MEDICOLEGAL ASPECTS OF PHYSICAL INJURIES Physical Injury effect of some forms of stimulus on the body Causes: A.

. Physical Violence B. Heat or Cold C. Electrical energy D. Chemical energy E. Radiation by radioactive substances F. Change of atmospheric pressure (Barotrauma) G. Infection A. Physical Violence - Effect: production of wound - Wound: disruption of the anatomic integrity of a tissue of the body - Effect of PI may not always be wound but the wound is always an effect of PI Physics of wound production: Wound = kinetic energy x time x area x other factors Kinetic energy = Mass x (velocity)2 2 Kinetic energy - Velocity is the most impt factor - Ex. M-16 bullet (v=3,200ft/s) do more damage than a 0.38 caliber bullet (heavier but slower) Time - The shorter the time needed for energy transfer, the greater the likelihood of producing damage - The longer the time of contact between the object causing injury, the greater will be the dissipation of energy - Ex. If a person hit moves towards the direction of force, injury is less than when in stationary position. Area of transfer - The larger the area of contact between force applied on the body, the lesser is the damage to the body - Ex. Stabbing has greater damage than a blunt injury Other Factors: 1. Elasticity and plasticity - Ability to return to its original size and shape after being deformed by pressure - Less elastic or plastic, the greater is the laceration 2. Movement of body parts - Resulting from force applied cause local stretching causing acceleration and deceleration - Cause most internal injuries 3. Force most transmitted through a tissue with fluid - Pushes fluid in all directions causing laceration Vital Reaction - Sum total of all reactions of tissue or organ to trauma Inflammatory Signs/Reactions of tissue to trauma 1. Rubor 2. Calor 3. Dolor 4. Tumor 5. Functio Lassa It may not be observed in: 1. PI inflicted during agonal state because of loss of potential capacity to react to trauma 2. If death is so sudden, no time to react to trauma Ex. Coronary occlusion Classification of Wounds: A. As to severity 1. Mortal wound - Immediately after infliction capable of causing death F. G. a. Heart and big blood vessels b. Brain, upper part of spinal cord c. Lungs d. Stomach, liver, spleen, intestine Non-mortal wound - Not capable of producing death immediately

2. B.

As to the kind of instrument used 1. Blunt instrument - Contusion, hematoma, laceration 2. Sharp instrument a. Incised wound sharp-edged b. Punctured sharp-pointed c. Stab wound sharp-edged and sharp-pointed 3. Tearing force laceration 4. Change of atmospheric pressure (barotraumas) 5. Heat or cold (frostbite, burns or scald) 6. Chemical explosion (gunshot or shrapnel wound) 7. Infection As to the Manner of Infliction 1. Hit bolo, blunt instrument, axe 2. Thrust/Stab bayonet/dagger 3. Gunpowder explosion projectile or shrapnel wound 4. Sliding/Rubbing/Abrasion As regards to Depth of Wound 1. Superficial inner and outer skin layers 2. Deep beyond the layers of the skin a. Penetrating - Enters but didnt come out - Impt factors: depth and direction - Ex. Punctured, stab and gunshot wounds b. Perforating - Produces communication between inner and outer portion of hollow organs - Piercing/traversing completely As to the relation of the site of application of force and location of injury 1. Coup Injury at the site of application of force Ex. Stationary head is hit by a moving object 2. Contre coup opposite the site of application Ex. Moving head hits a firm, fixed object 3. Coup-Contre-Coup at the site and opposite Ex. Stationary head is hit by a moving object and falls on another hard object 4. Locus Minoris Resistencia - At another site aside from coup and contre-coup that has least resistance to force Ex. Blow on forehead contusion 5. Extensive greater area of the body beyond site of force Ex. Fall or run-over victim (VA) - Not only wide area but also with varied types of injury As to the regions or organs of the body involved Special Types of wounds 1. Defense wound - Result of self-protection Ex. Hit by a blunt instrument on head raise forearm Stabbing a person injury to the palm 2. Patterned - In the nature and shape of an object or instrument and which infers object or instrument causing it Ex. Imprint of radiator grill on face Tire marks on the body

