TRAUMA

TRAUMA - bodily harm with or without structural alterations resulting from interaction with physicochemical agents, imparting energy to tissues. May cause morphologically apparent damage (wound) or produce physiological imbalance (eg reflex cardiac arrest by neural stimulation) and secondary effects (eg thrombosis, infection, obstruction of tubular organs)

TERMS: WOUND: disruption of the continuity of the tissues produced by external mechanical force INJURY: from the latin injuria (in- not, jus- the law). The term is often used synonymously with wound but can have a wider use, including damage to tissues by heat, cold, chemicals, electricity, radiation, in addition to mechanical force LESION: from the latin laesio (a hurt). Originally meant injury, now more widely applied to include " any area of injury, disease or local degeneration in a tissue causing a change in its function or structure"

TYPES OF TRAUMA Energy may applied to tissues in various forms 1) Mechanical Force Blunt force trauma (BFT) -a moving object (KE) striking the body as in a blow -the moving body (KE) striking a fixed object or surface as in a fall BFT causes bruises, abrasions and lacerations Sharp force: knife tip or edge, broken glass, jagged metal -applied force is concentrated over a small area, requires little force to cut tissues Firearm; high velocity, small mass projectile 2) Thermal energy: heat or cold 3) Electrical energy: flow of current may cause a burn if resistance is high 4) Atmospheric Pressure: high or low, in air or water 5) Radiation: particle or radiation 6) Chemical reaction with tissue releasing energy

MECHANICAL FORCE

Mechanical Force may cause: -Impact -Angulation -Compression -Traction -Torsion -Shearing -Acceleration/deceleration

BLUNT FORCE TRAUMA

Blunt force trauma (BFT) a moving object (KE) striking the body as in a blow; the moving body (KE) striking a fixed object or surface as in a fall;
Degree of Force or K.E. applied: Force = Mass x Acceleration Kinetic Energy = 1/2 Mass x Velocity2 Energy depends on mass of weapon or projectile, but on the square of its velocity Crash energy = (mph)2 x 0.034 + Stopping distance in feet.

DIFFERENT TOOLS, OBJECTS, WEAPON

The foot and the fist causes blunt trauma.

Small surface objects hammer and others.

Spherical object - dumb-bells, stone-ball, bottle,

Rod shaped weapon (cylindrical object)

whip, stick, truncheon, beater, handler, rod, baseball bat.

Blunt- edgy object - fingarnails , edge of board, iron, chair, radiator, stairs and a ladder, etc..

Subject with the triple and multiwall angles angle board, hammer, brick etc..

Blunt force trauma causes:

- BRUISES, -ABRASIONS, -LACERATIONS;

Types of injury to the skin.

BRUISES
From Old English brysan-to crush and Old French bruser-to break Syn: (contusions, ecchymoses) Definition: leakage of blood from ruptured small vessels (veins or arterioles) into the surrounding tissues. Haemorrhage or bleeding is the escape of blood from any part of the vascular system. Haemorrhage can also be external, from a skin wound, or internal into a body cavity. Bruising is haemorrhage into the surrounding tissues. Bruising may be seen in skin, muscle or any internal organ. Petechiae- pin head size bruise < 2mm

Mechanism of bruise.

Mechanism of bruise.

Mechanism of production
Moving object strikes the stationary body (blow with fist or weapon). Moving body strikes a stationary object (fall) pinching or squeezing. Often associated with skin abrasion or laceration (the more elastic overlying skin may be undamaged) Bruising less often associated with incised or stab wounds which allow outward escape of blood from cut vessels.

Bruise associated with skin abrasion

Bruise associated with skin abrasion (arrows left ).

CLASSICAL PATTERNS OF BRUISING

Intradermal bruise due to impact with a hard,

patterned object with ridges/grooves. Skin over ridges is compressed and vessels remain intact. Skin forced into grooves and dermal vessels ruptured. The resulting accumulation of a small amount of blood, near the epidermis may demonstrate the obvious pattern of the causal surface (tyre, shoe tread, car bumper, gun muzzle)

Child abuse.

