TRAUMA

TRAUMA - bodily harm with or without structural alterations resulting from interaction with physicochemical agents, imparting energy to tissues. May cause morphologically apparent damage (wound) or produce physiological imbalance (eg reflex cardiac arrest by neural stimulation) and secondary effects (eg thrombosis, infection, obstruction of tubular organs)

TERMS: ●WOUND: “disruption of the continuity of the tissues produced by external mechanical force” ● INJURY: from the latin injuria (in- not, jus- the law). The term is often used synonymously with wound but can have a wider use, including damage to tissues by heat, cold, chemicals, electricity, radiation, in addition to mechanical force ● LESION: from the latin laesio (a hurt). Originally meant injury, now more widely applied to include " any area of injury, disease or local degeneration in a tissue causing a change in its function or structure"

small mass projectile 2) Thermal energy: heat or cold 3) Electrical energy: flow of current may cause a burn if resistance is high 4) Atmospheric Pressure: high or low.TYPES OF TRAUMA Energy may applied to tissues in various forms 1) Mechanical Force Blunt force trauma (BFT) -a moving object (KE) striking the body as in a blow -the moving body (KE) striking a fixed object or surface as in a fall BFT causes bruises. requires little force to cut tissues Firearm. jagged metal -applied force is concentrated over a small area. high velocity. in air or water 5) Radiation: particle or radiation 6) Chemical reaction with tissue releasing energy . abrasions and lacerations Sharp force: knife tip or edge. broken glass.

MECHANICAL FORCE .

Mechanical Force may cause: -Impact -Angulation -Compression -Traction -Torsion -Shearing -Acceleration/deceleration .

BLUNT FORCE TRAUMA .

034 + Stopping distance in feet.Blunt force trauma (BFT) ●a moving object (KE) striking the body as in a blow. but on the square of its velocity Crash energy = (mph)2 x 0. ● the moving body (KE) striking a fixed object or surface as in a fall. . Degree of Force or K. applied: Force = Mass x Acceleration Kinetic Energy = 1/2 Mass x Velocity2 Energy depends on mass of weapon or projectile.E.

OBJECTS. WEAPON .DIFFERENT TOOLS.

The foot and the fist causes blunt trauma. .

.Small surface objects – hammer and others.

dumb-bells. bottle.Spherical object . stone-ball. .

.Rod shaped weapon (cylindrical object) – whip. stick. baseball bat. truncheon. beater. rod. handler.

radiator..edgy object . etc. edge of board.Blunt. iron. stairs and a ladder. chair. .fingarnails .

brick etc.. .Subject with the triple and multiwall angles angle board. hammer.

Blunt force trauma causes: . -LACERATIONS. -ABRASIONS. .BRUISES.

.Types of injury to the skin.

pin head size bruise < 2mm . ecchymoses) Definition: leakage of blood from ruptured small vessels (veins or arterioles) into the surrounding tissues. Haemorrhage or bleeding is the escape of blood from any part of the vascular system. Petechiae.BRUISES From Old English brysan-to crush and Old French bruser-to break Syn: (contusions. Bruising may be seen in skin. or internal into a body cavity. from a skin wound. muscle or any internal organ. Haemorrhage can also be external. Bruising is haemorrhage into the surrounding tissues.

Mechanism of bruise. .

Mechanism of bruise. .

Often associated with skin abrasion or laceration (the more elastic overlying skin may be undamaged) Bruising less often associated with incised or stab wounds which allow outward escape of blood from cut vessels. Moving body strikes a stationary object (fall) pinching or squeezing. .Mechanism of production Moving object strikes the stationary body (blow with fist or weapon).

Bruise associated with skin abrasion .

.Bruise associated with skin abrasion (arrows left ).

CLASSICAL PATTERNS OF BRUISING .

car bumper. gun muzzle) . Skin forced into grooves and dermal vessels ruptured. Skin over ridges is compressed and vessels remain intact. The resulting accumulation of a small amount of blood. near the epidermis may demonstrate the obvious pattern of the causal surface (tyre. shoe tread. patterned object with ridges/grooves.Intradermal bruise due to impact with a hard.

