Department of Forensic Medicine, University of Dundee Lecture Notes

Wounds II
Types of Trauma, Physical & Biological Factors Classification of Injuries
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Blunt Force Injuries (Bruises, Abrasions, Lacerations, Bites !harp Force Injuries (Incisions, Chop "oun#s, !tabs $unshot "oun#s (separate lecture notes Burns & !cal#s, %lectrical injuries

Internal injuries, %ffects of injury Interpretation of &oun# Pattern (!elf'inflicte#, Assault, Acci#ent, (TA

INJURIES OF MEDICO-LEGAL IMPORTANCE
WOUND: (legal #efinition )* breach of the full thic+ness of the s+in (or lining of lip , This e-clu#es abrasions, bruises, internal injuries an# fractures. WOUND: (me#ical #efinition * #isruption of the continuity of the tissues pro#uce# by e-ternal mechanical force* INJURY: from the latin injuria (in' not, jus' the la" , The term is often use# synonymously "ith "oun# but can ha/e a "i#er use, inclu#ing #amage to tissues by heat, col#, chemicals, electricity, ra#iation, in a##ition to mechanical force L !ION: from the latin laesio (a hurt , 0riginally meant injury, no" more "i#ely applie# to inclu#e ** any area of injury, #isease or local #egeneration in a tissue causing a change in its function or structure** "R#UM# ' bo#ily harm "ith or "ithout structural alterations resulting from interaction "ith physicochemical agents, imparting energy to tissues, 1ay cause morphologically apparent #amage ("oun# or pro#uce physiological imbalance (eg refle- car#iac arrest by neural stimulation an# secon#ary effects (eg thrombosis, infection, obstruction of tubular organs

TYPES OF TRAUMA
%nergy may applie# to tissues in /arious forms ) 2 Mec$anica% Force &%unt force trauma (BFT

'a mo/ing object (3% stri+ing the bo#y as in a blo" 'the mo/ing bo#y (3% stri+ing a fi-e# object or surface as in a fall BFT causes bruises, abrasions an# lacerations !$arp force) +nife tip or e#ge, bro+en glass, jagge# metal ' applie# force is concentrate# o/er a small area, re4uires little force to cut tissues Firearm5 high /elocity, small mass projectile 6 "$erma% ener'y) heat or col# 7 %ectrica% ener'y) flo" of current may cause localise# burn if resistance is high

8 #tmosp$eric (ressure) high or lo", in air or "ater 9 Radiation) particle or ra#iation : )$emica% reaction "ith tissue releasing energy

Mec$anica% Force may cause Impact, Angulation, Compression, Traction, Torsion, !hearing, Acceleration;#eceleration ((TA <ifferent tissues ha/e /arying properties of %lasticity (ten#ency of stresse# material to regain its unstresse# con#ition Plasticity (ten#ency to remain in stresse# con#ition =iscosity (resistance to change in shape "hen stresse# <ifferent tissues therefore ha/e #ifferent e%astic %imits (tolerance limits or brea+ points an# are /ulnerable to #ifferent stresses, !*in has greater elastic limit than un#erlying fat an# bloo# /essels ma+ing subcutaneous bruising more common than s+in laceration e,g, torsion often causes spiral fracture of tibia, soft tissues un#amage# compression often causes rupture of gas'fille# lung or intestine, but muscle an# s+in un#amage# Injury occurs "hen energy applie# e-cee#s the elastic limits (or tolerance of the tissues, &hether or not injury occurs follo"ing the application of energy, in "hate/er form, #epen#s on ($ysica% an# &io%o'ica% factors,

(+Y!I)#L F#)"OR! 2 De'ree of Force or 3,%, applie#) Force > 1ass - Acceleration 3inetic %nergy > 2;6 1ass - =elocity6 %nergy #epen#s on mass of "eapon or projectile, but on the s,uare of its ve%ocity Crash energy > (mph 6 - ?,?78 ÷ !topping #istance in feet 6 #rea o/er "hich force is applie#) 'same force sprea# o/er larger area is less li+ely to injure at site of impact e#ge or tip of +nife allo"s a great concentration of force applie# e#ge of a plan+ is more #amaging than its flat face

not in/ol/ing the full thic+ness of the s+in. catching a cric+et ball.e.'bo-er rolling "ith a punch sprea#s out the #uration of impact. A a portion of the bo#y surface from "hich the s+in or mucous membrane has been crushe# or remo/e# by rubbingA A superficial injury.g.in the bo#y &IOLO/I)#L F#)"OR! 2 Mo0i%ity of t$e 0ody part Fi-e# parts absorbs all applie# energy. <ue to blunt force trauma. !ite. forehea# on #ash -.to scrape !yn. se/erity of bruising are /ery /ariable (6 #0rasion From Latin ab' from an# radere. Aescape of bloo# from rupture# small /essels (/ein. 1obile parts are able to transform 3% into mo/ement 6 #nticipation and coordination e. i. Contusion.f. 0l# French bruser-to brea+ !yn. capillaries. Direction of application) Transfer of +inetic energy from "eapon or projectile is incomplete "ith a glancing blo" or e-iting bullet (some "oun#ing potential is "aste# an# complete "hen the "eapon or bullet come to rest on. confine# to . $raBe <efn.heel of stilletto is more #amaging than its sole !oft object #eforms an# flattens 7 Duration o/er "hich force is applie#) longer #uration allo"s tissues at site of impact to #eform an# #issipate the applie# energy eg fall onto soft surface (increases #uration an# area of impact seat belt stretching slo"s #o"n the rate of transfer of +inetic energy to the bo#y an# sprea#s the area of impact o/er the trun+ (c. !cratch. shape. %cchymosis <efn. siBe. arterioles into the surroun#ing tissuesA The resulting #iscolouration is seen through the o/erlying intact s+in. rolling "ith a fall 7 &iomec$anica% properties of tissue <ifferent tissues ha/e #ifferent strengths an# "ea+nesses 's+in is elastic an# more resistant than un#erlying tissues (Bruise @ Laceration 'bloo# /essels more resistant to compression than stretching 'bone more resistant to ben#ing than to torsion 'hollo" or flui#'fille# organs sensiti/e to compression 'brain (semi'flui# more resistant to #irect impact than rotational impact (''@ shearing of ner/e fibres 'bone an# joint may transmit force to a "ea+ point CLASSIFICATION OF INJURIES (2 &ruise (from 0l# %nglish brysan'to crush.

e.flat instrument. a sharp. BRUISES (!yn) contusions. Incise# "oun# is L0C$%( TDAC IT I! <%%P.rigi#.g..epi#ermis. <ue to a sharp. high /elocity projectile fire# from gun. muscle or any internal organ. Clean #i/ision of the full thic+ness of s+in (or other tissue by a sharp'e#ge# instrument. or a blunt. Tissue bri#ges Pro/i#es little specific information about the causal object (8 Incision From Latin incidere' to cut into. (G Firearm In3uries !mall mass. Co associate# bruising. or internal into a bo#y ca/ity. Associate# bruising. Bruising is haemorrhage into the surroun#ing tissues.g. e. Puncture is Aa small hole ma#e "ith a sharp pointA IT! <%PTD %EC%%<! IT! L%C$TD on the bo#y surface. . Characteristics) Clean cut e#ges.thin. <ue to (2 <irect impact) imprint (may reflect pattern of causati/e surface or (6 Tangential impact) 'ra1e or scratc$ (may reflect #irection of impact #%2ays occurs at t$e site of impact (7 Laceration From Latin lacerare' to tear.abrasion.abrasion. Full thic+ness tearing of s+in or tissue #ue to stretching an# crushing by blunt force Characteristics) (agge# e#ge. DL (: "$erma% in3uries Application of #ry or moist heat )0urns & sca%ds Col# injury (F %ectrica% &urns Deat pro#uce# by electrical flo".long. "oo#en sta+e ((UN)"UR . from a s+in "oun#. nee#le (N (UN)"UR .g. Co tissue bri#ges. Daemorrhage can also be e-ternal.#ermis. Botanical term' irregular e#ges <efn. Pro/i#es little specific information about the causal object (9 (enetratin' or (uncture Wounds <efn. Bruising may be seen in s+in. e. !hape an# siBe of "oun# often in#icate #imensions of "eapon. !urgical term incision "ith scalpel <efn. ecchymoses From 0l# %nglish brysan'to crush an# 0l# French bruser-to brea+ <efinition) lea+age of bloo# from rupture# small /essels (/eins or arterioles into the surroun#ing tissues. +nife (!"#&. +aemorr$a'e or blee#ing is the escape of bloo# from any part of the /ascular system.

