REGIONAL
INJURIES -I
Objectives:
1. General Objective
To study the injuries in region wise manner.
2. Specific Learning Objectives
Every student should know
➢a) Injuries to the scalp
➢b) Injuries to the face
➢c) Mechanism & Types of skull fracture
➢d) Coup &Contrecoup injuries
➢e) Intracranial haemorrhages
➢f) Diffuse Axonal injury
➢g) Injuries to the brain
Introduction:
Region wise study of mechanical injuries,
head, neck, thorax, abdomen, and limbs etc.
What is the need to study these injuries region wise?
-In living or dead individuals.
Medico legal importance:
➢ Type and nature of the injury
➢ Age of the injury
➢ Manner of the injury
➢ Causative agent/force
Head Injuries:
❖ Definition: Head injury is a morbid state,
resulting from gross or subtle structural changes in
the scalp, face, skull, and /or the contents of the
skull, produced by mechanical forces.
❖ Head is the target of choice in great majority of
assaults.
❖ Brain and its covering are vulnerable to slightest
degree of blunt trauma.
Anatomy of Scalp:
S
C
A
L
P
Scalp injuries:
❖Blunt force injuries- abrasions, contusions and
lacerations.
❖Sharp force injuries- Incised wounds, chop wounds and
stab wounds.
Abrasion Contusion
Lacerated Wound Incised Wound
Patterned laceration
Medico Legal Importance of
Scalp injuries:
• Grievous injury
• Suggest serious internal injury
Note: Absence of scalp injuries does not
rule out serious internal injuries.
Facial Injuries:
Abrasion Patterned abrasion
Contusion - Black Eye (Ectopic
Contusion).
Chop wound
Permanent Disfiguration- Grievous Hurt.
Eg: Scar Formation (Acid Attack).
Medico Legal Importance of
facial injuries:
• Grievous injury.
• Bleeding from orifices might suggest
intracranial injuries.
• Ectopic contusion.
SKULL FRACTURES
Mechanism of skull fracture
A) Fracture due to local deformation;
1).Direct Impact - When a small mass travelling at a
great velocity strikes the head Eg. Stone, wooden club
etc.
2).Indirect Impact - Fall on feet or buttocks leading to
skull fractures.
➢Force of impact should be greater than the elasticity of
the skull.
➢Depends on thickness & strength of the bone.
Mechanism of skull fracture
contd..
B)Fracture due to general deformation;
Whenever the skull is compressed,
• Between two external objects
• Between an external object and spinal column
Mechanism of skull fracture
contd..
Mechanism of skull fracture
contd..
Types Of
fractures of skull:
Fissured fracture:
- Commonest,
- Linear fracture
involving both tables of skull.
- Different shapes
- Produced against impact
against hard surfaces.
Ring Fracture:
Ring Fracture seen commonly with fall on feet
or buttocks
Hinge Fracture
Hinge Fracture seen commonly with motorcyclists
Hinge fracture
Crack Fracture:
• Crack Fracture - Involves only one table of the skull..
Comminuted fracture:
❑Fracture division of
bone into several
fragments.
❑Considerable force
over small area
Eg: RTA, Hammer
i)Depressed comminuted # :
• Impact causes the
outer table to be
driven inward.
• SIGNATURE #
The # provides a clue
about the striking
surface Eg. Weapon
used
ii) Non depressed comminuted#
The # site appears in the form of
several fissures, cobweb or mosaic
pattern.
Gutter fracture:
When a weapon strikes the skull tangentially
Eg. Bullet injury.
Pond or Indented Fracture:
Mechanical force produces a dent in the skull
Eg: Forceps delivery of a baby
Diastatic or Sutural Fracture
Separation along the sutures.
Cut Fractures:
A sharp heavy cutting weapon can cause
straight chops of the skull, involving the external plate or
both plates.
# is only at the line of contact of the weapon.
Perforating Fractures:
Penetration of the skull by a sharp pointed object or a
bullet.
Coup and countercoup injuries of
brain
• Coup Injury-occurs at site of impact Eg.