Finger pad bruises are round or oval, slightly larger than the finger tips due to outward spread of blood. Due to gripping by fingertips in forceful restraint. Found on limbs and face (child abuse), thighs (rape), neck (throttling (manual strangulation), arms (forceful restraint, defensive injuries)

Finger pad bruises (arrows) on the thighs in rape.

Doughnut bruise due to a spherical object (cricket ball)

Love bite (hickey).

Suction bruise caused by firm application of the lips against the skin, forming an air-tight seal, oral suction causing a shower of petechial bruises from rupture of numerous small vessels. Normally found on teenagers after the weekend! Also seen on neck, breasts in sexual assault. Must be human in origin. A similar appearance is seen between the dental arches of a true bite.

Not a bite ! No teeth marks !

Love bite on the neck.

Love bite on the shoulder.

Love bite on the thigh.

Love bite on the back (child abuse).

Love bite on the buttocks.

Bruises on the face -

black eye (peri-orbital haematoma).

Bruises on the faceblack eye and laceration.

The causes of black eye.

1- fist blow to orbit or

nose; 2- tracking from forehead bruise; 3- fractured skull basis;

Tramline bruising
due to a rod shaped weapon or stick. Compression of vessels centrally, not usually damaged unless crushed onto bone. Traction causes rupture of vessels along edges of rod.

Bruises of rod shaped weapon .

Direct skin abrasion by whip. Reproduction of surface of switch with steel wire.

Bruises of stick.

Bruises of truncheon.

Bruises of beater.

Formation of tramline bruising from the application of a rectangular or cylindrical object.

Formation of tramline bruising from the application of a cylindrical object.

Dermal, intradermal, subdermal and intramuscular bruise.

The site of bruising does not necessarily reflect site of trauma.

Bleeding into tissues may continue for some time after impact under circulatory pressure. Extravasated blood tracks along natural/traumatic planes of least resistance, influenced by gravity and body movement, e.g. -blow on temple bruise on cheek; -fractured jaw bruising on neck; -fractured hip bruise on thigh; -blow on shoulder bruise on arm; -fracture pelvis bruise on scrotum ;

Movement of bruises. Blow on left shoulder (arrow) bruise on arm (arrow).

Movement of bruises. Fracture pelvis

bruise on scrotum.

Bruises. Kicking (or foot assault).

Stamping, jumping may reproduce the pattern of the sole.

Pattern injuries associated with impacts from the bottom of a shoe while being stamped and kicked

AGE AND COLOUR CHANGE IN BRUISES

-immediately DARK RED (the colour of capillary blood) -soon turns DUSKY PURPLE Subsequent colour changes very variable in timing and result from HAEMOLYSIS by enzymes and cellular products. Colour changes begin at the periphery and progress towards centre if large. Smaller bruises may change colour uniformly. Pigments, including bilirubin and haemosiderin are released from haemoglobin within degenerating red blood cells

Subsequent colour changes: red the colour of capillary blood and oxyhaemoglobin (3 - 4 days); brown methaemoglobin (3 - 5 days); green biliverdin (4-6 days); yellow bilirubin (haematoidin)(8 -12 days).
DISAPPEARS 14-15 days (range 1-4 weeks).

A small bruise in a healthy adult may disappear in 1 week. A love bite (Hickey) may vanish in 2 or 3 days. N.B. The time course is very variable, time course depends on adequacy of lymphatic and venous drainage, size and depth of bruise, anatomical site, age of person (v. slow in elderly) and general health Accurate dating of an individual bruise is difficult.
Distinguishing FRESH from OLD is easier and often important, e.g. repeated assault, child abuse.

Bruises different colours.

1. Ecchymoses in meningococcemia on the leg.

Bruises (ecchymoses) in diseases

2. Ecchymoses in

Henoch- Shonlein purpura on the legs.

