct impact or as a result of contracoup injuries, resulting in black eyes or or as a result of contracoup injuries, resulting in black eyes or escape of CSF and blood from the noseescape of CSF and blood from the nose•Fracture of the middle cranial fossaFracture of the middle cranial fossa : is due to direct impact : is due to direct impact behind the ears or crush injuries of the head resulting in escape of behind the ears or crush injuries of the head resulting in escape of CSF and blood from the ear where petrous part of the temporal CSF and blood from the ear where petrous part of the temporal bone is fractured bone is fractured •Fracture of the posterior cranial fossaFracture of the posterior cranial fossa : is due to the impact on : is due to the impact on the back of the head , resulting in escape of CSF and blood into the back of the head , resulting in escape of CSF and blood into tissues of the back of the neck.tissues of the back of the neck.

• Fracture around foramen magnum (Ring Fracture) : This is a type of fissured fracture which encircles the base of skull around the foremen magnum running 3 – 5 cm outside foramen magnum at the back and sides of the skull. Such fractures are seen in following cases :

(A) Fall from height where a person falls on feet or buttock and impact passes upward through spinal column.

(B) Fall from height where head strikes the ground first.

(C) Fall of heavy load on head.

(D) Violent twisting of head.

• Hinge Fracture ( Transverse Fracture) : It is a fracture of the base of the skull where the fracture line runs from side to side across the floor of the middle cranial fossa , passing through the pituitary fossa in the midline following the course of least structural resistance.

INTRACRANIAL INTRACRANIAL HAEMORRHAGESHAEMORRHAGES

•EXTRADURAL EXTRADURAL •SUBDURAL SUBDURAL •SUBARACHNOIDSUBARACHNOID•INTRCEREBRALINTRCEREBRAL•INTRAVENTRICULARINTRAVENTRICULAR•PONTINEPONTINE•CONTRECOUP CONTRECOUP

EXTRA DURAL HAEMORRHAGEEXTRA DURAL HAEMORRHAGE

• It may occur as a result of violence with or without cranial fracture. It is generally due to rupture of middle meningeal artery or posterior meningeal artery, diploic veins or dural venous sinuses.

• In infants and old people, the dura is tightly adherent to the skull, so extra dural haemorrhage is less common in these ages, peak is seen in second and third decades.

EXTRA DURAL HAEMORRHAGE EXTRA DURAL HAEMORRHAGE (Cont)(Cont)

• As bleeding commences, it strips off the duramater from the under surface of skull with progressive accumulation of blood. It is usually unilateral. There is often free interval between infliction of injury and symptoms of extra dural haemorrhage, this symptom free period is known as LUCID INTERVAL which may vary from 2 hours- 7 days,but in most cases symptoms are apparent in 4 hours.

SUB DURAL HAEMORRHAGESUB DURAL HAEMORRHAGE

• It is also due to trauma, causing rupture of dural venous sinuses and cortical veins. Subdural haemorrhage is seen in old people, chronic alcoholics, blood diseases.

• It is generally diffuse over both cerebral hemispheres and tends to gravitate to the base of the brain.

• Increasing drowsiness and severe headache follows in 3-10 days after trauma. There may be weakness of one or other side of the body. Unilateral dilatation of pupil is frequently seen. Lucid interval is longer than that seen in extra dural haemorrhage.

SUB ARACHNOID HAEMORRHAGESUB ARACHNOID HAEMORRHAGE

• Between arachnoid and piamater due to, violence causing tearing of arachnoid

membrane or laceration of the cortex, in asphyxia such as strangulation, traumatic asphyxia, diseases such as rupture of athero sclerosed arteries, purpura, leukemia. It can occur at all ages. The diagnostic features are sudden onset of severe headache and stiff neck, followed by transient unconsciousness and finding of bloody cerebrospinal fluid under increased pressure.

INTRA CEREBRAL HAEMORRHAGEINTRA CEREBRAL HAEMORRHAGE

• It may be on the surface or in the substance of the brain. This is usually due to disease e.g. encephalitis, thrombosis, embolism or high blood pressure etc occurring as a result of sudden emotion, excitement or quarrel and rarely due to trauma with or without fracture of the skull.

• The effect varies with site. In rapidly fatal cases there is sudden onset of coma. In others consciousness may be lost for varying period of time. In acute stages the eyes are usually deviated to the side of the lesion and paralysis of the opposite side of the body. The neck is not as stiff as in sub arachnoid haemorrhage.

INTRACEREBRAL HAEMORRHAGE(Cont)INTRACEREBRAL HAEMORRHAGE(Cont)

• A chronic stage of forgetfulness, lack of coordination, tremors and dysarthria, known as PUNCH DRUNKENNESS, SLUG HAPPY or GOFFY is found among old boxers and is believed to be due to tiny haemorrhages in the brain during fights few years back.

