REGIONAL INJURIES• Regional injuries are the injuries sustained at

different anatomical regions of the body.• Those regions are of utmost importance, that

contain the vital organs , for example ; head, chest and abdomen.

• Head injuries are most common and maybe homicidal, accidental (RTAs) or rarely suicidal.

Classifications (3 Types)• Depending on the state of dura Closed head injury : Here dura remains intact irrespective of whether skull got fractured or not. Open head injury : Here dura is torn maybe due to, penetrating injury, bone fragments or as a consequence of skull fracture.• Depending on duration of consciousness and

Glasgow coma scale

• Depending on the extent of injury; Scalp injuries. Skull injuries. Brain injuries.

SCALP INJURIES:• Anatomy:Covering of the head that extends from the eyebrow anteriorly to sup.nuchal line posteriorly and laterally from one temporal line to another.Scalp is composed of;S -SkinC -connective tissueA -AponeurosisL -Loose areolar tissueP -Pericranium

Following sort of injuries maybe present over the scalp:

• Abrasion • Contusion• Laceration-maybe confused with incised

wound. Types are; Linear , Y- shaped , Stellate , Cruciate , Penetrating and Crescent etc.• Incised wounds• Avulsions• Puncture wounds.

• Injuries of the scalp may go unnoticed because of presence of hair.

• To differentiate between lacerations and incisions edges of the wound should be examined carefully.

• In incised wounds margins are clear cut and so are the hair bulbs but in lacerations margins are irregular and hair bulb, if present are crushed.

• Scalp usually bleeds profusely due to the rich blood supply but bruises maybe difficult to notice.

Injuries of the scalp having special medico legal significance are:

• CONTUSIONSBruise of the scalp may be mobile. BLACK EYE/PERIORBITAL HEMATOMA: 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/ RACOON EYES : 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 or a contusion in the temporal region.

INJURIES OF THE SKULL• Adult skull is a remarkably strong structure.• It is non resilient ad tends to fracture if subjected to

undue stress.• In adults, skull consists of two parallel tables of

compact bones. The outer table is twice the thickness of the inner table.

• Both the outer and inner tables are separated by a soft cancellous bone- the diploe.

• Skull varies in thickness, the average frontal and parietal thickness being 6-10mm temporal bone is 4mm and occipital bone in midline is 15mm or more.

MECHANISM OF SKULL FRACTURE

• FRACTURE OF THE SKULL MAY BE CAUSED BY: Direct application of force to the skull as seen when the skull sustains a blow with an iron rod. Indirect violence for example, fall from height.

TYPES OF SKULL FRACTURES ARE:1. Fractures of the Vault:• Linear or fissured• Depressed (signature)• Comminuted (Mosaic/ spider web)• Pond or indented• Gutter• Diastatic or sutural• Contre-coup• Basilar fractures

2. Fractures of the base of skull:• Fracture of the anterior cranial fossa• Fracture of the middle cranial fossa • Fracture of the posterior cranial fossa• Ring fracture• Hinge fracture

• 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.

• 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 or mosaic like.

• 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.

• 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: these 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.

Following are types of fractures of base of skull:• Fracture of the anterior cranial fossa : is due to

direct impact or as a result of contracoup injuries, resulting in black eyes or escape of CSF and blood from the nose

• Fracture of the middle cranial fossa : is due to direct impact 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 bone is fractured

• Fracture of the posterior cranial fossa : is due to the impact on the back of the head , resulting in escape of CSF and blood into 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 , splitting the base of the skull into two halves.

• Caused by a heavy blow on the side of the head.

• Also known as motorcyclist’s fracture.

COMPLICATIONS OF SKULL FRACTURE

• Injury to brain, intracranial hemorrhage.• Intracranial infections- meningitis/encephalitis• Cranial nerve injury• Traumatic epilepsy.• CSF Otorrhea• Coma • Cerebral edema• Increased ICP.• Death.

INTRACRANIAL HEMORRHAGES

• Extradural/ Epidural • Subdural• Subarachnoid• Intracerebral• Intraventricular• Pontine• Cotrecoup

EXTRADURAL/EPIDURAL HEMORRHAGE

• 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 hemorrhage is less common in these ages, peak is seen in second and third decades.

• 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 hemorrhage, 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.

SUBDURAL HEMORRHAGE• It is also due to trauma, causing rupture of

dural venous sinuses and cortical veins. Subdural hemorrhage 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 hemorrhage

SUBARACHNOID HEMORRHAGE

• Between arachnoid and pia mater 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.

INTRACEREBRAL HEMORRHAGE

• 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.

• 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 hemorrhages in the brain sustained during fights few years back.

INTRAVENTRICULAR HAEMORRHAGE

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

PONTINE HEMORRHAGE

• The hemorrhage 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 center in the pons.

CONTRE COUP HEMORRHAGE

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

• In contre coup hemorrhage, 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 hemorrhage.

MECHANISM 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 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.

DECELERATNG 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 INJURY

• 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 INJURIES

• 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.

INJURIES TO THE BRAIN

• CEREBRAL CONCUSSION• CEREBRAL IRRITATION• CONTUSIONS AND LACERATIONS• COMPRESSION OF THE BRAIN• HAEMORRHAGES

CEREBRAL CONCUSSION

• 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.

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 INFLAMMATION or COMPRESSION.

• 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.

• (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 IRRITATION

Include peculiar set of symptoms that may follow cerebral concussion. Here the patient lies curled up in bed with his head beneath the pillow, 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 & LACERATIONS

• 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 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 FEATURES• Loss of consciousness predominantly.• COMPLICATIONS-• Cerebral contusions may lead to, -Bleeding from torn 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 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 hemorrhages.

• 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 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 SYMPTOMS

• May appear immediately or maybe delayed for hours or days. There maybe paralysis of upper and lower limbs or lower limbs along 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 CERVICAL 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 VERTEBRAL, 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 LOWER CERVICAL SPINE

• Most common injuries are hyper flexion and hyper extension injuries famously known as the whiplash injuries , seen in motor car accidents where due to sudden stoppage of a vehicle in speed causes hyper flexion and then hyper extension of neck, pulling the nerves at the root of neck leading to paralysis of the limbs with fractures of C3 & C4.

THORACIC AND LUMBAR SPINE

T1 to T10 are more resistant to injuries because of additional stability of thoracic rib cage, so dislocation and rotational injuries are less common as compared to lower thoracic and lumbar spine because of increased flexibility as seen in seat belt syndrome. Lumbosacral spine is more prone to fractures and compression injuries.

INJURIES 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) is seen due to injury below the level of emergence of brachial plexus (1ST & 2ND THORACIC VERTEBRAE).

PENETRATING INJURIES OF THE SPINAL CORD

• Penetrating injures 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 NECKSerial no. SUICIDAL CUT

THROATHOMICIDAL CUT THROAT

1. 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 PRESENT.

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

Serial 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

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

9. 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

SERIAL NO.

SUICIDAL CUT THROAT HOMICIDAL CUT THROAT

10. AS HEAD IS THROWN BACK CAROTID ARTERY IS USUALLY SAVED

CAROTID ARTERY AND JUGULAR VEINS LIKELY TO BE CUT

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 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

• 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 PEDESTRIANS DURING RTA’s

• Primary impact injuries. Bumper fracture• Secondary impact injuries.• Secondary injuries.

Thank YouDr.M.Ikram Ali