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Rope marks on the neck Self-inflicted - No intension to end his life Motives: a. To create or magnify deliberately an existing injury for pension or compensation b. To escape certain obligations or punishment Ex. Soldiers cut fingers to prevent frontline assignments Prisoner may inflict injury to avoid hard labor or be confined in the hospital c. To create a new identity or destroy the existing one d. To gain attention or sympathy e. Psychotic behaviour

Slight PI 1. incapacitate for labor requiring medical attendance 1-9 days 2. didnt prevent him from engaging in his habitual work or which didnt require medical attendance (small contusion or superficial abrasion) 3. ill-treatment of another by deed without causing any injury (slight slap on face or holding tightly the arm of victim which didnt develop redness; tender slap) Tumultuous Affray 1. with tumultuous affray 2. participants with serious PI 3. persons who inflicted serious PI cant be identified 4. penalized by arresto from 5-15 days Types of Wound (Medical Classification) 1. Closed wound no breach of continuity a. Superficial underneath the skin or membrane 1) Petechiae 2) Contusion 3) Hematoma b. Deep 1) Musculoskeletal sprain, strain, dislocation, fracture, strain, subluxation 2) Internal hemorrhage 3) Cerebral concussion 2. Open wound - Abrasion, incised, stab, punctured, lacerated Petechia not always a product of trauma Contusion - Effusion of blood into tissues underneath the skin on account of the rupture of blood vessels as a result of application of blunt force or violence - May develop after a few minutes or hours - Contusion is usually greater than the size of object causing it - May indicate the shape of the object, extent may suggest possible degree of violence and distribution may indicate the character and manner of injury Age of Contusion: Red purple green (4-5 days) yellow (7-10 days) disappear (14-15th day) *Color change starts from periphery inwards Factors influencing degree and extent 1. General condition = some are easily bruised 2. Part of the body affected - Bloody parts produce larger contusion - Bruising easily in areas with excessive fat 3. Amount of force applied - Greater force=more effusion 4. Disease even without force 5. Age - Children=loose and tender skin - Old=less flesh and fragile blood vessels 6. Sex women esp. Obese 7. Application of heat and cold - After injury=cold - After contusion develops=warm Hematoma - extravasation of blood in a newly formed cavity underneath the skin

Some ways of self-mutilation 1. Head banging or bumping OA children 2. Exposure of body parts to heat radiation (thermophilia) 3. Penetrating nail or spike to the chest wall 4. Castration by amputation of penis 5. Trauma on female genitalia to induce abortion 6. Subcutaneous injection of fecal matter to promote infection 7. Nail-biting (onychophagia) 8. Grinding of teeth (bruxism) 9. Tribal customs of metal band around the neck or leg 10. Pulling of body hair (trichotillomania) Mutilation - Act of cutting off any part/s of the living body - Intentional or else its PI *Loss of an eye due to accidental stabbing not mutilation *tubal ligation and vasectomy Mayhem - Unlawful and violent deprival of another of the use of a part of the body to render him less able in fighting - Mutilation of other parts other than the organ of reproduction Serious PI 1. wounding, beating, assaulting or administering injurious substances without intent to kill 2. maybe through simple negligence or imprudence 3. may become insane, imbecile (pre-adolescent or arrest in mental devt), impotent (inability to grant sexual gratification), blindness may be total or both eyes 4. nature and character of wound or consequence 1. loss of use of speech, hearing, smelling, or loss an eye, a hand, a foot, an arm and a leg 2. becomes incapacitated for work 5. consequences: 1. deformity permanent physical ugliness, conspicuous (loss of teeth, front scar) 2. loss of use 3. becomes ill or incapacitated for work Administering injurious substances or beverages Elements: 1. there is serious PI 2. knows the effect of substance to be injurious or took advantage of victims weakness 3. no intent to kill *throwing of acid on face not serious PI *if intentional = frustrated murder Less Serious PI 1. incapacitate for labor requiring medical attendance 10 days or more but not more than 30 days Ex. Absence of proof although wound healed in more than 30 days = slight PI

