PHYSICAL INJURIES

Rey J. Millena, MD, MCHM, FPCAM

Legal Medicine
Physical Injuries Secondary to Physical
Violence

• Physical Injury = Wound

• The effect of the application of physical
violence on a person is the production of
wound.
• WOUND = Kinetic Energy X Time X Area X
“other factors”
 Vital Reaction
• Vital Reaction is the sum total of all reactions of tissue
or organ to trauma.
• These are the common reactions of living tissue to
trauma:
1. Rubor – redness or congestion due to increase of
blood supply as a repair mechanism.
2. Calor – sensation of heat or increase in temperature.
3. Dolor – Pain due to involvement of sensory nerve.
4. Loss of function – tissue may not be able to function
normally due to the trauma.
 Classifications of Wounds
• As to severity:
a. Mortal wound
b. Non-mortal wound
• As to the Kind of Instrument Used:
a. Blunt instrument (contusion, hematoma,
lacerated wound)
b. Sharp instrument
1) Sharp-edged (incised wound)
2) Sharp-pointed (punctured wound)
3) Sharp-edged & sharp pointed (stab wound)
Cont...
c. Tearing force (lacerated wound)
d.Change of atmospheric pressure
(barotraumas)
e.Heat or cold (frostbite, burns or scald)
f. Chemical explosion (gunshot or shrapnel
wound)
g.Infection e.g. Tropical ulcer (anthrax infection
of skin)
Cont...

3. As to Manner of Infliction:
a. Hit
b. Thrust or stab
c. Gunpowder explosion
d. Sliding or rubbing or abrasion
Cont...
• As Regard to the Depth of the Wound:
a. Superficial – involves only the skin
b. Deep – involves the inner structure beyond
the skin
1) Penetrating - piercing a solid organ or
enters the body but did not come out.
2) Perforating – piercing hallow organ or
traversing completely a part of the body.
Cont...
5. As regards to the Relation of the Site of the
Application of Force and the Location of
Injury:
a. Coup injury – injury at the site of
application of force.
b. Contre - Coup injury – injury found opposite
of the application of force.
c. Coup Contre - Coup injury
d. Locus Minoris Resistencia – injury at the
area of least resistance.
Cont....
6. As to the Regions or Organs of the Body Involved.
7. Special Types of Wounds:
a. Defence wound
b. Patterned wound – wound in the nature
and shape of an object that cause the
injury.
c. Self-Inflicted wound – injury produced on
oneself without the intent to end life.
 Motives of Producing Self-Inflicted
Wounds:
1 – To claim pension, workman’s compensation
or insurance.
2 – To escape obligation or punishment.
3 – To destroy the existing identity in order
create a new one.
4 – To gain attention and sympathy.
5 – Psychotic behaviour.
 Type of Wounds:
A. Close Wound – there is no breach of continuity of the skin or
mucous membrane.
a. Superficial
1) Petechiae – circumscribed pinhead size hemorrhage e.g.
Insect bite.
2) Contusion – bruising, wound in the skin and
subcutaneous tissue due to extravasations of blood.
The shape may follow the wounding weapon, so
that the position of the bruise may indicate the
manner of assault.
Cont...
3) Hematoma – an accumulation of blood
in a newly formed cavity within the
tissues that clots to form a solid swelling
usually due to trauma. Abscess,
gangrene, fibroid thickening and even
malignancy are possible complications.
Cont...
b. Deep
1) Musculo-Skeletal Injuries
a) Sprain – injury to ligament, caused
by sudden overstretching.
b) Dislocation – loss of contact of
joint surface.
Cont...
c) Fracture – breakage of bone.
(1) Simple fracture
(2) Compound fracture – w/ open* wound
extending to fracture site.
(3) Comminuted fracture – fragmented w/
separation of bone.
(4) Pathologic fracture – due to disease
rather than violence.
Cont...
d) Strain – injury to a muscle by overstretching
of overworking.

