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Regional injury


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Forensic Medicine

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Regional injury

  2. 2. Head injuries  Head injuries occur as a result of: Traffic accidents Assaults Falls .  If the brain is affected, the injury is serious.  If the brain is not affected, the injury is simple.
  3. 3.  Closed head injury: when the dura is remains intact.  Open head injury: when the dura is lacerated.
  4. 4. Head injuries 1. Injuries of Scalp 2. Injuries of Skull 3. Injuries of brain
  5. 5. Injuries of Scalp 1. Bruising of scalp 2. Laceration of scalp 3. Infections
  6. 6. Injuries of Scalp • Scalp injuries may or may not be associated with fracture of the skull. * Hair around the injury must be shaved for proper examination.
  7. 7. Bruising of scalp  A bruise over the scalp is covered by hair, can only be detected by palpation.  Marked swelling is a common  Bruising may occurs immediately or may be delayed .
  8. 8. Laceration of scalp  Laceration of scalp bleeds profusely and dangerously even fatal blood loss can occur.  There is problem to differentiation between incised wound and laceration:
  9. 9. Differentiation between incised wound and laceration:  Blunt laceration has: 1. Irregular and Bruised margins 2. Head hair crossing the wound are not cut. 3. Hair bulb and tissue bridging ( small nerves and vessels ) are in the depth of wound.
  10. 10. Black eyes  Black eye is also called Periorbital heamatoma, Spectacle haemorrhage, RACCOON EYES,  Causes 1. Direct violence 2. Gravitational seepage 3. Fracture of anterior cranial fossa
  11. 11. Fractures of skull
  12. 12. Fractures of skull  The fractures of skull can occur either by direct or indirect violence.
  13. 13. Direct violence 1. Compression of the head by obstetric forceps during delivery. 2. When head is crushed under the wheels of a vehicle. 3. When head is struck by a moving object, eg, brick, bullet, machinary, hammer, axe etc.
  15. 15. Direct violence 4. Head in motion striking an object, eg, in falls and traffic injuries. 5. Repeated blows to the head as in boxing `PUNCH DRUNK syndrome`.
  16. 16. Indirect violence 1. Fall from a height on feet or buttocks. 2. Pressure transmitted from the below, eg, by an explosion. 3. A blow on the chin when the force is transmitted from the mandible to the skull.
  17. 17.  The base of skull is relatively weak part due to its irregular shape and foramina, therefore it is the most common site of skull fractures.
  18. 18. MECHANISM OF SKULL FRACTURE  Direct injury to the skull:  1. Fractures due to local deformation ( Struck hoop analogy). when skull receives a focal impact, there is a momentary distortion of the shape of cranium. esp. infants. The area under the impact bends inwards, a compensatory distortion or bulging of other areas occur.
  19. 19.  2. Fractures due to general deformation: Skull is compressed like elastic sphere. when skull is deformed, compression occurs on the concavity of curved bone and tension force on convexity.
  20. 20.  Puppe`s rule:  When two fracture lines meet at a same point then the second fracture line never cross the first fracture line.
  21. 21. Types of fractures of the skull 1. Fissured fracture. 2. Depressed fracture. 3. Comminuted fracture. 4. Pond or indented fracture. 5. Gutter fracture. 6. Penetrating fracture. 7. Elevated fracture. 8. Spider web fracture or mosaic fracture.
  22. 22. Fissured ( linear), Hairline fracture.  This is a linear fracture or crack involving the outer or inner table or both.  Such fracture cannot be detected by an X-RAY.  It can only be detected at autopsy.  It is caused by direct or indirect violence.
  23. 23. Fissured ( linear) fracture.
  24. 24. Diastasis or sutural fracture  MOTORCYCLIST`S fracture: In children and young adults a linear fracture may pass into a suture line and causes a diastasis or opening of the weaker suture between bones.  The most commonly involved suture is sagittal.  Common in child abuse syndrome.
  25. 25. Depressed fracture  This is cause by a heavy weapon with a small striking surface, eg, hammer.  The fracture bone is driven inward and its shape may be indicate the type of the weapon, therefore it is also know as SIGNATURE FRACTURE.
  26. 26. Comminuted fracture  The bone is broken into two or more pieces.
  27. 27. Comminuted fracture  This is caused by * Vehicular accidents, * Falls from height * Blow from weapon with large striking surface.
  28. 28. Pond or indented fracture  Pond fracture occur in children due to elasticity of their skull bones.  The fracture is due to forcible impact against some protruding object.  Fissured fractures may be seen round the periphery of the dent.
  29. 29. Pond or indented fracture
  30. 30. Gutter fracture  When a part of the thickness of skull bone is removed, eg, in glancing bullet wounds.  It is usually accompanied by irregular depressed fracture of the inner table.
  31. 31. Gutter fracture
  32. 32. Penetrating fracture  This is clean cut opening due to a penetrating weapon, eg, dagger, rod or bullet.
  33. 33. Elevated fracture  Elevation one end of bone above the surface of skull while the other end may dip down in the cranial cavity.
  34. 34. Spider web fracture or mosaic fracture.  A comminuted depressed fracture may also have fissure radiating from it forming a spider web.