INTRAVENTRICULAR HAEMORRHAGEINTRAVENTRICULAR HAEMORRHAGE

• It is also due to trauma. Haemorrhage in ventricles can be demonstrated by lumbar puncture where the cerebrospinal fluid is tinged with blood.

PONTINE HAEMORRHAGEPONTINE HAEMORRHAGE

• The haemorrhage in pons is characterized by constriction of pupil of the affected side followed by constriction of pupil of the opposite side, the pupils are thus asymmetrically pinpoint . More over the body temperature rises markedly due to damage to heat regulating centre in the pons.

CONTRE COUP HAEMORRHAGECONTRE COUP HAEMORRHAGE

• In cases where head is supported and fixed the injury occurs just below the site of impact and small haemorrhage may also occur, this is coup haemorrhage.

• In contre coup haemorrhage, when head is free to move, the skull on contact with a blunt object stops, but the brain continues to move due to inertia, so due to these linear and rotational strain the meninges are torn leading to extensive haemorrhage.

DATING OF HAEMORHHAGEDATING OF HAEMORHHAGE

• Rough idea can be had from the colour and consistency of the clot, and the colour of cerebrospinal fluid.

• In fresh haemorrhage the clot is red and soft.

• In 6-7 days, the clot starts breaking down.• In 12-15 days, a small clot leaves as a

residue ,a yellowish stained slit or a small pale brown clot.

DATING OF HAEMORRHAGE(Cont)DATING OF HAEMORRHAGE(Cont)

• The fate of big clot is liquefaction, leading to slow removal of pigment while clear fluid is drawn in by osmosis.

• Eventually there is a cyst of several centimeters in diameter with gliosis forming a kind of capsule on it, the capsule becomes evident to naked eye by about 8 days. The capsule looks like duramater in about2-3 months and within a year becomes thick and fibrous, and the brain is dented by the cyst.

DATING OF DATING OF HAEMORRHAGE(Cont)HAEMORRHAGE(Cont)

• In the examination of CSF, if the supernatant of the centrifuged fluid show no tinge of pink, only few hours have passed.

• After that time the erythrocytes began to haemolyse and following sequence of events is observed.

• After 6 hours, the supernatant fluid is pink, indicating free haemoglobin, no intact RBCs are found microscopically in the sediment after 3-6 days and Xanthochromia, imparted by break down of haemoglobin, commences at 12-24 hours, reaches maximum in few days and fades away in 2-3 weeks.

INJURIES TO THE BRAININJURIES TO THE BRAIN

• CEREBRAL CONCUSSION

• CEREBRAL IRRITATION

• CONTUSIONS AND LACERATIONS

• COMPRESSION OF THE BRAIN

• HAEMORRHAGES

MECHANISM OF BRAIN INJURIESMECHANISM OF BRAIN INJURIES

• Before studying brain injuries it is necessary to understand the various mechanisms involved, which include-

• ACCELERATING INJURY

• DECELERATING INJURY

• SHEAR STRAIN/ ROTATIONAL INJURY

• COUP & CONTRE COUP INJURY

ACCELERATING INJURYACCELERATING INJURY

• WHEN A MOVING OBJECT HITS THE HEAD WHICH IS STATIC, THE SKULL PICKS UP THE MOMEMTUM FIRST AND HITS THE BRAIN WHICH IS STILL AT REST,YET TO PICK UP MOMENTUM. THIS IS CALLED ACCELERATING INJURY.

• Example is hitting the head with a hockey stick.

DECCELERATING INJURYDECCELERATING INJURY

• WHEN A NON MOVING OBJECT SUDDENLY ARRESTS THE HEAD IN MOTION, THE SKULL LOOSES ITS MOMENTUM MUCH PRIOR TO BRAIN, WHICH HITS THE INNER SURFACE OF THE SKULL BEFORE BECOMING STATIC. THIS IS CALLED DECCELERATING INJURY.

• Example- when a motor cyclist stricks head against a electric pole on the road.

SHEAR STRAIN/ ROTATIONAL SHEAR STRAIN/ ROTATIONAL INJURYINJURY

• SHEAR STRAIN IS A STRAIN PRODUCED TO CAUSE ADJOINING PARTS OF THE BODY TO SLIDE RELATIVE TO EACH OTHER IN A DIRECTION PARALLEL TO THEIR PLACES OF CONTACT.(LINEAR STRAIN)

• WHEN HEAD STOPS AFTER COMING IN CONTACT WITH AN OBJECT, THE BRAIN CONTINUES TO MOVE DUE TO INERTIA CAUSING ROTATIONAL INJURY.(ROTATIONAL STRAIN)

COUP & CONTRE COUP COUP & CONTRE COUP INJURIESINJURIES

• COUP INJURY- WHEN HEAD IS SUPPORTED AND FIXED THE INJURY TO THE BRAIN OCCURS JUST BELOW THE SITE OF IMPACT.

