REGIONAL TRAUMA
and contralateral hemiparesis seen in 60%.
TRAUMA – the leading cause of death in the first four decades of
life
-the third leading cause of death in all age groups today
Penetrating Trauma – particularly from handguns is becoming
common in nearly all areas of the country and in rebel infested areas,
high velocity firearms are the causes of violence
Death from trauma has a trimodal distribution:
1. Seconds to minutes of injury – due to injury to the brain,
high spinal cord, heart, aorta, and other large vessels. These
patients can rarely be salvaged.
2. Minutes to few hours of injury (the golden hour) – these are
due to subdural and epidural hematomas,
pneumohemothorax, ruptured spleen, liver lacerations,
pelvic or femur fractures or multiple injuries with significant
blood loss. It is in this period that Advanced Trauma Life
Support (ATLS) techniques are important.
3. Several days to weeks of injury – these are due to sepsis and
organ failure.
SPECIFIC INJURIES
1. HEAD
a. Types of head injuries:
A1. Epidural Hematoma – seen in about 1% of head
trauma patients. Usually due to laceration of the middle
meningeal artery by a fracture of the squamous portion
of the temporal bone, but can also be produced by by a
dural sinus tear. The classic presentation is brief loss of
consciousness followed by lucid interval, then
progressive obtundation, ipsilateral papillary dilatation
A2. Subdural Hematoma – twice as common as epidural
hematomas. The source of bleeding is usually venous.
If blood evacuation is done in less than four (4) hours,
there is a 30% mortality rate, but if evacuation of blood
from the brain is done after four (4) hours have elapsed,
there is a 90% mortality rate.
A3. Hemorrhagic Contusions – this is most commonly
found in the temporal, frontal and occipital lobes. Will
typically “blossom” with continued hemorrhage and
edema, 24-72 hours after presentation. Patients with an
isolated temporal lobe contusion can herniated and die
without evidence of increased intracranial pressure
because of the local temporal swelling.
A4. Diffuse Axonal Injuries – this results from
“shearing” of the white matter tracts from rotational
forces at the time of impact. If the brainstem is affected,
prognosis for functional neurologic recovery is
extremely poor.
A5. Skull fractures – can be classified as open, closed,
linear, compound, or depressed. The “Racoon’s eyes” is
diagnostic of fractures of the floor of the anterior skull
fossa. Basilar fractures are usually diagnosed clinically
with the presence of “Battle’s sign” which is the
presence of a retroauricular hematoma, cerebrospinal
fluid (CSF) otorrhea r CSF rhinorrhea. Usually an 8-10
mm. of skull depression must be elevated by surgery.

A6. Subarachnoid hemorrhage – (SAH) characterized
by the sudden onset of the “worst headache of life” with
nuchal rigidity, photophobia, and sometimes loss of
consciousness
Trauma – the common cause of SAH
75-80% - cerebral aneuryms causes spontaneous SAH
5% - Arteriovenous Malformations causes SAH
15% - unknown causes
A7. Intracerebral Hemorrhage – (ICH) this is
hemorrhage within the brain matter itself. ICH accounts
for approximately 10% of all strokes, both ischemic and
hemorrhagic.
A8. Carotid dissection – often seen in traumatic injuries,
but it can be spontaneous
A9. Vertebral dissection – this is associated with
cervical spine fractures especially if the fracture extends
into the transversarium foramen.
2. SPINE AND SPINAL CORD INJURIES
Anatomy – The spine is made up of 33 vertebrates, (7 cervical,
12 thoracic, 5 lumbar, 5 sacral, and 4 or 5 coccygeal.) There are
approximately 97 spinal joints. The spinal cord terminates at the
level of the disc between L1 and L2 vertebrae, the cord being
replaced by nerve roots at this level. Neurologic deficit due to
skeletal injury at or above T10 is due almost entirely to spinal
cord damage.
Injury between T10-L1: damages both cord and nerve roots.
Injury at the level of L1 downwards: damages only the nerve
roots.
Injury below L1: Cauda equine injuries
Injuries at L1-L2: produce the conus medullaris syndrome,
manifested by bladder and bowel symptoms with motor and
sensory deficits
Injuries at or above T10: result in Upper Motor Neuron Lesion
Injuries at cauda equina: result in Lower Motor Neuron Lesion
Fractures and dislocations of the spine are serious injuries
that most commonly occur in young people. The most common
causes of severe spinal trauma are motor vehicular accidents,
falls, diving accidents, and gunshot wounds. These injuries
usually cause severe spinal fractures and subluxations.
An incomplete spinal cord injury is one in which some
motor or sensory function is spared distal to the cord injury. A
complete spinal cord injury is manifested by total motor and
sensory loss distal to the injury.
Spinal Cord Injury Without Radiographic Abnormality or
SCIWORA – This traumatic injury is defined as objective signs
or symptoms or myelopathy as a result of trauma in patients
where there is no radiographic abnormality. It results from non
disruptive and self-reducing intersegmental deformation of the
spinal column, with injury to the spinal cord.
