Regional Injuries

Including Brain Injuries

Head Injuries

• Homicidal fatal injuries usually inflicted on head
• Fist blows, & street fights usually cause abrasions, bruises, and lacerations if with rings
• Lacerations if tissue crushed against bones of face or teeth or bones of skull
• Blunt injury to frontal region of head may manifest as Black eye or Racoon eyes
• Sometimes fracture dislocation of teeth
• Concealed puncture wounds in infanticide
• Inner canthus of eye, fontanelle, & nape of neck, thrust through nostril.

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Racoon Eyes

Scalp

• Mostly accidental and homicidal injury
• Wounds are usually incised looking even though caused by blunt weapon
• Superficial wounds bleed profusely
• X- rays and CT scan of head must always be prescribed to exclude fracture of skull and intracranial haemorrhage and injury
• Patient should be under observation for at least 24 hrs

Injuries to Face

• Severe injuries of face causing permanent disfiguration are grievous hurt
• Fracture of Maxillae and Zygomatic Bone (Malar bone) occurs with very heavy impact as in vehicular accident
• Fracture of Mandible may be associated with loss of teeth and easily becomes compound fracture due to laceration of mucus membrane of gum

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Face & Nose

• In smothering there may be injuries
• Abrasions, bruises & lacerations on face, around mouth or on under surface of lips by teeth
• Nasal bleeding very common accidental injuries and fist fight due to separation of mucous membrane.
• Nasal bones easily fractured by fist or blunt weapon and are grievous hurt
• Cribriform plate of ethmoid bone fractured on heavy impact and causes crebrospinal rhinorrhoea which may lead to meningitis

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Nose is symbol of honour and cut off or bitten off in enmity, or sexual jealousy. It is grievous hurt due to disfigurement deformity

The act of cutting Surpanakha's nose was taken to be the equivalent of disgracing her (insulting her).

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Nose

• Severe lacerated injury to internal area of nose sometimes causes anosmia which if permanent is grievous hurt
• In children some times sharp object like knitting needle is thrust through nose in to cranial cavity (cribriform plate) causing injury to brain which may be fatal.
• Nostril damaged if nose ring is pulled as in theft or as revenge

Injury to Ears

• Severe battering on ear may lead to rupture of tympanic membrane and internal ear may also be damaged
• Ears may be bitten off or cut off in quarrel or in violent sexual assault.
• Lobes of ear may be torn by pulling ear rings in theft
• Nature of injury is grievous if permanent disfiguration happens

"The Indian Method of Rhinoplasty," developed and practiced by Sushruta 600 BC involved cutting skin from the forehead or cheek, to repair noses and ears that were lost either as punishment for crimes (such as adultery) or in battle.

Injury to Eye

• Black Eye due to injury on frontal region of head very common
• Lacerated wound by stones or blunt weapon may necessitate enucleation- take opinion from another specialists
• There may be haemorrhage in vitreous or cataract later
• Blast injuries may cause orbital cellulitis, blindness and meningitis
• Eyes gouged out by finger but in dead bodies birds/ rats often take out eyes

Lips

• Accidental lacerated injury to lip common as pressed against teeth may be associated with fracture or dislocation of teeth
• Such injuries also occur in fist fight or teeth bite in sexual assault or jealousy
• Lips or gums may be bruised in cases of smothering or small lacerations seen

Teeth

• Fracture or dislocation of tooth/teeth is found in cases of traffic accident and sports accident
• Fracture/ dislocation also found in cases of mechanical violence
• False charge of tooth being knocked out is determined by:-
• 1.Condition of other teeth, shaky or diseased
• 2. No. of teeth in each jaw
• 3. Condition of the socket of missing teeth bleeding, lacerated etc.
• 4. Condition of lip, tongue etc.
• 5. Tooth ascertained that it belongs to the individual by its position and condition of fangs.

