Forensic medicine

Classification of injuries
Dr David Chumba
MBcHB, MMED (human
pathology), Dip. FOR Path

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Outline
Traumatology:
– Wounds
– Asphyxia
– Thermal, electrical and radiation injuries
– Firearm and explosion injuries
– Transportation injuries
Clinical forensic medicine
– Domestic violence
– Sexual offences
– Medicolegal aspects of drugs and poisons including alcohol
– Torture and custody related deaths
Forensic pathology
– Examination of the scene of death
– Autopsy
– Death and post mortem changes
– Sudden un expected deaths
– Human identification
– Mass disasters
– Forensic odontology
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Definitions: An injury is damage to the body
caused by application of force (violence). A
wound occurs when the force applied to the
body is greater than body’s ability to absorb
safely
Injury may be due to mechanical, chemical or
physical factors

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Medicolegal classification of injuries

Mechanical injuries
– Bruise ( contusion )
– Abrasion
– Wounds:
Lacerated wound
Incised wound
Stab wound
Fire arm wounds
– Fractures 4
Thermal injuries:
– Cold injuries include frost, trench foot and
immersion foot
– Heat include burns and scalds
Injuries due to electricity, lightning, x-rays,
radio active substance etc
Chemical injuries
– Corrosive acids
– Corrosive alkalis
An injury due to a mechanical force is the result
of an applied force evoking a counter force by
which energy is transferred to the body tissues,
causing change in their state of rest or motion. 5
Excessive energy results in a wound. The nature and
extent of the injuries depends on,
– Nature of object causing wound
– Amount of energy discharged
– Nature of affected tissue
– Condition of the target hence a blunt injury to the scalp is
different from that which affects the stomach
Determinants/factors that determine the nature and
extend of wounds are mainly four factors:
– Nature of instrument used: Sharp injury will result in small
area focal point or a line, so depending on the amount of
force the injury can be deep and penetrating to deeper
tissues. Blunt object will affects a relatively large area hence
the damage is less e.g. the flat surface of a ruler causes less
injury than the sharp edge. The consistency of the
instrument e.g. Wood or stone and rubber ball will affect the
severity of the injury
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– The amount of energy discharged: This is known as kinetic
energy and KE= 1/2mv^2 where m is the mass of the object
in kilogram's, v is velocity in meters per second. This kinetic
energy is discharged at once when the object hit the body. If
the body is free and moves on impact reduces the amount of
energy dissipated. If the time it takes to release the energy is
increased, the destructive effects of the energy is reduced
e.g. catching a cricket ball with movement of the arm in the
same direction
– Nature of the affected tissue and shearing force: Skin is
elastic and firm and strongly resistant to shearing forces
hence a blunt force may not damage the skin though severe
injury may be inflicted to the underlying tissues.
Subcutaneous connective tissue. This contain fat and
protects the body by its cushioning effect. Bones will fracture
when the elasticity limit is reached due to it rigid structure.
Body fluid are incompressible hence can cause rupture of
vessels at distant sites
– Condition of the target e.g. presence of protective clothing,
thickness of the scalp, physique, age of the victim old and
fragile/young and healthy
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Mechanical injuries

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 Abrasion
Is a blunt force injury that involve loss and
damage of the superficial epithelial layer of the
skin only
May be caused by compression of superficial
layer of skin, or by friction against some rough or
sharp surface that scraps away the epidermis
Since only epithelial layer involved, healing is
rapid and complete without scar formation

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 Types of abrasion
1. Scratch – refer to linear abrasions e.g by
fingernail. A tag of skin seen at the end.
2. Graze/brush – caused by lateral rubbing
movement. See heaps of skin tags at the end.
3. Friction abrasion – localised forces passing
linearly over the skin e.g ligature mark in
hanging or tramline abrasion of a whip
4. Imprint/impact abrasion – caused by the skin
being crushed by force perpendicular to skin