Distinction Between Contusion and Hematoma Contusion Hematoma In interstices of tissue In newly formed cavity underneath skin underneath the skin No elevation of skin or slight Always elevated because of inflammation No blood can be aspirated With presence of blood Musculoskeletal Injuries 1. Sprain - partial or complete disruption in continuity of a muscular or ligamentous support of a joint; caused by a blow, kick or torsion force 2. Dislocation displacement 3. Fracture discontinuity of bone a. Closed/Simple b. Open/Compound c. Comminuted d. Greenstick e. Linear f. Spiral g. Pathologic caused by weakness of bone due to disease 4. Strain overstretching 5. Subluxation incomplete/partial dislocation Internal Hemorrhage - rupture of blood vessels due to: 1. traumatic intracranial hemorrhage 2. rupture of internal organs 3. laceration of other parts of the body Cerebral Concussion (Commotio Cerebri) - jarring/stunning of brain characterized by suspension of its functions as a result of head injury - Ex. Moving head hits a fixed hard object is more severe than head is fixed and struck by a hard moving object S/Sxs: unconsciousness; muscle relaxed and flaccid; eyelids closed and conjunctivae insensitive; pale, cold, clammy body surface; respiration is slow and shallow; pulse is rapid, weak; temp is subnormal; sluggish reflexes Retrograde amnesia loss of memory for events just before injury - A constant effect of concussion Open wounds 1. Abrasion (Scratch/Graze/Impression Mark/Friction Mark) - Removal of superficial layer of skin caused by a rub and friction against a hard, rough surface - Exudes blood and lymph; forms scab or crust - Parallel linear injuries in line with direction of rub or friction - May exhibit pattern of wounding material - Usually ignored - fingernails = struggle or assault on face, neck, forearms, hands - located on bony parts with associated contusion and laceration - may infer degree of pressure, nature of rubbing object and direction of movement - heals in a short time and leaves no scar Forms: a. Linear pinching, sliding the point of a needle b. Multilinear often in VA c. Confluent linear marks are almost indistinguishable d. Multiple several abrasions in different parts of the body Types: a. Scratch - sharp, pointed object sliding across skin - commencement and termination are well-defined and depth depends on pressure - fingernail scratch may be broad at point of commencement and may terminate with a tailing

b.

c.

1) 2) 3) 4) d.

Graze - Forcible contact with rough, hard objects resulting to irregular removal of skin surface - Clean commencement and tags on the end Impact or Imprint (Patterned/Stamping/Abrasion A La Signature) - Pattern and location provide evidence to show cause, nature of wounding material and manner of assault or death Marks of radiator grill Tire marks Muzzle imprint in contact fire gunshot wound of entrance Teeth impression mark in skin bites Pressure or Friction - Pressure accompanied by movement - Hanging or strangulation (spiral strands of rope) Ante-mortem Reddish-bronze Any area Post-mortem Yellowish and translucent Over bony prominence elbow due to rough handling of cadaver (-)

Color Location

Vital reaction (+) 2. Incised Wound (Cut/Slash/Slice) - Sharp-edged (cutting) or sharp linear edge (knife, razor, bolo, glass, metal sheet) - May be Impact Cut (force) or Slice Cut (pressure + movement) Chopped/Hacked Wound heavy, cutting instrument like axe, big bolo, saber Characteristics: a. Edges are clean-cut except when skin is loose or folded at the time of infliction b. Straight c. Usually shallow near extremities and deeper at middle d. Profuse hemorrhage e. Gaping due to retraction but depends on the direction of incised wound with the line of cleavage (Langers line) f. Clothing will show clean-cut g. Without complication; healing is relatively fast and scar may or may not develop conspicuously h. Wound caused by broken glass may be irregular and may appear like a punctured or stab wound; particles may be present in the wound Complications Deep incised wound fracture blood vessels severed (hemorrhage) and cut nerves (paralysis) death Reasons for Incised Wound a. Therapeutic procedure b. Self-defense c. Masochistic d. Addicts and mental patients Types a. Suicidal - In peculiar parts of the body (neck; flexor surfaces of extremities elbow, groin, knee, wrist) and accessible to the hand inflicting injury - Most common instrument: razor blade - Usually with hesitation cuts - Most common sites: wrist (radial artery), neck b. Homicidal - Deep, multiple, involve both accessible and non-accessible parts - Defense wounds may be present - Clothings are always involved c. Accidental - VA, in kitchen

