HEAD

INJURY

Definition:
a morbid state resulting from
gross or subtle structural changes
in the scalp, skull and/or the
contents of the skull, produced by
mechanical force

Classification:
1. Closed Dura is intact
2. Open Dura is torn.

Classification (Severity):
Type

Unconscious Glasgow
ness
coma
scale

Mild
Modera
te
Severe

< 30 minutes

13-15

> 30 min and < 6

hours

9-12

> 6 hours

8 or less

SCALP
INJURIES:

Scalp:
Scalp is covering of head and
- extends from the eye brow
anteriorly to superior-nuchal line
posteriorly
and laterally from one temporal
line to the other.

Anatomy of Scalp:
Scalp consists of
1. S skin
2. C connective tissue
3. A aponeurosis (galea
aponeurotica)
4. L loose areolar tissue
5. P pericranium (periosteum)

Scalp injury, itself not fatal,

but indicator of underlying
trauma.

Scalp Injuries:
1.
2.
3.
4.
5.
6.

Abrasion
Contusion
Laceration
Incised wounds
Avulsion
Puncture wounds

a) Abrasion of Scalp:
- Less common.

b) Contusion of scalp:
- Common, but difficult to detect.
- Blood may be below aponeurosis
or
pericranium.
- Migratory contusion

Migratory contusion
1. black eye or spectacle
hematoma.
2. A contusion in temporal scalp
may shift
downward and appear behind
the ear
similar to battle sign.

c) Lacerations of Scalp:
Types of scalp laceration are:
Linear
Y-shaped
Stellate
Cruciate
Penetrating
Crescent etc.
Incised looking lacerated
wound

Injuries to Face:
Face may sustain:
1. Abrasion
2. Contusion
3. Laceration
4. Incised wound
5. Chop
6. Penetrating wound
7. Fracture of bone

Injuries to Face:
Various prominences suffer injuries
- chin, nose, lips, ears, eyebrows,
cheekbones
etc.
- Nose
- Distal part Flexible
Nasal bridge Fracture
- Mouth & Lips Beating up
- Kicking over face

Injury to Ear
External ear may sustain following
sort of injuries
1. Abrasion
2. Contusion
3. Laceration
4. Cut/chop
5. Avulsion from root
6. Hematoma of external ear pinna
7. Tympanic membrane rupture.

Injury to Eye
Blunt force may cause injury to
cornea,
iris, lens, vitreous hemorrhage,
and
detachment of retina, or even
traumatic
cataract.
Penetrating injury
Black eye
Subconjunctival hemorrhage

Black Eye (periorbital hematoma)

It is bruising of the eye lid i.e. periorbital area
It is caused in following ways:
1. By direct trauma
2. Blood gravitating or shifting downwards from an
injury on frontal area of scalp or
3. Fracture in the orbit commonly fracture of floor
of anterior fossa of skull.
Spectacle hematoma:
- black eye on both side.
- It usually suggests fracture of base of skull.

Injury to Teeth
Fracture/ fracture dislocation of
tooth/teeth
Contusion and laceration of
gums
Fracture of alveolar margin

INJURIES TO
SKULL

Forensic Anatomy of Skull:

Bones of head are collectively known
as
calvaria (cranium, skull).
-Brainpan - excluding the bones of
face.
-Skullcap or calva is roof of skull often
called as vault.
-Rest part is base of skull.

 Two tables:
- The outer table is twice in thickness that
of
inner table.
- Both, outer and inner, table of bones are
separated by a soft cancellous bone - the
diploe
- Skull varies in thickness, the average
frontal
and parietal thickness is 6-10 mm and
temporal bone is 4 mm, and the occipital
bone
in midline is 15 mm or more

Mechanism of Skull
Fracture:
As per Rowbothams hypothesis,
fracture of skull is caused by:
1. Direct application of force to skull
for example blow over head with iron
rod.
2. Indirect violence
for example fall from height on feet
or buttock.

Direct Force Fracture:

1. Local Deformation
2. General Deformation.

1. Local Deformation:
- momentary distortion of the shape of
skull.
-called as struck hoop analogy.
The skull bones of infant are more
elastic and may distort more than adult.
When the focal impact is severe,
depressed fracture may occur and may
follow the actual shape of the impacting
object.

2. General Deformation:
When skull is compressed in one plane,
it bulgesin other directions.
For example if the skull is compressed
laterally, the vertical and longitudinal
diameters are increased and fracture
may occur in these planes, if the bones
are stretched beyond the limits of skull
elasticity

Puppes Rule
When two or more separate fracture
occurs from successive impacts and
meet each other, the later fracture will
terminate in the earlier
fracture.

Skull Fracture Due to Indirect

Violence
The causative force applied may be away
from
skull but is transmitted to skull.
The force may be applied to:
1. Chin: Blow on chin may cause fracture of
glenoid fossa. Force applied below the
mandible may be transmitted through the
maxilla to the base of skull and fracture the
cribriform plate.
2. Feet or buttock: For example in fall from
height, the force is transmitted upwards
through the spinal column and may

Types of skull fractures are

A) Fracture of vault of skull
1. Linear or fi ssured
2. Depressed (signature)
3. Comminuted [Mosaic (spider web)]
4. Pond or indented
5. Gutter
6. Diastatic or sutural
7. Perforating
8. Cut fracture

B) Fracture of base of
skull (basilar fracture)
1.
2.
3.
4.
5.

Linear or fissured
Ring
Hinge
Longitudinal
Secondary

1. Linear Fracture:
- Most common fracture.
- May involve outer table, inner table or both.
- Straight or curved.
- Common in weak, unsupported plates like,
temporal or parietal.
- Linear fracture at base of skull may pass to
other side (Motorcyclists Fracture)
- In case of younger people, it may get
converted to sutural fracture. Can reopen
metopic suture.
- In case of infants, while crossing sutures
there
can be stepping of suture.