3. CHEST
A. Life Threatening injuries:
A1. Tension Pneumothorax – there is a one way valve
air leak from the lungs or the chest wall that allows air to
be forced into the thoracic cavity or pleural space
without means of escape, resulting into collapse of the
 affected lung and displacement of the mediastinum and
trachea to the opposite side.
A2. Open Pneumothorax – There is a large chest defect
that often remains open, causing a “sucking chest
wound.” The intrathoracic pressure equilibrates with
atmospheric pressure. If the chest wall opening is
greater than two-thirds of the diameter of the trachea, air
passes preferentially through the chest defect with each
inspiratory effort since it is a path of least resistance.
A3. Massive Hemothorax – loss of 1.5 liters of blood
into the chest cavity results into compression and
collapse of the ipsilateral lung, and also hypoxia. This is
usually due to penetrating thoracic injury that disrupts
systemic or pulmonary vessels. Loss of this 1.5 liters of
blood can also result from blunt chest trauma and also a
ruptured hemidiaphragm with intraabdominal injury.
A4. Flail Chest – This occurs when a segment of the
chest wall does not have bony continuity with the rest of
the thoracic cage, usually secondary to multiple rib
fractures. There is paradoxical motion of the chest wall.
The flail segment sinks in during inspiration. Hypoxia
results from the underlying pulmonary contusion and
associated bony pain, which hinders respiratory effort.
A5. Cardiac tamponade – The pericardial sac is a fixed
fibrous structure and only a small amount of blood is
required in an acute setting to severely restrict cardiac
activity. The vast majority are due to penetrating
injuries and rarely due to blunt trauma.
B. Potentially lethal injuries:
B1. Pulmonary Contusion with or without Flail Chest –
This is potentially lethal due to gradual development of
Respiratory Failure similar to Acute Respiratory Distress
Syndrome (ARDS). This is often present in vehicular
accidents. Often, there are multiple rib fractures.
B2. Thoracic Aortic Tear or Rupture – the most
common cause of sudden death after a vehicular accident
or fall (major deceleration injury); 90% of these are fatal
either at the scene or prior to arriving in the emergency
room. Of the 10% who make it to the hospital, half will
die each day if left untreated or unrecognized.
B3. Tracheobronchial tree injuries - tracheal injuries
are due to blunt or penetrating injury. There is a fracture
of the larynx. The bronchial injury is unusual but
potentially fatal and usually results from blunt trauma.
B4. Esophageal Injury - generally caused by
penetrating injury and rarely blunt injury. There is
hemothorax or pneumothorax without a rib fracture.
There are signs of hard blows to the lower sternum or
epigastrium, pain or shock out of proportion to the
injury.
B5. Traumatic Diaphragmatic Hernia – more common
on the left side because the liver protects the right
hemidiaphragm. Blunt trauma usually produces large
diaphragmatic tears with acute herniation of the stomach
or small bowels.
B6. Myocardial Contusion – This results from blunt
chest trauma, usually in an unrestrained driver in a head-
on collision that results in a bent or crushed steering
wheel column
C. SERIOUS CHEST INJURIES
C1. Subcutaneous Emphysema – This may result from
airway, lung, or rarely blast injury. Air is forced out of
 the lungs into the tissues surrounding the heart
(mediastinal emphysema) and even under the skin
(subcutaneous emphysema). Sometimes air is released
into the space between the lungs and the chest wall
(pneumothorax).
C2. Pneumothorax – results from entry of air either
from the lungs or the atmosphere into the pleural space.
This maybe due to penetrating or blunt chest trauma.
Most common cause is lung laceration associated with
rib fractures from blunt trauma. When air accumulates
in the pleural cavity under positive pressure, tension
pneumothorax develops, producing life threatening
circulatory collapse.
C3. Hemothorax – This is due to lung laceration or
laceration of an intercostals vessel or internal mammary
artery, seen in penetrating or blunt trauma. Initial blood
drainage of one liter or an hourly output of 200 cc of
blood, are indications for exploratory thoracotomy.
C4. Rib fractures – the upper 1-3 ribs are well protected
and their fracture implies a major impact, often with
associated head, neck, spinal cord, Sung or great vessel
injury. The middle ribs 5-9 are the most commonly
injured, often associated with pneumothorax,
hydrothorax, pulmonary contusions or flail chest.
4. ABDOMEN
a. Types of Injuries
A1. Penetrating
A1a. The limits of the abdomen are the nipples
superiorly, the perineum and gluteal folds inferiorly, and
the posterior axillary lines laterally. Gunshot wounds of
the abdomen carry a 95% probability of significant
visceral injury from the “blast effect” may occur whether
or not the abdominal cavity is entered. More often than
not, a bullet when it hits the abdomen will penetrate the
abdominal wall, enter the abdominal cavity and most
likely injure more than one organ. Although bullet
trajectory tends to follow a straight course, it is not
always the case. Therefore merely plotting a straight
Sine between the entrance and exit wounds will not
always predict the organ most likely injured. Any of the
abdominal organs maybe damaged in an abdominal
gunshot wound. The incidence of abdominal injury is
strikingly higher in gunshot wounds than in stab
wounds. Mortality and morbidity rates of gunshot
wounds are also considerably greater. The mortality and
overall complication rates rises progressively with the
number of organs injured. The major cause of death is
hemorrhage and this occurs within the first 24 hours.