  35. 35. Fracture of base of skull It is caused by i. Direct violence (not common) ii. Indirect violence (common) e.g fall from height, blow on chin iii. Blast from below
  36. 36. Fractures of base of skull Sites of fractures: 1. Anterior cranial fossa 2. Middle cranial fossa 3. Posterior cranial fossa 4. Around the foramen magnum.
  37. 37. FRACTURE OF ANT. CRANIAL FOSSA CAUSES: 1) Direct Impact 2) Heavy Blow On Chin 3) May result from contre coup injuries. MENIFESTATIONS: It manifests by escape of blood & CSF from nose & blood in the orbit result in black eye.
  38. 38. FRACTURE OF MIDDLE CRANIAL FOSSA CAUSES:  Direct Blow behind ears  Crash injuries of head MANIFISTATION :  Escape of blood and CSF from ears  Mastoid haemorrhage from fracture of middle cranial fossa (battle’s sign)
  39. 39. FRACTURE OF POSTERIOR CRANIAL FOSSA CAUSES:  Direct impact on back of head  Escape of blood and CSF in tissue of back of neck
  40. 40. RING (FRACTURE AROUND FORAMEN MAGNUM) CAUSES : 1. It results from fall from height on feet & buttocks. 2. Sudden violent turn of head on spine. 3. Severe blow on vertex 4. Heavy blow directed underneath the occiput or chin.
  41. 41. Mechanism of cerebral injuries ( Principles ) 1. The adult skull is a remarkably strong structure. Unless it is fractured, it does not change shape. 2. Injury to the brain can occur without injury to the skull. 3. Any impact (blow) on the head produces momentary acceleration. Brain responds by gliding and rotation as the head is fixed .
  42. 42. Mechanism of cerebral injuries ( Principles ) 4. The harmful effect is increased when the brain movement is prevented by the bony prominences . 5. Since the cerebellum is smaller and lighter, it is less likely to be damaged by rotational strains
  43. 43. Coup and Contre coup injuries
  44. 44. Coup injuries A coup injury ( coup = blow ) is one which occurs immediately subjacent to the area of impact.
  45. 45. Coup injuries  If the head is fixed and there is violent impact over the occiput, the fracture and underlying brain damage will be located beneath the site of impact.
  46. 46. Contre coup injury  A contre coup injury ( contre = opposite; coup = blow ) is one which is situated on the contralateral side of the area of impact.
  47. 47. Classification of injuries to cranial contents 1. Acceleration/Deceleration injuries 2. Impact injuries
  48. 48. Acceleration/Deceleration injuries 1. Diffuse neuronal injuries 2. Diffuse axonal injuries 3. Subdural haematoma
  49. 49. Diffuse neuronal injuries.  It is due to acceleration/deceleration movement of the head.  Characterized by diffuse neuronal damage involving brain stem.  Damage consists of intracellular disturbances and conduction defects at synaptic junctions.
  50. 50. Diffuse axonal injuries  It occurs due to rotational strains to the head, damage the axons and blood vessels.  Stretching of the axons leads to disruption and loss of function.
  51. 51. Impact injuries 1. Cerebral concussion 2. Cerebral contusions 3. Cerebral lacerations 4. Intracranial hemorrhages
  52. 52. Intracranial hemorrhages 1. Epidural hemorrhage 2. Subdural hemorrhage 3. Subarachnoid hemorrhage 4. Intracerebral hemorrhage.
  53. 53. Cerebral concussion  Cerebral concussion characterized by gross physiological disturbance of brain function due to diffuse neuronal injury but with little or no anatomical changes.  There is sudden loss of consciousness and spontaneous recovery .
  54. 54. Retrograde amnesia  The patient is unable to collect the exact manner in which he was injured.
  55. 55. Post traumatic automatism  The brain injured person may speak or act in an apparently purposeful manner but has no recollection about it afterwards.
  56. 56. Cerebral contusions  Cerebral contusions are caused by extravasations of blood from traumatically ruptured blood vessels.  Mostly found in frontal and temporal lobes.  They are characterized by small punctate or streak like haemorrhages.  A golden brown area of gliosis known as blood cyst, results when contusion is absorbed.
  57. 57. Intracranial haemorrhages 1. Epidural haemorrhage 2. Subdural haemorrhage 3. Subarachnoid haemorrhage 4. Intracerebral haemorrhage.
  58. 58. Epidural haemorrhage  Epidural or extradural haemorhage, is bleeding between the dura and skull.  It is commonly seen in falls and RTA.  It may be acute or subacute.
  59. 59. Acute epidural haemorrhage  It is due to rupture of MIDDLE MENINGEAL ARTERY.  Classical picture is: initial loss of consciousness then a lucid interval, followed by coma due to raised intracranial pressure.  Death is due to respiratory failure due to compression of brain stem.
  60. 60.  LUCID INTERVAL: it is a state of consciousness between two states of unconsciousness.
  61. 61. Sub acute epidural haemorrage  Occurs when fracture tears dural sinuses, middle meningeal veins or diploic veins.  Symtoms appear after 3 or more days.  Lucid interval – 50 % cases.
