CHAPTER XI – PHYSICAL INJURIES IN THE DIFERENT PARTS OF THE BODY
Presence of bleeding fro the ear, nostrils and mouth  basal fracture
Unconsciousness  cranial box
FACTORS INFLUENCING THE DEGREE AND EXTENT OF HED INJURIES:
a.
b.
c.
d.
Nature of the wounding Agent
Intensity of the force
Point of impact
Mobility of the skull at the time of the application of force
HEAD INJURIES ARE CLASSIFIED AS TO THE SITE OF THE APPLICATION OF FORCE:
a.
Direct or Coup Injuries:
- occur at the site of the application of the force and will develop as a natural consequence
of the force applied
- may result to:
1. in the compression of the head by the wheel of a vehicle
2. when the head strikes an object in motion, as bullets
3. when the head is in motion and strikes an object, as in vehicular accidents
b.
Indirect Injuries
- Injuries in the head which are not found at the site of the application of force
- May be at the opposite or in some areas offering the least resistance, or in areas which
have no relation with the site of the impact
1. Contre Coup Injuries
- develop opposite the site of the application of force
c.
2.
Remote Injuries
- produced in cases where the force is applied in some areas of the body which
have no relation to the head
3.
“Locus Minoris Resistencia”
- may not be found at or opposite the application of force but may found in some
areas of the skull offering the least resistance
Coup- contre-coup injuries ( Direct and Indirect Injuries )
- may be at the site of impact and at the same time found in some other parts of the head
which may be opposite the site of application of force, or elsewhere
WOUNDS OF THE SCALP:
A wound of the scalp although small and negligible is always potentially serious because:
a. It is difficult to prevent the spread of infection
b. There is proximity of the scalp to the brain
c. There is a free vascular connection between the structures inside and outside the cranium
d. It is frequently difficult to determine the extent of damage of the skull
FRACTURES OF THE SKULL:
a. Fissure fractures
- involves the inner and outer tables.
- Caused by the impact of a blunt object and may appear as a radiating crack from the site
of the application of force and may involve the base of the cranial fossae
b.
Localized Depressed Fracture
- “ Fracture a La Signature”
- shows the nature of the instrument that causes the fracture
d.
Penetrating Injuries of the skull
- sharp-edged instrument produces clean-cut fracture of the skull.
- The size and shape of the fracture may correspond to the shape of the wounding
instrument
e.
Comminuted Fractures
- may develop as a result of a fissure or a depressed fracture
- is an indication of the severity of force applied or the use of a heavy weapon
f.
Pond or Indented Fracture:
- in the skull of infants wherein there is undue elasticity, the production of a pond or
indented fracture is common
- a result of a simple compression of the skull as in a Ping-Pong ball
g.
Gutter Fractures
- a tangential or glancing approach of a bullet may cause the production of a furrow in the
cranium
- the furrow may cause injury on the blood vessels causing intracranial hemorrhage or
laceration of the brain
Bursting Fracture
- an extensive fracture running parallel to the two points of contact, if mechanical force is
applied on one side of the head, while it is pressed on the other side against a hard
substance, such as a wall, while the individual is standing or against the hard ground or
floor, when he is in lying posture
h.
INTRACRANIAL HEMORRRHAGE
a.
Extradural or Epidural Hemorrhage
- caused by a fracture of the skull
- the fracture will cause laceration of the blood vessels which are grooved at the inner table
of the skull
b.
Subdural Hemorrhage
- is essentially venous or capillary
- most common cause of cerebral compression
- may be a consequence of fracture of the skull, laceration of the brain, spontaneous
rupture of the blood vessels on the surface of the brain or laceration of the dura and
Meningeal vessels
- comes from the small blood vessels which cross the Subdural space to the subarachnoid
area

Ageing Subdural hematoma Munro-Meritt Method  please
see book
c.
Subarachnoidal Hemorrhage
- may be due to trauma or to spontaneous rupture of blood vessels
- causes:
1. It may be produced by severe head injury especially in contre coup kind
2. It may be due to ruptured cerebral aneurysm and is commonly seen at the base
of the brain
3. It may be an extension of the spontaneous hemorrhage of the brain which
extends to the subarachnoid space
4. In asphyxia there may be Subarachnoidal hemorrhage in the form of petechial
hemorrhage
d.
