SKULL & SCALP INJURY

HEAD INJURY : 

HEAD INJURY DR. JINESH P. S. 06/09/2011

REGIONAL INJURIES: 

Head Face Neck Spine & spinal cord Chest Abdomen Muscles Bones REGIONAL INJURIES

HEAD INJURIES: 

HEAD INJURIES Defined by ‘the National Advisory Neurological Diseases and Stroke Council’ as “a morbid state, resulting from gross or subtle changes in the scalp, skull, and/or the contents of the skull, produced by mechanical forces, directly or indirectly applied to the head”

HEAD INJURY: 

HEAD INJURY Injuries to the scalp Injuries to the skull Skull fractures Meningeal haemorrhages Cerebral Injuries Coup and Contrecoup Injuries Concussion

SCALP - LAYERS: 

SCALP - LAYERS S – Skin C – Connective tissue (Dense) A – Galea Aponeurotica – deep fascia – pierced by numerous emissary veins connects with intracranial venous circulation L – Loose connective tissue – dangerous area of scalp – allow accumulation of blood or pus P – Periosteum ( pericranium )

SCALP - LAYERS: 

SCALP - LAYERS

PERICRANIAL INJURIES: 

PERICRANIAL INJURIES As a rule, the marks of the pericranial injuries coincide with the marks of the scalp wound Tangential or vertical cuts caused by heavy knife Indentations caused by hammer Tangential ‘egg top’ lesion caused by the impact of head against an edge of an angular object

SCALP INJURIES: 

SCALP INJURIES In India – mostly homicidal Abrasions of Scalp – uncommon due to presence of hair Contusions of Scalp – better felt than seen – may be mobile (gravity ) Lacerations of Scalp – DD with incised wounds may bleed profusely – arteries and veins may have the pattern of the inflicting object Vertex of skull – fall from height or striking against projections An oblique blow generally cause large wound & direct blow produce a small wound

BRUISING OF SCALP: 

BRUISING OF SCALP Difficult to detect – remove hair Cephalo-haematoma – effusion of blood is more & forms a localised haematoma – DD of depressed fracture of skull – sensation of crepitus on palpation – Pulsation present if large artery involved – edge may raised above the surface of skull – if subcutaneous movale on its surface Small contusion over occipital protuberance often missed Can percolate & settle around orbit & visible as a black eye – ectopic contusion

SCALP LACERATIONS: 

SCALP LACERATIONS Stellate Linear Y shaped Penetrating Crescent

Slide 15: 

Often incised looking lacerations – use hand lens to differentiate Bleed profusely Usually heals rapidly Sometimes infection may spread to brain through unnoticed fissured fractures – may take weeks to cause death

INCISED WOUNDS OF SCALP: 

INCISED WOUNDS OF SCALP Heal rapidly In infections – fatal – emissary veins Produced by light cutting weapon or heavy weapon – can be differentiated by presence or absence of contused edges Bleed profusely

SKULL: 

SKULL

SKULL: 

Collectively called cranium Calvarium – roof of skull Thickness varies place to place Thin areas lie either side of skull Elasticity of adult skull is limited Outer & inner table may suffer damage differently SKULL

MECHANISM OF SKULL FRACTURE: 

MECHANISM OF SKULL FRACTURE When a force applied to head, first compression of area coming directly under the site of blow along with sideward expansion Usually inner table, stretch beyond elastic threshold & fractures Outer table fracture at the margin of compression Force required for fracture of skull may be as little as 5 ft/lb (fall from a sitting stool) Skull will not fracture even when the force exceeds 90 ft/lb

Slide 22: 

Fractures of skull may be with or without contusion or wound on scalp Temporal bone & orbital plate of frontal bone are easily fractured Fracture of the vault occurs at the place of contact by direct violence or on its opposite side by countercoup when head is not supported Fracture of vault is difficult to diagnose if it is not associated with external wound

TYPE DEPENDS UPON: 

TYPE DEPENDS UPON Shape of the skull Mobility of the skull Presence of scalp hair Covering on head – cap, hat, helmet, turban Weight & velocity of weapon Amount of force Type, edge, blade, sharpness of weapon

TYPES OF SKULL FRACTURES: 

TYPES OF SKULL FRACTURES Depressed fracture – impact of moving object on cranial vault Linear fracture – impact of moving head against a solid subject Specific type a) simple fracture b) complex fracture c) fracture by diastasis extents into separate suture lines d) meridional or brushing fracture (crushing of cranial bones) e) indentation f) counter coup fracture – orbital portions of frontal bones g) gutter fracture h) fracture dislocation of mandibular condyle i ) perforating fracture

DEPRESSED FRACTURE: 

DEPRESSED FRACTURE Considerable force is applied to a relatively small area Fractured segment displaced inwards Also called signature fracture – hammer striking the head Often shape of fracture correspond to shape of striking surface of object Area struck is driven along the same line of force into the subjacent structures, depth varying with the velocity with which the impact is delivered

LINEAR FRACTURE: 

