eat TT) ei EXIT LEN TNA YON FIRST EDITION VETRIVEL TEXTBOOK OF ORTHOPAEDICS COMPETENCY BASED UNDERGRADUATE CURRICULUM PN al te WITH SELF EVALUATION QUESTIONS <> Prof. S. Vetrivel Chezian ¢ MLS. (Ortho)., D.Ortho., FRCS (Glasgow)., Ph.DVETRIVEL Textbook of FIRST EDITION VOLUME - III MS(Ortho)., D.Ortho., FRCS(Glasgow)., Ph.D Director and Professor Institute of Orthopaedics and Traumatology Coimbatore Medical College Hospital Coimbatore.Copyright ©2021 by the Author Allrights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner. The author/ publisher is not responsible (as a matter of product liability, negligence, or otherwise) for any injury resulting from any material contained herein. This publication contains information relating to orthopaedic care and intervention for orthopaedic disorders that should not be construed as specific instructions for individual patients. Manufacturers’ product information and package inserts should be reviewed for current information, including contraindications, dosages, and precautions. Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author/ publisher is not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication, Applicaton of this information in a particular situation remains the professional responsibility of the practitioner. Readers are urged to confirm that the information, especially with regard to drug dose/usage, complies with current legislation and standards of practice. Please consult full prescribing information before issuing prescription for any product mentioned in the publication. ‘The author has made every effort to trace copyright holders for borrowed material. If they have inadvertently overlooked any, the author will be pleased to make the necessary arrangements at the first opportunity. First Edition: 2021 ISBN: 978-93-5437-862-1 Published by the author. For sales enquiry, please contact - Ph: 9843028096, e-mail: vetrivelortho@gmail.com.CONTEN FORENSIC MEDICINE & TOXICOLOGY FM3.7__ Describe factors influencing infliction of injuries and healing, examination and certification of wounds and wound as a cause of death: Primary and Secondary. Prof.T-Jeyasingh FM3.8 Mechanical injuries and wounds: Describe and discuss different types of weapons including dangerous weapons and their examination. Prof.T-Jeyasingh FM3.9 Firearm injuries: Describe different types of firearms including structure and components. Along with description of ammunition propellant charge and mechanism of fire-arms, different types of cartridges and bullets and various terminology in relation of firearm - caliber, range, choking. Prof.A.Edwin Joe FM3.10 Firearm injuries: Describe and discuss wound ballistics-different types of firearm injuries, blast injuries and their interpretation, preservation and dispatch of trace evidences in cases of firearm and blast injuries, various tests related to confirmation of use of firearms Prof.T.Jeyasingh FM3.11 Regional Injuries:Describe and discuss regional injuries to head (Scalp wounds, fracture skull, intracranial haemorrhages, coup and contrecoup injuries), neck, chest, abdomen, limbs, genital organs, spinal cord and skeleton Prof.T.Jeyasingh FM3.12 Regional Injuries: Describe and discuss injuries related to fall from height and Vehicular injuries - Primary and Secondary impact, Secondary injuries, crush syndrome, railway spine. Prof.T.Jeyasingh 916 923 925 932 937 946916 Vetrivel Textbook of Orthopaedics FM 3.7 DESCRIBE FACTORS INFLUENCING INFLICTION OF INJURIES AND HEALING, EXAMINATION AND CERTIFICATION OF WOUNDS AND WOUND AS A CAUSE OF DEATH: PRIMARY AND SECONDARY Prof. S. Vetrivel Chezian INguRY + Aninjury is any harm, whatever illegally caused to any person in body, mind, reputation or property (Sec. 44,1.P.C.). + Medically a wound or injury is a break of the natural continuity of any of the tissues of the tiving body. + Mechanical injuries (wounds) are injuries produced by physical violence. + Trauma is an injury inflicted by force on a living tissue. FACTORS INFLUENCING INFLICTION OF INJURIES + Awound is caused by a mechanical force which may be either a moving weapon or object or the movement of the body itself. + In the first case, the counterforce is provided by the inertia of the body and in the second case by the rigidity of some stationary object against which he falls. A combination of these two events is seen inmost cases. + Due to the impact between the forward moving force and the counterforce, energy is transferred to the tissues of the body, which ‘causes a change in their state of rest or motion. + The human body contains many complex tissues which greatly vary in their physical properties, such as state of solidity, fluidity, density and elasticity and because of this a change in the state of rest or motion of the body produced by a forceful impact does not affect the tissues uniformly. + Some of the energy is spent in moving the body asa whole, but most of the energy may cause 1m motion of localised parts of the body, due to which the affected tissues will be subjected to compression or to traction strains ‘or to.a combination of both. + All the body tissues, except those which contain gas, are resistant to compression, i.e., they resist force tending to reduce their volumes. Mechanical force does not cause compression of the tissue but causes their displacement, deformation and traction strains inthe affected tissues. + Such strains may be due to forces causing simple elongation of tissues, but they may be due to more complex mechanism, such as bending, torsion or shearing. + The rigid tissues like bones resist deformation, but if the limits of their elasticity is exceeded fracture occurs, FACTORS GOVERNING THE NATURE AND EXTENT OF WOUNDS: 1, THE NATURE OF THE OBJECT OR INSTRUMENT CAUSING THE WOUND + Ifablowis inflicted from a sharp-edged object, the force is concentrated to a very limited area or a point or a line which causes deep penetrated or clear separation of the issues. + With a blow from a blunt instrument having a flat surface, a relatively large area of body surface is involved. + Irregularities in the shape of the instrument or curvature of the part of the body struck such as at the top of head, may limit the area of the actual impact to a small size and damage will bemore. + Afall against a projection may produce moreserious injury than a similar fall against a flat surface, 2. AMOUNT OF ENERGY DISCHARGED DURING IMPACT + The velocity has far more influence on the energy compared to the mass of the object. 3. THE CONDITION UNDER WHICH THE ENERGY IS. DISCHARGED + Inan impact, most of the energy may be spent. in causing generalized movement of the body due to which the person may be knocked down, but local injury may be minimal. + If the body or the part of the body struck is immobilized, the greater part of the force is spent in causing localized tissue damage. + If the head is free to move, a blow may cause little damage, but a similar blow to a head resting on the ground may cause marked injury tothe skull. + Any factor which increases the period of time over which the energy is discharged will also decrease the destructive effect of ablow. 4, THE NATURE OF THE AFFECTED TISSUES SKIN: + The skin readily changes shape when itis struck as it is very pliable and little elastic. It is also resistant to traction forces. + Because of these factors, often the skin is not damaged when struck with a blunt instrument although underlying structures may be severely damaged, SUBCUTANEOUS TISSUES: + The subcutaneous tissues are very plastic due to their fat content and the pliability of connective tissue, due to which they protect the body by the cushioning effects which they have on blows. Vetrivel Textbook of Orthopaedics 917 MUSCLES: + The muscles are usually not damaged due to blows, because of their great plasticity and elasticity and their strong encapsulating sheaths. + They may be crushed against bone or lacerated by fragments of displaced and broken bone. BONES: + When a force is applied to a bone it may bend without breaking, but it fractures when it is bent beyond the limits of its elasticity. BODY FLUIDS: + Fluid is incompressible, but is readily displaced. A blow over a hollow organ which contains fluid may set up powerful hydrostatic forces in that fluid which are transmitted equally and uniformly in all directions, wich may cause rupture of anatomically distant and mechanically weak tissues. + Asudden compression of the chest may rupture distal venules and capillaries, as seen in traumatic asphyxia. GASES + Gases are readily compressible, lungs may be extensively compressed without any structural damage but when lungs are compressed suddenly and violently, sufficiently powerful pneumo static forces may cause damage to tissues. CLASSIFICATION OF INJURIES Injuries are broadly classified as 41. Mechanical or physical injuries Thermal injuries Chemical injuries Explosion injuries Miscellaneous-Electrical and Radiation injuries918 Vetrivel Textbook of Orthopaedics ‘MECHANICAL OR