Due to gripping by fingertips in forceful restraint. neck (throttling (manual strangulation).Child abuse. defensive injuries) . Finger pad bruises are round or oval. slightly larger than the finger tips due to outward spread of blood. Found on –limbs and face (child abuse). thighs (rape). arms (forceful restraint.

Finger pad bruises (arrows) on the thighs in rape.

Doughnut bruise due to a spherical object (cricket ball)

Love bite (hickey).
Suction bruise caused by firm application of the lips against the skin, forming an air-tight seal, oral suction causing a shower of petechial bruises from rupture of numerous small vessels. Normally found on teenagers after the weekend! Also seen on neck, breasts in sexual assault. Must be human in origin. A similar appearance is seen between the dental arches of a true bite.

Not a bite ! No teeth marks ! .

.Love bite on the neck.

Love bite on the shoulder. .

.Love bite on the thigh.

―Love bite ― on the back (child abuse). .

Love bite on the buttocks. .

Bruises on the face - ―black eye‖ (peri-orbital haematoma). .

.Bruises on the face―black eye‖ and laceration.

fractured skull basis. . 3.The causes of ―black eye‖. 1. 2.tracking from forehead bruise.fist blow to orbit or nose.

Compression of vessels centrally. Traction causes rupture of vessels along edges of rod.Tramline bruising due to a rod shaped weapon or stick. not usually damaged unless crushed onto bone. .

.Bruises of rod shaped weapon .

. Reproduction of surface of switch with steel wire.Direct skin abrasion by whip.

Bruises of stick. .

Bruises of truncheon. .

Bruises of beater. .

Formation of ―tramline‖ bruising from the application of a rectangular or cylindrical object. .

Formation of ―tramline‖ bruising from the application of a cylindrical object. .

Dermal. . intradermal. subdermal and intramuscular bruise.

g. -blow on temple → bruise on cheek. influenced by gravity and body movement.The site of bruising does not necessarily reflect site of trauma. Bleeding into tissues may continue for some time after impact under circulatory pressure. -fractured jaw → bruising on neck. -fracture pelvis → bruise on scrotum . -blow on shoulder → bruise on arm. . e. Extravasated blood tracks along natural/traumatic planes of least resistance. -fractured hip →bruise on thigh.

Movement of bruises. . Blow on left shoulder (arrow) → bruise on arm (arrow).

Movement of bruises. . Fracture pelvis → bruise on scrotum.

Bruises. Stamping. . Kicking (or foot assault). jumping may reproduce the pattern of the sole.

Pattern injuries associated with impacts from the bottom of a shoe while being stamped and kicked .

Colour changes begin at the periphery and progress towards centre if large. Pigments. including bilirubin and haemosiderin are released from haemoglobin within degenerating red blood cells .AGE AND COLOUR CHANGE IN BRUISES -immediately DARK RED (the colour of capillary blood) -soon turns DUSKY PURPLE Subsequent colour changes very variable in timing and result from HAEMOLYSIS by enzymes and cellular products. Smaller bruises may change colour uniformly.

5 days).4 days). . DISAPPEARS 14-15 days (range 1-4 weeks). ●yellow — bilirubin (haematoidin)(8 -12 days).Subsequent colour changes: ●red — the colour of capillary blood and oxyhaemoglobin (3 . ●green — biliverdin (4-6 days). ●brown — methaemoglobin (3 .

g.B. N. size and depth of bruise.A small bruise in a healthy adult may disappear in 1 week. repeated assault. time course depends on adequacy of lymphatic and venous drainage. The time course is very variable. child abuse. anatomical site. age of person (v. Distinguishing FRESH from OLD is easier and often important. e. slow in elderly) and general health Accurate dating of an individual bruise is difficult. A love bite (Hickey) may vanish in 2 or 3 days. .

.Bruises different colours.