  62. 62. Medicolegal significance 1. Epidural hematoma on the contralateral side should be carefully excluded. 2. Patient may discharged from the hospital during lucid interval and die at home. 3. Condition may resemble drunkenness, and patient may die in police custody.
  63. 63. SUBDURAL HAEMORRHAGE (HAEMATOMA) It occurs between under surface of dura & outer surface of arahcnoid .
  64. 64. CAUSES of Subdural haematoma: 1. Trauma 2. Rupture of aneurysm in cerebral blood vessels 3. Rupture of bridging or communicating veins 4. Common from trivial injuries not sufficient to cause unconsciousness or of fracture skull. 5. Cerebral neoplasms 6. Bleeding disorders. 7. During anticoagulants therapy.
  65. 65. SUBARACHROID HAEMORRHGES: It is haemorrhage between arachnoid & pia mater. CAUSES: TRAMAUTIC CAUSES: 1) Contusion or laceration of brain 2) Explosive blast 3) Asphyxia by strangulation 4) Traumatic asphyxia 5) Damage to vertebral arteries.
  66. 66. NATURAL CAUSES: 1. Rupture of aneurysm. 2. Atherosclerotic changes in old persons. 3. Leaking cerebral haemorrhage 4. Diseases like leukemia.
  67. 67. INTRACEREBRAL HAEMORRHAGE Causes:  RTA  Fall from height  In fatal head injury cases as a result of cope & contre cope injuries.
  68. 68. SPONTANEOUS HAEMORRHAGE 1. Obese person 2. High Blood pressure 3. Rupture of Aneurysm 4. Degenerative arterial disease
  69. 69. D/D OF TRAUMATIC & SPONTANEOUS HAEMORRHAGE (APOPLEXY) Apoplexy Trauma 1. Spontaneous bleeding in brain 2. Cause B.P, Atherosclerosis Aneurysm 3. Ganglionic regions involved 4. Coma starts from beginning 5. Young healthy person Not spontaneous Head injury White matter of frontal or tempo- occipital region 4.coma from beginning or concussion, Loss of consciousness & long coma 5. Adults & middle age.
  70. 70. Injuries to Spine and Spinal Cord 1. Concussion 2. Compression 3. Pithing 4. Laceration
  71. 71. SPINAL CONCUSSION It is transient loss of function of spinal cord, following a severe injury to spinal cord. Recovery is within hours few days e.g. Causes: severe blow to back, fall from height, RTA Railway accident.
  72. 72. RAILWAY SPINE OR TRAUMATIC SPINAL NEURASTHENIA It occurs in RTA, Railway accidents, mine workers trauma, Its ML importance as it leads to claim of compensation
  73. 73. SYMPTOMS 1. Backache, insomnia. 2. Weakness of limbs, sexual asthenia, incontinent bladder. 3. Tingling sensation & burning sensation. Complete recovery may occur unless the cord is lacerated
  74. 74. WHIPLASH INJURY It is momentary dislocation of C4 – C6 cervical spine. It is due to blow on chin, eyebrow, striking head against windscreen in RTA, Mechanism: Hyperextension of head.
  75. 75. DISLOCATION The commonest sites being C4 – C6. If the level of compression is above C4 region, death is immediate due to paralysis centre of Resp. muscle.
  76. 76. PITHING It is the process of killing by pushing a needle in nape of neck between C2 – C3. It damages medulla & upper cervical cord contain respiratory centre. Infanticide by pithing is common.
  77. 77. CHEST: Flail Chest (Collapse of the chest)  It occurs when at least three successive ribs are fracture at two points creating a floating segment of chest wall.
  78. 78. Chest: Flail Chest (Collapse of the chest) Floating segment is sucked inward during inspiration. Dysponea, Cyanosis, Pneumonia and Injury to heart etc.
  79. 79. Paradoxical Respiration  Breathing in which part of chest wall moves in on inspiration and moves out on expiration.
  80. 80. Abdominal injuries In case of abdominal injury, the trivial injury like abrasions may be found externally, but gross and fatal injuries are frequently present. The abdominal wall may allow the mesentry, gut, stomach and liver to be pin and crash across the spine with severe internal haemorrhage.
  81. 81.  So, whenever there is history of injury to abdomen, the patient should be kept under observation.  The most important viscerae to be injured are: i. Spleen ii. Liver
  82. 82. The spleen is most susceptible to injury due  Weakness of supporting tissues  Thin capsule  Extreme friability of its pulp SPLEEN
  83. 83. It is ruptured, i. By fall ii. Blow on abdomen iii. Crush injury due to RTA iv. Spontaneous rupture may occur due to a. Malaria b. Leukemia c. Typhoid d. Kala. azar
  84. 84. LIVER The susceptibility of liver injury is due to i. Large size ii. Central location iii. Relative Friability Cause of rupture is a fall, Blow, or kick on abdomen, RTA etc.
  85. 85. The death occur due to shock and haemorrhage. Sometimes bleeding occurs between capsule and liver (subcapsular Haematama) and serious symptoms became apparent only when the capsule ruptures.