Cerebral Hemorrhage
- may be traumatic or spontaneous in origin
- TRAUMATIC cerebral hemorrhage  is usually due to laceration or contusion of the
brain in contre-coup injuries; severe crushing of the skull in vehicular accident cases may
cause the sharp fractured edges of the bone to lacerate the brain and produces severe
cerebral hemorrhage
DISTINCTION BETWEEN CEREBRAL; APOPLEXY AND POST TRAUMATIC INTRA CEREBRAL
HEMORRHAGE
a. In traumatic intracerebral hemorrhage the interval between the injury and onset of stroke (
symptoms ) is usually a week or less
b. In traumatic intracerebral hemorrhage, the injury to the head must be sustained when the head is in
motion and the hemorrhage is the result of the coup-contre-coup mechanism
c. The location of traumatic intracerebral hemorrhage is in the central white matter of the frontal or
temporo-occipital region
d. History of hypertension prior to the “stroke” and evidence of degenerative disease are present in
cerebral apoplexy. There is a history of head trauma in traumatic intracerebral hemorrhage
BRAIN:
a. laceration of the brain
1. Direct or Coup Laceration
- produced by the fracture of the skull
- the edges of the fractured bone lacerate the arachnoid and the underlying brain tissue
- occur anywhere in the brain but it usually follows the line of fracture
- frequent site: PARIETAL and the FRONTAL lobes
b.
2. Contre- coup laceration
usually directly across the point of impact and fracture
occur only when the head is free to move at the time of the impact
Edemas of the brain
1. Localized Edema
- observed in deep brain lacerations
- edematous area is soft, swollen, gelatinous and yellowish red in appearance
- seen in abscess and neoplasms
-
2. Generalized Edema
associated with severe trauma of the head
brain has a swollen appearance, with the flattening and broadening of the convolutions
and diminution of the sizes of the ventricle
observed in a prolonged convulsive seizure, a sudden death due to tetanus antitoxin, an
encephalitis and in an excessive hydration
c.
Concussion of the brain
- is a transitory period of unconsciousness resulting from a blow on the head, unrelated to
any injury to the brain which is apparent to the unaided eye
d.
Compression of the brain
- may lead to paralysis or loss of consciousness
- natural diseases, like new growth, abscess and hydrocephalus may also cause
compression of the brain
FACE
a.
-
wounds on the face heal relatively faster as compared with wounds of the other parts of
the body on account of its great vascularity
facial injuries are always a threat to life wounds on the face may be due to a blow,
vehicular accident, kick, sharp instrument, gunshot, or a blunt weapon
fractures of the facial bones especially of the nasal bone and mandible are quite frequent
EYE
contusion of the soft tissue about the eyes is sub-conjunctival. Observed in a fist blow
the eye may be lacerated by a blunt weapon or by a piece of stone
acute inflammatory changes usually occur with injury of the cornea, iris, and lens and
may require total enucleation of the eyeball
penetrating wounds due to sharp instruments or bullets may cause meningitis or total
blindness
b.
-
NOSE
common sequelae of fist blows and may cause severe epistaxis and facial deformity
c.
-
EAR
a blow in the ear may produce a rupture of the tympanic membrane leading to permanent
or temporary deafness
hemorrhage coming from the ear  fracture of the base of the middle cranial fossa
-
d. MOUTH
- contusion, laceration, and swelling of the lips are usually observed in a fist blow, kick or
bite
- fracture of the lower jaw  due to direct violence and the most common site is at the
region of the insertion of the canine and at the region of the condyle
- fracture of the jaw is always associated with laceration of the gums which may extend to
the floor of the buccal cavity
NECK
-
abrasions of the neck may be present in cases of manual strangulation
ligature marks are present in death by hanging or strangulation by ligature
suicidal cut throat  diagonal
homicidal  horizontal
common causes of death : asphyxia, pneumonia, hemorrhage and shock
VERTEBRAL COLUMN AND SPINAL CORD
a. Fracture of the vertebrae
- dangerous to life because of the involvement of the spinal cord
- fracture of the upper 4 cervical vertebrae paralysis of the phrenic nerve
- fracture of the 5th cervical vertebrae to the 1st dorsal vertebrae  paralysis of all the
extremities
- causes of the fracture of the spine may be:
1. Direct Violence
- the fracture of the spine may be due to a blow by the heavy instrument coming from the
back, fall from a height, collision with motor vehicles and hit of a projecting instrument
2. Indirect violence
- due to a fall on the feet or buttocks, forcible bending of the body as in wrestling, a blow
on the chin or forehead, forcible bending of the head towards the sternum and slight twist
of the body if the person is suffering from Pott’s disease
b.
Concussion of the spine
- may occur even without any visible signs of external injuries
- usual complaints: h/a, restlessness, pain and tenderness over the spine. Loss of sexual
power, irritability of the bladder, inability to walk, weakness of the limbs and
derangement of the special senses
INJURIES IN THE CHEST
a. Injuries to the chest wall
- Most common: stab wounds  may involve the lungs, heart and the big blood vessels in
the chest cavity
- Bullet wounds may be superficial or may involve the pleura; hemorrhage, collapse of
the lungs due to the removal of the negative intrathoracic pressure and pneumonia may
develop if the victim does not die immediately
Fracture of the ribs may be caused by
1. direct violence
- stab, blow, or bullet wounds
b.
