Regional Injuries

1) Definition of head injury: a morbid state, resulting from gross or subtle structural changes in the
scalp, skull, and/ or the contents of the skull produced by mechanical forces.
2) Types of Skull fractures
1. Fissured fracture
2. Depressed comminuted fracture
3. Comminuted fracture
4. Elevated fracture
5. Blow-out fracture
FISSURED # DEPREESED #
6. Expressed fracture
7. Pond fracture / indented fracture
8. Gutter fracture
9. Ring fracture
10. Hinge fracture
11. Diastatic / sutural fracture
12. Perforating fracture
13. Crush fracture
14. Contre-coup fracture
15. Heat fracture Ring fracture
16. Cut fracture
I. Fissured fracture (Linear #)

Cause:--low-velocity impacts, with a large area of contact between the head and impact object—
1 Whole thickness/ inner table/ outer table
2 Linear thread like # in straight or curved line
3 Continue over sutures and bones
4 Impact with hard rough, flat surface- ground, plank
eg. a fall to pavement.
II. Depressed fracture or fracture ala signature /signature fracture
Cause:--High-velocity impacts, with a small area of contact between the head and impact object
1. Heavy localized force
2 Local depression- wedging of fragment with radiating fracture lines

III. Comminuted (MOSAIC #) fractures

Cause:--Significant force striking over a broad area
1 Cracks into pieces
2 2 or more intersecting lines of # dividing bone into pieces
3 Radiating fashion
4 Impact from fall from height, hit by iron rod, wood
5 “spider web or mosaic appearance”
6 Complication of fissured or depressed #

IV. Basal fractures

1. Ring fracture or Foramina fractures
Cause:-Indirect violence
1. 3—5 cm outside Foramen magnum- middle ear- roof of nose
2. Explosive fracture- spine in head
 3. Pressure on chin- boxers, others

2. Hinge fracture or motor-cyclist fracture

Cause— heavy blow to the side of the head, common in motor cyclists
Occur when the linear fracture passes across the middle cranial fossa, separating the skull base into two halves

V. Pond fractures:--
Infants / children- inadequate calcification- yielding bone
1 ‘ping pong ball dent’
2 Depression at site of impact
3 Inner table no # but outward table might show cracks at peripheral rim

VI. Elevated #:-

Cause—Blow from heavy sharp weapon—by lateral pull
One end of fractured is elevated over the surface of skull and the other end is depressed into cavity
VII. Gutter fracture
Cause—Tangential impact by sharp edge weapon, bullet
a. Outer table damaged, inner table +/-
b. Inner table- depressed fracture of inner table of skull
VIII. Diastatic fracture (sutural #)
a. Separation of sutures—sagittal
b. Usually in younger persons

3) COUP LESION –Injury is located beneath the area of impact—directly from impacting force.

4) CONTRECOUP LESION—injury is present opposite the side of impact

5) Intracranial Haemorrhages

1. Extradural / Epidural haemorrhage (EDH) EDH

a) Always by traumatic in origin
b) Least common and rare in children > 3yr and elderly due to adherence of dura to skull
c) Common B\W 20—40 yrs
d) Dura contains all sinuses, emissary veins
e) Firmly attached to skull
f) Strippage of dura from bone at time of impact-potential space for blood to fill
g) Bleed from: middle meningeal artery, meningeal veins, anterior ethmoidal artery, sigmoid sinus damage etc
h) Minimum amount of EDH necessary to produce clinical symptoms—30ml
i) Limitation of spread due to dural attachment at suture lines
j) Clot is clear cut, well defined, strips dura inwards and has a concavity of the external surface of the brain
k) Blood accumulation is high if from an artery than from vein
l) 50% have 2nd haemorrhage – SDH, SAH
LUCID INTERVAL:- A period of sanity between two insane periods, ie A period of normalcy with normal
mental activities may found sometimes in an insane person / head (EDH)injury condition
Features in Lucid interval
1. Compos mentis+++
2. Judgment, comprehension, awareness present
3. Varies with duration and from time to time
Occurrence—Epidural haematoma, certain phases of insanity
MLI:- Responsible for the acts