• Example- Impact on forehead causes injury in frontal lobes.

• CONTRE COUP INJURY- WHEN HEAD IS FREE TO MOVE, THE INJURY OCCURS ON THE OPPOSITE SIDE OF THE IMPACT.

• Example – Impact on forehead causes injury in occipital area.

THEORIES REGARDING THEORIES REGARDING CONTRE COUP INJURIESCONTRE COUP INJURIES

• DIRECT IMPACT THEORY.

• LINEAR AND ROTATIONAL STRAIN THEORY.

• LATEST IS VACCUM THEORY.

THEORIES ABOUT CONTRE THEORIES ABOUT CONTRE COUP LESIONSCOUP LESIONS

• STRUCK HOOP THEORY- Due to elasticity of skull, the flattening of the skull result at the point of impact resulting in compression of the skull so that skull assumes an ovoid shape shortly and thus damage is caused to the opposite side of the impact of brain.

• RUSSELL’S THEORY- Sudden displacement of the brain towards impact side due to brain reacting as a jelly mass

and a potential space is developed on opposite side injuring the vessels and resulting in subdural and cortical damage.

GAGGIO’S PRESSURE GRADIENT THEORY- At the moment of impact, there is positive pressure on the side of impact and negative pressure on the opposite side; this bursts the vessels on the opposite side.

HOLBOURN SHEAR STRAIN THEORY-(ROTATIONAL FORCE THEORY): Contre coup lesions are chiefly due to local distortion that causes shear strain due to pulling apart of constituent particles of brain.

WHEN MOVING HEAD is suddenly decelerated by hitting a firm surface, contre coup injury results, the sudden arrest of head results in brain that is still in motion striking the stationary skull.

RAWLING’S THEORY OF BONY IRREGULARITIES- Irregular bony prominences particularly orbital and cribriform plate, lesser wings of sphenoid contuse or lacerate base of frontal lobes and tips of temporal lobes, some times with fracture of orbital plate.

• Fall on side of head producing contusion on opposite side of brain due to formation of cavity or vacuum on opposite side of impact, the vacuum exerts a suction effect that damages the brain.

• MORITZ’S RADIATING WAVE THEORY- Energy of impact in a hollow organ propagates by radiating waves along the meridional lines that damages as they leave the site of impact and converge as they approach the opposite side.

CEREBRAL CONCUSSIONCEREBRAL CONCUSSION(COMMOTIO CEREBRI)(COMMOTIO CEREBRI)

• The term cerebral concussion is generally used to indicate a purely functional disorder that is reversible and of relatively minor nature.

• It is popularly known as STUNNING.

• Concussion is believed to be due to minor neuronal injury, with damage to any part of neuronal body, axons and synapses.

Cerebral concussion (Cont)Cerebral concussion (Cont)

• CLINICAL FEATURES:• In mild injury the essential feature is transient but

immediate unconsciousness or impaired consciousness following trauma to the head.

• In severe injury the victim falls down and become unconscious, but there is no paralysis. The face is pale and the pupils are constricted and react to light. Skin is cold and clammy and body temperature is subnormal. Sphincters are relaxed and there is incontinence of urine and faeces. Result may be death from SYNCOPE. Some times after apparent recovery death may occur from INFAMMATION or COMPRESSION.

CEREBRAL CONCUSSION (Cont)CEREBRAL CONCUSSION (Cont)

• RECOVERY- In cases of recovery without inflammation or irritation following functional disturbances may be seen.

• (a) RETROGRADE AMNESIA. COMPLETE LOSS OF RECENT PAST MEMORY, i.e. PRE AND POST INJURY EVENTS, USUAL DURATION IS 15-30 DAYS.

Cerebral concussion (cont)Cerebral concussion (cont)

• (b) POST TRAUMATIC AUTOMATISM: THE PATIENT MAY SPEAK AND ACT IN A PURPOSIVE MANNER, BUT DOES NOT KNOW WHAT HE WAS DOING AND RETAINS NO KNOWLEDGE OF HIS ACTIONS.

• (c) POST CONCUSSION SYNDROME: AFTER RECOVERY OF CONSCIOUSNESS THERE MAY REMAIN SYMPTOMS OF HEADACHE, MENTAL IRRITABILITY, LOSS OF HEARING, SIGHT AND INSOMNIA.