PHYSICAL INJURIES ‘These injuries are caused by blunt forces, sharp. objects like knives and firearm shooting, ‘A. INJURIES CAUSED BY BLUNT FORCE Abrasions: An abrasion is a destruction of the skin, which usually involves the superficial layers of the epidermis. It is caused by friction against a rough surface. (Fig. FM3.7-1) Fig. FM 3.7-1 Shows Abrasion Contusions: A contusion is an effusion of blood into the tissues, due to the crushing of blood vessels, caused by blunt trauma (Fig. FM3.7-2) Fig. FM 3.7- 2 Shows Contusion Lacerations: Lacerations are tears or splits of skin, mucous membranes, muscle or internal organs produced by application of blunt force to broad area of the body. (Fig. FM3.7- 3) FM, 3.7+ 3 Shows Laceration Fractures and dislocations- A fracture is a break in the continuity of a bone. (Fig. FM3. Fig. FM 3.7- 4 Shows Fracture Dislocation -A joint is dislocated when the contact between the two articular surfaces is completely lost. (Fig. FM 3.7-5) They are confirmed with X rays. i Fig. FM 3.7- 5 shows Dislocation B, INJURIES CAUSED BY SHARP FORCES Incised wounds - An incised wound is a clean cut through the tissues, caused by sharp-edged object. The wound is longer than it is deep. (Fig. FM3.7- 6) Fig. FM 3.7- 6 shows Incised wound‘Chop Wounds - They are deep gaping wounds caused by a blow with the sharp-cutting edge of a fairly heavy weapon.( Fig. FM3.7-7) Fig. FM 3.7- 7 Shows Chop Wound Stab Wounds - A stab wound is produced when force is delivered along the long axis of a narrow or pointed object. The stab wound is deeper than its length and width on the surface of skin. (Fig. FM3.7- 8) ig. FM 3.7- 8 Shows Stab Wound C. FIREARMS INJURIES Firearm wounds cause crushing of the tissues and produce a hole. (Fig. FM3.7-9) There are two types: a. Entry wounds b. Exit wounds Fig. FM 3.7- 9 Shows Firearm Injury Vetrivel Textbook of Orthopaedics 919. D. THERMAL INJURIES, Due tocold: a. Frostbite - Frostbite is ischaemia of the fingers and toes with edema, redness and later necrosis of the tissue beyond the line of inflammatory demarcation. (Fig. FM3.7- 10) Fig. FM 3.7-10 Shows Frostbite b. Trench foot c. Immersion foot Due to heat: a. Burns - A burn is an injury which is caused by application of heat or chemical substances to the external or internal surfaces of the body. (Fig. FM3.7-11) Fig. FM 3.7- 11 Shows Burns b. Scalds are injuries caused by hot liquids or steam. (FigFM3.7- 12) Fig. FM 3.7-12 Shows Scalds920 Vetrivel Textbook of Orthopaedics E. CHEMICAL INJURIES Chemical injuries occurs when a person is exposed toa strong acid, base or a cytotoxic agent such as mustard gas. Explosions: The injuries are caused by a combination of air blast, extreme heat and shrapnels, DIFFERENCES BETWEEN SUICIDAL, HOMICIDAL AND ACCIDENTAL INJURIES Table Fig. FM 3.7- 1 shows difference between Suicidal, Homicidal and Accidental injuries TRAIT SUICIDAL HOMICIDAL ACCIDENTAL Nature of wound Usually incised and stab wounds Usually chops, lacerations and stab wounds ‘Usually lacerations, abrasions and contusions Target area Accessible parts i.e., front and sides of the body such as neck, wrist, left side of chest, groin, ete., No fixed site. Vital parts such as head, chest, abdomen “Anywhere usually on ‘exposed parts and bony prominences. Direction In right handed persons from | Any direction ‘Any direction left to right and from above downwards Severity Mostly superficial, one or | Mostly severe and Variable severity two deep wounds extensive Defence wounds _| Absent ‘May be present Absent Hesitation marks _| Usually present Absent Absent Scene of crime Usually inside closed room, no disturbances of surroundings Disturbed and disorderly with signs of struggle and blood stains Varies with the nature of the accident SELF INFLICTED AND FABRICATED WOUNDS. 1. Usually incised wounds that are superficial, multiple and parallel. Usually avoiding vital and sensitive areas like eyes, lips, nose and ears. 3. Direction is from behind forwards on top of the head, from above downwards on outer side of upper arm, from below upwards on front of forearm.Vetrivel Textbook of Orthopaedics 921 CHARACTERISTICS OF ANTEMORTEMAND POSTMORTEM WOUNDS: ( Table FM 3.7-2) Table Fig. FM 3.7- 2 shows characteristics of Antemortem and Postmortem wounds ANTEMORTEM WOUND POSTMORTEM WOUND 1 | Bleed freely Bleeding is slight from cut veins 2. | Extensive infiltration of deeper tissues Less infiltration of deeper tissues 3. | Edges are gaping Edges are do not gap 4. | Edges are everted Not everted 5. | Firmly coagulated blood found in and about the wound Little or no coagulated blood will be found in and out the wound 6 | Arterial spurting marks may be found Absent WOUND HEALING ‘Wound healing can be accomplished in one of the following two ways 1. Healing by primary intention 2. Healing by secondary intention. Healing by primary intention: Clean, uninfected and surgically incised wounds without much loss of tissues heal by primary intention, Sequence of events that occur are described below: a. Immediate hemorrhage- Wound is filled with blood which then clots and seals the wound against dehydration and infection b. Acute 24 hours. Polymorphs appear from the margins of the wound and later by the 3rd day polymorphs are replaced by macrophages. c. Organization - Fibroblasts start invading the flammatory response- Occurs within wound area by 3rd day. By 5th day new collagen. fibrils appear and dominate till healing is complete, Complete Healing takes about 7 to 14 days. resulting in aneat linear scar. Healing by secondary intention: + Occurs in large tissue defects, infected wounds, unapproximated surgical wounds and ‘wounds with extensive tissue loss. + The initial hemorrhage and inflammatory response occur similar as in primary intention. The proliferating epithelial cells do not cover the wound space fully until granulation tissue from base has started filling up the wound space. + Granulation tissue: The main bulk of secondary healing is by granulation tissue. It is formed by proliferation of fibroblast and neo. vascularisation from adjoining viable tissues. + Wound contraction: It is an important feature of secondary intention, not seen in primary healing. It is due to the action of myofibroblasts from the granulation tissues. + Complete healing with scar formation takes about 3 to 4 weeks. Results in a contracted irregular scar.922 Vetrivel Textbook of Orthopaedics WOUND CERTIFICATE Wounds or injuries found on the person of a calling himself / hersetf aged years, an inhabitant of who was sent with, from and accompanied by. for report to ascertain Injuries said to have been caused on. and due to, Identification and scar marks: 1 2 The injured person was first seen by the undersigned at and the ‘examination was conducted at, on, when the following injuries were found: OPINION: Note: Mention should be made about the type, size, site, shape and age of the injury. The possible inflicting weapon should be opined. Special mention note to be made about the available investigation reports, viz., X-ray, CT, MRI, etc. Station: Signature of Medical Officer Date: Name, Designation @Regn. No. Original To: Duplicate To: WOUND AS A CAUSE OF DEATH: WOUND AS A SECONDARY CAUSE OF DEATH: PRIMARY AND SECONDARY + At autopsy certain injuries may be found which from their nature, site or extent may not appear to be sufficient to cause death in a healthy person, + But such injury may be the cause of death due to some complication resulting directly from the injury such as septicemia, etc. WOUND AS A PRIMARY CAUSE OF DEATH: + In some deaths, injuries may be found at autopsy which is incompatible with life in any person. + Eg: Decapitation, crushing of the head, avulsion of the heart from the large blood vessels. If they are ante mortem, they are the definite cause of death.FM3.8 Vetrivel Textbook of Orthopaedics 923 DESCRIBE AND DISCUSS DIFFERENT TYPES OF WEAPONS INCLUDING DANGEROUS. WEAPONS AND THEIR EXAMINATION Prof. T. Jeyasingh WEAPONS AND WOUNDS The shape of the wound usually corresponds to the weapon used, but the shape of the wounds made by the same weapon may differ on different parts of the body. 1. Ifasingle-edged weapon is used, the surface wound will be triangular or wedge-shaped, and one angle of the wound will be sharp, the other rounded, blunt or squared off. Blunt end of the wound may have small splits in the skin at each end of the corner, so called “fishtailing’, if the back edge of the blade is stout. Some stab wounds caused by single-edged weapon have bilateral pointed ends like those due to double-edged weapons. 