The other deaths are due to the consequence of shock,
renal failure and sepsis in the form of peritonitis. The
extent of damage to the tissues correlates well with the
type of missile. A low velocity missile usually creates a
clean penetrating wound damaging only a limited
amount of tissue in the immediate vicinity of the wound
and the track of the missile. A penetrating wound
caused by high velocity missile causes extensive
destruction of tissues in the bullet track. It also leaves a
severe “blast effect in the tissues along the track of the
bullet. The wound of exit is usually larger because the
missile may tumble, be deformed or break up into
fragments or even create secondary missiles when it hits
or shatters bone. In stab wounds of the abdomen, only
2/3 penetrate the peritoneal cavity; of these only one half
cause significant visceral injury that requires surgical
repair. The site and direction of the external wound will
suggest the organ most likely injured. The frequency of
penetrating injury to the abdominal viscera varies with
the size of the individual organ and the volume of space
it occupies in the abdominal cavity. Hollow viscera such
as the small bowel and colon are the organs most
commonly injured. This explains the high incidence of
death due to peritonitis and sepsis.
A2. Blunt
A2a. Injury is produced by compression of the
abdominal contents against the vertebral column or the
rib cage, by direct transfer of kinetic energy to an organ
or by rapid deceleration with resulting tears of the
structures. The spleen and liver are the most commonly
injured organs due to blunt trauma. The small bowel,
colon, pancreas, duodenum, and diaphragm can also be
injured by blunt or penetrating trauma. The damage is
produced when a blunt force crushes the intraabdominal
organs or shears an organ between two opposing
surfaces or ruptures a viscus with a sudden increase in
intraluminal pressure. This results in hematoma or
severe fractures or rupture, rather than a simple
laceration. A direct blow will also rupture a solid organ
if the force is limited or applied to a limited part of the
body, only a single organ maybe damaged. If the force
is great, multiple injuries are frequently encountered.
Blunt abdominal trauma with significant injury of one
organ is frequently associated with other intraabdominal
and or extraabdominal injuries. Their frequent incidence
also explains why the mortality rate following blunt
trauma is higher than that of a penetrating injury.
5. FRACTURES AND DISLOCATIONS
The word “fracture” comes from the Latin word “fractura”
which means a break in the bone continuity. It is also a
combination of a break in the bone and soft tissue injury.
A. Open Fractures – There is an open communication from
the fracture to the outside environment, because of a
break in the skin. Trauma sustained is severe to cause
the break in the bone with an open communication to the
outside environment. 90% of open fractures are caused
by vehicular accidents. One third of patients with open
fractures are multiple trauma victims, that is with two or
more organ systems injured. An open fracture is a
contaminated wound.
B. Close fracture – There is no break in the skin over the
fracture or near the fracture site.
C. Compartment syndrome – This syndrome usually is
found in fractures and dislocations. There is increase
pressure within a close space that causes irreversible
ischemic damage to the contents of that space.
Compartment pressures of more than 30 mmhg requires
fasciotomy of the compartment. In hypotensive patients
compartment syndrome maybe present even with
pressure of less than 30 mm hg.
D. Dislocations – Pure dislocations and fracture
dislocations represent an orthopedic emergency owing to
the associated risk of neurovascular compromise, acute
compartment syndrome, echondrophysis and
development of avascular necrosis.
 E. Intra-articular laceration – this is associated with open
fractures and joint penetration by foreign objects.
F. Pulseless extremity – This is encountered frequently in
trauma patients with vascular injuries and occasionally
in those with dislocations and complex fractures.
Common Fractures and Dislocations:
a. Pelvic fractures – mortality from severe pelvic fractures
maybe exceedingly high from 10% - 50% in open fractures.
Severe intrapelvic hemorrhage may result from fractures of
the pelvic ring.
b. Acetabular fractures – The posterior or anterior column and
acetabular fossa, maybe involved in these high energy
injuries. Also the femoral head maybe fractured.
Regrettably, the most common types of acetabular fractures,
which is a posterior wall fracture and the associated
transverse and posterior wall fracture, are frequently
associated with the failure to wear seat belts.
c. Hip fractures – very common in elderly people and are
usually caused by minor falls. It is the most common cause
of traumatic death after the age of 75. Hip dislocations are
considered serious injuries and reduction of the hip
dislocation must be done within 12 hours to minimize the
incidence of avascular necrosis of the femoral head.
d. Femoral fractures – usually the result of major trauma.
Most fractures are sustained by young adults during high
energy injuries such as vehicular accidents, falls, or gunshot
wounds. The middle distal third of the femur is commonly
fractured. Blood lost maybe 1-3 liters and can cause
hypovolemic shock.
e. Knee fractures - the knee is the largest and most
complicated joint of the human body. It is essentially a
hinge joint consisting of three osseous parts namely: patella,
distal femoral condyles, and proximal tibial plateau.
Fractures of the patella of the knee are common and usually
results from a severe fall or direct injury to the patella.