Fractures of Skull

• Fissure Partial fracture affects either outer or inner table of skull but more commonly inner table.
• Linear Fracture- linear fracture runs to varying length of the skull and affects both tables
• Depressed;-
• Elevated
• Stellate or radiating

Fracture of Skull

• Comminuted fracture- Broken in to pieces
• Punctured fracture
• Gutter fracture
• Crushed fracture

Injury to Bones

• Accidental fractures
• At the weakest point of bones
• No bruise or wound externally at the point of fracture.
• Fracture spiral or oblique
• Direct Violence
• At the point of impact
• Usually associated with bruise abrasion etc Ext.
• Fracture transverse or comminuted

Antemortem & Post mortem Fracture

• May be very difficult to differentiate if caused immediately after death
• Bleeding at the point of fracture will be much less in comparison to antemortem
• Ordinarily greater force required to cause post mortem fracture
• Haematoma gets absorbed in 14 days and provisional callus is formed around the fractured ends.
• In 1½ months Intermediate callus forms bone unites in 3 months
• Fractures heal quickly in young and healthy

Brain Injury

• Hippocrates
• "No head injury is too severe to despair of, nor too trivial to ignore."�-” No head injury is too slight to neglect or too severe to be despaired of”
• Mechanism & Pathology
• Mechanism of brain injury
• All degrees of brain injury resulting in loss of consciousness , concussion, contusion or laceration of the brain are produced by one mechanism namely displacement and distortion of the cerebral tissue occurring at the moment of impact

Hippocrates

"No head injury is too severe to despair of, nor too trivial to ignore."

BRAIN INJURY

Pathology of Brain Injury

• Brain not a perfect fit in cranial cavity. It is suspended in CSF by slings formed by Superior Cerebral Veins.
• Movement of brain in lateral direction restricted by falxcerebri but antero-posterior movement is possible with the result that blows on anterior or posterior aspect of skull cause maximum cerebral damage as cerebral hemispheres are displaced and distorted in relation to brain stem and hypothalamic area
• Damage is maximum at the junctional tissue of the commissures and corpus callosum. In boxing torn across medulla.

Pathology of Brain Injury

• Upper part of reticular formation is important for maintenance of consciousness
• Goltz’s dog Experiment
• On removal of both Cerebral hemispheres just above thalamus the dog was
• Deprived of all volition but responded to any stimulus by a show of violent uncontrolled rage similar to a condition observed in post traumatic delirium
• A state of imperfect consciousness was maintained therefore for consciousness to be completely lost, the level of injury must be still lower

Terms Used in Brain Injury

• Concussion (Stunning)
• Pathology
• There is physiological paralysis of function without any organic structural damage
• There is only slight stretch on brain stem
• Result
• Transient loss of consciousness for minutes only followed by complete and perfect recovery
• Treatment
• Rest, analgesic and observation in hospital

Cerebral Contusion

• Stretch is severe causing rupture of fibres.
• In severe cases additional sliding movement of the grey matter in relation to white with damage to nerve cells and axons.
• Unconsciousness is prolonged
• Or death due to lesion of vital centres without any change in intracranial tension
• Initial recovery is imperfect

Contusion of Brain

• Histological Changes
• There may be no visible surface injury
• Ring haemorrhages produced by bleeding in to the perivascular spaces of (Robin- Virchow) because of rupture of vessels at the point of maximum stress
• In the region of commissures
• Corpus callosum
• Third ventricle and substantia-nigra
• Cloudy swelling in the Choroid plexus
• Reduced CSF formation
• Low intra cranial tension

Contusion of Brain

• Diagnosis
• Unconsciousness is prolonged
• Recovers to a state of imperfect consciousness
• Signs of focal damage revealed on physical examination
• Imperfect Recovery
• Signs of cerebral irritation
• Body assumes a position of flexion and patient remains curled up
• Any stimulus is resented even violently
• Temperature raised