2. Ifadouble-edged weapon is used, the wound will be elliptical or stit-like and both angles willbe sharp or pointed. Ifthe knife penetrates to full length up to the guard, one or both ‘edges may be blunt because of ricasso. Around object like the spear may produce a circular wound A round blunt-pointed object, such as a pointed stick, or metal rod may produce a circular surface wound with inverted ragged and bruised edges. Foreign material, such as dirt, rust or splinters may be found in the wound. The blunter the tip of the object, the coarser or more stellate will be the hole it makes. A pointed square weapon may produce a cross-shaped injury, each of the 4 edges tearing its way through the tissues. A fall on a pointed article, e.g., pieces of broken glass, will produce a wound with irregular and bruised margins, and fragments of glass may be found embedded in the soft tissues. Stab wounds inflicted with a broken bottle, appear as clusters of wounds of different sizes, shapes, and depth, with irregular margins, and varying depth. Stabbing with a fork produces clusters of 2 ‘or 3 wounds depending upon the number of prongson the fork. A screwdriver will produce a slit-like stab wound with squared ends (rectangular) and abraded margins. |. Astab wound through a crease or fold in the skin, such as through a sagging abdomen or female breast, crease of the armpit or groin near the scrotum are likely to result inan atypical injury.924 Vetrivel Textbook of Orthopaedics 11. 12, 13. 14, 15. Truck relatively blunt-edged blades, e.g., bayonets, may produce cross-shaped stab wounds, because cutting and tearing of the skin occurs simultaneously and at right angles to each other. When a knife is ‘twisted as it is withdrawn from the tissues, the external wound may have a cruciate appearance. Ice-picks or similar instruments produce stab wounds, resembling small caliber bullet wounds. Irregularly-shaped stab wounds such as Lor V-shaped may be mistaken to be produced by two distinct stabbings in the same location. ‘These atypical injuries are produced by stabbing, followed by simultaneous twisting and cutting (rocking), or the victim moving relative to the knife, or by a combination of the two. There will be a primary stab wound with an extension of it, due to the knife edge cutting the skin in a different direction as it exists. Small notches in margins of the skin defects or curving can be produced by the same mechanism. If the scissors is closed, the tip of the scissors splits rather than cuts the skin, producing a linear stab wound with abraded margins. Deep penetration will produce 'Z-shaped wound. If the screw holding the two blades is projecting, there are small lateral splits in the wound centre, If the two blades of the scissors are separated, each thrust will produce two triangular stab wounds, A knife with a serrated back edge will produce a stab wound, the back edge of which may be torn or ragged. If the knife enters obliquely. Serrated abrasions may be seen on the skin adjacent to the end of the wound.FM 3.9 FIREARM INJURIES: DESCRIBE DIFFERENT TYPES OF FIREARMS Vetrivel Textbook of Orthopaedics 925 INCLUDING STRUCTURE AND COMPONENTS. ALONG WITH DESCRIPTION OF AMMUNITION PROPELLANT CHARGE AND MECHANISM OF FIRE-ARMS, DIFFERENT TYPES OF CARTRIDGES AND BULLETS AND VARIOUS TERMINOLOGY IN RELATION OF FIREARM - CALIBER, RANGE, CHOKING Prof.A.Edwin Joe FIREARM INJURIES + FIRE-ARM: Any instrument which discharges a missile by the expansive force of gases produced by combustion of explosive substances. + FORENSIC BALLISTICS: Science which deals with investigation of fire-arms, their ammunitions and related problems. COMPONENTS OF FIRE-ARMS: scion bere. ‘hanber Fig. FM 3,9-1 Parts of firearm 4, Stock / Butt - Rear part of gun, which is held in hand. (Fig. FM 3.9-1) 2. Barrel- Hollow cylindrical length of gun, which has the following functioning parts: + Chamber - itis the posterior part of the barrel that accommodates the cartridge to be fired + Taper / Lead - The part of the barrel, anterior to the chamber, tapers anteriorly. This part of the barrel is known as taper or leed. + Bore - The vast length of the hollow barrel anterior to the chamber cone or the taper is called the bore. + Muzzle - The anterior end of the bore is the muzzle end of the barrel. Fig. FM 3.92 Components of firearm Breach Mechanism: (Fig. FM 3.9-2) + Hammer with percussion pin. + Trigger with Trigger Guard + Rear and Front Sight. + Safety Catch. CLASSIFICATION OF FIRE-ARMS 1. Rifled Fire-arms: Rifled fire arm is a gun with a barrel, the bore of which is rifled, + Rifles: + Air and Gas Operated + Military Rifles. + Single Shot Practice Pistols. + Revolvers. + Automatic Pistols. + True Automatic (Machine) Guns. 2, Smooth Bored Fire-arms: (Shot Guns) + Single Barreted.926 Vetrivel Textbook of Orthopaedics + Double Barreled + Semi-Automatic. Caliber (Gauze): + Internal dimension of barrel in decimals of inch or millimeters. (Fig. FM 3.9-3) + Inrifled fire-arms, caliber is measured between two opposite lands. Fig. FM 3.9-3 Caliber of the rifle In shot guns, it is equivalent to the diameter of the bore (up to 1.27 cm), but beyond that, it is measured by the size of lead sphere that fits the diameter and denoted by the number of such sized spheres that can be made from 1 tb of lead (454 gm), Choke (In Shot Guns): + This denotes the constriction of bore in the muzzle end of the gun, + They may be of following types: + Full Choke. + 3/4" Choke. + Half Choke. + 1/4" Choke (Quarter choke). + Advantages: + Pellets remain compact and there is less dispersion. + Increases the explosive forces of the pellets. + Increases the velocity of the pellets. + Paradox Guns: Shotguns with rifling of terminal portion of bore. RIFFLING (RIFLED FIRE-ARMS) + These are parallel grooving made on the inner surface of the bore. + About 4-7 parallel grooves run spirally + Raised areas are called as ‘Lands’ and depressed areas are called as'Grooves’. + Ridges are produced on the surface of bullet when fired from such guns. + Advantages: + Gives a spinning effect to the bullets. + Straight trajectory of the bullets. + Prevents Wobbling ‘of bullets. + Increases penetrability. Cartridge (Ammunition): 5 = CATAIDEE CAmmvnin0%) @) Merioe crepes “AeTAMine cms aonan Di2e, ors peers Jaap a24e> Disc ae ron anDbenns DISC ‘om Pousek ent pninca car Fig. FM 3.9-4 Shotgun cartridge = (@ Bese au conresDee auueT SATRIDEE CASE CMETAL “A855 -PROPELLENT CHARGE ‘PERCUSSION CAP jnoc ve om Fig. FM 3.9-5 Rifled gun cartridgePrimer Mixture: Type - 1: + Mercury Fulminate. + Antimony Sulfide. + Potassium Chlorate, Type - 2: + Antimony Sulfide. + Lead Styphanate. + Lead Peroxide. + Barium Nitrate, Gun Powders Black Powder: + Charcoal. + Potassium Nitrate, + Sulfur. ‘Smokeless Powder: + Nitrocellulose. + Nitroglycerine. Semi-Smokeless Powder: + 80% Black powder + 20% Smokeless powder. Vetrivel Textbook of Orthopaedics 927 ‘SEQUENCE OF FIRING EVENTS: + Pulling of trigger. + Hammer release. + Hitting percussion pin, + Ignition of primer mixture. + Production of flame. + Ignition of gun powder. + Gas production, + Propelling of the shots / bullet / pellet. + Reporting of fire. COMPONENTS CAUSING INJURY: + Fire / Flame : Burning at entrance wound along with singeing of hairs. + Hot gases : Scorching effect. + Gun powder : Tattooing effect. + Felt wad : Minor abrasion and bruise. + Bullet / Pellet : Puncture wound. (Fig. FM. 3.9-6) Table FM 3.9-1 Effects of different firearms and distances SLNo. | Effect Shotguns Long Barrel Short Barrel 1 Tattooing 50 em 50cm 40cm 2 Blackening 30 cm 25 - 30cm 25 cm 3 Scorching 25 em 30 em 20-25 em 4 Singeing 12- 15cm 25 - 30cm 20cm928 Vetrivel Textbook of Orthopaedics Aki gE Oo. cet ge set S. Sa % = ae Fig. FM 3.9-6 Characteristics of shotgun wounds at various ranges FIRE-ARM INJURIES: 4. Shotguns: CONTACT SHOT: Fig. FM 3.9-7 Contact Shot + Single wound. (Fig. FM 3.9-7) + Round of oval in shape. + Large with ragged and irregular margins. + Skin margins - charred and abraded. ‘+ Unburnt gun powder in wound will be seen. + Muzzle impression over the skin wound. + Pink coloration of tissues due to carbon monoxide. + Cruciate shaped wound fs seen if bone lies underneath. + Contact shot on head shows disrupted margins on scalp wound, large irregular hole fon skull with fissure fracture and large exit wound with extruded brain matter. + Contact shot in abdomen show extrusion of coils of intestine. CLOSE RANGE: (Upto 1 meter) + Singeing, tattooing and blackening seen. + Rim of hyperemia and blister formation. + Circular if fired at right angle and oval if fired at an angle. + Cherry red coloration of tissue due to carbon. monoxide, + In smokeless powder, gray - white deposit seen. + Gross destruction of deeper tissues. + Felt wads will be found inside the wound. + If shot on skull, no bursting effect. + If range +60 cm, wontt be any singeing, tattooing, blackening or cherry red coloration. NEAR RANGE: (upto 4 meter) Fig. FM 3.9-8 Near range shot + Rat hole appearance of entry wound if range is 1-2m. (Fig. FM 3.9-8) + Satellite pellet holes seen if range »2 meter. + Wads will be seen inside the wound if range is within 2 meter,+ LONG RANGE: (4 meter) Fig. FM 3.9-9 Long Range shot + Individual pellet holes will be seen. (Fig. FM 3.9-9) + Area of dispersion is about 10 - 15 cm. + In fully choked barrel, dispersion of pellets will be: + 10 meter - 25 cm. + 15 meter - 35 cm. + 20 meter - 45 cm. EXIT WOUNDS: + Usually no exit wounds will be seen here. + Exceptions are: + Contact wound, + Tangential wounds + Thin body parts. + Large caliber weapons. 