Head struck with an object.
• Countercoup Injury - Occurs at site opposite to the point of
impact Eg fall.
Injuries to Intracranial bloodvessels
• Meninges- Duramater, Arachnoid ,Piamater
Intra Cranial Haemorrhage
• Extra dural
• Sub dural
• Sub arachnoid
• Intra Cerebral
• Intra ventricular
Extradural(epidural) Haemorrhage
Extradural(epidural) Haemorrhage
• Occurs between the Skull and Dura
• Causes-
1. Mechanical trauma
2. Following surgery
3. Bone eroding process Rare
4. Vascular malformations
Sources
• Meningeal artery- MMA
• Diploic veins
• Venous sinuses
Mechanism
• Skull fracture
• Separates dura from skull
• Injury to meningeal artery
• Sites
1. Temporo parietal- MMA
2. Occipital/ Basal
• 100 ml is fatal
• Features
1. Lucid Interval
2. Contralateral paresis
3. Exerts pressure on brain- contusion
4. Pupils on the side dilated
5. Displacement of cerebellar tonsils
6. Coma, Death
• Fate
1. Shrink
2. Resorption
3. Encapsulate
Medico Legal Importance:
• “Admit the patient” - The patient may be
asymptomatic (may be in Lucid Interval). The
Doctor may be sued for ‘Negligence’.
Immediate
Unconsciousness
unconsciousness Lucid interval
Compression
Concussion
Medico Legal Importance:
• Alcohol intoxication & Amount of Alcohol can be
estimated from the clot
• May be confused with heat hematoma
• Sudden death may occur after several days
• Always a Coup Injury
Sub-dural Haemorrhage
• Collection of blood in the subdural space i.e b/n dura
and arachnoid
• Sites
• Lateral aspect of cerebral hemisphere
• PCF, around brain stem
Causes
• Trauma- venous in majority
1. Rupture of bridging veins, dural venous sinuses,
2. Laceration/ contusion of brain and dura
• Pathological
1. Rupture of aneurysm
2. Hypertensive bleed within superficial part of brain
rupturing in sub dural space
Classification
• Acute- presents within 48- 72 hrs
• Sub acute- presents between 3- 20 days
• Chronic- presents after 3 weeks
Acute SDH
• Trauma
• Change in the velocity of head with rotational
component
• Gravitates-
• Common than EDH
• 35- 100 ml causes neurological signs
Clinical features
• Onset delayed when compared to EDH
• Lucid interval may be present
• Gradual decline of consciousness
• Contralateral hemiparesis
Chronic SDH
• Old, alcoholics
• Atrophy of brain- increase in sub dural space
• Permits movement of brain
• Higher risk of rupture of bridging veins
• Bilateral from natural causes
• Unilateral from traumatic causes
• Organized and encapsulated
• Pachymeningitis haemorrhagica
MLI
• Clinically mistaken for schizophrenia
• Dementia
• Lucid interval may be present
SDH
Chronic SDH
Sub-arachnoid haemorrhage
• Occurs in sub arachnoid space i.e. between
the Arachnoid and Piamater
• Causes- Traumatic/ Pathological
Traumatic Pathological
• Laceration of brain • Saccular aneurysm
• Cortical contusion • AV malformation
• Blunt impact • Bleeding dyscrasias
• Penetrating injury • Rupture of ICH into sub
• Blow on neck lacerating arachnoid space
vertebral artery
• Hyperextension of neck
Features Clinical features
• Most common intra • LOC
cranial haemorrhage
• Head ache
• Unilateral/ bilateral
• Neck stiffness
• Diffuse/ Localised
• Photophobia
• Basal- rapidly fatal
• Older – yellowish • Focal deficit
discoloured
MLI
• May be due to trauma or disease
• Trauma/ stress may precipitate rupture
of aneurysm
Intra Cerebral Haemorrhage
• in the cerebral tissue
Causes
• Trauma- Laceration of brain, blunt
trauma
• Natural- Hypertension, AVM
Basal ganglia bleed
Intra Ventricular Haemorrhage
• In the ventricular system of brain
• Trauma
• Non traumatic
1. Retrograde flow of SAH into ventricles
2. Rupture of AVM in the wall of ventricle
Features
• Arterial
• Yellowish discoloration of ependyma,
choroid plexus and leptomeninges due to
deposition of hemosiderin
• Suggestive of old blood
Brain Injury
• Closed/ Open
• Primary- caused at the time of impact
1. Diffuse Axonal Injury
2. Cerebral Concussion
3. Contusion/ laceration
• Secondary- subsequent damage
1. Intra cranial haematoma
2. Cerebral oedema
3. Cerebral ischaemia
4. Cerebral herniation
5. Infection
6. Epilepsy
7. Hydrocephalus
• Direct intrusion by foreign body/ object
• Distortion/ deformation of skull
• Movement of brain in relation to skull
Mechanism
• Compression
• Sliding/ shearing strains
1. Linear acceleration/ deceleration
2. Rotational
• Brain moves relative to skull- restrained by
falx, tentorium
• Brain tissue moves relative to each other
• Acceleration injury
An impact on a stationary head causing the skull to
move in the direction of force.