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 Age of abrasion
Appearance Duration
Bright red Fresh
Scab formation 12 – 24 hrs
Scab is reddish brown 2 -3 days
Epithelium covers defect 4 – 7 days
Falling of scab After 7 days
Medicolegal aspects of abrasions:
1. An abrasion indicates that a force has been applied at the site of injury
2. The direction of the applied force may be inferred from the way the epidermis is
grazed
3. allow inferences to be drawn about the nature and shape of the object used
4. Aging of abrasion can determine the time of injury
5. The type of asault can be inferrede from the type of abrasion e.g. finger nail
abrasion on the neck indicate strangulation
6. Foreign material found at the site of injury may provide clues of the object used
e.g. paint flakes or clothing fibres
7. Post mortem lesions must be distinguished from ante mortem, the post mortem
are leathery, dry, irregular and found at moist skin folds

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 Bruises or contusions
Is a form of blunt injury in which there is extravasations of
blood into soft tissue spaces due to breaking of blood vessel
walls. Results in discoloration of skin and soft tissues. No
discontinuity of skin.
The extent of bruising depends on amount of force applied to
the area and the type of tissue injured
Types of bruises:
1. Impression- bruise reflects the type of object that caused it
2. Peri-orbital hematoma (black eye) – bruises of and around
the eyelid due to direct or indirect force
3. Tramline – 2 parallel bruise lines caused by a longitudinal
object
4. Bite marks
5. Self-defense bruises – on the back of fingers, knuckles and
forearm/elbows
6. Iatrogenic 12
Forensic/medicolegal importance of bruising
– Generally they indicate blunt trauma but spontaneous hemorrhages
must be ruled out, the presence of associated abrasions and lacerations
indicate a traumatic etiology. The bruising may be pin point (petechie),
medium sized (echymosis) or large referred to as hematoma
– The extent depend on age ie old people brusie more easily than young
people and women more than men
– Shape e.g. tram line indicates ruler, stick or sjambok
– The determination of age of bruises may indicate the time of injury
– Careless dissection of the neck in case of hanging causes artefactual
bruising hence the need for a special procedure (bloodless neck
dissection)
– antemortem brusing should not be confused with post mortem lividity or
hypostasis, histology is confirmatory
– The site of the bruise may not be the site of injury as blood may move a
long facial planes e.g. Black eye may be seen fracture of the base of the
skull
– Contusion is synonymous with bruises but refers to internal organs

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 Age of bruises
Colour Age
Red Fresh
Blue Few hrs-3 days
Black-brown 4 days
Green-yellow 4 – 12 days
Normal 2 weeks

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 Lacerations
Are injuries that produce tearing of skin and subcutaneous tissues with
edges torn, jagged and irregular. Caused by blunt force, the tissues are
stretched to the point of tearing or splitting. It may be superficial or deep
Characteristic of lacerated wounds:
1. Wound margins are irregular
2. Deeper tissues are also torn
3. May occur without any external wound
4. Shape of injury doesn`t correspond to the weapon used
5. Bruises in the tissue around the wound
6. Foreign bodies like sand, grass can be found in the wound
7. Chances of infection more
8. Tissue bridges within the wound
– Special types of lacerations. Scalp lacerations may appear like incised wounds
only distinguished by above features
– Stretch tears are special laceration caused by stretching the tissue e.g. skin
over the hip
– Degloving or avulsion injury may appear like peeling off of the skin with
exposure of soft tissues
– Decollment injuries occur when the skin and subcutaneaous tissue move over
each other, forming a cavity filled with blood and fatty tissue without overlying
skin being open
– Hook lacerations 15
 Medicolegal importance of lacerations:
 This point to a blunt force trauma
 In the scalp lacerations may mimic incised wounds
 Lacerations of the lip may be due to fall or a fist of an
assailant
 Wounds by sharp objects: Cause incised wounds
with well defined edges – cutting or stabbing.
Wounds may be linear, curved or V-shaped.
 Characteristics of incised wounds
1. Sharply outlined edges
2. Absence of abrasion or bruise around the wound
3. No bridging strands of tissue
4. No foreign material
5. Bleeds profusely
6. No loss of hair around the wound
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 Medicolegal significance of incised wounds:
 Incised or penetrating wound indicates sharp force trauma
 The site and appearance may indicate e.g. defense wounds
suicide appear on the wrists, defense wounds on hands and
forehands
 Homicidal wounds are found on the chest, scalp, back,
abdomen while defense wounds are mainly found inside of the
palm, the fingers and the forearm
 In suicides the incisions are found on accessible areas neck,
wrists, antecubital surface, usually multiple with tentative pre
incisions called hesitation cuts. The incisions are not made
through the clothing unlike in homicide
 The surface size of an cut wound may not indicate the
seriousness of the injury e.g. a prick by a bicycle spoke on the
abdomen needs laparatomy as it may perforate small and
large gut
 Sarounding bruise indicates that the thrust was upto the hilt of
the knife
 17
Complications associated with injury:
Local include:
– Hemorrhage, primary, secondary or reactionary
– Infection. This may result in systemic infection seen as septicemai, pyemia. Gas
gangrene and tetanus are well known complications