Contusion of Brain

• Improvement shown by the tendency of the patient to turn on his back and increasing tolerance to his surrounding
• Residual Effect (Post Contusional State)
• Recovery may be apparently complete but it is doubtful that these cases ever recover completely
• 1. Irritability 2. Depression, 3. Lack of concentration, 4. Amnesia, 5. Dementia/ insanity 6. Personality changes
• Signs of Focal Damage:- Detected on recovery
• Anosmia, paralysis, aphasia, or hemianopia, Blood in CSF Causes stiff neck, pain in legs retention of urine

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Cerebral Laceration

• Internal changes are the same as seen in contusion but in addition surface of brain is lacerated at bony ridges and edges of the Dural septa causing effusion of blood in CSF.
• Sites of laceration
• Inner aspect of hemisphere against falx cerebri
• Under aspect of frontal lobes
• Tip of temporal lobes

Contre-Coup Injury

• Injury on surface of brain situated at a point diametrically opposite to the site of impact on the head.
• It is not because of brain hitting the skull on the opposite side as was originally thought
• It is because of
• Local distortion of skull
• Sudden rotation of head with displacement of brain and tearing of constituent particles
• Contre-coup injuries are caused because of movement of head. It will not occur if head is fixed and cannot rotate
• Site :- 1. Base of frontal lobes, 2. Tip of temporal lobes, 3. To a lesser degree in all parts.

Pathological Changes Leading to Rise in Intra Cranial Tension

• Intracranial haemorrhages
• Extradural, subdural, subarachnoid, intracerebral
• Local swelling over the area of brain (surface) injured
• Retention of fluid in Lateral ventricle
• Blockage of basal cisterns and arachnoid granulations by effused blood with defective absorption of CSF

Arteriovenous malformation (AVMs)/ Tumour

Intracerebral Haemorrhage (ICH)

Extradural Haematoma on Rt (Lemon) & Subdural on Lt. side (Banana) of Patient. Both are always of traumatic origin

CT Scan showing

Subdural haemorrhage. Hyperdense (bright) signal, indicating blood, is seen on the patient's left. There is a midline shift to the patient's right.

CT Scan Subarachnoid hemorrhage Hyperdense (bright) signal, indicating blood, surrounds the brainstem and fills the subarachnoid space. This appearance is typical of a ruptured aneurysm

CT scan showing large Intra Cerebral Haemorrhage (ICH).

Difference Between Contusion & Compression of Brain

Compression of Brain

• May present immediately after injury if an extensive area of in-driven bone present but in majority of cases a period of improvement seen after concussion
• Persons alleged to be drunk died in custody as it was a case of compression of brain showing excitement in early phase and had also taken alcohol.
• All cases of even minor concussion should be admitted in hospital CT Scan done and observed for 24 hrs particularly if there is any bruising in temporal region.

Punch Drunkenness (Goofy)

• A chronic state of lack of memory, incoordination, tremor, and dysarthria seen in some old boxers due to repeated tiny haemorrhages in brain

Intracranial Haemorrhages

• It is a serious medical emergency
• Extradural haemorrhage- Almost exclusively caused by mechanical violence
• Subdural- Is also traumatic in origin
• Subarchoid & intracerebral haemorrhage is caused by trauma, atherosclerotic changes, aneurism, Chr. hypertension, bleeding disorder, or is inflammatory in origin.