chee+s . Although hea/y impact "ill generally cause a large bruise. Blee#ing in the subcutaneous tissue seen as #iscolouration through the semi'translucent s+in IN" RN#L &RUI!IN/ Cot /isible at surface <eeper bruise in muscle or internal organ "ill not be /isible through o/erlying fat an# s+in. blo" on temple ''@ bruise on chee+ fracture# ja" ''@ bruising on nec+ fracture# hip ''@ bruise on thigh De%ayed appearance on 0ody surface <eep bruising may ta+e upto 6.traumatic planes of least resistance. orbit (buttoc+s "ill bruise easily. <egree of force cannot be accurately #e#uce# from the siBe of a bruise. la-. se/erity of bruising #epen#s on) (2 #natomica% site: o/er bony prominence (shin. nec+ in strangulation. e. blo"s to chest & ab#omen "$e site of 0ruisin' does not necessari%y ref%ect site of trauma5 Blee#ing into tissues may continue for some time after impact un#er circulatory pressure. /ascular tissue (eyeli#. fatal brain injuries.g.g. Pigments may sprea# closer to the o/erlying translucent s+in thus becoming /isible on the surface a fe" #ays after injury. Brea+#o"n of (BCs "ith time (haemolysis eleases brea+#o"n pigments "hich may sprea# out"ar#s an# stain the tissues o/er a "i#er area then the original intact re# bloo# cells of the fresh bruise. fatty tissue . D /R OF FOR) !+in has greater elastic limit than un#erlying fat an# bloo# /essels ma+ing subcutaneous bruising more common than s+in laceration. e. (e'e-amination of a bo#y or li/e /ictim after this time may re/eal bruises not initially apparent.$ours to appear at surface (come out . pinching or s4ueeBing 0ften associate# "ith s+in abrasion or laceration (the more elastic o/erlying s+in may be un#amage# Bruising less often associate# "ith incise# or stab "oun#s "hich allo" out"ar# escape of bloo# from cut /essels 4" RN#L &RUI!IN/ !uperficial bruise rapi#ly appears at the site of impact. influence# by gra/ity an# bo#y mo/ement. Iltra/iolet light may #isclose an other"ise uni#entifiable bruise.(etec$iae' pin hea# siBe bruise H 6mm <ue to &LUN" FOR) "R#UM# 1o/ing object stri+es the stationary bo#y (0%o2 "ith fist or "eapon 1o/ing bo#y stri+es a stationary object (fa%%. %-tra/asate# bloo# trac+s along natural.

li/er #isease ( inclu#ing alcoholism . some infections (meningitis . #/ #ND )OLOUR )+#N/ IN &RUI! ! 'imme#iately D#R9 R D (the colour of capillary bloo# 'soon turns DU!9Y (UR(L 'subse4uent colour changes /ery /ariable in timing an# result from DA%10LJ!I! by enBymes an# cellular pro#ucts. %l#erly) #egeneration of /essels an# connecti/e tissue allo"s easy bruising (7 O0esity 7 !e8 0bese in#i/i#uals bruise more easily than lean #ue to a greater proportion of subcutaneous fat Females generally bruise more easily #ue ha/ing a greater proportion of subcutaneous fat than males (8 Disease of c%ottin' AspontaneousA bruising (haemophilia. leu+aemia an# platelet #isor#ers . me#ications (9 !*in co%our blac+ s+in may mas+ bruising. fatty tissues "hich bruise easily. e. palms.B. /itamin C #eficiency (scur/ey .g.%scape# bloo# has room to accumulate in la. <ense fibrous tissue physically restricts accumulation of bloo#. soles. A lo/e bite (Dic+ey may /anish in 6 or 7 #ays. C. <ense.g. inclu#ing bilirubin an# haemosi#erin are release# from haemoglobin "ithin #egenerating re# blo# cells !ubse4uent colour changes) :5 6. !maller bruises may change colour uniformly.tissues. Distin'uis$in' FR !+ from OLD is easier an# often important. li/or mortis . poor nutrition. (6 #'e Infants ha/e loose. Colour changes begin at the periphery an# progress to"ar#s centre if large. &ROWN /R N 8'9 #ays or more Y LLOW F'2? #ays or more !"R#W DI!#(( #R! 28'29 #ays (range 2'8 "ee+s A small bruise in a healthy a#ult may #isappear in 2 "ee+. e. tightly boun# tissue. chil# abuse (O!" MOR" M LI. age of person (/. (esilient muscle of anterior ab#ominal "all rarely bruises (although there may be se/ere un#erlying /isceral injury . I= light nee#e#.IDI"Y (hypostasis. "$e time course is very varia0%e time course #epen#s on a#e4uacy of lymphatic an# /enous #rainage. anatomical site. -5 9. 7. slo" in el#erly an# general health Accurate #ating of an in#i/i#ual bruise is #ifficult. Pigments. siBe an# #epth of bruise. rarely bruises. #elicate. repeate# assault.