CEREBRAL IRRITATIONCEREBRAL IRRITATION

• INCLUDE PECULIAR SET OF SMPTOMS THAT MAY FOLLOW CEREBRAL CONCUSSION. HERE THE PATIENT LIES CURLED UP IN BED WITH HIS HEAD BENEATH THE PILLOWS, HE DISLIKES ALL FORMS OF INTERFERENCE AND EXPOSURE TO LIGHT. HE IS NOT UNCONSCIOUS BUT PAYS NO ATTENTION TO HIS SURROUNDINGS. HE IS LIABLE TO BECOME AGGRESSIVE IF DISTURBED. THE SYMPTOMS GRADUALLY DISAPPEAR WITH COMPLETE RECOVERY OR FOLLOWED BY POST CONCUSSION SYNDROME.

CEREBRAL CONTUSIONS & CEREBRAL CONTUSIONS & LACERATIONSLACERATIONS

• In this case due to head injury there is disruption of soft tissues of the brain especially the cortical region with damage to blood vessels with extravasation of the blood in to the substance of affected area, the area gets bruised and swollen and constitute a contusion.

NAMES OF CONTUSIONS IN DIFFERENT NAMES OF CONTUSIONS IN DIFFERENT

PARTS OF BRAIN’,PARTS OF BRAIN’,

• Contusions found in deeper structures of brain along the line of impact are called INTERMEDIATARY CONTUSIONS.

• Contusions caused by fractures of the skull are called FRACTURE CONTUSIONS.

• Contusions in frontal lobes due to gliding of brain due to severe impact are known as GLIDING CONTUSIONS.

• Contusions in the cerebellar tonsils and medulla produced by momentary shift of brain towards foramen magnum are called HERNIATION CONTUSIONS

CLINICAL FEATURESCLINICAL FEATURES

• Loss of unconsciousness predominantly.• COMPLICATIONS-• Cerebral contusions may lead to,

-Bleeding from torn plial blood vessels. -Edema of brain tissue. -Increased intracranial pressure. -Death when not properly treated. -Healing by gliosis may cause pressure symptoms.

• COUP & CONTRE COUP INJURIES ARE ALSO CONTUSIONS & LACERATIONS OF THE BRAIN.

CEREBRAL COMPRESSIONCEREBRAL COMPRESSION

• IT IS A CLINICAL CONDITION CAUSED BY INCREASED INTRACRANIAL PRESSURE WHICH DISTURBS THE BRAIN FUNCTION.

• CAUSES• FORMATION OF PRESSURE OVER AND AROUND

THE BRAIN STEM AS A RESULT OF DEPRESSED FRACTURE OF SKULL, FOREIGN BODY, EDEMA OR HAEMORRHAGES.

• Diagnosis of cerebral compression is very important as surgical treatment of the cause can relieve compression, which is a live saving measure.

INJURIES TO THE SPINEINJURIES TO THE SPINE

CONCUSSION OF SPINETHIS CONDITION CAN OCCUR WITHOUT ANY

EVIDENCE OF EXTERNAL INJURY TO THE SPINAL COLUMN, FROM A FORCIBLE BLOW ON THE BACK OR A FALL FROM HEIGHT OR A BULLET INJURY BUT IS COMMONLY SEEN IN RAILWAY ACCIDENTS AND MOTOR CAR COLLISIONS, HENCE ALSO KNOWN AS RAILWAY SPINE.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

• MAY APPEAR IMMEDIATELY OR MAY BE DELAYED FOR HOURS OR DAYS. THERE MAY BE PARALYSIS OF UPPER AND LOWER LIMBS OR LOWER LIMBS ALONE WITH INVOLVEMENT OF BLADDER AND RECTUM. THE PERSON MAY PRESENT WITH HEADACHE, GIDDINESS, RESTLESSNESS, NEURASTHENIA, LOSS OF SEXUAL POWER AND WEAKNESS IN THE LIMBS. THE PARALYSIS IS TEMPORARY AND RECOVERY OCCURS WITHIN 48 HOURS.

INJURIES TO THE UPPER INJURIES TO THE UPPER CERVICAL SPINECERVICAL SPINE

• VERTICAL IMPACT TO THE HEAD WITH STRAIGHTENED NECK MAY LEAD TO COMPRESSION FRACTURE OF ATLAS KNOWN AS JEFFERSON’S FRACTURE, ANOTHER COMMON FRACTURE SEEN IS IN SECOND CERVICAL VERTERBA, AXIS IS KNOWN AS HANGMAN’S FRACTURE IN WHICH THERE IS ANTERIOR DISLOCATION OF C2 WITH FRACTURE OF ODONTOID PROCESS OR IT’S ANTERIOR DISLOCATION CRUSHINING THE MEDULLA AND PONS WHERE VITAL CARDIAC AND RESPIRATORY CENTERS ARE SITUATED,THIS IS SPECIALLY SEEN IN JUDICIAL HANGING.