LINEAR FRACTURE Commonest type Also called fissured fractures Can be straight, curved or irregular Produced when head hit against a hard surface , or when object with large striking surface hits the head with sufficient force Temporal & parietal are easily fractured Fissured fracture may extend to base of skull Fissured fracture which involve only one table of skull – crack fracture – inner table common, more brittle

Pm no. 1121/11: 

Pm no. 1121/11

Pm no. 1123/11: 

Pm no. 1123/11

FRACTURE BY DIASTASIS: 

FRACTURE BY DIASTASIS Linear cracks without any displacement of the fragments Striking a relatively broad striking surface Direct impact to skull of young May extend to base of skull

COMPLEX FRACTURE : 

COMPLEX FRACTURE Also called comminuted fracture Bone is fractured into fragments due to heavy blunt impact, violent fall, vehicular accidents or repeated blows There is multiple adjacent fissured fractures When there is no displacement of bone - ‘spider web’ or ‘mosaic’ pattern Types – depressed comminuted non-depressed comminuted expressed fracture – free segments come to lie out side normal curvature of cranium

Pm no. 1121/11: 

Pm no. 1121/11

POND FRACTURE: 

POND FRACTURE Also called indented fracture Seen in elastic skulls in children Inner table is not fractured Fracture appears as indentation of outer table – without actual fracture Can result from application of forceps during delivery

GUTTER FRACTURE : 

GUTTER FRACTURE Outer table of skull is removed in the shape of a gutter Weapon strikes skull tangentially In bullet glancing injury

RING FRACTURE: 

RING FRACTURE Circular fissured fracture surrounding foramen magnum Fall from height & landing on feet or buttocks Force is transmitted upwards through vertebral column

COUNTERCOUP FRACTURES: 

COUNTERCOUP FRACTURES Seen in orbitel portions of frontal bones as linear or stellate fracture Commonly unilateral Arise from the pressure differentials bet intracranial orbital surface & intraorbital space as in occipital falls or heavy blows at back of head Negative pressure will be created in frontal region – leads to implosion of thin & weak orbital roof

PERFORATING FRACTURE: 

PERFORATING FRACTURE Penetration of skull by sharp pointed object or bullet Entry cause more damage to inner table than outer table while reverse at exit Wounds are funnel shaped – bevelling

CUT FRACTURE: 

CUT FRACTURE By heavy cutting weapon May involve both or outer plate

BASE OF SKULL FRACTURE: 

BASE OF SKULL FRACTURE May involve nasopharynx , nasal air sinuses, middle ear & mastoid By a blow or fall upon the vertex as the head is pressed on the other side of spinal column May also result from extension of fracture of vault Direct impact from a forward fall may cause depressed fracture of anterior fossa , while a backward fall may cause fracture of posterior fossa even extends into foramen magnum Impact behind ear or head injuries of head may involve middle fossa both side

Slide 55: 

On either side of base of skull, there is anterior, middle & posterior fossa - floor of these easily breakable thin plate May cause an arterio -venous communication between carotid artery & cavernous sinus Common in motorcycle accidents and other RTA and homicidal blows, fall from height The fracture may extend transversely across the middle region of base of skull, along two petrous ridges – two fragments may be able to brought together & displaced like a hinge – Hinge fracture

SYMPTOMS : 

SYMPTOMS Signs of concussion or compression of brain Effusion of blood in sub- conjuntival tissue or in sub-occipital & mastoid regions Bleeding, discharge of cerebrospinal fluid from nose, mouth or one or both ears Signs & symptoms of lesion of cranial nerves – olfactory, optic, occulo -motor, ophthalmic or maxillary divisions of trigeminal, facial, auditory issuing from base of skull

BLEEDING & FRACTURE OF SKULL: 

BLEEDING & FRACTURE OF SKULL Diffuse subconjunctival haemorrhage Anterior cranial fossa fracture Limited, flame shaped sub conjunctival haemorrhage Contusion of soft tissues of eye Swelling of temporal muscle & retromastoid bruising Signs of fracture Flow of blood from ear Isolated rupture of ear drum fracture external bony auditary canal Basal skull fracture Concurrent profuse bleeding nose & ears Internal carotid artery injury Bilateral haemorrhage from ear b/l longitudinal fracture of temporal bone combined with labyrinthine or transverse fracture

AGE OF SKULL INJURY: 

AGE OF SKULL INJURY Age Change 7 days Edge of fissured fracture stick together by serous exudate 14 days Edges of affected bones are slightly erodes & calcium deposits found on inner table 1 – 3 months Bands of new bony tissue union found along the crack, edges will be smooth & rounded if not touching & gap is joined by fibrous tissue

REFERENCES: 

REFERENCES K. Mathiraharan , Amrit K. Patnaik . Modi’s Medical Jurisprudence & toxicology 23 rd ed.5 th reprint. 2010 B. Umadethan . Forensic Medicine. 1 st ed.2011 V. V. Pillai . Textbook of Forensic Medicine & Toxicology. 16 th ed. 2011 Krishan Vij . Textbook of Forensic Medicine & toxicology, Principles & Practice 5 th ed.2011 http://www.sciencephoto.com/media/277260/enlarge. 25/08/2011 Jay Dix. Color Atlas of Forensic Pathology.2000

THANK YOU: 

THANK YOU