POST MORTEM LIVIDITY (hypostasis, livor mortis). The settling of blood into the lowermost blood vessels.under gravity after the circulation ceases. Results in a pinkish discolouration of the skin in the dependent parts of the body. Blood vessels compressed by pressure of contact with clothing or supporting surface will not fill and the area remains pale (contact or pressure pallor). Lividity is sometimes confused with bruising. Distribution and pallor help to discriminate. Incision of the skin shows oozing of blood from cut, engorged vessels which can be rinsed away in lividity. Incision of a bruise reveals escape of blood into the tissues which can not be rinsed away.

Post mortem lividity (hypostasis,

livor mortis).

Incision of a bruise reveals escape of blood into the tissues which can not be rinsed away.

BRUISES

LIVIDITY

1 Situation . 2 Cuticle . 3 Site . 4 Edges .

Occurs- epidermis or deep tissues May be abraded Abraded contusion Over the site of injury Not sharply defined

Engorged capillaries simple stain Not abraded Depend part of body sharply defined

5. 6. 7. 8.

Appearance Colour Incision On presenting

Raised above the Not raised surface red, blue, green yellow Shows extravasation. Colour repeated Uniform & Livid Slight oozing form cut end Blanching occurs in unfixed .

1. Evidence of application of blunt force. Accidental Homicidal Suicidal

2. Volume of blood- circulating diminished due to extravasation 3. Patterned Bruising Nature of agent used. 4. Healing Determination of age.

5. Bruising over the particular part of the body- Indicate some peculiar offence Ex : On the Neck Inner Side of Thigh FM Indicate Sexual Assault small bruises The so called six Penny Bruises

6.Character & manner of injury may be known from its distribution.

TRAIT

ATRIFICIAL BRUISES

TRUE BRUISES

1.
2. 3. 4. 5.

Causes
Site Colour Shape Markings

Juice of marking nut

Exposed accessible parts Dark brown Irregular Well defined & regular covered with small vesicles

Trauma
Anywhere Atypical colour changes Usually Round Not well defined, diffuse & irregular. No vesicles

6.

Redness & Seen in the surrounding skin Inflammati on Contents Acrid serum

Seen in the site.

7.

Extravasated blood

8.
9.

Itching
Vesicles

Present
May be found on the finger tips &other parts of the body due to scratching Positive for chemicles

Absent
Absent

10.

Chemical Test

Negative

1. Contusion contain 20- 30 ml of blood or even more. Multiple contusion can cause death from shock & internal haemorrhages. 2. Gangrene & death of tissue. 3.Good site for bacterial 4. Sudden compression of the subcutaneous tissue pulmonary embolism may occur.

CASE. Death of a bruises on the body.

Defence injuries (bruises).

Intradermal and subdermal haemorrhage or bleeding.

The cause of death is fat embolism. (staining by Sudan ).

Tramline bruising of stick.

ABRASION
(Syn: grazes, scratches, scarpes). From Latin ab- from and radere- to scrape Definition: "a portion of the body surface from which the skin or mucous membrane has been removed by rubbing" (from the Latin ab- from, and radere- to scrape). A superficial injury of the skin not involving the full thickness of the skin (confined to epidermis and epidermis dermis, or body lining epithelium). Usually due to BFT.

ABRASIONS DEFINATION : Abrasions are the injuries involving superficial layers of the skin the epidermis or mucus membrane, due to impact against some hard, blunt, & rough object/ weapon.

Mechanism. Determination of the direction of impact in an abrasion caused by a tangential force. The epidermis tags raised by the impact tend to pile up at the distal end.

Mechanism of production on abrasion.

Loss or scraping of epidermis/dermis by tangential friction on rough surface (graze) or sharp point (scratch).

Loss or scraping of epidermis/dermis by tangential friction on rough surface (graze) or sharp point (scratch).