INJURIES TO MIDDLE AND INJURIES TO MIDDLE AND LOWER CERVICAL SPINELOWER CERVICAL SPINE

• MOST COMMON INJURIES ARE HYPER FLEXION AND HYPER EXTENSION INJURIES KNOWN AS WHIPLASH INJURIES, WHICH ARE MOST COMMONLY SEEN IN MOTOR CAR ACCIDENTS WHERE DUE TO SUDDEN STOPPAGE OF A VEHICLE IN SPEED CAUSES HYPERFLEXION AND THEN HYPER EXTENSION OF NECK, PULLING THE NERVES AT THE ROOT OF NECK LEADING TO PARALYSIS OF LIMBS WITH FRACTURES OF C3 AND C4.

THORACIC AND LUMBAR SPINETHORACIC AND LUMBAR SPINE

• T1 TO T10 ARE MORE RESISTANT TO INJURIES BECAUSE OF ADDITIONAL STABILITY OF THORACIC RIB CAGE, SO DISLOCATOIN AND ROTATIONAL INJURIES ARE LESS COMMON AS COMPARED TO LOWER THORACIC AND LUMBAR SPINE BECAUSE OF INCREASED FLEXIBILITY AS SEEN IN SEAT BELT SYNDROME . LUMBOSACCRAL SPINE IS MORE PRONE TO FRACTURES AND COMPRESSION INJURIES.

INJURIES TO SPINAL CORDINJURIES TO SPINAL CORD

• SPINAL CORD INJURY MAY RESULT IN QUADRIPLEGIA OR PARAPLEGIA. QUADRIPLEGIA(PARALYSIS OF ALL FOUR LIMBS) IS SEEN WHEN INJURY IS ABOVE THE LEVEL OF EMERGENCE OF ROOTS SERVING THE BRACHIAL PLEXUS(4TH CERVICAL) AND PARAPLEGIA (PARALYSIS OF LOWER LIMBS) ISSEEN DUE TO INJURY BELOW THE LEVEL OF EMERGENCE OF BRACHIAL PLEXUS(1ST AND 2ND THORACIC VERTEBRAE).

PENETRATING INJURIES OF PENETRATING INJURIES OF THE SPINAL CORDTHE SPINAL CORD

• PENETRATING INJURIES ARE USUALLY CAUSED BY MISSILES SUCH AS BULLETS.

• ANOTHER TYPE OF PENETRATING INJURY IS PITHING IN WHICH A NEEDLE IS PUT IN NAPE OF NECK BETWEEN 2ND AND 3RD CERVICAL VERTEBRAE AND ROTATED TO SEPARATE SPINAL CORD FROM MEDULLA, THIS IS ONE OF THE COMMON METHOD OF INFANTICIDE.

INJURIES TO THE NECKINJURIES TO THE NECK(I)SUICIDAL CUT THROAT(I)SUICIDAL CUT THROAT

(ii)HOMICIDAL CUT THROAT (ii)HOMICIDAL CUT THROATS.NO SUICIDAL CUT

THROATHOMICIDAL CUT

THROAT1 LEFT SIDE OF THE NECK IN A

RIGHT HANDED PERSON COMMONLY ABOVE THYROID CARTILAGE

USUALLY IN THE CENTRE OR BOTH SIDES OF THE NECK COMMONLY BELOW THE THYROID CARTILAGE

2 HESITATION OR TENTATIVE CUTS SEEN AT THE COMMENCEMENT OF THE WOUND

NO HESITATION CUTS SEEN

3 SLOPED DOWN FROM LEFT TO RIGHT IN A RIGHT HANDED PERSON

SLOPED UP,ANY SIDE

4 GRADUAL DEEPENING AND SHALLOWING WITH TAIL OF THE WOUND ON THE RIGHT SIDE IN A RIGHT HANDED PERSON

BOLDLY CUTTING ACROSS. NO TAILING IS SEEN

CUT THROAT (CONT)CUT THROAT (CONT)

S.NO SUICIDAL CUT THROAT

HOMICIDAL CUT THROAT

5 CURVED ACROSS THE NECK MOSTLY HORIZONTAL

6 MAIN WOUND MAY CONTAIN MANY CUTS

MAIN WOUND SINGLE AND DEEPLY CUT

7 OFTEN ACCOMPANIED BY WOUNDS ACROSS WRISTS OR VITAL PARTS IN AN ATTEMPT TO COMMIT SUICIDE

NO ACCOMPANYING WOUNDS ON WRISTS, BUT THERE MAY BE SEVERE INJURIES OVER OTHER PARTS OF THE BODY, SO AS TO OVER COME THE VICTIM