2. Revolvers and Pistols: ‘CONTACT SHOT: + Large entrance wound will be seen here. + Triangular, stellate or cruciate shaped. + Cavitation effect will be seen in the tissues. + Absence of burning, blackening and tattooing. + Abrasion collar will be seen here. + Muzzle imprint will be seen on the skin. (Fig. FM 3.9-10) + Cherry red coloration of the tissues will be there. Vetrivel Textbook of Orthopaedics 929 Fig. FM 3.9-10 Muzzle imprint + ‘Corona’ will be seen in case of loose contact of the muzzle. + Back spatter will be seen in barrel. + Inhead, explosive effect will be seen along with burst fracture of skull, + In abdomen, there will be cavitation effect. CLOSE SHOT: (range of flame) + Inverted and large circular entrance wound will be seen. + Blackening, singeing and tattooing seen. + Abrasion and grease collar will be present. NEAR SHOT: (60 - 90 cm) + There won't be singeing and scorching effect. + Round shaped entrance wound is present and the diameter will be equal to that of the bullet. + Margins show bruising + Zone of blackening and tattooing will be seen. + Abrasion and grease collar also seen. DISTANT SHOT: + Entrance wound is smaller in size to bullet. + The margins will be inverted.930 Vetrivel Textbook of Orthopaedics + Absence of burning, blackening and tattooing. + Abrasion and grease collar will be seen. ABRASION COLLAR: + Due to gyrating effect of bullet. + If contusion also present, contusion collar. + Grease collar is due to lubricants, gun oil or lead. (Fig. FM 3.9-11) 8 a Fig. FM 3.9-11 Normal and Abrasion collar Black area - Entrance wound Orange area - Grease collar Blue area - Abrasion collar It will be round in shape if bullet has hit at right angle to body surface and oval if it hits at an angle. Effect on Skull Entrance wound: Fig. FM 3.9-12 Entrance wound on the skull + Looks like a punched-in hole on the outer table. (Fig. FM3.9-12) + Cone shaped beveled bony fracture on inner table. Exit wound: 13 Exit wound on the skull Fig. FM 3. + Looks like a punched-out hole on the inner table. (Fig. FM 3.9-13) + Bevelled bone chip fracture will be seen on outer table. PECULIARITIES IN FIREARM INJURIES: + Atypical entrance wound, which may be caused due to: + Tailwobble. + Yawning and tumbling bullet. + Ricocheting bullet. + Single entrance wound with multiple exit wounds. + Multiple entrance wounds with single exit wound. + Presence of entrance wound but no bullet inside. + Unexplained bullets like tandem bullet. EXAMINATION OF FIREARM INJURY CASE: Inthe living: + X-ray examination of the body. + Assessment of severity and extent of injury. + Examination of clothing. + Examination of scene of crime. + Surgical extraction of shots and preservation. Inthe dead: + PriorX-ray examination, + Examination of clothing. + Blood stains and direction of flow.+ Secondary injuries. + Entrance and exit wounds + Area of dispersion of shots. + Burning, singeing and tattooing (range of firing). + Muzzle impression marks on the body. + Track of wound, + Extraction of bullet. Preservation of materials: + Bullets - Identification mark to be put and not to be washed. + Skin from entrance wound and exit wounds preserved for Neutron Activation Analysis for metals. + Clothing materials. ‘MEDICO-LEGAL ASPECTS: Nature of death: Suicidal case: + Wound in approachable area of the body. + Use of short barrel weapons. + Contact shot pattern. + Cadaveric spasm with weapon in hand. + Suicide note. + Dermal nitrate test positive. + No disturbance at the site of offence. Homicidal: + Single or more shots. + Wound may be situated anywhere on the body. + Any type of shot may be seen. + Close shot on back is diagnostic of homicide. + Absence of weapon of offence at the scene of crime. + Disturbances will be seen at the crime scene. Accidental: + Due to wrong aim or confusion to be that of animal. Vetrivel Textbook of Orthopaedics 931 + Usually of contact or close range shot. ‘+ Single shot if exploded accidentally by self. Direction of firing: + Margin examination. + Direction of wound track. Distance of firing: + Presence of blackening, tattooing and singeing + Area of dispersion. + Muzzle impression on the body. Identification of firearm weapon: + Gun powder residue examination. + Examination of the grease material. + Comparative study of test bullet. Identification of assailant: + Dermal nitrate test (paraffin) test by Diphenylamine. + Spectrophotometry. + Neutron activation analysis for metals. Cause of Death: + Hemorrhage and shock. + Injury to vital organs. + Embolism and infection. + Chronic lead poisoning,932 Vetrivel Textbook of Orthopaedics FM 3.10 FIREARM INJURIES: DESCRIBE AND DISCUSS WOUND BALLISTICS-DIFFERENT TYPES OF FIREARM INJURIES, BLAST INJURIES AND THEIR INTERPRETATION, PRESERVATION AND DISPATCH OF TRACE EVIDENCES IN CASES OF FIREARM AND BLAST INJURIES, VARIOUS TESTS RELATED TO CONFIRMATION OF USE OF FIREARMS. Prof.T.Jeyasingh BLASTINJURIES: Bomb explosion inju Bomb is a container filled with an explosive mixture and missiles which is fired either by detonator ora fuse. When an explosion occurs explosive material produces a large volume of gas and releases large amount of gas and releases large amount of energy. Pressure of up to 1000 tons per sq inch can be generated. A minimum pressure of about 700 kilo Pascal is necessary for tissue damage in humans. Physical trauma results from direct or indirect exposure to an explosion. Blast Agents 1. High-order explosive: HE + Nitroglycerin (NTG) + Dynamite + Plastic + Ammonium nitrate/ fuel oil (ANFO) + Trinitrotoluene (TNT) + Triacetonetriperoxide (TAPT) . Low-order explosive: LE + Petroleum products (“Molotov cocktail”). + Gunpowder (“black” powder). + Can become HE, if contained (e.g., pipe bomb). + Inflict mutt system injuries on large groups of people. + Cause many simultaneous life-threatening injuries. + Hidden pattern of injury. Secondary Blast Injur ‘Types of Blast Injuries: Tertiary a Fig. FM 3.10-1 Types of blast injuries Primary Blast Injury (PBI) Damage to internal organs without visible external signs of injury that occurs as a direct result of the pressure wave contacting the body. (Fig.FM 3.10-1) + Result of atmospheric pressure changes (blast wave). + Heat of the explosion. + Sudden change in atmospheric pressure. Damage to the body with visible external signs of injury that occurs as a result of contact with objects that are propelled by the blast wave. + Result of projectiles thrown by blast - Classic shrapnel injuries. + Most common cause of death in a blast event is secondary blast injuries. + Caused by flying debris generated by the explosion. + Terrorists often add screws, nails, and other sharp objects to bombs to increase injuries.Vetrivel Textbook of Orthopaedics 933 Fig. FM 3.10-2 Types of Blast mechanisms Tertiary Blast Injury: 2. Compartment syndrome: Blast wave displacing the body and the body + Edematous muscle in an inelastic sheath contacting some object in the environment. promotes local ischemia, further swelling, + Injuries that result from secondary increased compartment pressures, impacts, after the blast wave has propelled decreased tissue perfusion and further ischemia. patient (victim displacement). + Victims close to blast are subject to being Miscellaneous Blast Injury (“Quaternary”) thrown into fixed objects by wind of + Explosion related injuries or illnesses not. explosions. due to primary, secondary, or tertiar + Also due to structural collapse and Primany ns " injuries. + Structural collapse + Exacerbations of preexisting conditions, fragmentation of building and vehicles. + Structural collapse may cause extensive blunt trauma. (Fig. FM3.10-2) such as asthma, COPD, CAD, HTN, DM, etc. + Burns (chemical and thermal) Complications include: + Toxic inhalation 1. Crush syndrome: + Radiation exposure -burn + Damage to muscles and subsequent release + Asphyxiation (carbon monoxide and of myoglobin, urates, potassium and cyanide) phosphates. + Oliguric renal failure. Blast Injuries (Combined Injuries): + Blast and Burn injury + Blast and Crush injury934 Vetrivel Textbook of Orthopaedics ‘Typical confined space (e.g., a bus) injuries include: + Primary — blast lung, intestinal rupture, TM rupture. + Secondary — penetrating injury to head, eye, chest, abdomen, + Tertiary — traumatic amputation, fractures tothe face, pelvis, ribs, spine. + Quaternary — crush injuries, superficial and partial to full thickness burns, Radiation exposure. Blast injuries most commonly involve air-filled organs and air-fluid interfaces. Middle ear is most sensitive to these injuries - tympanic Membrane ruptures. + Lungs: Blast lung -pulmonary barotraumas. + Gastrointestinal tract Abdominal hemorrhage and perforation (lower small intestine or caecum), + Others: + Globerupture + Traumatic brain injury (TBI) without physical signs of head injury. + Concussion + Blast injuries most commonly involve trauma to- + Head + Neck + Chest + Abdomen + Extremities + Inthe form of (penetrating and blunt) + Fractures + Traumatic amputations. + Soft tissue injuries. Ear: + Presentation: acute hearing loss ‘symptoms: Deafness Tinnitus Vertigo Bleeding from external canal. Mucopurulent otorthea, ‘Treatment: Observation Sensorineural hearing loss is often permanent. BLAST LUNG INJURY (BL): Second most susceptible organ. Direct consequence of blast wave on the body. Over pressure needed is about 40 psi. ‘At 80 psi-50 % have severe pulmonary damage (at 200 psi- fatal). Most common critical injury in victims close to bomb. Can be life threatening. May not have obvious external injury to the chest. Air embolism from pulmonary disruption (fatal). Results in tearing, hemorrhage, contusion andedema. Micro hemorrhages in alveoli Disruption and weakening of alveolar walls. Disruption of perivascular and peribronchial tissue. Resultant ventilation - perfusion mismatch, Symptoms: + Dyspnea + Hemoptysis + Cough + Chest pain Signs: + Tachypnoeic + Hypoxic+ Cyanosis + Wheezing + Xray features similar to pulmonary contusion, with bi-hilar (butterfly pattern) shadow. BLAST HOLLOW VISCERAL INJURY: + More common in underwater explosions. + Colon is more frequently involved than small bowel. + Mesenteric hemorrhage + Delayed rupture of bowel (high mortality in combination with blast lung). + Clinical manifestations include: + Abdominal or testicular pain + Tenesmus - Constant feeling of the need to empty bowel + Rectal bleeding + Solid organ lacerations + Rebound tenderness + Guarding + Absent bowel sounds + Signs of hypovolemia + Nausea + Vomiting Eye + Globe rupture, serous retinitis, hyphema, lid laceration, traumatic cataracts, injury to optic nerve. + Signs and symptoms include eye pain, foreign body sensation, blurred vision, decreased vision, drainage. (Fig. FM 3.10-3) iy Fig. FM 3,10-3 Eye injuries Vetrivel Textbook of Orthopaedics 935 Blast Injuries: Face + Mid face fractures + “Crushed eggshell” Blast Injuries: Head Consider the proximity of the victim to the blast particularly when given complaints of: + Loss of consciousness + Headache + Fatigue + Poor concentration, lethargy, amnesia, or other constitutional symptoms + Symptoms of concussion and post- traumatic stress disorder (PTSD) can be similar. + Concussions or mild traumatic brain injury (MTBI): without a direct blow to the head. + Traumatic Brain Injury (TBI) due to barotrauma of gas embolism. + Signs and symptoms include headache, fatigue, poor concentration, lethargy, anxiety, and insomnia. ‘Traumatic Amputation: + Caused by axial loading of bone by blast wave and subsequent flailing of limbs. (Fig. FM 3.10-4) Fig.FM 3.10-4 Traumatic amputation of hand936 Vetrivel Textbook of Orthopaedics Autopsy: + Before Autopsy - X Ray and Photograph is a must. + Identification of victims + Enlisting the injuries + Cause of Death + Reconstruct The Body. + Cloth for Chemical Analysis. + Detailed Record of Fingerprint and Dental Chart, + DNAAnalysis + Extremely Directional: + Explosion Ground Level - Lower Extremity Injuries. + Bending Over the Bomb - Upper limb, Face, Chest & Waist. + Implanting Bomb - Hands and Arms Torn Away. + Explosion at Back Side - Back of the Trunk, Back of Legs, Thigh.FM3.11 Vetrivel Textbook of Orthopaedics 937 DESCRIBE AND DISCUSS REGIONAL INJURIES TO HEAD (SCALP WOUNDS, FRACTURE SKULL, INTRACRANIAL HEMORRHAGES, AND COUP AND CONTRECOUP INJURIES), NECK, CHEST, ABDOMEN, LIMBS, GENITAL ORGANS, SPINAL CORD AND SKELETON Prof.T. Jeyasingh REGIONAL INJURIES HEAD INJURIES Of all the regional injuries, those of head are most common and account for about one- fourth of all deaths due to violence, and responsible for 60% of fatal road accidents. Reasons include ‘+ The head is the target of choice in the majority of assaults involving blunt trauma, ‘+ Onbeing pushed or knocked to the ground, the victim usually strikes his head. ‘+The brain and its coverings are vulnerable to that degree of trauma as would rarely prove fatal, if applied to other parts of the body. “Head injury’, as defined by the National Advisory Neurological Diseases and Stroke Council, “is 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”. FRACTURES OF SKULL Fractures may be caused by (A) Direct violence:- ‘+ Compression of head under a wheel. ‘+ Anobject in motion strikingthehead. eg: -Bullet, Bricks, Machinery ete. ‘+ Head in motion striking an object, as in falls and traffic injuries. (8) Indirect Violence:- Injury to the skull occurs from a fall on the feet orbuttock. ‘TYPES OF FRACTURE SKULL 1. Fissured Fracture Depressed Fracture Comminuted Fracture Pond or indented Fracture Gutter Fracture Ring or Foramen Fracture Perforating Fractures Diastatic or Sutural Fracture. Elevated Fracture 10. Blow-out Fracture FRACTURE BASE OF SKULL = Maybe produced by 1. Force applied directly at the level of base. 2, Due to general deformation of skull. 3, Extension of force from the vault, 4, Force applied to the base through the spinal column or face. © Fracture of anterior cranial fossa can be diagnosed by bleeding from mouth and nose. + Fracture of the middle cranial fossa diagnosed by bleeding from mouth. ‘+ Fracture of petrous temporal bone, which allows blood and CSF escape from ear.938 Vetrivel Textbook of Orthopaedics + Fracture of the posterior cranial fossa can be diagnosed by extravasations of blood behind the mastoid process or a large hematoma in the soft tissues of the back of neck. COUP AND CONTRE COUP INJURIES: + Coup ‘Means the injury is located beneath the area of impact and results directly from the impacting force. + Contre-Coup injury of brain It is one in which damage of the brain is noticed exactly opposite the site of impact of blow of coup injury. + Aline drawn between the centers of coup and contre coup indicates the directions of impact ‘Mechanism of Contre-Coup Injury ‘+ The injury depends upon the acceleration and deceleration forces. + Occurs only when a moving head is suddenly decelerated by hitting a firm surface (Fig. FM3.11-1) ‘+ It will not be seen when the head at the time of injury, is well fixed, held immovable and cannot rotate. soto wt) . Fig. FM 3.11-1 Mechanism of Contre-coup Injuries Acceleration injury : Deere let ate aac CTT Rol any Conc News aetom a Deceleration injury: aving head strikes a hard eTeaey Sead Sen Eee ing brain moves on and strikes the Skull(Deceleration injury) Anything which accelerates or decelerates the skull will cause mild ‘Piling up’ under the region of impact and mild ‘Rarefaction’ or ‘Stretching’ effect on opposite side.© Thus shearing strain will resutt in injuries due to relative twist of the 1) Skull over the meninges 2) Meninges over the brain 3) Brain over the brain ‘+ Results in contusion and laceration of brain due to twisting of brain with its meninges. ‘+ The brain stem gets bruised by tentorium cerebelli, corpus callosum gets bruised by falxcerebri: Table FM 3.11-1 Contre Coup Lesion Impact Area Contre Coup Lesion ‘Occipital area | Bruising and laceration of under surface of frontal lobes ane tips of temporal lobes Left parietal | External surface of frontal and area temporal lobe of opposite side Temporal or | Likely tobe diametrically opposite on Parietal area | the conta lateral surface ofthe brain Fall on top of | Contusion on the ventral surface of the head cerebral hemisphere © Contre coup lesions are usually more severe than the coup one, when both are present. ‘+ Contre Coup injuries are rare before the age of three years. Vetrivel Textbook of Orthopaedics 939 + Concussion most often occurs with acceleration or deceleration injuries, when the head is moving or is freely movable, + Thisisaterm popularly knownas’Stunning’. + Symptoms and Signs: i, Patient recovers completely after few minutes followed by symptoms of “Post- Concussional Syndrome”. li, Recovery from concussion is often followed by complete loss of memory of recent events. (Retrograde Amnesia). iil, This retrograde amnesia, often is due to the injury to the frontal lobes + Ithas great medico legal significance as it may be associated with Post-Traumatic ‘Automatism. + When the shock due to concussion is severe the patient may die without regaining consciousness. Postmortem Findings:- ‘= May not be revealing but in some cases, may show Petechial hemorrhages over cerebral cortex at the junction of gray and white matter. © Diffuse neuronal injury on microscopic Medico legal importance: Indicates, whether the head was fixed or mobile at the time of impact examination INTRACRANIAL HAEMORRHAGES + If a bleeding is small and thin layered it is CONCUSSION OF BRAIN OR COMMOTIO calledas hemorrhage CEREBRI + If ft is large and space occupying, it is ‘+ State of temporary unconsciousness, due called as haematoma, to head injury seen immediately after 4d ir thaye follaved by a + According to their situation in relation to eee eee eee ey anes the membranes, intracranial hemorrhages ind tends to recover spontaneous! ‘and