Direction Severity Superficial cut Position of body Wounding weapon Blood distribution Motive

Suicidal Oblique, below L ear, downwards across neck just above Adams apple Usually not so deep (trachea, carotid, esophagus) Usually present before doing the deeper wound May be sitting facing a mirror or standing Firmly grasped (cadaveric spasm) or found beside victim In front of body and hand Hx of mental depression may prove suicide May be present

Homicidal Horizontal below Adams apple Usually deep (bones and cartilage) Practically absent; may rarely be present if with struggle Usually lying on bed or other place Weapon is absent At the back of neck; hands are clean Absence of such hx

Previous hx Absent of suicide 3. Stab Wound - Sharp-pointed and sharp-edged instrument - Diameter of wound reflect width of instrument - It may be made wider if withdrawal is not on the same direction or because of slashing movement - Double-bladed=sharp sides/extremities - Single-bladed=1 rounded and contused - Direction of surface defect for determining possible position of offender and victim - Depth influenced by size, sharpness, area of body and force - Tapered end may remain in the body - Hemorrhage=always the most serious consequence of stab wound Note: a. Length of defect must be coaptated before length is measured not including abrasion tailing which tells the direction of withdrawal b. Condition of extremities c. Condition of edges Single stab = clean cut Several stabs = edges are serrated or zigzag d. Linear direction of wound surface e. Location f. Direction of penetration must be 3D g. Depth h. Tissues and organs involved Suicidal Homicidal Over vital parts of the body Injuries other than stab wound may be present Usually solitary In any part of the body If multiple, located on 1 part only On covered parts, clothings Usually multiple not involved If accompanied with slashing With motive; if w/o motive, movement, the wound tailing offender must be insane abrasion is seen towards the hand inflicting the injury Suicide note may be present With disturbance in crime scene No disturbance in death scene Medical evidences showing intent to kill a. Multiple stab wounds b. In different parts or n parts where vital organs are located c. Deep d. Serrated or zigzag borders (alternative thrust and withdrawal to increase damage)

Irregular or stellate shape due to changing direction at the level of the skin as the lever *Different measurement of stab wounds may be produced by one weapon if its tapering towards the sharp point *Hemorrhage is the most common immediate cause of death *Accidental stab wounds rare; falling against a projecting sharp object like broken glass 4. Punctured wound - From thrust of a sharp, pointed instrument - External injury is small and depends on the sharpness and shape of the end of the wounding instrument - Wound opening may vary depending on the cross-section of the instrument which may be appreciated on flat, hard parts of the body especially the skull - External hemorrhage is quite limited but internal injuries may be severe - Opening can easily be sealed off by dried blood so anaerobes can grow inside (tetanus) - Usually accidental but may be homicidal or suicidal - The wound is much deeper than it is wide Puncturing instrument with poison a. Poison dart = cyanide b. Fish spines c. Dog bites = with virus (rabies) d. Injection of air or poison 5. Lacerated wound (Tear/Rupture/Stretch/Putok) - Due to forcible contact with blunt instrument - Shape and size of injury do not correspond to the wounding instrument - Usually on areas where bones are located superficially (scalp, malar region, shin bone, dorsum of the foot) - Under hand lens, it shows bridging tissue joining edges - Bleeding is not extensive because blood vessels are not severed evenly - More tendency to develop scar - May be homicidal or accidental but rarely suicidal (Ex. Hitting head on wall) Incised Lacerated Edges are clean-cut, regular, Roughly cut, irregular, illwell-defined defined No swelling or contusion around With swelling and contusion incised wound Under lens, hair bulbs are cut Intact hair bulbs Healing is faster Delayed Scar is linear Irregular Caused by sharp-edged Caused by a blunt instrument instrument Fatal Effects of Wounds 1. Directly fatal a. Primary hemorrhage immediately after trauma b. Mechanical injury to vital organs c. Shock disturbance of fluid balance 2. Indirectly fatal a. Secondary hemorrhage delayed b. Specific infection tetanus c. Scarring effect causes structures to vital organs (ex. lungs) d. Secondary shock Embolism foreign substance causing sudden block to blood flow - Most common: fat and air Regenerates rapidly: 1. Connective tissues 2. Blood-forming tissues 3. Skin Limited capacity or no power to regenerate: 1. Muscle 2. Neurons

