WOUNDS

The human body is constantly subjected to mechanical forces during the

course of life. The body usually absorbs such forces either by the resilience and
elasticity of its soft tissues or the rigid strength of its skeletal framework.
If the intensity of the applied force exceeds the capability of the tissues to
adapt or resist, a wound or injury occurs.
A wound means any solution or breach in the natural continuity of a tissue or
organ caused by application of mechanical force to the body.
CLASSIFICATION OF WOUNDS
1- Legal classification: according to their results, time of treatment and punishment.
a) Slight or simple wound : which heals rapidly in less than 20 days leaving no
deformity and no permanent infirmity.
b) Dangerous wound : which heals in more than 20 days and/or leaving a permanent
infirmity.
c) Fatal or mortal wound : which cause death immediately or later due to
complications.
2-Medicolegal classification: according to the instrument used.
a) Wounds inflicted by blunt instruments: as abrasions, contusions, contused and
lacerated wound.
b) Wounds caused by sharp instruments as incised wounds and stab wound.
c) Firearm wounds.
d) Wounds caused by physical agents e.g.. burns (fire, hot liquid), electrical injuries
and radiation injuries.
c) Chemical agents: e.g. strong acid and alkalis (corrosives).
HOW A WOUND IS PRODUCED
The mechanical force causing a wound maybe caused by:
1-A moving instrument or object (force) on a stationary body (counter force).
2-By movement of the body itself (force) on a stationary ground (counter force) e.g.
in falls.
As a result of impact between the force and the counter force, an energy is
produced which can displace or deform (change the shape) of the affected tissues e.g.
the rigid tissues like the bones undergo fractures, soft tissues may change their shape,
or if the force is more than their tensile strength they rupture and wounds are
produced.
FACTORS INFLUENCING THE TYPES AND EXTENT OF WOUNDS:
I. Instrument used:
a. Type of instrument used: whether blunt, sharp or firearm weapon.
b-Size of the striking surface area of the instrument .
- Small surface area e.g. screw driver —> Small localized wound.
- Large surface area —> large size wound.
c. Shape of the striking surface area of the instrument usually a wound takes the shape
of the causal instrument.
d. Material from which instrument used made:
Instruments made of a wooden or plastic material —> less damage than a rigid
instrument, because part of the energy is used in deforming or breaking the
instrument.
2- Amount of energy produced during the impact
This is measured by the formula £ =1/2 mv2 where m= mass or weight of
instrument, v = velocity of instrument. The velocity of the instrument is more
important than the weight because:
If the weight of the instrument doubled, the kinetic energy doubled,
If the velocity of the instrument doubled, the kinetic energy
quadrupled
3- State of the body at the time of impact
If the body or part of the body affected by the impact is free to move e.g. a
blow to the head which is free to move may cause less damage (because part of the
force is absorbed in moving the head), but a similar force or blow to a resting head
(supported) may cause marked damage.
4- Nature of the affected tissue
a) Skin: is very pliable and somewhat elastic, so if blunt instrument is applied to the
skin, no damage but the underlying structures may be severely damaged (bruises).
Although the skin may split when crushed against rigid bone. (E.g. skull, chin of tibia,
eye brow).
b) Subcutaneous tissues: a blunt force applied —> subcutaneous bruises (due to
presence of fat and fragile connective tissue).
c) Muscles: Muscles may be crushed, torn or lacerated (by fragments of broken bone)
or ruptured if unduly stretched.