tends ta recover spontaneously. are classified as (Fig. FM3.11-2)940 Vetrivel Textbook of Orthopaedics Shut ura mater re Arcrois—{ ' Pia mater— Cerebrum © Extra Dural = Subdurat + SubArachnoid = Intra Cerebral which may be of + Cerebellar + Cortical, Thalamic, Pontine or Medullary EXTRADURAL / EPIDURAL HAEMORRHAGE Fig. FM 3.11-3 Extradural haemorthage © Bleeding occurs between inner table of the skull and the dura (Fig. FM 3.11-3) FEATURES OF EDH: © Ovalor semicircular in shape. = May be 10-20 cm in diameter, 2-6 cm in thick and weighs between 30-300gm. Subdural Subarachnoid Intracerebral Haemorrhages Classification © Theclot will press the brain inwards. localized concavity or flattening of external surface of brain. = Produces a Clinical Features: + Following injury, patient loses consciousness due to concussion. + Lucid interval: After an initial period of unconsciousness, a period of normal consciousness occurs, this may last for a few hours (2 to 4) to.a week. Itis seen only in 30 to 40% of cases + Later on due to continuous bleeding or recurrence of fresh bleeding causes cerebral compression and patient merges intocoma. + Death results from respiratory failure from compression of brainstem. + Nearly 25-50% of cases become fatal. + Early diagnosis and surgical intervention usually saves the patient. + Medico legal importance of lucid interval: Criminally liable SUB DURAL HAEMORRHAGE = Occurs in the subdural space in between the dura matter and arachnoid mater often referred as subdural hematoma. (Fig. FM3.11-4) Subdural space is very narrow and contains a small amount of fluid which permit the thin and tough arachnoid to move relatively to the dura. This is commoner than extradural hemorrhage, It is invariably traumatic following a blow or fall. in. origin It may occur even without any fracture of skull or injury to the scalp. May follow insignificant trauma to head without loss of consciousness. Subdural hemorrhage is essentially venous or capillary bleeding and not arterial bleeding, Fig. FM 3.11-4 Subdural haemorrhage ‘SUBARACHNOID HAEMORRHAGE The space between the arachnoid and the pia is called sub arachnoid space. It is filled with CSF produced by the choroid plexuses of the lateral and fourth ventricles. This is the most common form of intra cranial hemorrhages. In all cases of significant brain injury some Vetrivel Textbook of Orthopaedics 941 degree of SAH is found. Subarachnoid hemorrhage usually spreads out. Rarely forms a hematoma and removed by phagocytosis. Mostly found over the orbital surface of frontal lobes and anterior third of temporal lobes. CLINICAL FEATURES Diagnostic feature of SAH Include sudden onset of intense headache with stiff neck and photophobia followed by unconsciousness. Lumbar puncture Will reveal CSF intimately mixed with blood coming out under pressure. INTRACEREBRAL HAEMORRHAGE, This may be found on the surface or in the substance of the brain Itoccurs most frequently and spontaneously inthe elderly and middle agedhypertensives. Due to rupture of lenticulostriate artery in the basal ganglia, pons etc. Large hemorrhage occurs at the junction of gray and white matter of frontal and temporal lobes. CLINICAL FEATURES Intracranial hemorrhage may cause rapid loss of consciousness and death. In Pontine hemorrhage: Pin point constricted pupil, hyperpyrexia and crossed paralysis. Cerebellar hemorrhage:- Vertigo, persistent vomiting, deviation of eyes to942 Vetrivel Textbook of Orthopaedics the site of lesion, patient usually falls over the affected side. NECK INJURIES: . and lower cervical regions and junction of thoracic and lumbar segments. Fracture-dislocations and fracture of ‘© Superficial wounds of the neck may or may not cause serious bleeding, but penetrations, incisions and deep lacerations usually produce copious bleeding due to severance of carotid and/or jugular vessels. ‘+ A forceful blow over the neck can cause a fracture of the larynx, involving thyroid cartilage or rupture of the trachea to cause death either by spasm or edema of glottis or by suffocation due to internal bleeding into the larynx or due to surgical emphysema. ‘+ Wounds of the sympathetic and vagus nerves may be fatal, and those of the recurrent laryngeal nerves cause aphonia. + Incase of a wound of the larynx, speech is usually not possible, if the wound is below the vocal cords. + The chief danger in incised and stab wounds of the neck is from hemorrhage due to an injury to blood vessels. ‘= Death is due to hemorrhage, air embolism consequent upon the entry of air into the venous system, or due to asphyxia from filling of air passages with blood. VERTEBRAL COLUMN: Fractures of the spine are caused b (1) Direct violence, and (2) Indirect violence, as by forcible bending of the body or bya fall on buttocks or feet. + Hyperextension is the most common mechanism of fracture of spine. Falling from a height, diving and being thrown from automobile are the common causes. + The common sites of fracture are upper the lamina can damage the spinal cord. Concussion of Spine (Railway Spine) Can occur without any evidence of external injury to the spinal column. Causes:- + Forcible blow over the back. + Fall from ahefght. + Bullet injury, Commonly seen in railway accidents and motor car collisions, hence the name railway spine. May be associated with paralysis of upper and lower limbs, with or without involvement of bladder and rectum. There may be inability to walk, irritability (oss of sexual power. Patient may improve gradually within 48 hrs. Medico Legal importance: May be awarded compensation in civilsuits. Whip Lash Injury of Spinal Cord CHEST: Sustained by occupant of front seat of a car When his head gets suddenly hyper extended or hyper flexed due to sudden stoppage of a high speed vehicle or sudden movernent of a resting vehicle. Resulting in fatal contusion or laceration of spinal cord without fracture of spine, Injuries of the chest may be, 1. Non penetrating or close+ Do not open up any part of thoracic cavity. + Severe blows on chest wall may produce concussion of chest, shock and death ‘even when the viscera are not injured. 2, Penetrating or open: Penetrating wounds of heart, pleura, lungs, trachea and esophagus. Flail Chest (Collapse of the chest): ‘+ Multiple unilateral or bilateral rib fractures give rise to Fail chest’ or ‘Stove inches + Causes paradoxical respiration and interferes with respiratory exchange and also blood return to the right atrium. ‘+ Dyspnea, Cyanosis, Pneumonia and Injury toheart. Cardiac Tamponade ‘+ It is the accumulation of blood in the pericardial sac. Accumulation of 400-500CC of blood will be sufficient to cause death + Causes + Penetrating wounds of heart and blood vessels. + Contusion and laceration of pericardium and heart by fractured ‘ends of ribs and sternum, + Rupture of heart or aorta from indirect force + Accidentally occurs during sternal Puncture or intra cardiac injections in ‘emergency. ‘+ Mechanism of Death Collection of blood in pericardial sac prevents ventricular dilatation in diastole. Vetrivel Textbook of Orthopaedics 943 - Compression of Right atrium and venous openings. - Progressive failure of circulation fall in arterial pressure and rise in venous pressure. = With intact parietal pericardium cardiac tamponade will be rapid, it will be slow when it is punctured or lacerated as blood canescapes out. ABDOMINAL INJURIES: ‘= In case of abdominal injury, the trivial injury like abrasions may be found externally, but gross and fatal injuries are frequently present. + The abdominal wall may allow the mesentry, gut, stomach and liver to be pin and crash across the spine with severe internal hemorrhage. + So, whenever there is history of injury to abdomen, the patient should be kept under observation. ‘= The most important viscera to be injured are: 1) Spleen 2) Liver 3) Stomach and Intestines 4) Kidneys SPLEEN: The spleen is most susceptible to injury due ‘+ Weakness of supporting tissues + Thin capsule ‘+ Extreme friability ofits pulp Liver It is the most frequently damaged abdominal organ and is second only to the brain in overall visceral susceptibility1 ci at Tt 944 Vetrivel Textbook of Orthopaedics he susceptibility of liver injury is due to 4) Largesize 2) Central location 3) Relative Friability ause of rupture is a fall, Blow, or kick on bdomen, RTAetc. he death occurs due to shock and hemorrhage. Sometimes bleeding occurs between capsule at ind liver (sub capsular Hematoma) and serious symptoms became apparent only when the capsule ruptures. STOMACH AND INTESTINES: Injuries of stomach and intestines may be caused by, i Forces of compression or ‘Crushing’ forces: + Produce contusions or lacerations. + Mesenteric blood vessels may be damaged and thrombosis may produce infarcts of the intestine. + Contusions may occurin any layer of the bowel wall * Compression may result in partial rupture of stomach wall, with longitudinal mucosal tears parallel to the lesser curvature. Traction or Tearing'forces + Cause