CUT THROAT (CONT)CUT THROAT (CONT)S.NO SUICIDAL CUT THROAT HOMICIDAL CUT THROAT

8 NO CUTS ON HANDS FREQUENTLY DEFENCE WOUNDS OVER PALMER ASPECTS OF HANDS IN AN ATTEMPT TO CATH HOLD OF WEAPON OF ASSAULT

9 AS HEAD IS THROWN BACK CAROTID ARTERY IS USUALLY SAVED

CAROTID ARTERY AND JUGULAR VEINS LIKELY TO BE CUT

10 WEAPON FOUND NEAR THE BODY OR FIRMLY GRASPED IN THE HAND DUE TO CADAVERIC SPASM

WEAPON NOT FOUND ON THE SCENE OF CRIME AND NO CADAVERIC SPASM SEEN

11 SELECTS A QUITE ROOM USUALLY BED ROOM OR BATH ROOM BOLTED FROM INSIDE USUALLY IN FRONT OF A MIRROR WHICH SHOWS ARTERIAL SPOUTING,MORE OVER FAREWEL LETTER MAY BE PRESENT

DISTURBANCE OF SURROUNDING FURNITURE IS SEEN AT THE SCENE OF CRIME.NO FAREWEL LETTER SEEN

12 MOSTLY ADULT MALES ANY BODY

INJURIES TO THE FACEINJURIES TO THE FACE

• LOSS OF SIGHT• LOSS OF HEARING• DISLOCATION OF A TOOTH• CUTTING OF NOSE• CUTTING OF EAR LOBES• CUTTING OF LIPS• CUTTING OF TONGUE• DISFIGURATION OF THE FACE (VITRIOLAGE)

• FRACTURE OF ZYGOMATIC BONE• FRACTURE/ DISLOCATION OF MANDIBLE

INJURIES TO THE FACE (cont)INJURIES TO THE FACE (cont)

• A COMMON INJURY TO THE FACE SEEN IN ROAD TRAFFIC ACCIDENTS TO THE DRIVER IS BIRD FEET INJURY WHICH IS DUE TO BREAKING OF WIND SCREEN CAUSING PIECES OF BROKEN GLASS TO CAUSE LACERATED WOUNDS OF THE FACE AND IT APPEAR AS IF SOME BIRD HAS INJURED THE FACE WITH CLAWS.(WIND SCREEN INJURIES)

INJURIES TO THE CHESTINJURIES TO THE CHEST• TRAUMATIC ASPHYXIA • Traumatic Asphyxia or crush Asphyxia, is a form of Asphyxia resulting

from trauma to the chest, or pressure on the chest and back, which prevents respiratory movements. This may occur accidentally through.

• The chest being pressed violently in crowds at big fairs.• Being trampled in stamped crowds.• Chest trauma from run over car accident.• Steering wheel injury.• Building collapse.• AUTOPSY FINDING• In addition to signs of asphyxia, there are 4 characteristic features.• Deep cyanosis of the face.• Numerous Petechial hemorrhages.• Demarcating line between discolored upper part and normal colour

below the line.• Blood shot eyes.

Traumatic Asphyxia (cont)Traumatic Asphyxia (cont)• The mechanism is as follows. Compression of the

chest displaces blood from superior vena cava and subclavian veins in to smaller veins and capillaries of the head and neck which are considerably engorged and pressure in them rises so rapidly as to burst their walls. Therefore the face and neck of the victim are deeply cyanosed, almost black, eyes are bloody red (blood shot), and numerous petichae are found over the scalp, face, neck and shoulders. The level of compression is indicated by a well defined demarcating line between dis coloured upon portion of the body and lower normally colour part.

CHEST INJURIES (cont)CHEST INJURIES (cont)

• RIBS. MOST COMMON ARE FRACTURES OF THE RIBS.

THE RIBS WHICH ARE MOST COMMONLY FRACTURED ARE 4TH ,5TH ,6TH, 7TH AND 8TH RIBS, AS THEY ARE MOST PROMINENT AND FIXED AT BOTH ENDS.THE MOST COMMON SITE OF FRACTURE IS AT THE MOST CONVEX PARTS OF THE RIBS NEAR THEIR ANGLES.BILATERAL FRACTURES OF RIBS ARE SEEN IN RUN OVER VEHICULAR ACCIDENTS.THE BROKEN ENDS OF RIBS MAY RUTURE THE PLEURA OR LUNGS LEADING TO PNEUMOTHORAX OR HAEMOTHORAX.

