HEAD INJURIES

By Dr. Naveen
Brief
 In criminal and accidental injuries, the
head is especially vulnerable and an
understanding of the mechanism of
head injuries is essential in forensic
medicine. The head is the heaviest part
of the body relative to its size and is
poised on the spine in a rather unstable
position, being mainly secured by the
tone of the neck muscles.
 Though the brain is enclosed within a
strong bony cranium, distortion and
transmitted forces can cause a variety
of lesions within the skull, both to blood
vessels and neural tissue. It is most
convenient to describe head injuries in
sequence from the outside to the
interior.
Scalp injuries
 The scalp consists of hairy skin over
subcutaneous tissue, beneath which is the
fibrous membrane of the aponeurosis or
galea,which is really the tendon of the
vestigial epicranial muscles. Underlying this is
a thin layer of connective tissue, then the
periosteum of the outer table of the skull. The
scalp is very vascular and bleeds profusely
on damage. It can continue to bleed after
death, especially if the head is in a dependent
position.
 The scalp is often lacerated by impact, as the
underlying rigid skull acts as an anvil, against
which the scalp can be crushed, Even a blunt
impact, from a blow from an instrument or a
fall against a hard object, can cause a sharply
defined split. This may be mistaken for an
incised wound from a cutting instrument,
though close inspection of the wound edges
will show a narrow zone of crushing and
bruising with hairs and fibrous strands
crossing the depths of the wound.
 When injured by a blunt impact, the
scalp often swells markedly, due to
oedema and haematoma collecting
either above or below the aponeurosis.
A severe glancing or tangential force,
either from a blow or especially from a
rotating wheel in traffic accidents, may
tear off a large flap of scalp, exposing
the skull. This may also occur when
long hair is entangled in machinery in
industrial accidents.
Injury to the bones of the head
-
 Fractures of skull –
Fracture of the skull bones may
be simple or compound . However ,
irrespective of whether closed or open ,
the fractures of the skull bones may
may be of the following types -
Fissures fracture – These are linear or
thread like fractures running in a line ,
straight or curved . A fissured fracture
may be continuous over one or two or
more bones . Fissured fractures are
caused due to impact with hard , tough
and flat surface , This type of fracture is
often the result of a fall on the ground
or after being knocked down on the
ground by a vehicle .
Comminuted fracture – When a part
of the skull bone cracks into pieces
, it is termed comminuted fracture .
This occurs often in radiating
fashion , with the center being at
the site of the impact and fissures
radiating from that point in more
than one direction , along the
direction of radiation of the force of
impact .
砖击颅底骨折
砖击左颞骨折
颅底粉碎性骨折
凹陷性骨折—凹陷明显处
 凹
陷
船 性
挤 骨
折
压 —
凹
陷
明
显
处
二
次
打
击
 Depressed comminuted
fracture – This occurs due to
forceful localised impact causing
multiple linear fractures radiating
from the site of impact with
depression of the site of impact
where the bone breaks into pieces
.
 Depressed comminuted
fractures are called ‘Fracture
Ala Signature’ , because , like
the signature of a person the
weapon which has caused the
fracture may leave its
impression on the fracture from
which the shape and size of the
striking part of the weapon can
be known .
钉
耙
打
击

粉碎性骨折—碎片最多处
 Thus the depression may be
circular , if the striking surface is
circular , it will be elongated if the
object of impact was an
elongated one . This type of
fracture may occur in case of
primary impact by a vehicle .
 In such a case , from the
size and shape of the fracture ,
part of the vehicle striking the
head can be known . In
homicidal cases , if a hammer
has been used , then that also
can be guessed from the shape
and size of the depressed
fracture .
Pond fracture
 Happening in infant skull.
 Where the bones are not yet fully
calcified and hence are soft and yield
on application of force. Thus, at the site
of impact of the force there is a
depression but there is no cracking
anywhere or there will be very small or
minor cracking.
Suture fracture or sutural
separation
 When the impact is over an wider area
of the head, there may be separation of
the bones at the sutures. In case of
elderly subjects where partial
calcification of the sutures have
occurred there may be fracture in the
line of the sutural obliteration, if similar
impact is applied on the head over an
wider area.
Contre-coup fracture
 When the impact is over the occipital region, then the
force will be directed anteriorly. In case of its path the
force causes vibration. Wherever the force passes
through a thin and weak bone in its path, it may
cause fracture of the bone.THus , in a case of
reasonably heavy impact on the occipital bone,there
may not be any fracture at the site of impact due to
toughness of the occipital bone,but the force , when
passes anteriorly causes frature of the thin orbital
plates of the frontal bone, Mechanism of contre coup
injury to brain is totally different.
Fracture on the anterior fossa
 Fracture at the anterior fossa of the base of
the skull occurs mostly due to an impact in
front of the head. Fissured fracture of the
orbital plates of the frontal bone may occur
due to impact over the occipital bone
posteriorly. If the anterior fossa fracture
extends upto the sinuses, then there is a
chance that this will lead to infection inside
the cranial cavity. It is often the extension of
fracture of the middle fossa
Fracture of the middle fossa
A linear fracture may extend across the
middle fossa including the pituitary
fossa. Such fracture commonly occurs
due to heavy side by side compression.
Middle fossa fracture may extend to the
anterior fossa.
Posterior fossa fracture
 Occur due to the direct impact over the
posterior part of the skull.
Fracture of the mandible
 Due to direct impact. Vertical fractures
by the sides of premolars are the most
common ones.