displacement of stomach and intestines. * May stretch and rupture the attachment of stomach and intestines. + Mesentery may be torn intestinal attachment. near its * Traction force applied to the intestines may rupture the junction of the fixed and mobile parts, e.g.: duodeno Jejunal junction. '* Duodenum is the widest and most fixed part portion of the small intestine. A blow to central abdomen especially in children may crush the duodenum against the front of spinal column Forces of disruption or Bursting'forces + E.g.: A severe blow over the abdomen, ‘cause contusions or ruptures. ‘+ The jejunum is the commonest site of rupture, followed by ileum, duodenum, caecumand large intestine. Spontaneous rupture of the stomach may ‘occur when there is an ulcer. Laceration of a single large mesenteric artery can cause death due to massive intraperitoneal hemorrhage. vi. In stab injuries, small intestine is injured more commonly than the large intestine. Stomach often escapes as it is partially protected by ribs. KIDNEYS: Injuries to kidneys are uncommon as they are situated retroperitoneally. Contusions and lacerations usually result from blunt force applied directly to the posterior or lateral aspect of the kidneys as from blows to loins. Contusions over the upper pole of right kidney is caused by crushing against lower ribs by force transmitted through liver. Lacerations of kidneys may be 1) Transcapsular 2) Subcapsular 3) Transrenal ‘There may be hemorrhage into perinephric fat forming a large perinephric hematoma.LIMBS If renal artery is torn, death may occur rapidly from hemorrhage. Partial tearing of renal artery may be followed by thrombosis and renal infarction. Pascal's law: i. Force exerted upon any part of enclosed fluid stransmitted equallyinall directions. fi, The kidney is encapsulated and filled with blood and urine due to which a severe blow can cause bursting injuries with fragmentation or multiple bisections. Penetrating wounds are produced by bullets or pointed weapons usually through loin with retroperitoneal hemorrhage. if Arms are more often involved in knife wound during defense, they are rarely dangerous. Blunt injuries and brush burns are common in road traffic accidents , the latter occurs when the body is skidded across rough surface. Abrasions, contusions and deep lacerated wounds involving muscles and extending up to bone are common in road traffic accidents and industrial accidents. Injuries leading to amputation or permanent impairmentare grievous hurt. Deep seated limb injuries affecting the muscles, vessels, nerves or bone may occur without any external evidence of injury. FEMALE GENITAL ORGANS: ‘Traumatic lesions to vulva and vagina are mainly due to sexual activities. Contusions and lacerations of the vulva and vagina may be due to kicks during assaults or falls on a projecting substance. Vetrivel Textbook of Orthopaedics 945, Wounds of vulva caused by a blunt weapon may resemble incised wounds. Lacerated wounds of the vulva may bleed profusely. The vaginal wall may be lacerated during delivery, which may extend into the bladder or rectum. The uterus, ovaries or the fallopian tubes may be contused or lacerated in severe compression injuries of the pelvis. The non-gravid uterus isnot usually injured. The gravid uterus may be ruptured by a blow, kick, trampling on the abdominal wall, by instrumental criminal abortion, or in obstructed labor. Placenta may separate from uterus and cause death of fetus. Penetrating wounds are not common, MALE GENITALORGANS: The penis may be injured by a squeeze or ccrush and the engorged erected penis may be completely avulsed from the pubes by forceful pull. Self-inflicted injuries may be seen in insane persons. Accidental injuries are rare, but they may be injured or amputated from motives of revenge. Penile strangulation may occur due to placement of a constricting apparatus around the penis. Edema developing in the distal portion prevents removal of the device. The testicles are contused from blows, kicks and squeezes. Compression or crushing of the testis may cause sudden death from cardiac inhibition.946 Vetrivel Textbook of Orthopaedics FM3.12 DESCRIBE AND DISCUSS INJURIES RELATED TO FALL FROM HEIGHT AND VEHICULAR INJURIES - PRIMARY AND SECONDARY IMPACT, SECONDARY INJURIES, CRUSH SYNDROME, RAILWAY SPINE Prof.TJeyasingh FALLFROMHEIGHT: Factors influencing the pattern of injury: + Height + Orientation of body at point of impact: Vertical landing with feet first (most common) or the head first. + Surface impact: The surface on to which a body falls determines the pattern of deceleration and energy exchange. + Deceleration: Quicker the body is brought to rest, greater will be forces acting on it. + The site of primary impact shows most severe injury. 4. Ina typical case of primary impact with the feet (about 60%), Fractures can occur in, + Caleaneum and other tarsal and metatarsal bones + Fracture-dislocation of the ankles + Comminuted or oblique fractures of the tibiae and fibulae; + Fractures of the femurs (shaft, condyles and neck) + Pelvic fractures; + Fractures and dislocations of the vertebral column associated with lacerations or transection of spinal cord; + Ring or comminuted fractures of the base of the skull and injuries to the brainstem and inferior surface of the brain. + Fractures in the lower limbs could be unilateral orbilateral. ‘There may be lacerations of the, + Liver and spleen. + The aorta - Usually ruptures at the junction of the aortic arch with the descending thoracic aorta, 2. Incase of primary impact with the head, + Open comminuted or depressed skull fractures with brain lacerations + Partial or complete extrusion of the brain may ‘occur (about 10%) + This may also be seen with primary impact of the feet and subsequent secondary head impact. 3. In case of primary impact with the side of the body, + Fractures of multiple ribs, + Shoulder girdle and arm + Contusions and lacerations of back, + Buttocks or limbs, and + Severe abdominal and thoracic injuries can ‘occur. Other specific injuries that can occur are, + Imprint abrasions and contusions - when the body tands on hard patterned surfaces. + Bruising of the palms and fingers- when the victim clings into the edge of the building or parapet before releasing the grip. + Perineal bruising due to relative movement of the pubic-perineal region against the clothing (may be misinterpreted as resulting from sexual assault),Vehicular injuries Alarge variety of injuries are sustained by persons involved in traffic accidents. A) Injuries to Pedestrian: Three types of injuries are seen: 1) Primary impact injuries: caused by initial strike, i.e., the first part of the vehicle that strikes the victim (usually legs). 2) Secondary impact injuries: After the primary ‘impact, the victim is then again thrown back over the vehicle, causing further injuries. 3) Secondary injuries: Then the victim is thrown ‘on the ground causing secondary injuries. 4) Finally, the victim is run over by the vehicle ‘causing crush injuries. 1. Primary impact injuries: The part of the body struck depends on the position of the person in relation to the vehicle struck. a) Pedestrian struck from behind, both feet fixed to the ground: Whether feet are fixed or not, depends on the nature of the road surface, whether slippery or not, whether it has rained or not etc. The injuries produced are: Bumper injuries: + Injuries at the site of bumper impact, in the form of abrasion, contusion, laceration, internal hemorrhage in the calves etc. + Most characteristic fracture due to bumper fractures are fracture of the tibia. + The fracture fragments are wedge shaped and is displaced forwards (Fig. FM 3.12-1). + The base of the wedge indicates the site of the impact, the apex points in the direction in which the vehicle was travelling Vetrivel Textbook of Orthopaedics 947 unger if Buroer HB) — ee pet Fig. FM 3.12-1 Bumper injuries + If the bumper fractures are on different level on both legs, then it indicates that the victim was either running or walking. + Inchildren, bumper fracture is seen in femur, + Femoral head may be driven through the acetabulum. + The vehicle can be identified from the height of the bumper fracture from the ground and matching the same with the offending vehicle's height of bumper from the ground, + When brakes are applied, the height of the bumper dips down, thus the height of the bumper fracture is less than the height of the bumper. + When accelerator is pressed, the phenomenon isreversed Impact against mud guard or head lamp: This will cause fracture of the pelvis, pubic ramus fracture, fracture-dislocation of the Sacro-iliac joints, imprint abrasions-due to head lamps and radiators. + Injuries usually depend how the victim was positioned, + Frontal impacts may cause head injury, chest injury, fracture of ribs. + Side impact causes injuries of arms. + Rear impact causes injuries to buttocks and sacroiliac joints. + The fractured portion of the vertebral column may move forward and may cause transection of the spinal cord and thoracic aorta.948 Vetrivel Textbook of Orthopaedics b) Struck from behind when feet not firmly fixed with car at high speed: + This situation arises when the victim is walking, + Ifone leg sifted, fractures often transverse. €) Struck from front: + Injuries are virtually the same, except that the injuries are more on the frontal aspect. + Intra-abdominal injuries are seen, like linear superficial tears of the abdomen and inguinal regions, due to over stretching of the skin, + They appear dry, yellow and bloodless. + Liver and splenic injuries are common. + There may be injuries to chest wall and thoracic contents. + Direct impact to thorax may cause rupture of the aorta below the arch at the level of ligamenturn arteriosum due to sudden increase in the intravascular pressure. + The heart may show bruising, laceration and rupture. 