Fractures commonly occur in the lower pole of the patella.
f. Fractures of the tibia-fibula – This make up about 10% of
emergency cases seen at a government hospital from 1972-
1977. Fractures of the tibia and fibula are produced by
direct or indirect trauma.
g. Ankle fractures and dislocations – Fractures of the lateral,
medial and posterior malleoli are common in this region,
usually after a severe inversion or eversion of the ankle joint
while walking.
h. Foot fractures and dislocations – they are more common than
ankle injuries, in a five year statistics in a government
hospital, foot injuries were 75 % of all ankle and foot
injuries and about 10% of all orthopedic trauma cases seen.
i. Fractures of the wrist – they are extension and flexion
fractures generally resulting from a fall on the dorsiflexed
hand and depending on the patient’s age are usually
associated with serious complications.
j. Fractures of the radius and ulna – this is a common fracture
of the upper extremity which usually occurs after a fall on an
outstretched hand. Direct violence causes severe soft tissue
injury with an open fracture. Indirect violence occurs as a
result of a fall on an outstretched, pronated arm and at
moment of impact the hand becomes fixed to the ground.
Colles fracture is a common fracture of the distal 2.5 cm
from the distal end of the radius with a “silver fork
deformity.”
k. Elbow dislocation – The posterior elbow dislocation
accounts for almost 95% of cases.
l. Humeral shaft fractures – this also occurs after a severe
injury to the arm, either due to a direct injury to the bone or
after a fall.
m. Shoulder Dislocation – Dislocation of the glenohumeral joint
maybe classified as anterior, posterior, or inferior, depending
on the displacement of the humeral head in relation to the
glenoid fossa. The most common is the anterior shoulder
dislocation.
n. Clavicular fractures – the superficial location of the clavicle
makes it one of the commonly fractured bones in the body.
o. Maxillofacial trauma – most commonly due to blunt trauma,
with motor accidents as the leading cause. A man’s face is
his single most distinguishing physical characteristic.
Fractures of the middle and lower third of the face are
known as Maxillofacial fractures which is of three types:
a. Le Forte 1 – Transverse fracture
b. Le Forte 2 – Pyramidal fracture
c. Le Forte 3 – Craniofacial dysfunction
6. UROLOGIC
6.1 HEMATURIA following trauma – the degree of
hematuria has no correlation to severity of urologic
injury. In general, greater than 50 Red Blood Cells
per high power field should be investigated for
serious physical injuries.
6.2 Kidneys
a. Etiology – Blunt kidney injury is usually due to
motor vehicular accidents which account for
70% - 90% of kidney trauma. Any patient
sustaining injury to the flank, abdomen, or lower
chest should be suspected of having kidney
trauma. The renal parts that can be involved are
the renal parenchyma, renal pelvis and or the
renal pedicle where the renal artery and vein are
located.
b. Etiology – penetrating kidney injury is usually
due to knife or gunshot wounds. Oftentimes,
injury to contiguous intra peritoneal organs is
present. Minor injuries to the kidneys include
renal contusion, or cortical laceration. Major
injuries include deep laceration and renal pedicle
injury.
6.3 Ureters
The ureters are rarely injured due to blunt
trauma. However the “blast effect” from
projectiles can injure the ureter even in the
absence of actual transaction. Most injuries
are iatrogenic from pelvic surgery with
transaction or ligation of the ureter.
6.4 Bladder
a. Etiology – external blunt trauma (blow to the
lower abdomen) pelvic fractures (account for
90%), penetrating injury, iatrogenic (gynecologic
or pelvic surgery).
b. Presentation – the bony pelvis generally protects
the bladder from external violence.
Nevertheless, 10% to 15% of patients with pelvic
fracture will have a bladder or urethral injury.
Bladder rupture may present as an acute
 abdomen with extravasation of urine into the
peritoneal cavity.
6.5 Urethral trauma
Anatomy – the urethra in the male is divided into
anterior and posterior divisions. The anterior urethra
consists of the urethra distal to the urogenital
diaphragm. The posterior urethra extends from the
inferior edge of the urogenital diaphragm to the
proximal bladder neck.
6.6 Penile injury
Anatomy – The erect penis is usually 6-8 inches long
and 1-2 inches in diameter. Priapism is a state of
sustained often times painful erection. The penis is
composed of three fibroelastic cylinders which are
filled with spongy or erectile tissue.
Avulsion of the Prepuce – This may follow accidents
where the foreskin called prepuce is detached or
lacerated by a blunt force.
Fracture of the Penis – This is the traumatic rupture
of the corpora cavernosa penis resulting from a
forceful external trauma to the flaccid organ.
Amputated Penis – The penis of an avid womanizer,
is sometimes intentionally cut or amputated by a
jealous deranged wife or lover. The bladed
instrument used is usually a sharp edged instrument
like a knife, or commonly a scissor.
7. Arterial trauma
1. Blunt – injury to the vessels, as a consequence of joint
dislocations, i.e. posterior knee dislocation
2. Penetrating – direct injury to the vessels by blasting,
fractures, dislocations of the knee, severe ligament tears.
Indirect injury through cavitation of a missile.