e.

Factors affecting healing: 1. Vascularity 2. Age of person 3. Rest and immobilization 4. Nature of injury Determination whether wounds were inflicted during life or after death: 1. Hemorrhage profuse during life 2. Signs of inflammation 3. Signs of repair - Fibrin, scab or scar formation during life - Absence may still be during life because tissue may not have been given ample time to repair before death took place 4. Retraction of wound edges - Retraction and gaping of wound during life - Wound edges are closely approximated after death Ante-mortem wound Post-mortem wound Clotted blood Not clotted but if clotted it is only a soft clot Deep staining of edges and Stains can be removed by tissues not removed by washing washing *Suicidal wounds are frequently due to sharp instruments but homicidal and accidental wounds may be of any kind Healing of wound *small clean-cut wound - covered with lymph in 36hrs - edges adhere in 2 days - heals on 7th day with scar *large incised wound 8-12 hrs = swelling of edges 2 days = blood-stained serum 3 days = seropurulent discharge 12-15 days = red granulation tissue After = scar develops *If the fatal wound is inflicted first in a treacherous way rendering victim incapable of defense, then murder is committed. *If fatal wound was last, homicide may be possible. Physical Injuries in Different Parts of the body 1. head Factors affecting the degree and extent of head injuries: a. nature of instrument *weapon with small striking phase may cause depressed fracture with laceration of scalp which depends upon the degree of violence applied, thickness of scalp and weight of weapon *penetrating injuries of the skull like those caused by dagger, nail, bullet, leave a clean-cut opening with the shape or size of the weapon *glancing hit of a bullet may cause a gutter-like depression on the skull b. intensity of a force force = degree of damage - less force required to produce injury to the temple - heavy weapons may require less force c. point of impact d. mobility of skull mobile = contusion, laceration or hemorrhage to brain w/o any fracture of skull fixed = jarring movement of brain is absent but fracture is extensive 2. face - wounds heal relatively faster due to greater vascularity - always life-threatening because it may cause ugly scars, deformities and because of proximity to the brain 3. vertebrae dangerous; may cause paralysis etc 4. lungs hemorrhage = 1.5L

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atelectasis = lung collapse severe pneumothorax = air in the pleural cavity hemoptysis = coughing out of blood subcutaneous emphysema = air under the skin heart - ventricle injuries less serious than atrium because of thickness - R ventricle is the most common site of wound because it is the most exposed part of the heart - Wounds of the aorta and pulmonary vessels are rapidly fatal Abdominal injuries - Triangle bounded by ribs and at the level of umbilicus is vulnerable to trauma in any direction because of the blood vessels a. Stomach - Blunt force may cause bruising and rupture - Pylorus and greater curvature of stomach are most frequent sites of rupture b. Liver - One of the most vulnerable organs because of its size, weight, location, friability and fixed position - R lobe more frequently involved than L due to size and location c. Intestines d. Spleen e. Kidney - R kidney is more prone to injury f. Pancreas g. Extremities