Systemic:
– Shock syndrome: This is a syndrome resulting from inadequate perfusion of the
tissue leading to multiple tissue injury and later failure. It is classified as
cardiogenic or hypovolemic shock. Loss of 10% (500 ml) is tolerated, while 10-
20% 500-100 ml can be tolerated if the compensatory mechanism is intact. 30%
causes peripheral circulatory failure and rapidly fatal.
– Effects of shock. The effects of shock is mainly seen in the brain heart lungs and
kidneys. This is seen as ischeamic changes on areas of selective vulnarabilty
e.g. purkinje fibres of cerebellum, Sommers sector of hippocampus and neurons
of watershed areas (areas of brain between adjacent arterial blood supply).
– The heart findings include subendocardial hemorrhage and necrosis
– The lungs show shock lung characterised by diffuse alveolar damage or ARDS
– The kidneys show acute tubular necrosis
– The GIT show Cushings ulcers or mucosal hemorrhages
– The adrenal show lipid depletion and liver shows centrilobular necrosis and fatty
degeneration

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 Embolism is defined as intravascular solid, air or liquid that is
carried in the blood stream. Classified as:
 Thrombo-embolism, most common and is a complication of injury. This
clotting of blood in the blood vessels during life. Related to being
immobilised, direct trauma to blood vessels. They can cause sudden
death when saddle emboli or small pulmonary emboli causes
pulmonary hypertension

 Air embolism occurs if a large vessel is damaged as in the neck, or

iatrogenic
 Amniotic fluid embolism: Due to prolonged labour or dificult labour
resulting pasage of amniotic fluid and its components into veins, and
cause death by acusing anaphylaxis aor DIC
 Fat embolism: Fat enter veins and transported to the lungs. This is
common after traumatic injury to bones, burns and non-traumatic
causes like pancreatitis, osteomyelitis and eclampsia
 Foreign body embolism: Foreign bodies include pellets of drugs,
microbes like parasites etc

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Regional injuries: Will not be covered read as
you had been taught
– Head
Scalp injuries, fractures of the skull, contsions,
diffuse brain injury, extradural, subdural,
subarachnoid and intracerebral hemorrhages. Brain
swelling, features of raised intracranial pressure,
hypoxic brain injury
– Abdominal injuries
Blunt and penetrating injuries
– Injuries to the limbs
– Thoracic injuries
Immediate life threatening injuries e.g. tension
pneumothorax, open pneumothorax, massive
hemothorax, flail chest including mechanism of death
in chest injuries
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Asphyxia:This is defined as interference with
respiration or interference with ability to breath.This
definition includes all modes of death including anoxia
resulting from any cause. The better definition should
therefore include the cause of anoxia e.g. chocking,
strangulation, or carbon monoxide poisoning
Classical signs of asphyxia:
– Cyanosis: This occurs after 5 g of reduced hemoglobin per
100 ml of blood irrespective of the total amount of blood
– Petechial hemorrhages, arising in the skin, the sclera,
conjunctiva and serous membranes
– Visceral congestion, this is due to decreased venous return
and may lead to edema and hypoxia leading to increased
permeability
– Post-mortem fluidity is due to fibrinolysis after as part of
decompensation process
– Right sided cardiac dilatation is non specific finding in people
dying of asphyxia 21
Mechanism of death in asphyxia: There are six
possible mechanisms of death in mechanical
asphyxia:
– Airway occlusion
– Occlusion of neck veins will lead to reduced blood to the
right side of the heart and manifests as facial congestion and
petechial hemorrhages
– Occlusion of neck arteries: This is more difficult and rare
– Neural effect: The pressure on the baroreceptors in th
carotid sinus will lead to reflex bradycardia or asystole
– Cervical spine injury: Usually damage to the brain stem
– Combined mechanism:
Classification of asphyxia: Divided into three broad
categories:
– Environmental: High altitude
– Mechanical e.g. obstruction of the airway
– Toxic. This is replacement og oxyhemoglobin by carbon
monoxide, depression of the CNS by alcohol or narcotics
and interference by cytochrome oxidase by cyanide 22
Mechanical asphyxia:

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Types of asphyxia:
– Vitiated atmosphere, this refers to high altitude, lack of oxygen in a
closed truck etc
– Smothering: The refers to external blockage of the air ways by hands,
pillows, plastic bags etc
– Chocking: This refers to blockage of internal air passages by foreign
objects such as food, dentures etc
– Manual strangulation (throttling): This refers to application of force
usually by hands or forearm on the neck
– Ligature strangulation: This refers to the use of a rope cord or wire to
constrict the neck
– Hanging: constriction of the neck by a ligature in which it is tightened by
down ward pull of the bodies mass
– Sexual asphyxia: This refers to deprivation of oxygen to heighten sexual
gratification during masturbation by use of ligature, or plastic bag,
although it looks like suicide, this deaths are accidental
– Traumatic asphyxia: This refers to fixation of the chest by a heavy object
eg. Sand, car atc which restrict breathing
– Drowning: Deaths that occur as a result of partial or complete immersion
of the body in water or another liquid

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Drowning: 85%-95% die of water inhalation referred to as wet
drowning. The mechanism is inhalation of water resulting in
respiratory tract inhalation, hypoxia due to interference of the
alveolar-capillary air-blood interface
The other 5-15% get a reflex laryngeal spasms due to
unexpected entry of water into the larynx
Autopsy findings after drowning: They are not specific hence it
considered as one of exclusion. Suggestive features include:
– Post mortem lividity is usually marked on the face, head and neck, this is
because bodies immersed in water will float head down
– Cutis anserina or goose flesh is spasms of erector pilae muscles
– Whitening and wrinkling of the skin referred to as washer woman
appearance
– Peeling of the epidermis is seen in prolonged immersion in water
– Mastoid air cell hemorrhages are seen as bleeding form the ears

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Thermal, electrical and radiation injuries:
Burns: classification is based on type or cause e.g. flame,
contact, chemical, electrical, radiation and inhalation
Also classified based on severity of burns: first degree limited to
the epidermis, second degree invoves all the epidermis and
part of the dermis, third degree and fourth degree (where there
is charring of the body)
Factors influencing the severity of burns: This include the
surface area affected, cause and intensity of the heat source,
the duration of the exposure, site of the burn, age of the victim
(y and elderly) and prior physical condition or concomitant
injuries
Identification of charred bodies: This is based on the
radiological studies prosthesis artificial hip, pace maker etc,
teeth antemortem records of dental work can be compared with
post mortem, stigmata e.g. congenital abnormalities, scars,
absent organs, prosthesis, clothing fragments of clothing are
found under the arm pits or hidden areas, finger prints and
intrenal viscera e.g. the presence of prostate or uterus 26
Determination of whether dead or alive at the time of
fire
– Carbon monoxide level should be measured the upper limit
of normal is 10% values greater than 10% person indicate
that the person was alive at the time of the fire
– The presence of smoke ash, soot, or other products of
combustion in the air ways lungs etc
– Demonstration of pulmonary fat embolism indicates the
circulation was intact during the burns
Electrical injuries: The cause of death are mainly four:
– Ventricular fibrillation due to passage of current through the
heart muscle
– Respiratory muscle paralysis due to spasms of the
diaphragm and costal muscles
– Brainstem paralysis causing respiratory failure
– Associated injuries such as thermal injuries 27
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The firearm discharge residue consist of the following:
– Primer which contains lead, antimony and barium
– Powder consisting of nitrocellulose, nitroglycerine (grease
wipe)
– Projectile which is made of lead, copper and iron
– Cartridge made of copper, zinc, nickel
– Barrel made of iron and oil
Firearm injuries: Types of fire arms
– Rifled firearms
Hand guns e.g. pistols and rivolvers
High velocity riffle e.g. R1, R4/5 and AK47
– Smooth bore firearms (short guns)
– Home made fire arms
– Fire arms that fire rubber bullets and plastic bullets, tear gas
– explosives
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