Fracture of the maxilla
 Itoccurs due to direct impact, when the
face of a person directly gets an impact
with some hard structure like a wall or a
tree, as usually happens in motor-
cyclists, colliding against a wall or a tree
when he is forcefully thrown forward.
INTRA-CRANIAL
HAEMORRHAGES -
 Haemorrhages inside the skull cavity may
occur at different levels and at different sites .
Intracranial haemorrhages may be traumatic ,
or atraumatic (pathological) . When traumatic
in origin , there may be accompanying
fracture of the skull bone . But in many cases
, intracranial haemorrhages may be without
fracture of the skull bone , though traumatic in
origin.
According to the levels , intra-
cranial haemorrhages may be of
the following types –
1. Extradural or epidural
2. Subdural
3. Subarachnoid
4. Intra-cerebral
Extradural haemorrhage –
In most
circumstances ,haemorrhage at
this level is traumatic in nature .
The vessels involved in the trauma
are middle meningeal artery (most
common due to the peculiar site of
involvement ) and dural venous
 The accumulation of blood occurs
most commonly in the temporal region
with fracture of petrous part of the
emporal bone .The blood which
accumulates causes compression of
he brain substance and exerts
 The blood is not encapsulated
and may not be absorbed for over a
long period . Thus chronic cases of
extradural haemorrhage are seen .
Chronic extradural haemorrhage is
more
common on the posterior fossa .
 Extradural haemorrhage may
occasionally occur due to blood
dyscrasias In children .
Fatality is due to compression
effect and timely evacuation of the
blood may save the life of the
patient .
 Subdural haemorrhage is almost
always traumatic in nature .
Traumatic subdural haemorrhage
occurs due to laceration or rupture
of the superior longitudinal sinus
near the debouchment with superior
cerebral vein of the side of impact .
 This causes PRIMARY
SUBDURAL HAEMORRHAGE
when he accumulation of the
blood usually occurs at the
dorsolateral aspects of the
upper surface of either or either
or both hemispheres.
 SECONDARY SUBDURAL
HAEMORRHAGE occurs due to
injury (laceration) of the brain
substance when the primary site
of the haemorrhage is in the brain
substance and the extravasated
blood accumulates in the subdural
space.
 . Evacuation of the primary
subdural haemorrhage gives
good prognosis .
 Secondary subdural haemorrhage
may cause accumulation of blood on
the medial aspects of the occipital
lobes or in the midbrain above the pons
.Secondary subdural haemorrhage may
get encapsulated to form a cyst
,(pachymeningitis haemorrhagica
interna). Prognosis of exploration of the
secondary subdural haemorrhage is
generally grave.
 In the general conception
,subdural haemorrhage is more
common phenomenon in young
adults . when due to trauma ,it
involves victims of almost all ages
and in many cases almost the
whole of the surface of the brain
.Even the base may have
accumulation of the blood .
Subarachnoid haemorrhage –
May be traumatic or natural .When
traumatic it may be primary or
secondary .In primary subarachnoid
haemorrhage the vessels of the
circle of Willis ,anterior cerebral
artery and less commonly the
posterior cerebral artery are
involved .
砖击致蛛膜下出血
砖击致蛛膜下出血
割耳后跳楼致额顶挫伤伴蛛膜下出血
通
奸
女
被
夫
兄
杀
被追捕过程中，硬膜外血肿，蛛膜下出血
 Young and elderly adults
are the usual victims and it is
assumed that even in
traumatic subarachnoid
haemorrhage trauma may
actually be a minor factor in
causing the haemorrhage.
More important is the
condition of the vessels .
 Secondary subarachnoid
haemorrhage occurs due to
contusion and laceration of the
cerebrum, the blood defusing to
the undersurface of the arachnoid
 Natural subarachnoid
haemorrhage is primarily due to
degenerative changes of the
vessels in elderly persons or due to
rupture of congenital aneurysm in
the young ,which usually occurs in
small amount ,mostly near the base
of the brain .
CEREBRAL CONCUSSION
 This being a sequelae of trauma is a
more complicated condition of brain
structure and function than the term
suggest . Literally , cerebral concussion
means a ‘jar’ or ‘shock’ to the brain .
Though that is what actually happens in
cerebral concussion ,there are
something more to consider .
陈旧性挫伤
Its pathological and legal status
have been questioned in many
occasions . Some claim that ,it is a
condition which essentially is a sort
of shock neurosis without any real
pathology or damage to the brain
and the ‘cause’ of the individual
himself alone ,which should not be
linked with any circumstance of
assault or accident.
During post-mortem
examination of these cases ,no
gross or microscopic pathology
could be detected in many of
these cases .
The most constant post-
concussional features are
headache ,dizziness and
nervousness though there may
be other features depending on
the extent of internal pathology .
During autopsy in many cases
,cerebral contusion ,oedema or
minute haemorrhagic spots may be
noticed macroscopically and
changes in the nuclei of the nerve
cells may be observed by
microscopic examination .
Cerebral concussion is more
commonly complained of in impacts
received on the brain due to
sudden deceleration of the moving
head than in an impact received by
a static head .
In cerebral concussion , there may
or may not be any morphological
change of the brain .Though the
condition may have some functional
element in it ,the individual should
not be made responsible outright ,in
spite of the accepted fact that the
condition may be feigned for
extracting certain benefit from a
circumstance of accident or assault
割耳后跳楼致额顶挫伤伴蛛膜下出血