CHEST INJURIES (cont)CHEST INJURIES (cont)

• STERNUM FRACTURE OF STERNUM IS RARE EXPECT

IN CASES OF STEERING WHEEL INJURY TO THE DRIVER OF A CAR WHEN HIS CHEST STRIKES THE STEERING WHEEL IN CAR COLLISION. THE MOST COMMON FRACTURE IS A TRANSVERSE FRACTURE EITHER BETWEEN THE MANIBRIUM AND BODY OF STERNUM OR SLIGHTLY BELOW.BACKWARD DISPLACEMENT OF LOWER SEGMENT OF FRACTURE CAN CAUSE DAMAGE TO VISCERA BEHIND IT.

CHEST INJURIES (cont)CHEST INJURIES (cont)• LUNGS WOUNDS OF THE LUNGS ARE MORE COMMON

BECAUSE OF FRACTURE OF THE RIBS CAUSING LACERATIONS OR PENETRATING INJURIES DUE TO SHARP POINTED WEAPONS OR FIRE ARMS.MOVE OVER HIGH EXPLOSIVE BLAST CAN ALSO CAUSE EXTENSIVE INJURIES TO THE LUNGS CAUSING CONGESTION, HAEMORRHAGE AND SUBPLEURAL BULLAE IN THE LUNGS.BECAUSE OF GLIDING IN CAR ACCIDENTS CONTRE COUP INJURIES MAY BE SEEN IN THE LUNGS.THE INJURIES CAN CAUSE PLEURISY, AIR EMBOLISM, PNEUMOTHORAX, HAEMOTHORAX, EMPHYSEMA.

CHEST INJURIES (cont)CHEST INJURIES (cont)

• SIGNS OF LUNG INJURIES.• DURING LIFE INJURY TO THE LUNG

CAN BE DIAGNOSED BY• SEEING SPUTUM WHICH CONTAIN

TRACES OF BLOOD AND IN MORE SERIOUS CASES FRANK HAEMOPTYSIS.

• TRAUMATIC EMPHYSEMA• DYSPNOEA

CHEST INJURIES(cont)CHEST INJURIES(cont)

• HEART. THE INJURIES TO THE HEART CAN BE,• NON PENETRATING• PENETRATINGNON PENETRATING INJURIES ARE DUE TO BLUNT

TRAUMA CAUSING BRUISING OF THE HEART WITH SUDDEN DEATH DUE TO VENTRCULAR FIBRILLATION OR VALVULAR RUPTURE. ANOTHER COMMON CONDITION IS CARDIAC TEMPONADE IN WHICH A DISEASED HEART MAY RUPTURE DUE TO TRAUMA CAUSING ACCUMULATION OF BLOOD IN THE PERICARDIAL SAC WHICH CAN INTERFERE WITH NORMAL CONTRACTION AND RELAXATION OF THE HEART(250-300 ML), LEADING TO CARDIAC ASYSTOLE AND DEATH.

HEART INJURIES (cont)HEART INJURIES (cont)• PENETRATING INJURIES ARE MOST COMMONLY DUE TO,• SHARP EDGED POINTED WEAPONS.• BULLETS. STAB WOUNDS OF AURICLES ARE MORE DANGEROUS

BECAUSE OF THEIR THIN WALLS THEY BLEED MORE PROFUSELY,AS COMPARED TO VENTRICLES WERE WALLS ARE THICK, IN THE SAME WAY STAB IN RIGHT VENTRICLE IS MORE DANGEROUS THAN STAB OF LEFT VENTRICLE WHERE THE WALL IS MORE THICK AS COMPARED TO THE RIGHT SIDE

• SOME TIMES HEART MAY BE INVOLVED WHEN INJURY IS OVER TRIGGER AREAS SUCH AS CAROTID SINUS ,SOLAR PLEXUS OR TESTES WHERE AS A RESULT OF TRAUMA VAGUS NERVE IS STIMULATED WHICH ARRESTS THE HEART(VASOVAGAL SHOCK)

CAUSES OF DEATH IN HEART CAUSES OF DEATH IN HEART INJURIESINJURIES

• HAEMORRHAGE• SHOCK• CARDIAC TEMPONADE• CORONARY ARTERY LESION CAUSING ISCHAEMIA OF

THE HEART.

BIG VESSELS- AORTA & PULMONARY VESSELS. THESE ARE USUALLY INJURED BY PENETRATING

WEAPONS OR BULLETS,RUPTURE OF AORTA MAY OCCUR FROM TRAUMA OR DISEASE, SUCH AS RUPTURE OF AORTIC ANEURYSM.

FIRE ARM INJURIES WITH BULLETS WHICH IMPART VIBRATION WAVES DUE TO SPINNING MOVEMENT CAN CAUSE RUPTURE OF HEART, LUNGS AND BIG BLOOD VESSELS.