3. Iatrogenic – due to an arterial monitoring, angiography,
cardiac catheterization, arterial blood, sampling,
intravenous fluids. The six (6) “P”s of acute arterial
insufficiency are – Pain, Paralysis, Paresthesias, Pallor,
Pulseless and “Polar” (cold). The “golden period” of six
(6) hours before ischemia and myonecrosis may become
irreversible must always be noted.
8. Burns
First degree burns – epidermal layer is involved, basal layer
is intact, painful, pink in color and no blisters.
Second degree burns – partial skin thickness burns. Partial
dermal layer involved, painful white to pink skin color with
blebs and blisters present.
Third degree burns – full skin thickness burns. The entire
dermal layer is involved with all dermal appendages
destroyed.
Fourth degree burns – The underlying fascia, muscle, and or
bone is also burned
CLASSIFICATION OF WOUNDS
1. AS TO LEGAL CLASSIFICATION
Revised Penal Code, Chapter 1, DESTRUCTION OF
LIFE
a. Article 246. PARRICIDE. – Any person who shall
kill his father, mother, or child, whether legitimate
or illegitimate, or any of his ascendants, or
descendants, or his spouse, shall be guilty of
parricide and shall be punished by the penalty of
Reclusion Perpetua to Death.
b. Article 247. DEATH or PHYSICAL INJURIES,
inflicted under exceptional circumstances. – Any
legally married person who, having surprised his
spouse in the act of committing sexual intercourse
with another person, shall kill any of them or both of
them in the act or, immediately thereafter, or shall
inflict upon them any serious physical, shall suffer
the penalty of destierro.
If he shall inflict upon them physical injuries of any
other kind, he shall be exempt from punishment.
These rules shall be applicable, under the same
circumstances, to parents with respect to their
daughters under eighteen years of age, and their
seducer, while the daughters are living with their
parents.
Any person who shall promote or facilitate the
prostitution of his wife or daughter, or shall
otherwise have consented to the infidelity of the
other spouse shall not be entitled to the benefit of
this article.
c. Article 248. MURDER. – Any person who, not
falling within the provisions of Article 246 shall kill
another, shall be guilty of murder and shall be
punished by Reclusion Perpetua, to death if
committed with any of the following attendant
circumstances:
1. With Treachery, taking advantage of superior
strength, with the aid of armed men, or
employing means to weaken the defense or of
means or persons to insure or afford impunity
2. In consideration of a price, reward or promise.
3. By means of inundation, fire, poison, explosion,
shipwreck, stranding of a vessel, derailment or
assault upon a railroad, fall of an airship, or by
means of motor vehicles, or with the use of any
other means involving great waste and ruin.
4. On occasion of any of the calamities enumerated
in the preceding paragraph, or of an earthquake,
eruption of a volcano, destructive cyclone,
epidemic or other public calamity.
5. With evident premeditation.
6. With cruelty, by deliberately and inhumanly
augmenting the suffering of the victim, or
outraging or scoffing at his person or corpse.
d. Article 249. HOMICIDE. – Any person who, not
falling within the provisions of Article 246, shall kill
another without the attendance of any of the
circumstances enumerated in the next preceding
article, shall be deemed guilty of homicide and be
punished by reclusion temporal.
e. Article 251. Death caused in a tumultuous affray. –
When, while several persons, not composing groups
organized for the common purpose of assaulting and
attacking each other reciprocally, quarrel and assault
each other in a confused and tumultuous manner,
 and in the course of the affray, someone is killed,
and it cannot be ascertained who actually killed the
deceased, but the person or persons who inflicted
serious physical injuries can be identified, such
person or persons shall be punished by prision
mayor.
f. Article 252. PHYSICAL INJURIES INFLICTED
IN A TUMULTUOUS AFFRAY. – When in a
tumultuous affray as referred to in the preceding
article, only serious physical injuries are inflicted
upon the participants thereof and the person
responsible thereof cannot be identified, all those
who appear to have used violence upon the person of
the offended party shall suffer the penalty next lower
in degree than that provided for the physical injuries
so inflicted.
g. Article 253. GIVING ASSISTANCE TO SUICIDE.
– Any person who shall assist another to commit
suicide shall suffer the penalty of prision mayor, if
such person lends his assistance to another to the
extent of doing the killing himself, he shall suffer
the penalty of reclusion temporal. However, if the
suicide is not consummated, the penalty of arresto
mayor in its medium and maximum periods shall be
imposed.
h. Article 254. DISCHARGE OF FIREARMS. – Any
person who shall shoot at another with any firearm
shall suffer the penalty of prision correccional in its
minimum and medium periods, unless the facts of
the case are such that the act can be held to
constitute frustrated or attempted parricide, murder,
homicide or any other crime for which a higher
penalty is prescribed by any of the articles of this
code.
i. Article 255. INFANTICIDE. – The penalty provided
for parricide in Article 246 and for murder in Article
248 shall be imposed upon any person who shall kill
any child less than three days of age.
j. Article 256. INTENTIONAL ABORTION. – Any
person who shall intentionally cause an abortion
shall suffer:
1. The penalty of reclusion temporal, if he shall use
any violence upon the person of the pregnant
woman.