Classical triad: Head injury with

1. Lucid interval
2. Ipsilateral mydriasis
3. Contralateral paresis

Medical emergency

A. CT without contrast
B. Evacuate via burr holes
 SDH SAH ICH
2. Subdural haemorrhage (SDH)
3. Subarachnoid haemorrhage (SAH)
4. Intracerebral haemorrhage (ICH)
5. Intraventricular haemorrhage (IVH)

5) Types of cerebral injuries

1. Cerebral concussion
– Temporary unconsciousness (partial/ complete paralysis)
– Associated with head injury; comes after injury
– Amnesia to events and spontaneous recovery
– Low level forces- less anatomical but physiological disruption
2. Diffuse axonal injury (DAI)
– Injury to axons with immediate LOC and coma
– Mild <6h, Mod 6-24h, Severe >24h
– Anatomical changes produced by shear forces disrupting the histological structures,
transecting axons – dilated, club shaped, RETRACTION BALLS
– Petechial hmrges., at junction of grey white
3. Cerebral contusions
4. Cerebral haemorrhages
5. Cerebral lacerations
6. Coup and contrecoup injuries

6) BOXING INJURIES- This is also called as Punch-drunk syndrome

Deterioration in speed & coordination is the chief of onset symptom.

In final form—is recognized by slurred speech, defective memory, slow thought process, stiff limbs,
ataxia, broad-based gait, expressionless face like parkinsonian-like facial appearance and dementia

• Intracranial findings in boxers

– Subdural
– Subarachnoid
– Intracerebral
– DAI
– Focal ischemic lesions
– Dissecting aneurysms
– Cortical atrophy
– Thinning or tears of corpus callosum
– Loss of neurons from cerebellum and substantia nigra
7) Flail chest
Multiple rib fractures usually due to a severe blunt trauma causes this flial chest,
and is often associated with pulmonary injuries such as hemothorax and pneumothorax.

Flail chest results in a loss of stability of the chest wall.

The loss of continuity with the remainder of the rib cage causes the flail segment to move paradoxically,
area of injury "sinks in “with inspiration, and expands with expiration (opposite of normal chest wall
mechanics)chest wall deformity can be seen
During inspiration pressure within the chest

is negative causing the flail segment to retract.

During expiration intrathoracic pressure becomes positive and the flail segment bulges.

Treatment can be non-operative or operative depending on the presence

of respiratory compromise, the number of consecutive rib fractures, and the

presence of open fractures.

8) Cardiac Tamponade
This is also called as Commotio cordis- cardiac concussion
Causes
1. Traumatic Lacerating and penetrating injuries into pericardium or heart as well as non-
penetrating wounds of Heart
2. Pathological—between 7 to 10 days after Myocardial infraction

Atrial wounds dangerous than ventricular wounds

Full chamber dangerous than empty chamber

9) Whiplash injury
This is injury to spinal cord due to violent cervical acceleration–deceleration force without fracture of spine
applied to the passenger, usually front seat occupant.

The exact injury mechanism that causes whiplash injuries is forceful sudden hyperextension followed by hyper
flexion of the cervical vertebrae, this double movement being known as the whiplash.

A whiplash injury may be the result of impulsive retracting of the spine, mainly the ligament: anterior
longitudinal ligament which is stretched or tears, as the head snaps forward and then back again causing a
whiplash injury.
Severe neck pain, concussion to spinal cord may also occur
Most of the injuries happen in C-5 and C-6.
Fatal contusion or laceration of the spinal cord may occur without fracture of spine
Head restraints prevent hyperextension of neck to certain degree
MLI—automobile accidents who have no head restraints
10) Puppe`s Rule
The course of second fracture will be interrupted by
the earlier fracture
MLI—To determine the sequence of multiple blunt
force injuries of the skull as well as to determine the
sequence of gunshot wounds or blows of the skull.