ABDOMINAL INJURIESABDOMINAL INJURIES

• DEATH MAY OCCUR WITH A BLOW WITHOUT DAMAGE TO ABDOMINAL VISCERA DUE TO REFLEX INHIBITION OF THE HEART THROUGH VAGAL NERVE STIMULATION.

• COMMON INJURIES ARE STABS, GUN SHOT INJURIES AND BLOWS.

ABDOMINAL INJURIES (cont)ABDOMINAL INJURIES (cont)

• LIVER. OWING TO IT’S SIZE, IT’S FIXED POSITION AND

FRIABLE CONSISTENCY, IT IS COMMONLY INVOLVED IN STABS IN ABDOMEN,KICKS, BLOWS,ROAD TRAFFIC ACCIDENTS AND SOME TIMES BY FRACTURED RIBS AFTER PIERCING THE DIAPHRAGM.

COMPLICATIONS OF INJURY TO LIVER ARE,• SHOCK• MASSIVE INTERNAL HAEMORRHAGE• INFECTION, SUCH AS PERITONITIS

ABDOMINAL INJURIES(cont)ABDOMINAL INJURIES(cont)

• SPLEEN.

• IT IS ONE OF THE COMMONEST ORGAN TO RUPTURE DUE TO INJURIES IF ENLARGED IN DISEASES SUCH AS MALARIA.

• DEATH MAY OCCUR DUE TO,• SHOCK• EXCESSIVE INTERNAL HAEMORRHAGE

ABDOMINAL INJURIES (cont)ABDOMINAL INJURIES (cont)

• STOMACH AND INTESTINES. MAY BE RUPTURED IN BLAST INJURIES OR WHEN ALREADY DISEASED SUCH AS PEPTIC ULCER OR ULCERS IN INTESTINES IN TYPHOID AND AMOEBIASIS. OTHER COMMON CAUSES ARE STAB AND GUN SHOT INJURIES.

• KIDNEYS- BECAUSE OF THEIR ANATOMICAL LOCATION ARE USUALLY NOT RUPTURED, EXCEPT IN STABS AND GUN SHOT INJURIES

INJURIES TO THE GENITAL INJURIES TO THE GENITAL TRACTTRACT

• IN FEMALES, GRAVID UTERUS IS COMMONLY RUPTURED WHEN INSTRUMENTATION IS DONE TO PROCURE CRIMINAL ABORTION.

• RUPTURE OF FOLLAPIAN TUBES IS COMMON IN ECTOPIC GESTATION.

• BRUISING AND LACERATION IS COMMON IN FEMALE GENITAL TRACT IN SEXUAL ASSAULT.

• IN MALES, INJURY TO TESTES BY A KICK CAN CAUSE DEATH DUE TO SHOCK,SOME TIMES CONTUSIONS, LACERATIONS AND EVEN INFARCTION IS SEEN.

• SOME TIMES THERE MAY BE RUPTURE OF URETHRA DUE TO FALL IN MANHOLE(GUTTER) WITH FRACTURE OF FEMUR OR PELVIS.

• AMPUTATION OF PENIS MAY ALSO BE SEEN.

CAPT DR F H MIRZACAPT DR F H MIRZA

PELVIC INJURIESPELVIC INJURIES In severe trauma , the pelvis undergoes various

fractures as well as dislocations such as : (i) When there is application of great pressure to the front of the abdomen or pubic area such as in run over by the wheel, the pelvis is splayed open, symphysis pubis separates and one or both sacroiliac joints also dislocate (ii) When an impact occurs from the side , superior and inferior pubic ramus are fractured with dislocation of sacroiliac joint on the side of impact (iii) In circumstances of fall from height on to the feet , due to transmission of force up the legs , both the sacroiliac joints may dislocate and even one or both femoral head may also be driven into acetabulum. When the hip joints remain intact, the pelvic girdle may fracture and sacroiliac joints may dislocate (iv) Due to a kick or heavy fall on to the base of spine , fracture of sacrum or coccyx may result

CAPT DR F H MIRZACAPT DR F H MIRZA

(v) Empty bladder is rarely injured in trauma but a full bladder gets injured from blows , kicks and other blunt trauma. Other pelvic organs are quite protected from blunt injuries (vi) Male urethra may be injured as a result of direct trauma such as falling astride a solid object like a gate or being kicked in the crutch, due to being compressed against the undersurface of the pubis (vii) External genitalia may suffer injuries especially scrotum is quite vulnerable to severe bruising resulting from kicks. Scrotum and vulva may suffer injuries from falling astride on objects and in vehicular accidents.

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CAPT DR FARHAT H MIRZA