Consistency &Timing of Bleeding

• Consistency-
• Firm with passage of time & laminated
• Chronic subdural haematoma is capsulated
• Appreciated in 8days, like Dura in 2-3 months
• Within 1 yr thick & fibrous.
• Brain surface depressed according to the shape of haematoma
• Timing
• Time cannot be accurately given
• Recent- Bright red
• A few days old- Chocolate or brown
• 12-25 days- Ochre coloured

Trauma & Intracranial Infection

• Firm opinion can be given in penetrating wound & depressed fractures
• Abscess or meningitis from infection from middle ear and mastoid following injury has to be critically evaluated

Neck

• Mostly incised wound sometimes punctured. Frequently compressed
• More often homicidal than suicidal, sometimes accidental
• Supposed to be instantly fatal if large blood vessels are cut
• Cutting of larynx and trachea not necessarily fatal unless air passage blocked by blood, inflammatory oedema, or lung sepsis follows
• Speech not possible if wound gaping and below vocal cords. Whispering possible if wound not gaping and some air passes through vocal cord and mouth

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Neck

• Oesophagus:- Wound associated with that of trachea & blood vessels
• Food and acid from stomach may pass in to mediastinum, pleural cavities usually left sometimes right
• May result in to pneumothorax
• Wounds of sympathetic or vagus nerve may cause death that of recurrent laryngeal nerve causes aphonia
• Blow on neck or compression may cause- Unconsciousness or death by vagal inhibitory action

Neck

• Blow on neck may cause fracture of thyroid and or cricoid cartilage with haemorrhage or oedema in tissue
• Mucus membrane of trachea or larynx may get torn and cause sub-mucosal oedema spreading in neck and mediastinum which may cause death by asphyxia.

Chest

• Blunt Injuries are mostly accidental, occasionally homicidal and rarely suicidal
• Traumatic asphyxia due to pressure on chest wall or buried under falling building or debris
• Face and neck deeply cyanosed.
• Ecchymosis of the skin/ conjunctiva
• Due to mechanical pressure and bursting of smaller blood vessels
• Contusion or laceration- Blows from blunt W
• Compression of chest causing asphyxia may be without external injury or fracture of ribs
• Sternal fractures are rarely of any consequence, except when they result in blunt cardiac injuries.

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Thoracic injuries are a contributing factor in up to 75% of all trauma-related deaths.. Most important cause of significant blunt chest trauma is motor vehicle accidents (MVAs) and of penetrating chest wall trauma is homicidal injuries by firearm or sharp penetrating weapon

Left pulmonary contusion following a motor vehicle accident involving a pedestrian

CHEST INJURIES

Chest

• Fracture of ribs-
• At the most convex part that is angle of rib if chest pressed or indirect violence, coughing etc.
• In case of direct violence fracture at the point of impact. Splinters may be driven inside. May result in infection of lung
• Ribs most often fractured – 4-8^th
• Great force required for fracture of upper three ribs and as a rule viscera also injured
• Lower ribs escape due to their great mobility
• Symmetrical fracture of ribs on both sides occurs when pressure applied on front of chest- Bansdola, sitting on chest or pressing by knee.

Wounds of Chest

• Wounds of lungs may cause immediate death
• Due to profuse haemorrhage
• Suffocation due to respiratory embarrassment on account of blood in pleural cavity or air passage
• Delayed death from septic pneumonia
• Haemorrhage recognised by frothy fresh blood from mouth and external wound
• Subcutaneous emphysema due to tearing of parietal pleura with lung and escape of air in tissue may be present
• Weapons:- sharp, sharp pointed, and firearm cause penetrating wound

Heart

• Wounds of the heart are usually fatal from shock & haemorrhage
• Usually due to stabbing instruments, firearm, or sharp end of fractured rib or sternum
• Where wound has not pierced the wall or where weapon plugged the wound then the individual may survive for sometimes.
• Wound of auricle more dangerous as wall thinner
• Rt ventricle most often damaged as situated anteriorly
• Pericarditis or mediastinitis may be secondary causes of death

Heart

• Contusion of heart may be caused by blow from blunt weapon or compression of chest. There may or may not be associated external injury or fracture
• Traumatic rupture of heart may take place if wheel of a vehicle runs over chest or due to fall on a projecting substance
• Heart may be completely severed from its attachment or there is round, oval or star shaped wound
• It is usually associated with external injury
• Spontaneous rupture of diseased heart may occur
• Usually in elderly people
• Usually left ventricle is affected