d) Bones: Bones are rigid so they may either bend without fracture especially in
children e.g. ribs, or fractured if the force is more than the limits of its elasticity.
e) Body fluids and gases:
- Fluids: are incompressible, so it may be displaced by forces which lead to rupture of
anatomically distant and weak tissues e.g. sudden compression of the chest as in
traumatic asphyxia (fall of buildings) may cause displacement of blood in the great
thoracic veins —÷ rupture of the distal venules and capillaries producing petechial
hemorrhages .
1- Longitudinal or linear scratches: caused by dragging of finger nails across the
skin, it has a broad commencement.
o Semi lunar or crescent scratches: when nails dug into the skin, if the thumb
inflict the injury --- semi lunar scratches plus small ecchymosis.
o Triangular scratches: if nails were pointed.
o Small cuts if finger nails were long.
2- GRAZES = Brush abrasions
They are multiple parallel linear scratches. It occurs when a broader surface of
the skin comes iii contact with a rough object.
If friction occurs on a rough surface e.g. gravel —> coarse graze with particles in the
wound, if friction occurs on a smooth surface e.g. asphalt --fine graze. The
direction indicated by a clean commencement with tags at the end. Variation in depth
occurs in different parts. Grazes caused by fall on the ground are found usually over
the prominence of elbow, front of the knees and hands
3-IMPRESSION OR IMPACT ABRASIONS
It is caused by stamping of some object against the skin .for a short
time, e.g. impact abrasions caused by the radiator of car, tyre marks, and steering
wheel abrasions. These are called patterned abrasion i.e. they keep the pattern of the
impacting object.
4- PRESSURE ABRASIONS
It is caused by a linear pressure on the skin plus movement commonly seen in
hanging or strangulation caused by the rope.
5- BITE ABRASIONS
Human bite abrasions are elliptical in shape, Present mainly in the upper Part of the
body. Human bite may be inflicted upon the victim e.g. in rape or upon the assailant
in self defense or on the body of a child in child abuse. Animal bites usually present in
the lower half of the body especially in the lower limbs, it is in the form of two
Parallel rows with prominence of the canine. Human marks may be found on food
stuff e.g. cheese, buffer, chocolate or on human tissue.
Bite marks can be photographed soon as possible before changes in the tissues or by
ink imprintation and compared with that of the suspect as regards irregularities, size
of teeth, spacing, arrangement, missing of some teeth .etc
So, the suspect could be identified from the characteristics of teeth as well from DNA
typing of the saliva left at the site of bite.
Medicolegal importance of abrasions:
1-It may be the only evidence of a crime or violence be. signs of resistance.
2- It can give an idea about the type of the crime from its site. e.g
 Finger nail abrasions around the mouth and nostrils means smothering.
 Finger nail abrasions on the sides of the neck means throttling (manual
strangulation).
 Finger nail abrasions on the inner side of the thighs means rape.
o Rope mark on the neck means strangulation or hanging.
3- It can give an idea about the instrument used from its shape e.g. finger nails,
radiator of motor car, rope mark.
4- Differentiate incised and contused wounds.
5- The age of abrasion gives an idea about the date of the crime. First it is reddish,
tender, oozing serosanguinous for a day or two. On the 3rd day it is covered with
Gradually the scab dries up and become dark brown. Fallen of the dry scab occurred
from 7-10 days leaving a red colored area. Disappearance of the abrasion occurred in
three weeks and this depends on the width and depth of the abrasion.
6- Ante mortem and postmortem abrasion