e.g. !+in o/er ri#ges is compresse# an# /essels remain intact. !uction bruise cause# by firm application of the lips against the s+in. not usually #amage# unless crushe# onto bone. near the epi#ermis may #emonstrate the ob/ious pattern of the causal surface (tyre. %-pansion an# mo/ement blur the outline. patterne# object "ith ri#ges."ill"rap aroun# the con/e-ity pro#ucing a longer an# often cur/e# tramline bruise. gun muBBle It is often useful to trace the outline onto an acetate sheet for later comparison.The settling of bloo# into the lo"ermost bloo# /essels un#er gra/ity after the circulation ceases. Li/i#ity is sometimes confuse# "ith bruising. A fle-ible strap or fle. Traction causes rupture of /essels along e#ges of ro#. !+in force# into groo/es an# #ermal /essels rupture#. The resulting accumulation of a small amount of bloo#. !+#( #ND !I= of bruises are /ery /ariable & poor in#icator of causati/e object. <istribution an# pallor help to #iscriminate. nec+ (throttling (manual strangulation .groo/es. blo" o/er clothing or je"ellery An associate# imprint abrasion is more useful. bumper. forming an air'tight seal. arms (forceful restraint or post mortem mo/ement of the bo#y "ram%ine 0ruisin' #ue to a ro# shape# "eapon or stic+. bac+ of the hea#. shoe trea#. Dou'$nut 0ruise #ue to a spherical object (cric+et ball Love 0ite >$ic*ey. imme#iately prior to #eath may retain the pattern of the causati/e object. Incision of the s+in sho"s ooBing of bloo# from cut. Incision of a bruise re/eals escape of bloo# into the tissues "hich cannot be rinse# a"ay. After #eath bloo# is un#er physical pressure only. !ome bruises inflicte# "ith a small har# object. <ue to gripping by fingertips in forceful restraint Foun# on 'limbs an# face (chil# abuse . oral suction causing a sho"er of petechial bruises . engorge# /essels "hich can be rinse# a"ay in li/i#ity. A soli# stic+ bruise is limite# to the con/e-ity of the bo#y surface (remember that a soft bo#y part such as a buttoc+ "ill moul# an# flatten. Bloo# /essels compresse# by pressure of contact "ith clothing or supporting surface "ill not fill an# the area remains pale (contact or pressure pallor . grille or hea#light on pe#estrian. Fin'er pad 0ruises are roun# or o/al. car bumper. %scape of bloo# cells an# haemolytic pigments from /essels into the surroun#ing tissues #ue to putrefactive 0rea*do2n may be #ifficult to #istinguish from bruising. Compression of /essels centrally. nec+ ligature. Co teeth mar+s. There is only a passi/e ooBe from bloo# /essels rupture# after #eath rather than the acti/e e-tra/asation un#er pressure "hich occurs in life. 1ost li+ely to occur "ithin areas of post mortem li/i#ity "here bloo# is un#er greater physical pressure an# o/er bony prominences "here tissues may be crushe# against the un#erlying bone. slightly larger than the finger tips #ue to out"ar# sprea# of bloo#. clothing. Cot a bite. (esults in a pin+ish #iscolouration of the s+in in the #epen#ent parts of the bo#y. thighs (rape .g. (O!"<MOR" M &RUI!IN/ can occur but nee#s great force to pro#uce small bruise. (api# #eath "ill limit the e-tension an# blurring of the outline "hich usually occurs un#er circulatory bloo# pressure. )L#!!I)#L (#"" RN! OF &RUI!IN/ (atterned Intraderma% 0ruise #ue to impact "ith a har#. e.

&%ac* eye (peri'orbital haematoma fist blo" to orbit fracture# s+ull ((. A superficial injury of the s+in not in/ol/ing the full thic+ness of the s+in (confine# to epi#ermis an# papillary #ermis. groin. loin. "ife.arious a'es: suggests repeate# assaults (chil# abuse. or bo#y lining epithelium .an# radere' to scrape . scratches From Latin ab' from an# radere. especially the face Causes bruising.. 1ore common in muscles than s+in. laceration o/er bony prominences an# teeth. Associate# internal injury is often se/ere &ruisin' of .B. fracture# nose & face. )ounter pressure 0ruises of bony prominences of shoul#er bla#es. Also seen on nec+. Bruising usually #ue to Acci#ent or assault5 it is rarely self'inflicte# (too painful an# unimpressi/e. Bruising or abrasion of +nuc+les #ue to thro"ing punches 9ic*in' >or s$od foot assau%t.groun#. alcoholics Medica% intervention 'sternal an# car#iac bruising 'bruising aroun# nee#le puncture mar+s 'pinching s+in to test conscious le/el (butterfly bruise C. A similar appearance is seen bet"een the #ental arches of a true bite. breasts in se-ual assault. 1ust be human in origin.husban# beating. Cormally foun# on teenagers after the "ee+en#. nec+.to scrape <efinition) Aa portion of the bo#y surface from "hich the s+in or mucous membrane has been remo/e# by rubbingA (from the Latin ab' from . bac+. jumping may repro#uce the pattern of the sole $lancing +ic+ may cause a scuffe# abrasion <irect blo" (s"inging +ic+ may result in bruising. (unc$in' is #irecte# at the upper bo#y .T. ABRASIONS (!yn) graBes. abrasion.(scratch 6 !uperficial crushing of epi#ermis. Isually #ue to BFT. e-ception is a scratch 6 "ypes) 2 Loss or scraping of epi#ermis.#ermis cause# by DIR )" IM(#)"5 1ore often seen in fatalities . sacrum an# bac+ #ue to forceful restraint against "all.#ermis by "#N/ N"I#L FRI)"ION on rough surface (graBe or sharp point.from rupture of numerous small /essels. el#erly (beating or poor balance . !tamping.A. gunshot trac+ing from forehea# bruise. chest. laceration or a cur/e# imprint abrasion Typical target sites) face.

'bo#y thro"n across roa# surface (gra/el rash Falls Assault "ith a rough surface# instrument. Animal bite is #eeply arche# or *I'shape#*. Duman bite is near circular or shallo" o/al !iBe 'in#icates "hether inflicte# by an a#ult or chil# Teeth may close #o"n on flat surface but more often a bloc+ of tissue is #ra"n into the mouth. 2. Clarity #epen#s on contour of part bitten an# the force applie#.1any abrasions ha/e both a /ertical an# tangential component.T.g.''@ scrapin' of epidermis #ue to friction against a rough or sharp surface. or a combination. bruises or lacerations. "#N/ N"I#L IM(#)" <ue to a glancing (tangential impact by a mo/ing object against stationary bo#y or the mo/ing bo#y against a rough stationary surface. <eeper loss of epi#ermis may e-pose capillary loops in papillary #ermis an# cause blee#ing <irection of impact can often be assesse#) starting e#ge has be/elle# #escent5 a series of parallel furro"s in#icate #irection of sli#ing motion5 finishing e#ge has tags of heape# epi#ermis e. Finger nail scratches (same sites as imprint nail mar+s but #ra"n across surface. !hape of resulting bite mar+ is affecte# by flattening on release.A. R"I)#L IM(#)" causes )rus$in' of epidermis The causati/e object may stamp its shape or surface pattern on the s+in ''@ IM(RIN" #&R#!ION e. (ope "ea/e in hanging or ligature in strangulation Fabric "ea/e of seat belt.g. leathery. Abrasions are often associate# "ith bruising an# laceration FOR N!I)#LLY . DIR )" . Deals "ithout scarring (by re'epithelialisation . "rists thighs an# /ul/a in rape 6. (esults in suction bruise (hic+ey bet"een the #ental impressions. blee#ing. BITE MARKS Teeth mar+s may be abrasions. <epth an# brea#th often useful for comparison "ith assailant <ragging of #ea#. Duman bite may present as a series of separate bruises "ith . Post'mortem #rying of abra#e# surface causes a gol#en yello" or re##ish.injure# a"ay from scene of crime. RY IM(OR"#N"5 0ften the most informati/e of all injures) #%2ays ref%ect site of impact Often indicate causative o03ect?surface Often indicate direction of impact Assessment of age of abrasions is #ifficult. although they are painful. Abrasions are c%inica%%y trivia%. parc$mented appearance. causing e-u#ation of flui#. !tratum corneum an# superficial epi#ermal cells remo/e#.e-u#ation is slight an# lea#s to crust. "hip Tyre trea# in (TA Bite mar+ ( #ouble crescent of space# linear impressions Fingernail impressions (crescentic on nec+ in throttling. clothes. nec+.scab formation. (.