1 ―Bruises‖ (ecchymoses) in diseases 2. Ecchymoses in Henoch.1. Ecchymoses in meningococcemia on the leg.Shonlein purpura on the legs. 2 .

The settling of blood into the lowermost blood vessels. Blood vessels compressed by pressure of contact with clothing or supporting surface will not fill and the area remains pale (contact or pressure pallor). engorged vessels which can be rinsed away in lividity. livor mortis). Lividity is sometimes confused with bruising. Incision of a bruise reveals escape of blood into the tissues which can not be rinsed away.under gravity after the circulation ceases. Results in a pinkish discolouration of the skin in the dependent parts of the body. Distribution and pallor help to discriminate. Incision of the skin shows oozing of blood from cut.POST MORTEM LIVIDITY (hypostasis. .

Post mortem lividity (hypostasis. . livor mortis).

.Incision of a bruise reveals escape of blood into the tissues which can not be rinsed away.

Occurs.epidermis or deep tissues May be abraded ―Abraded contusion Over the site of injury Not sharply defined Engorged capillaries simple stain Not abraded Depend part of body sharply defined . 4 Edges .BRUISES LIVIDITY 1 Situation . 3 Site . 2 Cuticle .

green yellow Shows extravasation. Colour repeated Uniform & Livid Slight oozing form cut end Blanching occurs in unfixed .5. . 7. blue. 8. 6. Appearance Colour Incision On presenting Raised above the Not raised surface red.

1. Evidence of application of blunt force. Accidental Homicidal Suicidal .

circulating diminished – due to extravasation 3.2. Healing – Determination of age. . Volume of blood. Patterned Bruising Nature of agent used. 4.

5.Indicate some peculiar offence Ex : On the Neck Inner Side of Thigh – FM Indicate Sexual Assault small bruises The so called “six Penny Bruises” 6. Bruising over the particular part of the body. .Character & manner of injury may be known from its distribution.

TRAIT ATRIFICIAL BRUISES TRUE BRUISES 1. 2. 4. diffuse & irregular. Causes Site Colour Shape Markings Juice of marking nut Exposed accessible parts Dark brown Irregular Well defined & regular covered with small vesicles Trauma Anywhere Atypical colour changes Usually Round Not well defined. No vesicles . 5. 3.

Redness & Seen in the surrounding skin Inflammati on Contents Acrid serum Seen in the site. Extravasated blood 8. 9. 7. Chemical Test Negative .6. Itching Vesicles Present May be found on the finger tips &other parts of the body due to scratching Positive for chemicles Absent Absent 10.

Multiple contusion can cause death from shock & internal haemorrhages. Contusion contain 20.1.30 ml of blood or even more. Sudden compression of the subcutaneous tissue – pulmonary embolism may occur. 3.Good site for bacterial 4. 2. Gangrene & death of tissue. .

. Death of a bruises on the body.CASE.

Defence injuries (bruises). .

Intradermal and subdermal haemorrhage or bleeding. .

(staining by Sudan ІІІ). .The cause of death is fat embolism.

Tramline bruising of stick. .

.from. or body lining epithelium).to scrape Definition: "a portion of the body surface from which the skin or mucous membrane has been removed by rubbing" (from the Latin ab.ABRASION (Syn: grazes. A superficial injury of the skin not involving the full thickness of the skin (confined to epidermis and epidermis dermis.to scrape). scarpes). Usually due to BFT. and radere.from and radere. From Latin ab. scratches.

ABRASIONS DEFINATION : Abrasions are the injuries involving superficial layers of the skin the epidermis or mucus membrane. . due to impact against some hard. blunt. & rough object/ weapon.

The epidermis tags raised by the impact tend to pile up at the distal end. Determination of the direction of impact in an abrasion caused by a tangential force.Mechanism. .

Loss or scraping of epidermis/dermis by tangential friction on rough surface (graze) or sharp point (scratch).Mechanism of production on abrasion. .

.Loss or scraping of epidermis/dermis by tangential friction on rough surface (graze) or sharp point (scratch).