Ante mortem abrasions Postmortem abrasion

a-Reddish, swollen a-Yellow, translucent.

 b- May be accompanied by bruises b-No bruises

c-On microscopic exam. ----vital tissue c-On microscopic exam.----No vital

reaction. tissue reaction

d-Some remnants of the damaged d-Devitalized epithelium

epithelium.

e-Occur anywhere Usually on prominence.

Vital tissue reaction:

a. Inflammatory response:
Revealed microscopically within 1-6 hours
b Histochemical changes:
- Decrease in enzyme activity: in the zone adjacent to the wound
- Increase in enzyme activity: in the periphery.
c. Biochemical changes:
- Increase in serotonin and histamine levels.
7- Abrasions must be distinguished from
a. Post mortem injures caused by ants or insects (usually are found at mucocutaneous
junctions e.g. angles of mouth, eyelids, margins of nose.
b. Excoriation of the skin by excreta seen in infants.
c. Pressure sores.
Danger of abrasions:
I. Tetanus 2. Erysipelas
CONTUSIONS = BRUISES ‫كدمات‬
DEFINITION
Extravasations of blood in the tissues following rupture of blood vessels as a
result of application of blunt force. It varies in size from a small pin head ecchymosis
to a large collection of blood, known as hematoma.
SITE
1-Subcutaneous tissue —> subcutaneous hematoma.
2-In the deep organs e.g. brain contusion, cardiac contusion, lung contusion.. etc.
SIZES
The size of a bruise depends mainly on the amount of force, part injured,
delicacy of tissue, condition of arteries and sex of patient.
SHAPE
Usually it takes the shape of the causal instrument e.g. small rounded bruises
caused by fingertips, closed fist and the end of stick. An elongated bruise caused by a
stick. A bruise in the form of two thin parallel lines produced by a whip or a pliable
stick, it may be curved and partially encircle the body.
SITE:
 The site of a bruise does not usually indicate the site of violence. The position
of a bruise may show the manner of assault e.g. when the arms are grasped by the
hands there may be 3 or 4 bruises on one aspect (caused by the fingers) and one larger
bruise opposite (caused by the thumb) indicating the position of the assailant in front
or behind the victim.
AGE
The age of a bruise usually depends on its size and depth. The color of a bruise
is first bright red (oxy HB) —> violet, then bluish color (reduced HB) —> green
colour (biliverdin) —> yellow color (bilirubin) and gradually disappears in 15 days
(range from 2-4 weeks). The color changes occur from the periphery inwards.
Generally the size, site and shape of a bruise depend on:
I. The amount of violence applied to the body.
2-The instrument used.
3-The condition and type of tissues.
Bruises are more easily and extensive in loose and lax tissue e.g. eyelids and
in tissues with excessive subcutaneous fat. On the other hand, bruises are Tess and
even absent in tissues strongly supported by fibrous tissues e.g. scalp, palms and
soles, also in persons with good muscle tone e.g. in boxers.
4-Texture and colour of the skin: Bruises are more apparent in fair people than dark
people.
5- Age: Children and old peoples tend to bruise easily, In the former it is due
to looseness and delicacy of skin as well the presence of subcutaneous fat.
While in the latter it is due to loss of flesh and subcutaneous fat, as well vascular
changes in the form of atherosclerosis.
6- Sex: Women bruised more easily than men due to delicacy of tissues and presence
of subcutaneous fat especially if obese.
7- Certain diseases: Patients suffering from hypertension, cardiovascular degenerative
changes, purpura, hemophilia, leukemia and survey are more easily bruised.
8- Gravity: bruises can appear at places away from the site of violence e.g. a blow on
the forehead -+ bruise round the eye, a blow on the abdomen
- bruise in the scrotum.
ANTEMORTEM OR POSTMORTEM BRUISE
The production of postmortem bruise is possible, within 2 hours after death,
but requires severe violence, and the resulting bruise is usually, small in size.
Antemortem bruise is tender, with swelling of the tissues, discoloration of the skin,
infiltration of tissues with blood and cellular infiltration.
DANGER OF A BRUISE:
1- Neurogenic shock: due to reflex vagal inhibition of the heart especially in areas
rich in parasympathetic supply e.g. mastoid, neck, pericardiurn, epigastria,
hypogastria and genitalia.
2-Injury to internal organs.
3. Liability to sepsis and death from septicemia.
DIFFERENTIATION BETWEEN 1IYPOSTASIS AND BRUISES:

Hypostasis Bruise

1-A postmortem change I. Occur in the living

2. Site: dependent parts 2. Anywhere

3. Skin: intact 3. Accompanied by abrasions

4. No swelling, no color changes 4. There is swelling, color change

and no marked edges. and well marked edges.

5. By pressure the color 5. By pressure the color dose not

disappear disappear.

6. The blood is intravascular 6. The blood is extra vascular not

washable and fluidly. washable and clotted.

7. No cellular infiltration. 7. There is cellular infiltration

MEDICOLEGAL IMPORTANCE OF A BRUISE:

1-May be the only evidence of crime or Violence.

2-May be the only evidence of signs of resistance.

3-The date of the. crime can be estimated from it age..

4-Give an idea about the instrument used (from its shape).

5-Differentiate between incised and contused wound.

6- May be the cause of death.

7- It should be differentiated from hypostasis.