4) Struck on one sid + The injuries are seen predominantly on one side. + The opposite side receives injuries while falling onthe road. ) Struck on front corner of car: + Knocked diagonally out of the path of the car, may be run over by other cars coming from behind. f) Pedestrian walks into the side of the moving vehicle: + There may be injuries on the side of the front of face, chest and arms in the form of glancing abrasions, patterned abrasions, crush lacerations, tear lacerations, fracture ribs with ‘or without lung involvement, abdominal injuries ete, 2, Secondary impact injuries + If the feet stide forward, the whole body falls backwards, with a secondary impact of the head against the windshield. + Ifthe victim falls on the hood, tangential force is directed by hood to the buttock and thigh, ‘causing separation of the skin and sub cutaneous tissues from the muscle. + This produces a pocket in the upper thigh and buttock, leading to collection of large amounts of blood, which is often not visible, externally. + Ifthe feet are not firmly fixed on the ground, the victim may be scooped up and thrown in the air and may land over the roof of the vehicle, head hitting first, or may even land on the road behind the vehicle, where he may be run over by other vehicles. + Atlanto-occipital dislocation and partial disruption of intervertebral discs are quite ‘common in this situation. Secondary Injuri + Due to striking of the victim on ground: It may be caused after secondary impact injuries + Immediately after primary impact injuries, when the victim is thrown high up in air and strikes the ground, + All kinds of injuries, including abrasions, contusions, lacerations, fractures etc. may be seen. Run over injuries: Abrasions in the form of grazes, impact or imprint abrasions of the tire marks may be seen. ‘They are spread out a little due to yielding and flattening of body from pressure. ‘The rotator effect against a fixed limb may strip off almost al tissues down to the bone, causing avulsion laceration. The avulsed wound may be segmental or circumferential, completely encircling the arm orleg. If head is involved, complete avulsion of the ear may occur. If intestines or scrotum are involved, they may be extruded out, Head injury with egg shelling of the skull- skullmay be crushed from side to side or forced open with extrusion of the brain matter. ‘The ribs may be fractured at multiple places. ‘The abdomen may be ruptured with extrusion of the contents. ‘The whole body maybe crushed or hemisected, if the vehicle is very heavy and passes through the middle of the body. ‘The legs may be crushed. Brush burn may be seen due to dragging of the body. Rolling over injuries: ‘This is produced when a vehicle with low chassis rolls the victim along the roadway, instead of running him over. Injuries produced are abrasions like graze, patterned (caused by undersurface of chassis), burns from exhaust system, fractures, soiling of garments and skin by grease. These injuries will be present circumferentially all around the body. B) Injuries to Vehicle Occupants: Usually depends upon type of impact. ‘Two broad types are recognized- Non-ejection and ejection injuries. Non-Ejection Injuries: A) Frontal impact: This is the most common and about 80% of the injuries are frontal impact. The sequence of events upon frontal impact is that, the driver and passengers receive some common (due to deceleration injuries) and some different set of injuries. Secondary accident: + The driver, if not wearing seat belt, slides forward, so that his legs strike the instrument and dashboard area, and his chest and lower Vetrivel Textbook of Orthopaedics 949 abdomen strikes the lower edge of the steering wheel. + This isknown as second collision. + The first collision is the one between the vehicle and the outside object. + Facial impact on windscreen causing imprint abrasions, bruises, fracture jaws, facial bones. Flexion across the steering wheel: + The body flexes across the steering wheel and begins to rise, causing steering wheel injuries ‘on the chest and abdomen like chest contusion, bilateral fracture of the ribs, liver laceration. Flexion of the spine: + The head goes forwards causing flexion of the cervical and thoracic spine, + It is followed by hyperextension, resulting in whiplash injuries. + The upward and forward component of the force of impact causes the head to strike the windscreen. Airbag injuries + Although air bags decrease the incidence of fatal injuries, they themselves also may cause serious injuries. + At least one air bag related injury occurs in every 43% of airbags deployed. + This injury is common in adults with short stature and children. + Majority of the injuries are minor e. lacerations and abrasions over the skin and eyes. + Fatal injuries may be seen in children sitting in passenger seat. + Fatal injuries are caused by impact of chest against the airbag. + Multiple rib fracture with bilateral hemothorax, subdural hemorrhage, laceration of pericardium and right atrium with hemopericardium, retro pharyngeal hematoma950 Vetrivel Textbook of Orthopaedics with airway obstruction etc. may be seen. + Non-fatal lesions are seen in the form of ocular injuries. + Itis caused due to the impact of face against air bag or projection of any object leading to contusion, abrasion, lacerations of face. + Orthopedic injuries in upper and lower limbs for lateral airbags, fracture of ribs, sternum, pulmonary contusions, cardiac trauma, spinal lesions are less common. Forearms, especially the distal third may be involved. Deceleration Injurie: Deceleration injuries include a variety of thoracic injuries resulting when the moving thorax decelerates rapidly as a result of impact against a stationary or relatively stationary object. Salient features: Not peculiar to driver only and canbe seen inall vehicle occupants. + Aortic injuries are classic in deceleration injuries. + The location of the aortic injuries is usually in the aortic isthmus, a few centimeters distal to the ostium of the left subclavian artery. + This is most frequently seen in frontal and near -side crashes where a large magnitude of force isbeing involved. Following appearances are seen commonly- + Aortic rupture- which is circular, clean cut, appears sharp as if transected with knife. + Ladder tears- multiple transverse intimal tears, adjacent tomain rupture. Myocardial injuries- there may be contusions, lacerations, contusions of the pericardium and myocardium may be seen without fracture of the ribs, avulsions and laceration of the chambers of heart. + Tracheo bronchial disruption- Bruising of the lungs especially on the posterior aspect, due to blunt impact etc. + Two or more deceleration injuries are mostly fatal. Seat belt injuries: + Seat belts reduces the risk of death by 40% by keeping away from potentially hazardous object like steering wheel and wind screen and also spreads the deceleration force over the broad surface area of thestrap. + Although it reduces the risk of aortic injury, the same is not true for side impact crashes. Seat belt syndrome: Caused by lap-strap belts: Frontal collision where the driver is forced forwards violently, then jack- knifes over the lap belt at the waist. + The injuries sustained are- Surface injury to abdomen, injury to abdominal organs at the mid lumbar level, omental and mesenteric lacerations, lacerations of the abdominal organs, fracture and dislocations of the thoracic and lumbar vertebrae and spinal damage causing paralysis. + The most characteristic triad of injuries associated with rapid deceleration against a fixed fulcrum is spinal trauma, seat belt aorta and bowel injuries. hese were + Caused by modern 3-point belts: developed to minimize the seat belt syndrome. + However, even though the abdominal injuries were reduced, the diagonal strap introduced new injuries, + It contributes to the hyper flexion and hyper extension of the neck, leading to the fracture of the cervical and upper thoracic vertebra, carotid laceration, tracheal transection, injuries to brachial plexus, accidental strangulation in children etc.