The mar+ may represent only part of the #ental arca#e &hen fresh. 7. e. Ro%%in'?'rindin' mo/ement of /ehicle "heel strips an# tears Lacerations are c$aracterised 0y: 2 .blee#ing. cur/e# line of bruising. LACERATION From Latin lacerare' to tear. !ame type of trauma "hich causes bruising an# abrasion but full thic+ness injury Typically o/er B0CJ P(01IC%CC%! "here tissue is pinned and crus$ed against un#erlying bone. &oun# infection fre4uent (F.g.central linear abrasions or a continuous. Tissue Bri#ges in #epth of "oun# (intact ner/es. (arely self'inflicte# 4#M(L ! Crescentic. roun#'hea#e# hammer J'shape# . scalp. bulging fat. causing progressi/e loss of #efinition. psychiatric .B. crushe# hair bulbs 6 .Deals by scarring FOR N!I) IM(OR"#N) 2. chee+. !hape an# siBe not usually relate# to causal object 6. eyebro". Associate# Bruising an# Abrasion of s+in e#ges an# a#jacent tissue (BFT 7 . . Pinning. nec+. ab#omen an# /ul/a in se-ual assault. BLICT F0(C% T(AI1A by mo/ing object or fall. metal ro# . !elf'inflicte# (fabricate# assault.g..circular . ten#ons A tangential component may gi/e one clean'cut e#ge. Botanical term' irregular e#ges <efinition) Full thic+ness tearing of the s+in (or other tissue #ue to stretching. /essels. Trace e/i#ence in "oun# (F. Fights. Bruising #ue to in#i/i#ual teeth sprea#s out an# blurs.. Any site in chil# abuse. thighs. "restling & football. pinning an# crushing of tissues by blunt force trauma. )LINI)#L IM(OR"#N) 0ften little e-ternal bloo# loss (e-cept scalp #ue to crushing an# retraction of /essels. (agge# e#ges (torn apart . Associate# internal injury. may pro/i#e useful e/i#ence of asssailant*s i#entity) !iBe an# shape of #ental arca#e influence# by #istinguishing features e. 1issing teeth. shin A single blo" may cause more than one laceration !oft tissue areas of limbs may be lacerate# by a 0%unt pro3ectin' o03ect 2$ic$ pu%%s o0%i.ue%y against the tension of the s+in causing stretching an# tearing. inclu#ing sport (rugby.. crushing an# stretching forces result in splitting an# tearing of tissues.. <isplace# teeth Allo"s comparison "ith suspect. !een on breasts. %arly e-pert #ental opinion an# photographs re4uire#. other ragge#. Accessible. un#ercut or flap'li+e.B.

but many miss. cubital fossae. clean . rape !tellate . )$op 2ound is a /ariant of an incision.stretching of s+in o/er limb in (. jagge# metal (irregular. fol#e# s+in.. Cut slopes up"ar#s an# bac+"ar#s. #o"n from the left. often gapes ' often #eeper at starting en# ' jagge# if inflicte# through loose. trun+ . An incise# "oun# is L0C$%( TDAC IT I! <%%P #ue to s2ipe action. ' lie both higher an# lo"er across nec+ ' no tentati/e cuts.. across the mi#'line. blo" to mouth Flaying laceration .A.. chest.. !shallo" ''@ #eep centrally ''@ shallo". INCISED WOUNDS !yn) cuts.T. e/erte# e#ges ' no tissue bri#ges or abrasion of margins ' linear or elliptical shape. lo" self'esteem #!!#UL" IN)I!ION! Compare# to suici#al cuts.Insi#e lips (trauma against teeth . assau%t or accident. rolling. jagge# ... Air embolism may occur. all are forceful an# #eepen rapi#ly . up to"ar#s the right ear. Das clean'cut e#ges but an abra#e# margin #ue to in/ersion an# friction against the si#es of the "i#e bla#e on insertion. !urgical term incision "ith scalpel <efinition) Clean #i/ision of the full thic+ness of s+in (or other tissue un#er the pressure of a sharp'e#ge# instrument. nec+. bro+en glass )+#R#)" RI!"I)! OF #N IN)I!ION@ ' clean cut. O"+ R ! LF<INFLI)" D IN)I!ION! Fabricate# assault ' superficial "oun#s to hea#. Incision isusually through le/el of thyrohyoi# ligament an# may be #o"n to spine. not "eapon type Co trace e/i#ence Profuse e-ternal haemorrhage an# air embolism <anger to life #epen#s on site an# #epth Incise# "oun#s may be !e%f<inf%icted. arms. suc$ as: +nife (linear... chest ab#omen. (epetiti/e nic+s at the base of the "oun# (sa"ing . s"eeping cuts. Blee#ing is /enous. FOR N!I) IM(OR"#N) (eflect sharp e#ge. ab#omen.. Parasuici#al mutilation ' face. thighs. slashes From Latin incidere' to cut into. groin !uicida% cut "$roat) tentati/e incisions (left si#e of nec+ if right han#e# . ! LF INFLI)" D At sites of election ("rists. 1ay be aime#. Instrument is s$arp<ed'ed. loss of consciousness is slo". homici#al cuts) ' lac+ the unhurrie# election of site. hea/y /ertical blo". left arm. Perineum .. one or more #eep.

obli4ue e !iBe ) length & "i#th "ith e#ges oppose# f <irection )in 7 planes g <epth h <amage to tissues along trac+ i %ffects ) e-ternal & internal haemorrhage. +nife !"#& (6 !harp an# thin.g. long an# rigi#. pneumothora-. stabs through fol#s. e. bloo# flo" & #rip patterns.' ' ' no repetition in same trac+ slope bac+"ar#s an# #o"n"ar#s associate# "ith *#efence injuries* to han#s an# arms #))ID N"#L IN)I!ION! ' ran#om pattern ' usually single ' often #eep an# forceful PENETRATING WOUNDS (!yn) !tab & Puncture "oun#s Puncture is Aa small hole ma#e "ith a sharp pointA <efinition) Penetrating injuries cause# by separation of the s+in an# soft tissues un#er the pressure of a sharp or blunt pointe# instrument. IT! <%PTD %EC%%<! IT! L%C$TD on the bo#y surface. /ertical. e. scre"#ri/er. the greatest #imension being its #epth. heel. e. trace e/i#ence b !ite in relation to anatomical lan#mar+s. c !hape # Alignment (horiBontal. mi#line. tooth (UN)"UR WOUND P%C%T(ATIC$ ' passes into but not through organ P%(F0(ATIC$ 0( T(AC!FIEIC$ ' from Latin perforare. "oo#en sta+e. air embolism A#e4uate #escription may pro/i#e /ital information about ) 2 Type of "eapon (c ) usually a +nife 6 <imensions of the "eapon (e 7 Taper of bla#e (e 8 1o/ement of +nife in "oun# (c 9 <irection of thrust (f . nee#le N DL (UN)"UR >7 Blunt. per-through & forare' to bore passes through an# through an organ STAB WOUNDS <escriptors of penetrating "oun#s a <amage to clothing (slashes. 0ften appear tri/ial e-ternally (short incision or laceration &U" often causes internal trauma an# haemorrhage. Cause# by thrusting of (or falling onto 7 types of instrument (2 !harp an# flat.g. spi+e.g.