CONTUSED WOUND ‫الجرح الرضي‬

Definition:
An open injury produced by the impact of blunt force against the body. It is
caused by a stick, stone, or fall from a height. The edges are usually abraded with
contusions around, and the angles may be multiple and irregular.
Classification:
According to the way by which they are produced:
1-Contused wound: When there is crushing of the skin between two hard objects e.g.
scalp, chin of tibia, cut eye brow of the boxer. (Here contused wound may simulate
cut wound ).
2-Laceration: ‫ جرح رضى متهتك‬it is a contused wound where the edges are
severely damaged an highly irregular, with multiple angles. The
appearance of the laceration may not accurately reflect the instrument that
produces it. One can have lacerations of internal organs as well as skin.
3- Crush injury: When a heavy blunt mobile instrument runs over a limb or a body
e.g. runs over by a motor car.
4- Torn wound: Caused by belts of machines ----- tearing of the whole limb and we
called it tearing injury or torn wound, here the tissues are twisted (skin, muscles( .
5- Cut laceration: inflicted by heavy sharp cutting instrument e.g. by the blade of axe.
Medico legal importance of contused wound:
I. it indicates the type of injury and causal instrument.
2-Could simulate incised wound in the skin stretched over bone e.g. scalp.
3-If in the head it may accompanied by fracture
Danger of contused Wounds:
1-Liability to sepsis.
2-Neurogenic shock.
3-Crush syndrome. Myoglobinuria Renal failure.
4-Fat embolism (fracture of long bones(.
5- On heating a scar is produced . may leave permanent infirmity.
INCISED WOUND (CUT WOUND)‫الجرح القطعى‬
Definition:
It is produced by drawing the edge of a sharp instrument along the
surface of the skin with sufficient pressure e.g. of sharp instrument, knife. razor. and
broken glass.
The wound is. usually more long than deep, having clearly cut sharp edges and base.
in some cases the edges are irregular and ragged which may be due to overlapping by
multiple incisions, or may. be due to corrugation and looseness of the skin at the site
of injury eg. neck, axilla and scrotum, (here cut wound may simulate contused
wound( .
The edges of the wound are usually gaping due to the elasticity of the skin and cuffing
of the underlying muscles especially if the muscles are cut transversely. External
bleeding is usually free, sepsis is less and usually the wound heals by first intention.
Shape of the wound
It is usually linear, but it may be curved or V shaped if the direction of the weapon is
changed during infliction of the wound.
The cuts in the clothes do not always coincide with the wound especially when
clothes are loose.
Therapeutic incised wound:
Following surgical interference e.g. for exploration.
Differentiation between homicidal, suicidal and accidental cut wounds:

Suicidal
Arranged
Homicidal Vulnerabfe sites Accidental
(neck, groin,
wrist)
 Irregular Arranged Irregular Any part
1. Characters Accessible Vulnerable sites .
2. Site & vulnerable (neck, groin, wrist) .
(face, neck)

3. Number Multiple Multiple parallel Usually single

4. Clothes May be involved Not involved May be involved

May be present
5. Defense wounds Absent Absent
.

Medicolegal importance of incised wound

1-It indicates the type of instrument used.
2-Its site indicates the type of crime whether homicidal or suicidal.
3-Could simulate contused wound.
Danger of incised wound
1-Severe bleeding.
2- Cutting of important nerves and tendons.
3- Air embolism.
4. Infection.
 Differentiation between Cut and Contused Wounds
Cut wound Contused wound

1. Instrument Sharp cutting Heavy blunt

Sharp regular, except in

Ragged, irregular, with
wounds in corrugated
2.Edges . contusions and abrasions
areas
around
Acute

3-Angles Acute Irregular

4, Base Sharp Irregular

5. Bridging Not present Present

6. Gaping Present Absent

Free external bleeding

7. Bleeding Less bleeding
—

Incompletely torn
8. Blood vessels . Sharply cut
.