e) Subluxation – partial dislocation of a joint,

bone ends are mis-aligned but still in contact.
Continuation of deep...
2) Internal Haemorrhage
a) Intra-cranial hemorrhage – bleeding in
the cranial cavity.
b) Rupture of organ – injury of hollow
organ inside the body.
c) Laceration of an organ
Continuation of deep...
3) Cerebral concussion – condition of the
brain resulting from a sudden jarring of
the head, characterized by headache,
dizziness, confusion, semi-consciousness
to unconsciousness, and amnesia
(retrograde).
Cont... type of wounds
B. Open Wounds:
a. Abrasion – removal of the superficial epithelial layer of
the skin caused by a friction against a hard rough surface.
-develops at the precise point of impact of the force
causing it
-injury consist of parallel linear injuries that are in line
with the direction of the friction causing it
-may exhibit the pattern of the wounding instrument
-usually does not require medical treatment but with
medico-legal importance e.g. Abrasion by fingernails may
indicate struggle or assault.
Cont...abrasion

• Forms of abrasion
a. Linear – appears as a single line, may be curve or
straight.
b. Multi-linear – several linear marks parallel to one
another.
c. Confluent – linear marks indistinguishable on
account of the severity of friction and roughness of the
object.
d. Multiple – several abrasion of varying sizes and
shapes found in different parts of the body.
Cont...abrasion
• Types of abrasion:
a. Scratches – caused by the sliding sharp pointed instrument
over the skin e.g. Pin, thorn or finger nail.
b. Grazes – due to forcible contact with a rough, hard object
resulting to irregular removal of the skin surface.
c. Impact or imprint abrasion – due to contact with rough,
hard object in which the structural form of the object is
reflected over the skin.
d. Pressure abrasion – caused by pressure accompanied by
movement usually observed in hanging. The spiral strands
of the rope may be reflected on the skin of the neck.
Cont...open wound

b. Incised wound – produced by sharp edged or

sharp linear edge of instrument.
-impact cut when there is forcible contact of the
cutting instrument.
-slice cut when injury is due to the pressure
accompanied with sliding movement of the
instrument.
Cont...incised wound
• Characteristics of incised wound
a. Edges are clean cut and extremities are sharp.
b. Wound is straight and may be shelving if instrument
is applied at acute angle to the surface of the body.
c. Usually shallow near the extremities and deeper at
the middle portion.
d. Profuse bleeding is often due to clean cut blood
vessels.
e. Gaping is due to the retraction of the edges
depending on the direction of the wound with the
line of cleavage (Langer’s line).
Cont...incised wound

f. Covering clothing will show clean cut over the wound.

g.Healing is relatively fast w/out complication or deeper
involvement.
h.Incised wound made by glass may have particles of
glass in the wound.
Cont...Incised Wounds
Determination whether:
a. Suicidal – located where major blood vessels are
found and conveniently accessible to the
inflicting hands. Usually with hesitation cuts and
direction of cuts depends on the location and
the hand used.
b. Homicidal – located both in accessible & non-
accessible parts of the body to the hands of
injured. Clothing is usually included & there may
be presence of defence and other forms of
wounds.
Cont...classification of incised wounds
c. Accidental – multiple incised wound is
commonly seen in vehicular accidents due to
the broken windshield and glass windows, in
using the kitchen knives while cooking,
etc...usually depending on the instrument
used by the trade.
Cont...open wound
c. Stab Wound – produced by penetration of sharp-pointed and sharp-
edged (bladed) instrument.

In describing must include:

1. length of skin defect, tailing measured and described separately.
2. condition of extremities
3. condition of the edges – clean cut or serrated.
4. linear direction of surface wound – vertical, horizontal, oblique to
right or left.
5. location – region of the body & measurement from anatomical
landmark.
6. direction of penetration – tri- dimensional.
7. depth of penetration
8. tissue and organ involved
Cont...stab wound
Determination whether:
a. Suicidal
- located over vital parts of the body
- usually solitary, if ever multiple only in one location.
- accessible to the hands of the suicidal person.
- hands smeared with blood.
- instrument used is in the hands of the person.
- suicidal note present.
- presence of motive for suicide.
- no disturbance in the scene.
Cont...stab wound
Determination whether:
b. Homicidal – most common.
- presence of other forms of injuries.
- located in any part of the body.
- usually more than one stab wound.
- usually there is motive for stabbing.
- usually there is disturbance in the crime
scene.
c. Accidental stab wound – are rare.
Cont...stab wound
Medical evidence to show the intent to kill the
victim:
- more than one stab wound.
- inflicted on vital parts of the body.
- serrated edges.
- irregular or stellate shape of skin defect.

*most common cause of death is hemorrhage.