2. The penalty of prision mayor if, without using
violence, he shall act without the consent of the
woman.
3. The penalty of prision correccional in its
medium and maximum periods, if the woman
shall have consented.
k. Article 257. UNINTENTIONAL ABORTION. –
The penalty of prision correccional in its minimum
and medium periods shall be imposed upon any
person who shall cause an abortion by violence, but
unintentionally.
l. Article 258. ABORTION PRACTICED BY THE
WOMAN HERSELF OR BY HER PARENTS. –
The penalty of prision correccional in its medium
and maximum periods shall be imposed upon a
woman who shall practice abortion upon herself or
shall consent that any other person should do so.
m. Article 259. ABORTION PRACTICED BY A
PHYSICIAN OR MIDWIFE AND DISPENSING
 OF ABORTIVES. –The penalties provided in
Article 256 shall be imposed in its maximum period,
respectively, upon any physician or midwife who,
taking advantage of their scientific knowledge or
skill, shall cause an abortion or assist in causing the
same.
n. Article 260. RESPONSIBILITY OF
PARTICIPANTS IN A DUEL. – The penalty of
reclusion temporal shall be imposed upon any
person who shall kill his adversary in a duel. If he
shall inflict upon the latter physical injuries only, he
shall suffer the penalty provided therefore, according
to their nature.
o. Article 261. CHALLENGING TO A DUEL. – The
penalty of prision correccional in its minimum
period shall be imposed upon any person who shall
challenge another, or incite another to give or accept
a challenge to a duel, or shall scoff at or decry
another publicly for having refused to accept a
challenge to fight a duel.
CHAPTER 2, PHYSICAL INJURIES
a. Article 262. MUTILATION. – The penalty of reclusion
temporal to reclusion perpetua shall be imposed upon any
person who shall intentionally mutilate another by depriving
him, either totally or partially, of some essential organ of
reproduction.
b. Article 263. SERIOUS PHYSICAL INJURIES. – Any
person who shall wound, beat, or assault another, shall be
guilty of the crime of serious physical injuries and shall
suffer:
1. The penalty of prision mayor, if in consequence of the
physical injuries inflicted, the injured person shall
become insane, imbecile, impotent or blind.
2. The penalty of prision correccional in its medium and
maximum periods, if in consequence of the physical
injuries inflicted, the person injured shall have lost the
use of speech or the power to hear or to smell, or shall
have lost an eye, a hand a foot, an arm or a leg or shall
have lost the use of any such member, or shall have
become incapacitated for the work in which he was
therefore habitually engaged.
3. The penalty of prision correccional in its minimum and
medium periods, if in consequence of the physical
injuries inflicted, the person injured shall have become
deformed or shall have lost any part of his body, or shall
have lost the use thereof, or shall have been ill or
incapacitated for the performance of the work in which
he was habitually engaged for a period of more than
ninety days.
4. The penalty of arresto mayor in its maximum period to
prision correccional in its minimum period, if the
physical injuries inflicted shall have caused the illness or
incapacity for labor of the injured person for more than
thirty days.
c. Article 264. ADMINISTERING INJURIOUS
SUBSTANCES OR BEVERAGES. – The penalties
established by the next preceding article shall be applicable
in the respective case to any person who, without intent to
kill, shall inflict upon another any serious physical injury, by
knowingly administering to him any injurious substances or
 beverages or by taking advantage of his weakness of mind or
credulity.
d. Article 265. LESS SERIOUS PHYSICAL INJURIES. –
Any person who shall inflict upon another physical injuries
not described in the preceding articles, but which shall
incapacitate the offended party for labor for ten days or
more, or shall require medical attendance for the same
period, shall be guilty of less serious injuries and shall suffer
the penalty of arresto mayor.
e. Article 266. SLIGHT PHYSICAL INJURIES AND
MALTREATMENT. – The crime of slight physical injuries
shall be punished:
1. By arresto menor when the offender has inflicted
physical injuries which shall incapacitate the offended
party for labor from one to nine days, or shall require
medical attendance during the same period.
2. By arresto menor or a fine not exceeding 20 pesos and
censure when the offender has caused physical injuries
which do not prevent the offended party from engaging
in his habitual work nor require medical attendance.
3. By arresto menor in its minimum, period or a fine not
exceeding 50 pesos when the offender shall ill-treat
another by deed without causing any injury.
CHAPTER 3, RAPE. – Rape is included in this chapter of physical
injuries, bec of the means or manner of commission which involves
force or violence and the consequential injuries sustained by the
victim.
Article 266-A. RAPE.- When and how committed – Rape is
committed:
1. By a man who shall have carnal knowledge of woman under
any of the circumstances:
a. Through force, threat, or intimidation;
b. When the offended party is deprived of reason or
otherwise unconscious;
c. By means of fraudulent machinations or grave abuse of
authority; and
d. When the offended party is under twelve (12) years of
age or is demented, even though none of the
circumstances mentioned above be present.
2. By any person who, under any of the circumstance
mentioned in paragraph 1 hereof, shall commit an act of
sexual assault by inserting his penis into another person’s
mouth or anal orifice, or any instrument or object into the
genital or anal orifice of another person.