Blood Vessels

• Injury of aorta, and pulmonary artery rapidly fatal
• Traumatic injury of aorta localised just above valves and is usually transverse
• Injury of small arteries may also prove fatal on account of profuse bleeding
• Large veins of neck if cut may cause fatal air embolism

Abdomen

• Contusion/ laceration of internal organs may be present without any external mark of injury
• Penetrating wounds of abdomen as a rule are dangerous for they may cause death by shock, haemorrhage or subsequently by peritonitis
• Non penetrating injuries though are simple may be dangerous if they cause tear of some large blood vessel or death by vagal inhibition

Abdominal Injuries

• Stomach:-
• Full & diseased stomach ruptures easily
• Site pyloric end & greater curvature
• Penetrating stab wound usually fatal
• Intestine
• Rupture usually fatal as leak causes peritonitis
• Rupture also caused during criminal abortion if uterus perforated and intestinal damaged
• Site usually is at commencement of jejunum and/or last 3 feet of ileum

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Abdominal Injuries

• Liver is commonly damaged in abdominal injuries because of
• Its large size
• Fixed position
• Friable nature
• It may also be lacerated by fractured rib
• Rupture usually involves Rt. Lobe and inferior surface
• Direction of tear usually is antero -posteriorly or obliquely, rarely transversely
• Cause of death- Shock and haemorrhage
• Time of death- very short but may be long or may survive if portal veins or Inf. Venacava not injured

Injury of Abdomen

• Spleen:- Normal spleen rarely ruptures but enlarged spleen easily ruptures because of size and friability
• Site Inner surface. Death very quickly because of increased vascularity
• Sometimes capsule of spleen not torn though substance is torn; may survive
• Abdominal wall may not show any injury externally
• Puncture wound of spleen rare; 50 ruptures to one stab

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Vehicular Accidents

• Injury to Driver
• Also to be examined for
• Drunkenness & Drugs
• For evidence of unconsciousness preceding accident
• Injury to Occupants
• Front seat
• Back seat
• Injury to Pedestrian

One serious road accident in the country occurs every minute; and one person dies in a road traffic accident every 3.6 minutes. 1.46 lakh death in 2015& 2017 Road Transport ministry report

• The increasing number of fatalities and road crashes - up from 4.89 lakh in 2014 to over five lakh in 2015 in which 1.46 lakh death took place in 2015, that is one person dying every 3.6 minutes  
• Uttar Pradesh recorded the maximum number of road deaths (17,666) in 2015

followed by:-

• Tamil Nadu (15,642),
• Maharashtra (13,212),
• Karnataka (10,856) and
• Rajasthan (10,510).

While the number of road fatalities increased in all big states,

10 smaller ones and UTs, including

• Delhi and Chandigarh, reported a decline.
• Assam registered the sharpest decline of 115 deaths in 2015 in comparison to the previous year, while fatalities dipped by 49 in Delhi.

2016/2017 MVA in India

• A total of 4,80,652 road accidents took place
• Loss of 1,50,785 lives
• Serious injuries on 4,94,624 persons.
• In 2017 –Fatality -146377
• Drivers' fault was the single most important factor 

Vehicular Accident� Injury to Pedestrian

• Direct Impact Injury-
• The part first struck
• Secondary Impact Injury
• Other injuries by vehicle
• Secondary Injury
• By fall on ground etc.
• To be examined also for
• Deafness & Blindness
• Drunkenness & drugs

Spinal Injuries

• Railway spine (Concussion of spine)
• Seen in railway accidents. There is functional paralysis of lower limbs but recovery is complete
• Also seen in falls or other vehicular accidents sometimes
• It is due to blow on back, pitting of spine especially at the level of 1^st to 3^rd cervical may be found
• Spinal injury
• Depending on site of fracture which may be associated with dislocation & haemorrhage in spinal column