Thermal Injuries and Deaths From cold Local Effects (Forstbite/Trench foot) a. Blanching and paleness of the skin b. Erythema, edema, paralysis c. Blister formation d. Necrosis, vascular occlusion, gangrene Systemic Effects a. Slowing down of respiration, heart and metabolic processes b. Blood is fluid in the heart and blood vessels c. Audible cracking sound of extremities d. Body fluid evaporates slowly e. Tissues and organs are well-preserved II. From heat 1. General/systemic effects a. Heat cramps - Involuntary spasm, painful muscle contraction due to dehydration or excessive loss of chlorides from sweating - Face is flushed, pupils dilated with tinnitus and abdominal pain - Relieved by fluids and saline solution b. Heat exhaustion (heat collapse/Heat syncope) - Heart failure due to heat - Face is pale, skin is cold - Pupils dilated, weak pulse c. Heat stroke (sunstroke) - Headache, muscle weakness - Temperature suddenly rises, skin is dry with burning sensation, complete cessation of sweating - Face is congested - Pulse is full and pounding - Pupils contracted - Death after to 1 hour after onset of symptoms I. Local effects of Heat: 1. Scald - Caused by hot liquid - geographical lesion

2.

- May be in covered parts w/o affecting clothings - No burning of hair or carbon deposits - Redness and blister Thermal burns - Dry heat

Purposes of Intentional Fire: a. Destruction of victim to conceal identity and cause/manner of death b. To kill or with homicidal intent c. To perpetuate insurance fraud both property and life d. Victim might have been trapped in the building may set a fire e. In pursuance of a cause by burning himself to death Types of Burns: a. Thermal b. Chemical c. Electrical d. Radiation e. Friction Degree of Burns: a. Partial thickness 1) 1st degree = epidermis; dry and painful (sunburn) 2) 2nd degree = epidermis + upper part of dermis - Blister, painful, wet b. Full thickness 3) 3rd degree entire thickness - Painless; involves nerves; eschar Factors Affecting Burns a. Degree of heat applied heat = injury b. Duration of exposure or contact exposure = injury c. Extent of surface involved >1/3 of 2nd and 3rd degree = fatal d. Portion of body involved - Genital, lower abdomen, head, neck and trunk = serious e. Age of victim f. Sex of victim - Men can resist burns better than women g. Septic infection h. Depth of burns Causes of Death in burns and Scald a. Immediate fatal result 1) Shock 2) Physical injury 3) Suffocation b. Delayed 1) Exhaustion 2) Dehydration 3) 2 shock 4) Hypothermia 5) Complications: infection *In a gas furnace incinerator, it takes about 4 hrs of continuous heat to transform body to ashes. Proofs that the victim was alive before burned to death a. Presence of smoke in the air passage b. Increase carboxyhemoglobin blood level - CO = cherry-red color c. Skin redness, edema, vesicle formation d. Subendocardial left ventricular hemorrhage

Postmortem findings: a. Eternal 1) Pugilistic position or fencing posture 2) Blackening of body surfaces 3) Rupture of skin, muscle, limbs, skull 4) Exposure of internal organs 5) Singeing of scalp and body hair b. Internal 1) Blood is cherry red in color 2) Dehydration is severe 3) Hemoconcentration 4) Congestion of visceral organs 5) Swelling of liver, kidneys and spleen 6) Lungs are shrunken 7) Brain and spinal cord are shrunken 8) Presence of carbon particles in respiratory tract Spontaneous Combustibility - Hardly possible because there is 72% of the human body to be water *Presence of phosphorescent light in graveyards due to gases from microorganisms in a corpse 3. Chemical Burns (Corrosive Burns) - Staining of skin or clothing - Presence of chemical substance - Ulcerative patches on skin - Healing is quite delayed - Absent blister - Borders are distinct simulating a geographic appearance - In thermal burns, lesion is diffused a. Sulfuric acid most intense action - Blackish-brown; clothing destroyed b. Nitric acid - Yellow or yellowish-brown on skin - Clothing may be destroyed c. HCl irritation and local ulceration - Red or reddish-gray color d. Caustic soda and potash - Bleached appearance and greasy feeling - Skin becomes brown and parchment-like Electrical Burns depth is greater than the surface appearance a. Contact burn small, superficial lesion to charring of the skin b. Spark burn due to poor contact and dry skin; white center and red surrounding c. Flash burn pattern of lightning burn or crocodile skin appearance Radiation Burn - Bronze color, blister, dermatitis

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