9. Hair Sharply cut ends Brushed, irregular ends

10. Sepsis Less . More

11-Healing By first intension with By secondary intension

 minimum scar formation leaving permanent scar

STAB WOUND ‫الجرح الطعنى‬

A wound caused by thrusting or forcing sharp pointed instrument into the
body, having a sharp edged blade e.g. knife, scissors.
Punctured Wound: Caused by thrusting an instrument with a blunt edge and pointed
end e.g. nail.
Penetrating Wound: These are stab or punctured wounds reaching a body cavity e.g.
chest (pleura, pericardium), abdomen (peritoneum), joint cavity.
Transfixing Wound = Perforating Wound: These are stab or punctured wounds
transfixing a limb or even the whole body.
Characters of Stab Wound:
1-Is usually more deep than long.
2-Its depth being usually relative to the length of the blade.
3-The width is also relative to the breadth of the blade, sometimes the wound may be
enlarged on withdrawing the instrument.
4-The edges are cleanly cut without surrounding abrasions or contusions except in
punctured wounds and those produced by the handle of the knife.
5-The shape of the wound is related to the shape of the causal instrument,
- Bibladed knife —> Two pointed sharp angle.
- Monobladed knife —> One end is sharp pointed, the other is transverse
- Closed scissor ---> Quadrangular rhomboid wound .
- Stabbing with rounded end of the nail —, Circular wound.
The Shape of the Stab in the Skin May be Affected by:
a. Direction of thrust and withdrawal of the instrument e.g. if the knife is twisted as it
is withdrawn —f Cruciate wound.
b. If the direction of stab is oblique - oval shape wound.
c. The shape of the wound changed if partial withdrawal of the instrument then re-
thrusting it again.
d. The shape of the wound may be changed with movement of the victim.
Danger of stab wound
1-Neurogenic shock.
2-Injury to vital organs.
3- Internal hemorrhage.
4-Sepsis.
DEFENSE WOUNDS = SELF PROTECTION WOUNDS
These results from the victim’s spontaneous reaction of self protection when
he is attacked. lie may either grasp the weapon to prevent it injuring a vital part, or
may raise his arm or hand to ward off an attack.
- When the weapon is blunt there is abrasions mid bruises on the forearms wrists and
back of hands.
- When the weapon is sharp it depends on stabbing attack, slashing attack or both .
In stabbing attack: in an attempt to grasp the knife there was cuts on the palm of the
hand, and the opposing bends of the fingers or thumb. But in an attempt to ward off
the knife there wilt be cuts on the back of hands, wrists, skin between thumb and
fingers.
In slashing attack: the victim usually holds the hand or the forearm leading to
serious cuts on these parts.
Defense wounds on the lower extremities (legs, knees) are more common in females
and suggest sexual assault.
FABRICATED WOUNDS
They are usually done by the person himself (self inflicted wounds) to give
suspicious of self defense or by the aid of another person in agreement with him.
Type of wound: often cut wounds, may be stab, sometimes bruises, rarely firearm
wounds and contused wound.
Characters of the wound:
1-They are usually superficial, consists of a series of parallel or crossing incisions.
2- Commonly seen over accessible parts e.g. top of the head, forehead, and neck, front
of chest or abdomen.
3- Usually there are no corresponding cuts on the clothes and if present they are in a
way incompatible with the length, direction, nature and number of wounds.
CAUSES OF DEATH IN WOUNDS
L TRAUMATIC SHOCK
A. Primary or neurogenic shock: This includes
i. Death from reflex vagal inhibition of the heart i.e. parasympathetic
stimulation —+ slowing of the heart —+ instantaneous death.
Causes: usually follow minor trauma but rarely follow severe one as in cut throat.
1-Psychic shock e.g. hearing of unexpected bad news.
2-Sudden rise of pressure in the carotid sinus, e.g. pressure on the neck by a finger or
application of ligature (at or above the sinus) and especially if accompanied with
excitment.
3-Minor painful stimuli to parasympathetic peripheral nerve endings following
unexpected blows in areas as larynx, precordium, epiglottis, suprapubic region,
external genitalia... etc.
4-During minor operations as puncture of the pleural cavity, passing uterine sound or
urethral catheter.
5-Impaction of foreign body in the Larynx.
6-Sudden distension of hollow organs e.g. during insuflation of the uterus.
7-Pulling upon the intestinal loops during operation especially with light anaesthesia.
Clinical features:
- Bradycardia may be complete asystole.
Sudden fall of blood pressure.
-. No cyanosis, no evidence of respiratory distress.
Post mortem picture:
1-History of sudden death following any of the previous causes.
2-The tissues and organs are pale. Right heart and big veins are empty and collapsed.
3-No congestion of the lungs or brain.