be/el of lo"er e#ge C. single'e#ge# bla#e ''@ !lit "ith one sharp an# one *fishtail* en# #ue to stretching & laceration o/er blunt e#ge !tab "oun#s are typically elliptical "ith clean cut e#ges an# no bruising or abrasion of margins (incision (6 Direction of insertion o/erhang of upper e#ge. #eepest "oun# ("eapon fully inserte# !+#( OF WOUND 1ay in#icate) (2 )ross<sectiona% s$ape of *nife 0%ade e. &oun# length an# "i#th must be assesse# "ith the e#ges tape# together because the "oun# is often shortene# an# "i#ene# into an ellipse by s+in elasticity (Langer*s lines of tension an# un#erlying muscle tone.: <epth of thrust (g F Amount of force use# G Li+ely effect on /ictim (h. Cutting e#ge e-ten#s "oun# length The best in#icator of bla#e 2idt$ is the shortest (least roc+ing . (7 Movement of instrument on 2it$dra2a% !mall change in angle ''@ notch T"isting ''@ crescentic "oun# WOUND "R#)9 D ("+ H length of instrument if not fully inserte# @ length of instrument if fully inserte# an# bo#y surface compresse# e. "hen stan#ing. A small pen+nife can perforate heart or ab#ominal aorta. The #irection of the "oun# trac+ through the tissues is assesse# at post mortem. (6 tapere# bla#e not fully inserte# &oun# length @ bla#e "i#th "hen bla#e #oes not pass straight in an# out ' entry an# "ith#ra"al at angle.g. chest. ' <ouble'e#ge# bla#e ''@ !lit "ith t"o sharp en#s C. ab#omen. A(oc+ingA of +nife on "ith#ra"al. one sharp en# ' Thic+. &oun# length H bla#e "i#th (2 stretching of s+in o/er point on insertion an# subse4uent recoil on "ith#ra"al. The position of the internal organs is #ifferent in life. D /R OF FOR) &oun# #epth is a poor in#icator of force applie# Pressure re4uire# to penetrate is often slight "ith sharp tippe# instrument .B. single e#ge bla#e ''@ Triangular slit.B.g. single e#ge# +nife may gi/e similar "oun# #ue to clean splitting o/er blunt en# ' Thin. i WOUND L N/"+ A straight in an# out stab "oun# is slightly shorter than the "i#th of the bla#e #ue to stretching of the s+in o/er the point of the +nife on insertion an# elastic recoil on "ith#ra"al. sitting an# breathing. "ith the bo#y lying flat on its bac+.

Pneumothora. The time ta+en to incapacitate the /ictim an# "hat actions are still possible is /ery #ifficult to estimate. Peripheral stab blee#s less an# may seal if lung collapses. Thin'"alle# right /entricle less li+ely. internal organs an# uncalcifie# cartilage. Cut through bronchus may blee# an# obstruct air"ays. most often on chest (emember to consi#er counter'pressure by /ictim) falling or running onto instrument.may itself be fatal. FF )"! OF !"#&&IN/ =ictim may not initially be a"are of injury. #na%a'y is sta00in' a me%on Penetration of bone re4uires consi#erable force an# may brea+ the tip off the "eapon. (ate of blee#ing from stab "oun# to the %un' #epen#s on the siBe of /essels cut.6 m /6 ) 4uic+ thrust penetrates s+in more easily than slo". #0domina% stab may penetrate major /essels. !pee# of "eapon*s approach (F> 2. $reat /essels #o not re'seal. sustaine# pressure Bony #amage is useful in#icator of #epth an# implies significant force 1ost resistance offere# by CL0TD%! AC< !3IC The compresse# s+in *gi/es* su##enly. releasing the energy store# in the compresse# s+in an# tissue (elastic reser/oir . Large pulmonary /eins & arteries branch out"ar#s from the hilum. Consi#erable force an# #etermination re4uire# to remo/e +nife from clothe# bo#y. !e/ering a caroti# artery or jugular /ein results in rapi# e-anguination. A 4uic+ stab re4uires less force to penetrate than a slo" push. li/er or spleen "ith rapi# haemorrhage into the ab#ominal ca/ity. blunt tip re4uires greater force. PUNCTURE WOUNDS DUE TO BLUNT INSTRUMENTS . "ithout the nee# for further application of force. Pulmonary air em0o%ism originating in a partially se/ere# jugular /ein may be rapi#ly fatal before much bloo# is lost. nose an# temple "here bone is relati/ely thin. There may be little or no e-ternal bloo# loss.<epen#s on sharpness of point. Internal bloo# loss may be profuse an# rapi#ly fatal or slo" enough to allo" time for me#ical treatment. resulting in slo" bloo# loss or spontaneous healing. 1ain effect is blee#ing. the bla#e slips easily through the un#erlying muscle. 0nce the s+in has been penetrate#. not of cutting e#ge. Left ventricu%ar "oun# may partially reseal. If pericar#ial #efect is small or #oes not communicate "ith the pleural ca/ity car#iac tampona#e may result (6??'89?ml . Forcible insertion may cause imprint abrasion or bruising of s+in by the hilt of the +nife. !tabbing to the $ead an# face may allo" penetration of bone in the region of the eye. A stab to the $eart may blee# profusely out into the confine# space of the pericar#ium. !harp tip re4uires little force to penetrate. (are. The +nife #oes not nee# to be supporte# rigi#ly if tip is sharp.

!+ull #eforme# by impact. "ith contusion. contre'coup. hinge. insi#e a car#boar# bo. chil#ren. ring. "rappe# in cling film (arachnoi# . 'ass.#ecel. In/ersion of s+in on entry causes abra#e# margin.(s+ull . laceration of brain 'or blo" to si#e of nec+ 'often rapi#ly fatal &rain in3ury 'may occur "ithout fracture or intracranial haemorrhage 'rotation & accel.g. blo" or (TA Dea# is hea/y. Animal tooth ASSOCIATED INTERNAL INJURIES !urface "oun#s may be informati/e but are often simply the tri/ial mar+ers of lethal un#erlying injury.Blunt instrument typically ''@ Irregular. Dayfor+ ''@ %lliptical Ice pic+ ''@ (oun# &oo#en sta+e ''@ Cruciate Po+er ''@ !tellate laceration File ''@ Triangular laceration !cissors ''@ <epen#s on #egree of closure. ra#iating. #epresse#. Injury to bloo# /essels an# brain may occur "ithout o/erlying fracture. laceration'li+e "oun#. Any layer may be #amage# by impact (blo" or #ropping (fall Intracrania% $aemorr$a'e often follo"s hea# injury) 8tradura%' fracture tears arteryL ' easily o/erloo+e# (concussion. "rappe# in bro"n paper (scalp . coma ' imme#iate or #elaye# accumulation of bloo# ' causes pressure on brain ' amenable to surgical #ecompression !u0dura% ' common in el#erly. If e-cessi/e s+ull may fracture at the site of impact) linear. alcoholics ' small bri#ging /eins torn by tri/ial impact or rotation ' may remain asymptomatic. e. partially heale# an# an inci#ental fin#ing at autopsy !u0arac$noid' natural (aneurysm rupture or traumatic. luci#. #na%a'y: blancmange (brain . in paper bag (#ura . +ead in3ury (separate lecture notes by fall. *K*. !calp bruising an# laceration common o/er bone. !hape may in#icate cross section of instrument. mobile an# unstable. $reater force nee#e# to penetrate s+in. immobile hea# 'blo" accelerates the hea# causing contusion at the point of impact (coup contusion 'fall #ecelerates the hea# causing more ob/ious contusion at the #iametrically opposite point . Crushing an# stretching of the tissues causes bruising of the margins. split. injury more #amaging than #irect impact against the fi-e#.