Loss or scraping of epidermis/dermis by tangential friction on rough surface (graze) or sharp point (scratch).

Superficial crushing of epidermis/dermis caused by direct impact.

Imprint abrasions. Fingernail impressions (crescentic) on neck in throttling.

Imprint abrasions. Fingernail impressions (crescentic) on face in rape.

Abrasions. Body of pedestrian received brush injuries by scraping along the road surface.

Bite mark-dynamic abrasion.

Bite mark- static abrasions.

BITE MARKS. Teeth marks may be abrasions, bruises or lacerations, or a combination. Clarity depends on contour of part bitten and the force applied.

AGE (FATE) OF AN ABRASIONS Usually heals that out any formation of scar FRESH : Reddish- Due to oozing serum & little blood. Dermis : Congested & painful 12- 24 Hours :- Exudation dries up to form reddish scab. Comprising of Dried blood, lymph & injured epithelial cells. 2 - 3 Days :- SCAB Reddish Brown. 4 5 Days :- SCAB Dark Brown 5 -7 Days:- SCAB- Brownish Black & Starts falling from the margin. 7-10 Days:- SCAB Shrinks & falls off leaving depigmented area underneath

Scheme of aging of abrasion (see previous slide).

Fresh abrasion. Blood and lymph (arrow). First stage.

Abrasion. Scab. Second stage.

Abrasion. Scab. Third stage.

Abrasion. Fourth stage.

CLINICAL IMPORTANCE: Abrasions are trivial, although they are painful, bleeding/exudation is slight and leads to crust/scab formation. Heals without scarring (by reepithelialisation). Abrasions are often associated with bruising and laceration.

MEDICOLEGAL IMPORTANCE: 1.Point of impact of the blunt force. 2.Indicated causative object/surface. 3.Direction of impact. 4.Pattern - Nature of force. 5.Site & Distributions over the body. 6.Various stages of healing.
7.Presence of material like mud, grit, coal- dust, cement etc.

LACERATION
(TEAR, LACERATED WOUND)
From Latin lacerare- to tear. Botanical termirregular edges. Definition: Full thickness tearing of the skin (or other tissue) due to stretching and crushing of tissues by blunt force trauma.
Blunt force trauma by moving object or fall.

A Laceration is a rupture or tear or split in the skin, mucus membrane, muscle or any internal organ, involving depth more than the covering epithelium of the skin or that of an organ & are produced by application of blunt force.
Many factors influences the formation & appearances of laceration.

Lacerations (lacerated wounds) have the following characteristics :

1. Ragged edges (torn apart), bulging fat, crushed hair bulbs 2. Associated bruising and abrasion of skin edges and adjacent tissue (BFT) 3. Tissue bridges in depth of wound (intact nerves, vessels, tendons). A tangential component may give one clean-cut edge, other ragged, undercut or flap-like.

Lacerated wound on head. ragged edges; bruising and abrasion of skin; tissue bridges;

Lacerated wound on head ragged edges; bruising and abrasion of skin; tissue bridges;

Lacerated wound on head. Fall from high.

Lacerated wound on head- SCALP. A tangential component may give one clean-cut edge, other ragged, undercut or flap-like.

Object in comparison with wounds.

When skin is closely applied to the bone & the subcutaneous tissue is scanty, blunt force may produce a wound which by linear splitting of the tissue resembles an incised wound.

Lacerated wounds on head and object wooden stake.

See previous slide.

22
1 1

2 1

3
Lacerated wounds on head and object (arrow 3).

HEALING of LACERATED WOUNDS.

1. Phase of inflammation. 2. Phase of proliferation. 3. Phase of scar formation and remodeling.

Healing of lacerated wounds. Scheme.

CLINICAL IMPORTANCE Often little external blood loss (except scalp) due to crushing and retraction of vessels. Associated internal injury/bleeding. Wound infection frequent. Heals by scarring.

Truncheon- Women.