ii. Death from sympathetic stimulation of the cardiovascular system
Causes:
1-Painful stimuli accompanied by emotion and fear.
2-Decrease in tension of the carotid sinus e.g. if ligature is applied below the sinus.
3-Precipitating factors e.g. persons suffering from previous cardiac diseases e.g.
coronary atherosclerosis, fatty degeneration of the head, chronic valvular diseases.
Clinical features:
1-Angina pain, anxiety.
2- Marked Dyspnea and cyanosis.
3-Rapid pulse, dilated pupils, sweating.
4- high blood pressure.
5- Signs of pulmonary edema with cough, expectoration of blood stained froth.
The cause of death is ventricular fibrillation which occurs in a few seconds or
minutes.
Postmortem picture:
1-General congestion of organs with fluidity of the blood.
2-Heart is full of blood, with preexisting cardiac diseases if present.
3-Pulmonary edema and congestion, peticheaf hemorrhages under serous coats.
B. Secondary or hematogenic shock =Surgical shock
It is of gradual onset, there is reduction of the total circulating blood volume due to
local loss of fluids (blood, plasma) at the site of injury with capillary dilatation due to
absorption of histamine like substance liberated from the injured tissues.
II- HEMORRHAGE
Loss of blood is the commonest cause of death in wounds e.g. stab or incised wounds
and especially if it. results from injury of an artery. Symptoms from hemorrhage start
to appear if the person loses one liter of blood and grave danger occur if he loses 2
liters or one third of the total blood volume, this is termed external hemorrhage.
The gravity of the hemorrhage depends on :
1-The amount of blood loss.
2-The site of hemorrhage: hemorrhage inside a body cavity or tissue is much more
serious than external bleeding because of the possibility of compressing vital organs.
- Hemorrhage in peritoneal or pleural cavities is fatal if amounts to V2 -1 liter of
blood or more.
Hemorrhage in pericardial cavity is fatal if amounts to 200-300 cc of blood or more
(cardiac tamponade).
- Small amount of blood is fatal in extradural or subdural spaces.
- Few CC of blood are fatal if effusion occurs in the brain substance e.g. pontine
hemorrhage.
3- Rate of hemorrhage rapid loss is much dangerous than slow loss (piles).
4- General condition of the patient.
Types of hemorrhage
1-Primary hemorrhage: follows immediately after injury.
2-Reactionary hemorrhage is usually delayed for several hours up to 24 hours after
injury.
3-Secondary hemorrhage is due to infection of a wound, it occurs between 10-16 days
after injury.
Postmortem picture of death from hemorrhage
Externally:
- Large amount of blood at the scene and on the clothes (may be inside a body cavity),
also a wound is present.
- The body looks pale.
- Post mortem hypostasis is ill defined or even absent.
Internally:
- Pallor of organs (heart, lungs, brain).
- Heart and big vessels are empty of blood.
- Petechial hemorrhages under serous coats especially the endocardium
(subendocardial petechial hemorrhages).
- Spleen is contracted.
III. INFECTION OF THE WOUND
Wound infection may be caused by organisms which are normally present on the
body surfaces e.g. staphylococci, streptococci, pneumococci or by organisms which
invade the tissues from the environment. infection of the wounds may be:
a. Primary is caused by organisms which are carried into the wound at the time of the
injury e.g. from the skin, clothing or street dirt (tetanus). Primaty infection often
cannot be avoided.
b. Secondary is caused by organisms which. invade the wound after the injury e.g. by
air droplet infection, contaminated dressing . It can be prevented by adequate aseptic
surgical measures.
IV. EMBOLISM
A. Air embolism
The minimum amount of air to cause air embolism is 60 ml.

Common
Open injuries
(neck, chest) Less common
Incidence * I)uring blood Stab in chest communicating a bronchus with
Causes transfusion pulmonary vein
* Others: criminal .
abortion,
insuflation.

Puncture of right
P.M. ventricle Puncture of Lt. ventricle under water —> air
picture under water —* comes out. beaded coronary & cerebral arteries.
air comes out

B. Pulmonary embolism due to deep vein thrombosis:

Injury to the veins of a limb leads to deep vein thrombosis, the effects of pulmonary
embolism depend upon the size of the emboli released from the venous thrombus.
When a large branch of one of the pulmonary arteries is obstructed, an infarct may
develop in the lung. it occurs 2-3 days after trauma and about the 10th day of
operation.
C. Fat embolism
It is due to obstruction to the flow (f blood through the capillaries by fat globules. It
usually occurs after fractures involving Long bones i.e. bones containing marrow fat,
but it may follow severe injury or burn to fatty tissues in any part of the body.
Pulmonary fat embolism occurs less than 2 days after fracture while cerebral fat
embolism occurs 2 days and more after fracture.