mesentery or major /essels such as aorta. +ic+. $reater force may %acerate the brain <eep intracere0ra% $aemorr$a'e may occur &i#esprea# subtle microscopic ner/e fibre (Diffuse #8ona% In3ury. #na%o'y is 0o8 of 3e%%y Coup> 3ic+ (hea# is accelerate# Contre'coup> <ropping the bo. major bloo# /essels an# lungs /ulmerable to impact.injury is common #ue to shearing stress of rotational impact or #eceleration #na%o'y is s$a*in' or *ic*in' a ". stabs. jugular /eins 'sensiti/e major ner/ous conections an# refle-es 'cer/ical spine an# spinal cor# 'incisions. falls. may obstruct air passages. spleen. Nec* in3ury '/ulnerable area. +i#ney. lacerate# lung. access to /ital structures such as the trachea. +i#neys. heart. particularly if impact is o/er a broa# area 'Li/er. 1ay also occur in a fall onto one si#e but not after a for"ar# fall. mouth an# sinuses often profuse. may be complete or incomplete close# (simple or open (compoun# . blo"s an# pressure /ery #angerous (air embolism )$est in3ury 'heart. Facia% in3ury 'acci#ents ((TA 'assault by punch. compression an# penetration 'blunt impact of (TA is common multiple rib M*s pre/ent respiration pneumothora-. intestines are /ulnerable to compression an# laceration against the spine follo"ing the blunt impact of (TA or assault '!ite of election for stab "oun#s "ith penetration of /ascular organs such as li/er. Lim0 in3uries Common in many acci#ents ((TA .(contre<coup contusion "here the brain gli#es o/er the irregular. blunt "eapon 'fragile facial bones susceptible to injury 'blee#ing into nose.(all contents #ecelerate# Typically a bac+"ar# fall stri+ing the bac+ of the hea# (occiput on the groun# causes scalp abrasion. assaults Fracture (M (> a #isruption in the continuity of a bone (esult of #irect or in#irect force. bruising or laceration "ith localise# coup contusion at the occipital pole an# more mar+e# contre'coup contusion o/er the frontal an# temporal poles "here s+ull surface is rough. spleen. large /essels (caroti# arteries. /ena ca/a "ith se/ere bloo# loss into the peritoneal ca/ity 'Peritonitis may follo" intestinal #amage. 'lacerate# aorta #ue to #eceleration 'site of election for stab an# gunshot "oun#s "ith profuse haemorrhage into pericar#ial sac or pleural ca/ities #0domina% in3ury 'Ab#ominal s+in injury is rarely seen. set Associate# s"elling (cere0ra% oedema is often fatal by raising the pressure "ithin the cranial ca/ity (raise# ICP s4ueeBing an# #amaging /ital structures. jagge# contours of the s+ull.

+i#neys. spiral comminute# (more than 6 fragments compression M of spine. F2N of stab "oun# /ictims an# 8ON of gunshot /ictims sur/i/e at least 9 minutes. . an# "hat actions are still possible is /ery #ifficult to estimate. The /ictim may not be a"are of the injury initially. The time ta+en to #o so. &ill ultimately incapacitate the /ictim. !uch acti/ity "ill cease "hen physical factors such as bloo# loss lea# to immobility. Fit young a#ult "ill sur/i/e longer an# be capable of greater acti/ity than an el#erly. #isease# bone (osteoporosis. heart an# else"here. muscles an# joints. coma. A stab "oun# through the thin'"alle# ri'$t ventric%e. %-tensi/e #estruction of the frontal cerebral lobes of the brain may permit sur/i/al an# acti/ity before #eath occurs from associate# brain #amage an# shoc+.trans/erse. 9th metacarpal (bo-er*s M #epresse# M of s+ull stress M pathological M in "ea+ene#. 1ay be fatal. Cumerous /ariables e-ist. Acti/ity /aries from staggering a fe" paces to running consi#erable #istances or up flights of stairs. %stimation of sur/i/al perio# is almost impossible. Become entrappe# in the small /essels (mainly capillaries of the lungs or may pass through the lungs to bloc+ the capillaries of the brain. atrium or coronary artery is unli+ely to re'seal itself an# "ill blee# out into the pericar#ium "ith fatal results. <eath "ill only occur if continue# lea+age of bloo# into the pericar#ial sac interferes "ith the pumping action of the heart (car#iac tampona#e . Le/y & (ao suggest that o/erall. an# "hat actions are still possible is /ery #ifficult to estimate. infirm in#i/i#ual. 1ultiplicity of "oun#s an# in/ol/ement of the heart an# brain are associate# "ith a short post' injury sur/i/al perio#. A suprising amount of acti/ity is often reporte# follo"ing infliction of an ob/iously lethal injury. longitu#inal. <estruction of the brainstem or arch of aorta cause almost instantaneous loss of consciousness an# rapi# #eath. /ena ca/a. renal failure. #rteries carry bloo# at higher pressure than /eins of similar siBe an# therefore blee# more rapi#ly "hen cut. s+in rash. &oun#s in/ol/ing the 'reat vesse%s of the thora. 1ain effects of injury are blee#ing an# shoc+.(aorta. SURVIVAL TIME AND ACTING CAPABILITY AFTER WOUNDING Post'injury sur/i/al time is important in reconstructing e/ents +o2 %on' did t$e victim surviveA Was t$e victim sti%% capa0%e of fi'$tin'. !ur/i/al of such a "oun# is common. malignancy Fat em0o%ism clusters of fat cells escape from "ithin the central marro" ca/ity of a fracture# bone or subcutaneous fat an# enter the circulation /ia /eins. Pyre-ia. obli4ue. pulmonary arteries an# /eins blee# profusely an# offer no chance of closure. A partially transecte# /essel is less li+ely to seal off than one "hich is cleanly #i/i#e#. A stab "oun# through the %eft ventric%e of the heart may almost completely seal itself by contraction of the car#iac muscle aroun# the #efect. ho"e/er fit or young the /ictim. The time ta+en to #o so. resistin' or f%eein'A !ome injuries are incompatible "ith any significant sur/i/al. loss of consciousness or #eath. The effects of injury to major ner/es. Pain is suppresse# by the a#renaline response of Afight or flightA an# /igorous acti/ity may be maintaine# for a perio# of up to a fe" minutes "hen the "ill e-ists. follo"e# by blee#ing an# shoc+ "ill ultimately incapacitate the /ictim. 1any remar+able e-amples in the literature.

!hallo". Acting capability an# sur/i/al time #o not appear to be influence# by the #egree of alcohol into-ication. For this reason e-ternal bloo# loss is less profuse than from the gaping #efect of a gunshot "oun# at the same site.The /ictim may remain ali/e for se/eral hours "ith interna% 0%ood %oss in e-cess of 6 litres. length of instrument (6 Order of Inf%iction Tentati/e or scattere# FI(!T Fatal or groupe# LAT%( <istant shots before close shots (7 Manner of inf%iction By assessment of Circumstances. are preferre# Blunt force injuries are rarely self'inflicte#. !tab "oun#s are typically slit shape#. !ame <irection e. nec+.g. Tentati/e ADesitation "oun#sA e. incisions to "rist an# nec+ stabs to chest an# ab#omen Closely groupe#. "i#th. INTERPRETATION OF WOUNDS (2 )ausative o03ect or 2eapon Imprint abrasion from #irect impact "ith patterne# surface Trace material in sli#ing abrasion. Accessible target sites (often unilateral "ith Ahan#e#nessA e. heart Clothes #ra"n asi#e 1ultiple. The cut /ein may #ra" in air "hich then forms a fatal air'loc+ (air embolism in an artery supplying the brain. Consciousness may be maintaine# #espite internal bloo# loss of 2. !cene of #eath. incisions to "rists. cubital fossae. The rate of bloo# loss is an important factor. Pattern of injuries as a "hole SELF-INFLICTED: $unshot "oun#s an# ncise# or stabbe# "oun#s "ith sharp or pointe# object. groins stabs to chest (precor#ium .g.g . An incise# "oun# on the nec+ in/ol/ing a 3u'u%ar vein may pro/e rapi#ly fatal before much bloo# has been lost. temple. Parallel.9 litres.Asa"e#A incision in same trac+ stabs at same angle partial "ith#ra"al an# reinsertion . allo"ing the possibility of closure of the "oun# #ue to s+in an# soft tissue elasticity. laceration !tab may in#icate shape. ab#omen (epigastrium shots to mouth.