2. AS TO THE DEPTH OF THE WOUND
a. Superficial – when the wound involves only the layers of
the skin.
b. Deep – when the wound involves the structures beyond
the layers of the skin.
b1. Penetrating – the wound enters the body but does
not come out. Punctured, stab and gunshot wounds
usually belong to this type of wound.
b2. Perforating – there is a communication between
the outside, inner and the outside. There is both a
point of entry and exit.
3. AS TO MORTALITY
a. Deadly wound – death results immediately, after the
infliction of the wound, when there is severe blood
 loss, or the heart, big vessels, brain and upper spinal
cord, lungs, liver, spleen, kidneys are injured.
b. Non-deadly wounds – does not result to death
immediately, after the wound is inflicted.
4. AS TO THE WOUNDING INSTRUMENTS USED
a. Sharp instruments – a sharp edged instrument
produces an incised wound, i.e. blade; A sharp
pointed instrument produces a punctured wound, i.e.
ice pick; A sharp edged and sharp pointed –
instrument produces a stab wound i.e. dagger or a
kitchen knife.
b. Blunt instruments – A block of wood or iron, etc.,
produces contusion, hematoma, abrasions, lacerated
wound, when used to strike, attack, wound, beat or
assault another.
5. AS TO THE CONSEQUENTIAL INJURY AFTER
THE APPLICATION OF FORCE:
a. Coup Injury – the consequential injury is found at
the site of the application of force.
b. Coup Centre Coup Injury – The consequential injury
is found at the site of the application of force and
also opposite the site of application.
c. Contre Coup Injury – The consequential injury is
found opposite the site of the application of force.
d. Locus Minoris Resistencia – The consequential
injury is located only at a site offering least
resistance to the force applied.
e. Extensive Injury – The consequential injury,
involves a bigger area of the body, than what was
expected.
6. AS TO THE INTEGRITY OF THE SKIN:
A. CLOSED WOUNDS – Presents no break in the
integrity or continuity of the skin
1. PETECHIAE – a circumscribed extravasation of
blood in the subcutaneous tissues due to
destruction or increased permeability of the
capillaries.
2. CONTUSION – effusion of blood into the
tissues underneath the skin as a result of a blunt
force.
3. HEMATOMA – extravasation or effusion of
blood in a newly formed cavity underneath the
skin.
4. BLUNT INJURY – seemingly innocuous on the
outside, because there is no break in the skin or
there maybe no external signs of injury.
5. MUSCULOSKELETAL INJURIES – These are
close wounds, though located in the
musculoskeletal system.
a. Sprain – partial or complete disruption in the
continuity of a ligamentous support of a
joint
b. Dislocation – complete displacement of a
joint
c. Fracture – break in the continuity of a bone
d. Subluxaton – partial dislocation of a joint
e. Strain – overstretching of a muscle
CEREBRAL CONCUSSION – there is a brief loss of consciousness
and sometimes memory after a head injury that doesn’t cause
obvious physical damage. Memory loss of past events called
Retrograde amnesia is characteristic.

Post Concussion syndrome – Some people develop dizziness,
difficulty in concentration, forgetfulness, depression, lack of feeling
or emotion, and anxiety for a few days to several weeks but rarely
longer.
CEREBRAL CONTUSION – They are bruises to the brain, usually
caused by a direct, strong blow to the head.
B. OPEN WOUNDS: There is a break in the continuity
of the skin.
B1. ABRASION – characterized by removal of the
cuticle or superficial epithelial layer of the skin due
to friction against a hard rough surface. Also called
scratch, Impression or Friction mark.
B2. BRUISE – caused by blunt injury to the tissues
which damage blood vessels beneath the surface,
allowing blood to extravasate or leak into the
surrounding tissues.
B3. INCISED WOUND – caused by a sharp edged
instrument like a knife, razor, etc.
B4. STAB WOUND – caused by a sharp edged and
sharp pointed instrument like a knife, saber, dagger
etc.
B5. PUNCTURED WOUND – a result of a thrust by
a sharp pointed instrument
B6. PERFORATING WOUND – a thrust from a
sharp pointed instrument producing a thru and thru
injury to the body.
B7. LACERATED WOUND – a result of an injury
from a blunt instrument.
B8. BITES – They maybe abraded, bruised or rarely
lacerated
B9. GUNSHOT WOUNDS – Wounds due to a
bullet, slug, missile or projectile, propelled by the
explosion of gunpowder
GUNSHOT WOUND CHARACTERISTICS OF
THE DIFFERENT DISTANCE FIRE:
1. Firm contact fire – commonly observed on the
head characterized by the ff:
a. The wound of entrance is large frequently
star shaped.
b. Edges of the wound maybe everted.
c. Entrance wound is blackened by burns,
tattooing and smudging.
d. Muzzle imprint
e. The bullet may cause a radiating fracture.
f. Fragments of lead and bullet maybe found.