Loss or scraping of epidermis/dermis by tangential friction on rough surface (graze) or sharp point (scratch). .

.Superficial crushing of epidermis/dermis caused by direct impact.

. Fingernail impressions (crescentic) on neck in throttling.Imprint abrasions.

Imprint abrasions. . Fingernail impressions (crescentic) on face in rape.

Abrasions. . Body of pedestrian received brush injuries by scraping along the road surface.

. Teeth marks may be abrasions.static abrasions. Bite mark. BITE MARKS. or a combination.Bite mark-dynamic abrasion. Clarity depends on contour of part bitten and the force applied. bruises or lacerations.

SCAB. 2 .24 Hours :. 7-10 Days:.AGE (FATE) OF AN ABRASIONS Usually heals that out any formation of scar FRESH : Reddish. lymph & injured epithelial cells.Exudation dries up to form reddish scab.Due to oozing serum & little blood.Brownish Black & Starts falling from the margin.3 Days :. Comprising of – Dried blood.SCAB – Dark Brown 5 -7 Days:.SCAB – Shrinks & falls off leaving depigmented area underneath . 4 – 5 Days :.SCAB – Reddish Brown. Dermis : Congested & painful 12.

.Scheme of aging of abrasion (see previous slide).

Fresh abrasion. . Blood and lymph (arrow). First stage.

.Abrasion. Scab. Second stage.

. Third stage. Scab.Abrasion.

Abrasion. . Fourth stage.

bleeding/exudation is slight and leads to crust/scab formation. Heals without scarring (by reepithelialisation). Abrasions are often associated with bruising and laceration.CLINICAL IMPORTANCE: Abrasions are trivial. . although they are painful.

MEDICOLEGAL IMPORTANCE: 1.Point of impact of the blunt force. 2.Indicated causative object/surface. . coal.Pattern .Various stages of healing. 4. cement etc. grit.Site & Distributions over the body. 5.dust. 6. 3. 7.Direction of impact.Presence of material like mud.Nature of force.

. LACERATED WOUND) From Latin lacerare. Definition: Full thickness tearing of the skin (or other tissue) due to stretching and crushing of tissues by blunt force trauma.to tear.LACERATION (TEAR. Blunt force trauma by moving object or fall. Botanical termirregular edges.

muscle or any internal organ. . mucus membrane.A Laceration is a rupture or tear or split in the skin. involving depth more than the covering epithelium of the skin or that of an organ & are produced by application of blunt force. Many factors influences the formation & appearances of laceration.

tendons). Associated bruising and abrasion of skin edges and adjacent tissue (BFT) 3. other ragged. Tissue bridges in depth of wound (intact nerves. undercut or flap-like. A tangential component may give one clean-cut edge. . Ragged edges (torn apart). bulging fat. vessels.Lacerations (lacerated wounds) have the following characteristics : 1. crushed hair bulbs 2.

● tissue bridges. ● ragged edges. ● bruising and abrasion of skin.Lacerated wound on head. .

Lacerated wound on head ● ragged edges. ● tissue bridges. . ● bruising and abrasion of skin.

Lacerated wound on head. . Fall from high.

SCALP. other ragged.Lacerated wound on head. undercut or flap-like. A tangential component may give one clean-cut edge. .

Object in comparison with wounds. .

When skin is closely applied to the bone & the subcutaneous tissue is scanty. blunt force may produce a wound which by linear splitting of the tissue resembles an incised wound. .

.Lacerated wounds on head and object –wooden stake.

See previous slide.

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1 1

2 1

3
Lacerated wounds on head and object (arrow 3).

HEALING of LACERATED WOUNDS.

1. Phase of inflammation. 2. Phase of proliferation. 3. Phase of scar formation and remodeling.

Healing of lacerated wounds. Scheme. .

Heals by scarring. Wound infection frequent. Associated internal injury/bleeding.CLINICAL IMPORTANCE Often little external blood loss (except scalp) due to crushing and retraction of vessels. .

.Women.Truncheon.

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