shot to hea# ' Lac+ the unhurrie# site of election ' no time to chose ' Inflicte# through clothes ' 1ore uniform force ' 1ultiple #irections e. Bruises. jumping ''@ pattern of sole glancing +ic+ ''@ scuffe# abrasion #irect blo" ''@ bruising. bac+. chest. not completely suprise# by attac+ an# at least partly mobile. . Causes bruising. ' Isually multiple ' &oun#s aime# at /ital area but scattere# an# groupe# A single "oun# suggests the /ictim "as sleeping. #efence an# secon#ary injuries common. of incisions or stabs ' !e/eral may be potentially fatal ' Associate# #efence injuries Defence in3uries< a pattern of injuries sustaine# by ta+ing protecti/e action against anticipated trauma (acci#ental or assault . laceration o/er bony prominences an# teeth an# fractures of nose of facial bones 3ic+ing'stamping. gunshot fre4uently in combination Punching '#irecte# at upper bo#y . bruise. #run+. "$e Road "raffic victim :.0ne or t"o potentially fatal !cars from pre/ious attempts 1ore than one metho# trie# ASSAULT: Any type of "oun# (abrasion.g. The single "oun# is usually targete# (stab to heart. laceration. Particularly chil#ren & el#erly. laceration. loin. especially the face. abrasion.g. Associate# internal injury is often se/ere !$arp force is favoured 'stabs & incisions ' Any site ' often inaccessible to /ictim. usually single Clothing in/ol/e#. bac+. incision. 1ay also see a cur/e# imprint abrasion !ites) face. incisions. e. The #ynamics of the crash #epen# on the relati/e heights abo/e the groun# of the impact site an# the centre of gra/ity of the pe#estrian. nec+. (edestrian 1ost /ulnerable roa# user. any site. abrasions. gunshots Absence #oes not e-clu#e assault (surprise# !econ#ary injuries #ue to falls onto nearby objects ACCIDENTAL Any type of "oun#. groin. stabs. stab. Typically seen on han#s an# forearms. In#icates that /ictim "as conscious. #rugge# or incapacitate#.

/ehicle. fracture . mo#erate or se/ere. 9? N of those serious injure# are hit at less than 62 mph 6 . "in#screen & pillars (s+ull & brain 5 'steering "heel (chest'lacerate# lung & heart 5 parcel shelf (M +nees & pel/is pe#als trap the an+les 'rear passenger hits seatbac+ or o/er into front '#eceleration causes "hiplash (fle-. 'Primary injuries may harbour trace e/i#ence (paint. !+i# mar+s offer the only objecti/e e/i#ence of /ehicle spee#. <AI brain injury an# rupture# thoracic aorta 6'(ear impact 'spee#s subtracti/e . !peed of impact cannot be estimate# from the se/erity of injuries. chest. another /ehicle (spee#s an# impact energy a##iti/e The #ri/er an# front passenger may stri+e '#ashboar#. !econdary in3uries are #ue to impact against the bonnet. Runnin' over results in flaying lacerations to the limbs. ab#omen '''@ Typical sli#ing abrasions. if fi-e# by "eight bearing (bruise. The height of injury abo/e heel of shoe is important. "in#screen.e-tension nec+.Impact belo" centre of gra/ity thro"s /ictim onto bonnet (or roof at greater spee# . abrasion. 'A high fronte# /an "ill hits the thigh. 'Flat fronte# lorry or bus hits torso. laceration. =ictim ac4uires /elocity of /ehicle only to be thro"n onto the roa# surface by /iolent bra+ing. Can only state "hether injuries "ere mil#. metal of e/i#ential /alue in *hit an# run* collisions. roa# surface or other object. !peed of impact 2O'68 mph 68'7? mph 72'7: mph B Fata%ities 2?N 8FN F7N 9?N of fatalities are hit at spee#s less than 7? mph. 'Car bumper injury to lo"er leg. lacerations. There are 9 mainpatterns of impact) 2'Dea# on into a stationary object li+e a tree.e$ic%e occupants 0ccupants mo/e to"ar#s the point of impact. 'Bonnet & "in#screen frame may fracture s+ull or injure chest & ab#omen. 'Thro"n onto the roa# injures hea#. Impact at C of $ shunts /ictim in #irection of tra/el Impact abo/e C of $ thro"s /ictim un#er /ehicle (rimary in3uries are #ue to #irect impact of /ehicle against /ictim.

nec+. Duman factors' rec+less. spee#ing. ribs. . Ot$er safety features 'airbags 'crumple Bones absorb impact energy an# increase the #uration of impact 'laminate# "in#screens #eform "ithout shattering an# pre/ent ejection 'si#e impact bars 'burstproof #oor loc+s to pre/ent ejection 'pa##e# steering "heel an# collapsable column 'brea+able controls an# mirrors 7 Motor )yc%ist Digh spee#s. lung '(ight) limb. Primary impact injury may be to leg. unstable. bo"el 'lumbar spinal injury (arely more #amaging than if a seatbelt is not "orn. L +i#ney. 1echanical failure'tyres. #rugs. shoes. cla/icles 'lacerate# mesentery. %n/ironmental' fog. li/er. spleen. inattention. )ontri0utory Factors in crashes Into-ication'alcohol. lung 8'!i#e s"ipe 'glancing 'less ris+ of si#e intrusion 9'(oll o/er 'less #amaging (rolling sprea#s the time of impact unless occupant is ejecte# !eat0e%ts %-tremely effecti/e in re#ucing mortality an# injury in lo" to me#ium spee# impacts) '#iagonal strap restrains upper torso (pre/ents impact "ith steering "heel. parcel shelf 'area of straps sprea#s #eceleration force o/er a "i#er area than localise# impact 'stretching of strap fabric increases the time o/er "hich the #ecel. forces are sprea# 'pre/ents ejection through "in#screen or burst #oor !eat belt injuries are common 'bruising across chest & ab#omen 'nec+ injury an# caroti# artery rupture 'fracture# sternum. chest an# ab#ominal injury Delmet an# leathers pro/i#e the only protection. Catural #isease'Ischaemic heart #isease. (pre/ents impact "ith lo"er #ash. epilepsy. steering. rain. obstruction to /ision. fatigue. no protection. ice.'seats an# hea# restraints support torso an# nec+ '"hiplash (e-tension.fle-ion "ith no restraint 'ris+ of petrol fire 7'!i#e impact '#irect 'ris+ of si#e intrusion 'Left) limb. ine-perience. carbon mono-i#e. sun. ( +i#ney. !econ#ary hea#. sno". %nergy must be #issipate# by sli#ing or rolling along the roa#. upper #ash 'horiBontal strap restrains lo"er torso an# pel/is. Isually "arning symptoms gi/e enough time to pull o/er. #ifficult to see. lea/es. bra+es. stro+e.