Cont...open wound
d. Punctured wound – due to a thrust of sharp
pointed instrument.
Characteristics:
- nature of external injury depends on
sharpness and shape of instrument, maybe small
or unnoticeable due to elasticity of skin & clotting
of blood.
- external haemorrhage limited.
- sealing of wound is conducive for anaerobic
microorganism.
Cont...punctured wound
Medical evidence to show it is homicidal:
- same as stab wound except for serration and
stellate defect of skin injury.

As suicidal:
- same as stab wound.
Cont...open wound
e. Lacerated wound – is a tear of the skin and the underlying tissues
due to forcible contact with blunt instrument.

Characteristics:
- shape & size of injury not correspond to the inflicting instrument.
- usually developed on where bones are superficially located.
- edges is rugged with extremities irregular and ill-defined.
- borders of wound is contused & swollen.
- bridging of tissue joining the edges and hair bulbs intact.
- bleeding not extensive.
- healing process is delayed.
Cont...lacerated wound
Classification of lacerated wound:
1. Splitting – crushing of skin between 2 hard
objects.
2. Overstretching e.g. Avulsion – the
remaining tissue is that of laceration.
3. Grinding compression
4. Tearing or cut laceration – produced by
heavy cutting blunt or semi-sharp edge
instrument, like chopper.
Cont...lacerated wound
Lacerated wound maybe accidental or homicidal
but rarely suicidal.

Differentiate lacerated wound from incised wound

as to:
- edges
- extremities
- healing
- scar formed
- inflicting instrument
Factors for the severity of wounds:
1. Hemorrhage
a. Loss of blood incompatible with life.
b. Increase pressure in or on the vital organs
to affect functioning, e.g. Intracraneal
hemorrhage, cardiac tamponade, etc.
c. Mechanical barrier to affect functioning,
bleeding in the tracheo-broncheal lumina,
epistaxis, hemoptysis.
Causes of hemorrhage*
a. Trauma
b. Natural causes:
- Stroke/cerebro-vascular accident
- rupture of aneurism
- rupture of esophageal varices
- pulmonary hemorrhage due to PTB, lung
abscess, ca
- rupture of ectopic pregnancy
- rupture of enlarge spleen in malaria, typhoid
fever
Cont...factors for the severity of
wounds:
2. Size of injury – bigger wounds are more
exposed to infection and effects of
environment.
3. Organs involved – if vital organs.
4. Foreign body or substance introduced in the
body – may be toxic or may act as physical
irritant, e.g. Pathogenic organism, chemical
(cyanide, nicotine, mercury), toxins (venoms)
5. Absence of medical or surgical intervention.
 Fatal Effects of Wounds
1. Directly Fatal Due to:
a. Haemorrhage
b. Injuries on the vital organs
c. Electrolyte imbalance
2. Indirectly Fatal Due to:
a. Secondary haemorrhage following sepsis
b. Specific infections, e.g. Tetanus, gas gangrene
c. Scarring effect e.g. Strictures, adhesions
d. Embolism
 Healing of Wounds
1. Regeneration of human tissue
-capacity for regeneration decreases as age
increases.
-state of nutrition affects the capacity to
regenerate.
-more highly specialized tissue the less
capacity to regenerate
Cont... regeneration
Rapidly regenerates:
-connective tissues
-blood forming tissues
-surface epithelium of skin
Limited capacity to regenerate:
-smooth muscle cells
-neurons of the central nervous system
-specialized organs
Factors affecting the time of healing:
a. Vascularity
b. Age of person
c. State of nutrition of person
d. Degree of rest or immobilization
e. Nature of the injury
f. Medical intervention
Kinds of healing of wounds:
a. Healing by primary intention
-minimal tissue loss, more approximation of edges
-without significant bacterial contamination.
-within 24 hours there is acute neutrophilic response
& scab formation
-after 3 days macrophages and fibroblast activities in
the epithelial layer, collagen bridge the raw area &
newly formed capillaries will proliferate these to
cover the exposed area
-after a month complete return to normal state with
or without scar formation.
Cont...healing of wound
b. Healing by secondary intention
Cont...healing of wound
c. Aberrated Healing Process:
1. Formation of exuberant granulation
2. Keloid formation
3. Stricture
4. Fistula or sinus formation
GUNSHOT WOUNDS