2. Loose contact fire
a. Entrance wound maybe large circular or
oval depending upon the angle of approach.
b. Abrasion collar or ring is distinct.
c. Smudging, burning and tattooing are
prominent with singeing of the hair.
d. Muzzle imprint maybe seen.
e. There is blackening of the bullet tract to a
certain depth.
3. Short Range fire (1-15 cm distance)
a. Entrance wound shows inverted edges.
b. If within the flame reach, which is less than
3 inches in ordinary handguns, there is an
area of burning.
c. Smudging is present due to smoke.
d. Powder tattooing is present.
 e. Presence of an abrasion ring or collar. 2. Use of Scanning Electron Microscope with a linked X-ray
4. Medium Range fire (16-60 cm) analyzer.
a. Gunshot wound with inverted edges and SPECIAL TYPES OF WOUNDS:
with abrasion collar is present. 1. Assailant’s wounds – wounds are sustained by the
b. No Burning effects. assailant from the victim, while the former is in the
c. Smudging maybe present if less than 30 cm. process of attacking, wounding, assaulting, beating or
d. Gunpowder tattooing is present with wider killing his victim.
area of distribution. 2. Defense’ wounds
e. Contact ring is present. 3. Victim’s wounds
5. Far distance fire (more than 60 cm) 4. Self-inflicted wounds
a. Circular gunshot wound with abrasion 5. Homicidal wounds
collar. 6. Accidental wounds
b. No burning, smudging, tattooing. 7. Suicidal wounds
c. A contact ring is present.
PHYSICAL INJURIES DUE TO AUTOMOTIVE CRASH OR
DISTINCTION BETWEEN GUNSHOT WOUNDS OF VEHICULAR ACCIDENTS
ENTRANCE AND EXIT:
1. Smaller than the missile due to elasticity of tissues – always Evidences in Vehicular Crash:
bigger than missile. 1. From the SCENE OF THE CRIME:
2. Edges are inverted – everted edges. a. A photograph or sketch must be taken to determine who
3. Oval or round depending upon angle of approach of bullet – violated traffic rules.
no definite shape. b. The skid arid tire marks on the road must be noted.
4. Contusion collar or contact ring is present due to c. Condition and position of the victim.
invagination of the skin – absent. d. Condition of the vehicle whether road worthy.
5. Tattooing or smudging maybe present when firing is near – e. Blood, paint stains, etc on the clothing or vehicle.
always absent. f. Narration or testimony of witnesses.
6. Underlying tissues do not protrude beyond the skin – 2. From the DRIVER:
protrusion maybe seen. a. Fitness to drive
7. Entrance wound is always present – exit wound maybe b. Alcoholic drunkenness
absent. c. Examine for drug addiction or intake of drugs that
TEST FOR THE PRESENCE OF POWDER RESIDUES: impair alertness.
1. Paraffin test or Dermal Nitrate test
 d. Injuries due to second collision like steering wheel
imprints, fractured skull, multiple abrasions and
lacerations
3. From the VICTIM:
a. Crush injury
b. Thread marks
c. Abrasion marks
d. Paint marks
e. Blood, hair, clothing of the victims
f. Physical defects of the victim
g. Inebriation of the victim
CHILD ABUSE OR NEGLECTED CHILD – called also Battered
child syndrome, Maltreatment syndrome, Physically abused child.
Maltreatment of a child includes the following:
1. Physical Abuse – The law allows the parents to chastise or
discipline the child to the extent that is reasonable under the
circumstances.
2. Physical Neglect – The failure to provide the child adequate
support as defined in Article 290 of the Civil Code, which
states that, “Support Is everything that is indispensable for
sustenance, dwelling, clothing and medical attendance,
accdg to the social standing of the family.
Article 276 of the Revised Penal Code provides that, “The
penalty of arresto mayor and a fine not exceeding five
(500)hundred pesos shall be imposed upon anyone who shall
abandon a child under seven (7) years of age, the custody of
which is incumbent upon him.
Article 277 of the Revised Penal Code provides for
Abandonment of minor by persons entrusted with his custody:
INDIFFERENCE OF PARENTS – The penalty of arresto mayor
and a fine not exceeding five (500) hundred pesos shall be
imposed upon anyone, who having charged with the rearing or
education of a minor, shall deliver the said minor to a public
institution or other persons, without the consent of the one who
entrusted such child to his care or in the absence of the latter,
without the consent of the proper authorities.
Medical evidences to show PHYSICAL INJURIES due to child
abuse:
1. Skin imprints from forcefully striking objects.
2. Multiple bruises particularly on the trunk, head and face.
3. Multiple small burns from cigarettes, iron, hot water.
4. Multiple fresh healing fractures from twisting etc
5. Trauma to the mouth, nose, ears and eyes.
6. In case of sexual abuse, injuries to the genitalia, perirectal
and peri-vaginal areas.
7. Signs of malnutrition, poor hygiene, infection, poor growth
and development.
FACTS TO BE CONSIDERED TO SUSPECT CHILD ABUSE:
1. The child is emotional, fearful, and with a vague history of
injuries.
2. The parents present a vague and defensive detail of the
child’s injuries or illness.
3. Many unexplained signs of injuries.
4. Delay in seeking medical care and treatment.
5. Poor growth and development of the child.