bone. Blister resorbs or bursts. Blisters "ill ha/e collapse# "ith shre#s an# sheets of "hite epi#ermis o/er an angry re# base. bro"nish (part'coo+e# . Correction of flui# #eficit is main initial aim of treatment. carbonise# or completely #estroye#. <eep muscle #ehy#ration an# #enaturation causes P1 contracture5 the fle-or groups more po"erful ''@ *pugilistic attitu#e*. clothes as a "ic+. !plit in epi#ermis or at epi. no scarring. !+in of limb or chest may nee# to be incise# to relie/e pressure. hea# ON. the applie# temperature 6. Palm is 2N. Con/ection from li4ui# or gas. the time for "hich the heat is applie# 7. prolonge# heat . effect "ith prolonge# e-posure ' slo" coo+e# muscle un#erlying intact s+in. epi#ermis gro"s in from e#ges an# from epi#ermis in sur/i/ing #ermal structures (s"eat. anterior trun+ 2GN. Dair *clubbe#* by melting an# re'soli#ifying. 1ore se/ere burn ''@ stiffene#. !+in surface often blac+ene# by soot #eposition. re'epithelialises. or completely burnt a"ay. bac+ 2GN.(a#iation 'absorption of infra're# &urns (#ry heat Classification of se/erity (&ilson FIR!" D /R ' erythema & blistering. &hen application of heat is prolonge# the tissues may be charre#. !+in may ignite "ith subcutaneous fat burning as a fuel. scarring centrally. yello"'bro"n leathery s+in #ue to partial carbonisation. more in chil#ren "+IRD D /R #estruction of un#erlying fat. muscle.BURNS AND SCALDS %-tent of heat'in#uce# injury #epen#s on 2. the ability of the bo#y surface to con#uct a"ay the e-cess heat 9 hours at 8PC or 7 secon#s at :?PC "ill cause a burn Deat may be applie# by Con#uction from soli#. 1a-. Intense. !"elling of burnt s+in may result in touni4uet effect on /enous return an# e/entual arterial obstruction an# tissue ischaemia an# necrosis. may necrose if hypo-ia or infection super/ene. Infection often occurs an# pre/ents s+in grafts from ta+ing. surroun#e# by Bone of hyperaemia. regulates bo#y temperature an# pre/ents infection. ! )OND D /R #estruction of the full thic+ness of s+in not painful as ner/es #estroye# epi#ermis coagulate# or charre# central necrosis surroun#e# by Bone of hyperaemia or F<B central area sloughs. In/ol/ement of 7?'9?N of bo#y surface usually unsur/i/able (less in el#erly. leg 2GN. In#erlying muscle becomes pale. P1 #rying of e-u#ing s+in ''@ parchmente# surface. (ule of Cines in#icates clinical prognosis) each arm is ON of bo#y area. Post mortem burning obscures ante'mortem burns. s"elling an# e-u#ation blister.#erm junction painful #ue to e-posure of ner/es no loss of #ermis capillary #ilation. Contractures may occur less painful than F<B !+in normally pre/ents "ater loss. hair follicle un#erlying Bone of tissue is precarious. <ea# bo#y may sho" "i#e /ariation in se/erity from re##ening tocomplete #estruction of a bo#y part. Burnt s+in loses salt'rich flui# from the circulation. resulting in lo" bloo# pressure (shoc+ an# renal failure.

other. Intensely re# base co/ere# by "rin+le#. grey'"hite splinters. Current Injury #epen#s on 4uantity of electrical flo" ( Amperes. through carpete#. Coulombs. macerate# epi#ermis. . !purious "oun#s appear e. steam. blistere#. ELECTRICAL MARKS !e/erity of tissue #amage #epen#s on /oltage applie# an# its #uration. Li4ui# runs un#er gra/ity ''@tric+le pattern.g. resistance of tissues an# the current "hich flo"s. upstairs "oo#en floor (poor earth. <omestic mains supply is 9? DB. centre paralysis 68? = entering finger. lo" current flo" gi/es painful spasm. oil.secon#s 7? mA applie# to han# ''@ painful muscle spasm 8? mA ''@ unconsciousness 9?'G? mA for @ fe" secon#s ''@ often fatal. and I C . through "et.?R (0hm*s La" Alternating current (AC is more #angerous than <irect current (<C as it is more liable to cause car#iac arrhythmia. <C use# in #efibrillator to re/ert to sinus rhythm. across heart causing /entricular fibrillation (=F . high current flo" potentially fatal. %/en bone may be re#uce# to brittle. carbonisation or hair singeing as seen in #ry heat. 68? = applie# to han# may cause forearm muscle spasm. <eath most often the result of shoc+. or more accurately. C I 8 R. Ta+es shortest route bet"een entry an# best e-it point. Areas of initial contact most se/erely scal#e#. !hoc+ may be fatal if current flo"s across a /ital part of the bo#y. . s+in splits !ca%ds (moist heat Injury by hot li4ui# '"ater.may #estroy all soft tissues. groun# le/el. Immersion (relati/ely long perio# of contact "ith li4ui# '@ uniform area of injury "ith a horiBontal flui# le/el. =ery high /oltage may be para#o-ically safer as muscle contraction cause# by shoc+ may physically fling subject off the source. heat haematoma (e-tra#ural . han# to opposite foot. !cal# sharply #emarcate# by limits of contact "ith hot li4ui#. Injury occurs in short perio# of time. necessitating /ery hot or boiling li4ui#. falling a"ay un#er gra/ity "ith rapi# cooling. heat fracture. =oltages of 68 or 2?? =olts may be lethal if applie# for long time. #es4uamation. 68? = entering finger. though irregular if splashe# Tippe# or splashe# ' 1omentary contact. (esemble first #egree burn 're#. the pro#uct of amps . !"elling an# e-u#ation of serum. Infection may super/ene. The path ta+en from entry point to e-it point #epen#s on the relati/e resistance of possible e-it points.g. =oltage Consi#erable /oltage must be applie# to #ry s+in to cause flo" of 9? mA. e. across chest ''@ respiratory muscle paralysis through hea# ''@ car#iac & resp. concrete floor (goo# earth. %ntry an# e-it on same han# may cause se/ere burn. flui# an# electrolyte #isturbance. Cot accompanie# by charring. AC of 8?'28? DertB or cycles per secon# is most #angerous. Bo#y must form part of an electrical circuit so that current flo"s from an entry point to an e-it point if injury is to occur.

an# e-it or earthing point. Burns occur "hen current flo"s #ue to energy transfer to heat. 2?? += "ill leap 79 cm. har# bro"n no#ule on cooling (the spar+ lesion . The peripheral Bone outsi#e the blanche# area may be hyperaemic. current flo"s more easily through electrolyte'rich cytoplasm an# bloo# /essels.gripping the source an# prolonging contact. "et s+in ) 26?? 0hms. (esistance of #ry s+in ) 2??? ??? 0hms. Lesion may thus appear as Blister'(e#ness'Pallor'(e#ness from centre out"ar#s. !maller mar+s may appear as tiny "hite #iscs (epi#ermal split "ith no pallor or hyperaemia Prolonge# contact "ith #omestic supply (usually after #eath may cause se/ere burning "ith a "i#e area of epi#ermal peeling. !een at point of entry. ha/ing /ery high resistance. &hen current ceases the blister collapses to pro#uce a raise# "hite or grey ring "ith a #epresse# centre. The mar+ may repro#uce the shape of the con#uctor e.g. There may be no s+in mar+. =ery localise# point of entry creates a /ery high temperature causes melting of epi#ermal +eratin "hich fuses into a slightly raise#. If the s+in is #amp or the area of contact is "i#e (less resistance per unit area then the heating effect is proportionately less Firm contact "ith con#uctor Passage of current heats up tissue flui#s to pro#uce steam "hich splits s+in "ithin epi#ermis or epi#ermo'#ermal junction. . Loose contact (narro" air gap Current leaps the gap as a spar+. e/en in fatality. linear "ire or shape# metal object. 2??? = "ill leap fe" millimetres across #ry air. usually han#. Copyright 2OOO ' <r < & !a#ler. "$e e%ectrica% s*in mar* The electrical mar+ is a type of localise# thermal burn #ue to heat pro#uction "hen current flo"s through highly resistant s+in. 0nce insi#e #ermis. (esistance The s+in is the major barrier to electrical current. 1ore current flo" for gi/en /oltage. Digh /oltage transmission cables may cause similar #eep burns or multifocal spar+ lesions (croco#ile s+in . Arteriolar spasm causes a surroun#ing areola of s+in blanching aroun# the central blister. hyperaemia an# #eep charring an# coo+ing of muscle.

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