2. Indirect violence
crush injuries in vehicular accidents, a pressure on the chest by heavy objects, a fall of
earth or pressure with the knee
the usual site of fracture of the sternum  junction of the manubrium and the gladiolus
Injuries to the lungs
- may cause compression and collapse of the lungs and the patient may die of respiratory
embarrassment or anemia
- may be injured by a sharp pointed instrument or by a bullet
- may cause bloody froth coming out of the mouth
- death may be due to severe shock or a rapid hemorrhage
Complications of Lung Injuries
a. Hemorrhage
- injury to the lung may cause severe hemorrhage and about 1, 500 cc of blood may be
recovered free in the pleural cavity
b. compression of the lungs
c. severe pneumothorax
d. cerebral air embolism
e. Hemoptysis
f. Subcutaneous emphysema
Injuries to the heart
- may fail and causes death due to an existing natural disease independent of trauma
- common lesions: coronary insufficiency, myocardial fibrosis, valvular lesion or
tamponade due to rupture of the ventricle
- produced by sharp instruments or the sharp ends of the fractured ribs
- most common site of the wounds: right ventricle  most exposed part of the heart
- rupture of the heart is usually produced by a blunt instrument or by crushing injury due to
vehicular accidents  commonly ruptured at the right side towards the base
Injuries of the diaphragm
- due to sharp instrument and bullets are caused by injuries either of the chest or abdomen
- rupture of the diaphragm is due to a sudden increase of intraabdominal pressure crushing
injuries caused by vehicular accidents or traumatic compression of the chest
ABDOMINAL INJURIES
a.
b.
c.
d.
Abdominal wall
- skin may remain unmarked inspite of extensive internal injuries with bleeding and
disruption of the internal organs most vulnerable: point of attachment of the internal
organs, especially at the source of its blood supply and the point where blood vessels
change direction
- vulnerable to trauma: area in the middle superior half of the abdomen, forming a triangle
bounded by the ribs on the two sides and a line dawn horizontally through the umbilicus
forming its base
Stomach
- observed in cases of gastric ulcer or new growth
- frequent site of rupture: pyloric end and the greater curvature
Intestine
- ulcer at the duodenum may rupture spontaneously common causes of death: peritonitis
and hemorrhage
- due to kick, blow, fall,. vehicular accident
- sharp instruments and gunshots: cause multiple lesions in the intestine and may involve
visceral organs
Liver
- one of the most vulnerable organs in the abdominal cavity because of its size, weight,
location, friability and fixed position
- due to blow, kick, crush , fall sudden contraction of the abdominal wall
- more frequently involved: right lobe
e.
Spleen
- suffers traumatic rupture resulting from the impact of a fall or blow and from the
crushing and grinding effects of wheels of motor vehicles
- more common at the region of the hilus and the lesion may be longitudinal or transverse
f.
Kidney
- may be due to a blow at the lumbar region somewhere at the region of the 12 th rib
- ruptured at the slightest violence when it is diseased as in cases of hydronephrosis,
pyelonephritis, tuberculosis, abscess or tumor
“ Crush syndrome”
- are secondary changes in crush injuries.
- Edema and anuria follow a crush
- Kidneys are swollen , pale with marked degeneration of the cells lining the tubules
g.
Pancreas
- injured by a violent blow at the epigastric region
- due to hemorrhage , shock, insulin insufficiency
PELVIC INJURIES
a.
Urinary Bladder
- involved in a blow, crush, kick at the hypogastrium especially when distended with urine
- may be involved in fractures of the pubic bones
- spontaneous rupture is rare when it is over-distended due to urethral stricture,
enlargement of the prostate or tumor
- symptoms: pain, tenderness at the lower portion of the abdomen, bloody urine, difficulty
in urination, and rigidity of the abdominal muscles
b.
Uterus
- gravid uterus is likely to be ruptured in a blow, kick, or crush injuries
- spontaneous rupture of the uterus is commonly observed among pregnant women due to
injudicious use of drugs or abnormal presentation
c.
Vagina
- May be due to sexual act or a faulty instrumentation to induce a criminal abortion
- Vaginal wall may be lacerated during parturition
EXTREMITIES
a. Direct violence
- will result in a contusion and when the force applied is severe it may cause interstitial
muscular hemorrhage and fractures of the underlying bone
- due to fall, vehicular accident , or a direct application of force
b.
Indirect violence
- twisting or pathological fracture of the bone underneath causes laceration of the muscles
around with marked hemorrhage
- may suffer deformity, shortening of the extremity and shock
c.
Crushing injuries
- result in severe soft tissue trauma and are most commonly caused by vehicular accidents
or fall of heavy materials
- accompanied by marked swelling, comminution of the bone and extravasation of the
blood