[Link] with a wooden club.
• Deceleration injury
When a moving head strikes against a stationary
object Eg. Fall from height
Cerebral concussion
• Commotio cerebri/ stunning brain shock
• Head injury
• Instantaneous transient paralytic state
• Amnesia from the moment of accident, can recall
up to or within few moments of injury
• Automatism
• Cerebral Concussion
Reversible or irreversible derangement of
neuronal activity.
• Clinically - 3 grades.
Grade I - No loss of consciousness.
Grade II-Loss of consciousness less than 5 mins
Grade III-Loss of consciousness more than
5 mins & Memory loss more than 24hrs.
• Severe cases- Immediate death.
• Reversible cases-consciousness is regained
• Retrograde amnesia.
Retrograde amnesia
Anterograde
amnesia
Features MLI
• LOC
• Post traumatic /
• DAI- submicroscopic retrograde amnesia
• Fatal occasionally • Punch drunk or
• No structural damage at drunkenness
autopsy
Diffuse Axonal Injury
• Rotational forces
• Axonal swelling/ retraction balls
• Midline structures
• Corpus callosum
• Rostral brain stem
Gross HPE finding C/s showing diffuse white matter
haemorrhages
DAI
Cerebral Oedema
• Accumulation of fluid in extracellular space
• Breakdown of BBB
• Increased vascular permeability
Flattening of gyri, obliteration of sulci.
Cerebral Compression
Generalized
Compression of
swelling, space Unconsciousness
brain
occupying lesion
Cerebral Contusion
• Circumscribed areas of brain tissue destruction
resulting from extravasations of blood
• Shearing forces
• Produced by distortion of skull or rotation of the brain.
• Found mainly - Cortex
Cerebral contusion
• Associated with some
degree of SAH
• Haemorrhage/ Necrosis/
Tears
• Conical in shape
• Complications - Brain
abscess,cortical atrophy.
Contusion of the cerebral cortex
Classification
• Coup - Contra coup
• Intermediary
• Fracture
• Gliding
• Herniation
Cerebral Lacerations
• Loss of continuity of brain substance
• Tears in piamater
• Severed pial vessels
• SAH
• Penetrating injury
Cerebral Lacerations
• Common where there are
projecting parts of the
skull.
• Intracranial Tension
-> Fatal.
Summary
✓- Region wise study of injuries
✓a) Injuries to the scalp
✓b) Injuries to the face
✓c) Mechanism & Types of skull fracture
✓d) Coup &Contrecoup injuries
✓e) Intracranial haemorrhages
Summary
• Extra dural haemorrhage- exclusively from trauma
• Sub dural haemorrhage- commonly from trauma, rarely
from a natural cause
• Sub acrachnoid haemorrhage- when present alone is
always because of a natural disease
• SDH+ SAH is the common presentation at autopsy
