Content:  Introduction  Scalp Injuries  Skull Fractures  Brain damage

 Introduction:

Of all regional injuries, those of the head and neck are the most common and most important in forensic practice.

Importance because:    The head is the target of choice in the great majority of assaults involving blunt trauma. When the victim is pushed or knocked to the ground, he often strikes his head. The brain and its coverings are vulnerable to degrees of blunt trauma that would rarely be lethal if applied to other areas.

Head Injuries is divided in to: -Scalp injuries -Skull injuries -Brain injuries -Facial injuies Sometimes facial injuries are classified as a separate category.

 Scalp Injuries:
All types of wounds can occur in the scalp as abrasion, laceration, & contusion. Examination of the scalp injuries usually requires shaving the area around the injure. Anatomy of the scalp: Layers of the scalp: The scalp consists of 5 layers. These layers arranged from superficial to deep can be remembered from the letters of the scalp: 1) S Skin: It is thick, hairy and contains numerous sebaceous glands. 2) C Connective tissue: It is dense fibro-fatty layer. Its fibrous septa uniting the skin to the aponeurosis. All nerves and vessels of the scalp are present in this layer with free anastomosis between the vessels. 3) A Aponeurosis: It is the tendon of the occipitofrontalis muscle. It is separated from the periosteum of the skull by a space called the subaponeurotic space. It is a continuous space closed at the margins of the scalp. 4) L Loose areolar tissue: It consists of loose fibrous bands occuping the subaponeurotic space and extending from the aponeurosis to the periosteum. It contains few small arteries and some important emissary veins. These veins are valveless veins connecting the scalp veins with the skull diploic veins and the intracranial dural venous sinuses. 5) P Pericranium (outer periosteum of the skull): It is loosely attached to and easily separated from the skull bones. It is continuous with the inner periosteum at the sutures and so there is a separate space between the pericranium and each skull bone.

A. Abrasion of the scalp: Less common than other sites of the body, always needs shaving the hair of the scalp to be appearent, & sometimes missed, minimal or no bleeding. A. Bruising of the scalp: -Hair should be removed -Marked swelling is common. -Usually mobile under graphite A. Lacerations of the scalp: Lacerations of the scalp bleed profusely, and dangerous and even fatal blood loss can occur from an extensive scalp injury. Laceration can resemble incised wound due to thin scalp and tightly fixed to the bony skull.

 Skull fractures:
It is rarely the skull fracture itself that is a danger to life, but the concomitant effect of transmitted force upon the cranial contents. Anatomy:   The anterior fontanelle closes hnctionally between 9 and 26 weeks after birth, though is not tightly sealed until about 18 months. The posterior fontanelle closes between birth and 8 weeks of age.

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Suture lines close by interdigitation during childhood and osseous fusion occurs irregularly at variable dates during adult life. The cranium varies in thickness in adults and varies from place to place, thin plates being reinforced by stronger buttresses, such as the petrous temporal, the greater wing of the sphenoid, the sagittal ridge, the occipital protruberance and the glabella. Thickness is widely variable from 0.5 to 1.5 cm. Thin areas lie in the parietotemporal, lateral frontal and lateral occipital zones.

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General principle theory is that the force applied exceed the ability of the skull to absorb. Child skull have more ability to distort but good elasticity Brain injuries may occur without underlying bony fracture.(& Vice Versa is true).

Types of fracture: (see the graph next to description)
1. Ring Fracture: In the posterior fossa around the foramen magnum and are most often caused by a fall from a height onto the feet. Energy is transmitted from the fall through leg, pelvis, & spinal cord to the base of the skull. 2. Linear Fracture: These are straight or curved fracture lines, often of considerable length. They may involve the inner or outer table, but commonly traverse both. They may extend downwards into the foramen magnum, across the supraorbital ridges, or into the floor of the skull. A common basal linear fracture

is one that passes across the floor of the middle fossa, often following the petrous temporal or greater wing of the sphenoid bone into the pituitary fossa. In children and young adults, a linear fracture may pass into a suture line and cause a 'diastasis' or opening of the weaker seam between the bones. This is most often seen in the sagittal suture between the two parietal bones. In the child abuse, a linear fracture of a parietal bone may reach the sagittal suture and continue across it into the opposite plate. 3. Pond Fracture: A descriptive term for a shallow depressed fracture forming a concave 'pond'. So common in infants. 4. Hinge Fracture: In motorcycle accident separating the base of the skull in to two half. 5. Mosaic spider’s web Fracture: A comminuted depressed fracture may also have fissures radiating from it, forming a spider's-web or mosaic pattern. 6. Depressed Fracture: Focal impact causes the outer table to be driven inwards. Many factors affect the outcome of skull fracture include: -The area affected. -Thickness of the skull and other layers at the side of energy. Force needed to produce skull fracture is estimated to be about 5 foot-pounds (73 N). Outcome of the fracture is mainly: -Infection (Meningitis, & brain abscess) or -Hemorrhage.

 Brain damage: Mainly either infection or later on epilepsy. 1. Trumatic epilepsy: A late effect of a depressed skull fracture may be 'traumatic epilepsy'. This is of great medico-legal significance because it may result in lifelong neurological disability for which very large monetary compensation may be awarded. It usually manifests as tonic and clonic fits, which may be difficult to differentiate from idiopathic epilepsy, if the injury occurred in early life. When fits begin within weeks, or a year or two of a major head injury in a mature person who had never had fits before, the diagnosis is easier, but all cases need expert neurological examination. It can develop from 2weeks up to 2 years after the impact. In open fractures it develops quickly & with infection is also quickly.

2. Infections: Infection can gain access via skull fractures:    Direct spread through a compound fracture, especially where there is a contaminated scalp injury. Spread from the nasal cavity when a fracture of the cribriform plate has allowed communication with the anterior fossa. Spread from fractures that involve a paranasal sinus, such as the frontal or ethmoid, or from the mastoid air cells or middle ear cavity. A history of leakage of cerebrospinal fluid from the nose or ear must alert both clinician and pathologist to the possibility of communicating basal fractures.


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