2. Depressed Fracture:
- With severe local force
application say for
example hammer; the fracture
bone is
driven inward into cranial cavity.
- Thus also called as signature
fracture

3. Pond fracture:
- There is dent (dimple like)
formation over
the skull.
- This type occurs only in skull of
infants
due to pliable bones of infant.

4. Comminuted Fracture:
- the bone is broken into pieces
i.e.
fragmentation of bones occurs.
- Non-displaced comminuted
fracture
resembles a spider web or
mosaic
pattern.

5. Gutter Fracture:
- Gutter fracture is formed when
part of
the thickness of skull bone is
removed so
as to form a gutter or furrow in
the bone.
- They are caused when the
weapon
strikes the skull tangentially
i.e. glancing bullet injury.

6. Diastatic or Sutural
Fracture:
- the fracture occurs along the line
of
sutures of skull
- Usually occurs in children and
young
adults because of non-fusion of
sutures
and results in separation of skull
sutures.

7. Perforating Fracture:
- the skull is perforated by a
sharp pointed
object or bullet.
- The fracture involves injury to
outer and
inner table of skull.

8. Cut Fracture:
- These fracture are accompanied
with
sharp weapons like sword or
chopper
- Fracture involves either outer
table or
both tables.

9. Ring Fracture:
- This is a fissured fracture that
occurs
round the foramen magnum in
posterior
cranial fossa.
It occurs due to:
1. Fall from height and person
landing on
the feet or buttock.
2. Severe impact on the vertex.

Complication of Skull Fracture

1. Injury to brain
2. Intracranial hemorrhage
4. Intracranial infections meningitis/encephalitis
5. Cranial pneumatocele or
pneumocranium
6. Cranial nerve injury
7. Traumatic epilepsy
9. Coma
10. Cerebral edema

Forensic Anatomy of
Meninges
1. Dura mater
2. Arachnoid mater
3. Pia mater

Dura Mater:
- Dura is composed of two layers;
the
outer layer is attached to the
skull
internally and acts as internal
periosteum.
- The meningeal (dural) arteries
are
situated between outer layer of
dura and
skull.

Arachnoid mater:
- is thin vascular membrane
closely
associated with pia.

Pia Mater:
- is an inseparable membrane
covering
the brain.

Epidural (extradural)
space:
- is a space between dura and
skull and
contains meningeal (dural)
arteries.

Subdural space
- space between dura and
arachnoid is
called as subdural space.
- The cerebral veins cross this
space to
reach the sinuses. (Bridging
Veins)

Subarachnoid space
- is a space between arachnoid
and pia.
- Subarachnoid space contains
blood
vessels that enter and exit the
brain and
cranial nerves.
- The space is filled with CSF.

Intracranial Hemorrhage
Intracranial hemorrhages are of
following types:
1. Extradural or epidural
2. Subdural
3. Subarachnoid
4. Intracerebral
5. Intraventricular

1.Extradural (Epidural)
Haematoma:
- a hemorrhage that occurs in the
epidural
space between the skull and dura

1. Extradural (Epidural)
Haematoma:
Causes
1. Mechanical trauma most
common cause
2. Following surgery - rare
3. Bone eroding process rare cause
4. Vascular malformation rare

1. Extradural (Epidural)
Haematoma:
Sources:
1. Meningeal artery most common
2. Diploic veins rare
3. Venous sinuses rare

1. Extradural (Epidural)
Haematoma:
Sites :
1. Temporoparietal area common site
(rupture of middle meningeal artery)
2. Occipital and basal area least common
sites
3. Bilateral extradural hematomas are rare
and if present, they are commonly found
in
parietotemporal area.

1. Extradural (Epidural)
Haematoma:
Fatality:
- It is suggested that volume of 35
ml is
needed for clinical signs to appear
and
- a volume of 100 ml EDHis
considered as
fatal.

1. Extradural (Epidural)
Haematoma:
Features
1. Presence of lucid interval
2. Contralateral paresis
3. exerts pressure on the brain contusion may
appear. (simulates alcohol intoxication.)
4. The pupils on the side of hematoma is usually
dilated and not reactive to light
5. The continued added pressure on deep brain
may induce coma.
6. Death may occur as a result of compression of
brainstem and downward displacement of
cerebellar tonsils.

1. Extradural (Epidural)
Haematoma:
Medicolegal Importance of
EDH
1. EDH is associated with lucid
interval
2. They are not conter-coup injury
3. EDH may be confused with heat
hematoma
4. EDH may be confused with alcohol
intoxication.

2. Subdural hematoma:
- It is collection of blood in the
subdural
space i.e. between dura and
arachnoid
membrane

2. Subdural hematoma:
Site
1. Most common site lateral
aspect of
cerebral
hemisphere
2. Least common site posterior
cranial
fossa, around the brainstem
and
cerebellum

2. Subdural hematoma:
Mechanism: In traumatic lesion, there
is
1. Gliding type movement between
dura and
skull tearing of bridging veins
2. Sometime, SDH is arterial in origin
and is
caused by small rents in the
arachnoid and
adjacent cerebral arteries.

2. Subdural hematoma:
Classification
1. Acute patient presents within
48-72
hours of injury
2. Subacute patient presents
between 3
20 days
3. Chronic patient presents from 3
weeks
to several months.

Acute Subdural hematoma:

Trauma is common cause and may be
associated with closed or open head
injury
Mechanism involved in causing acute
SDH is change in the velocity of the
head, with rotational component.
SDH may gravitate to lower side.
- It is common lesion than extradural
hematoma
-35 100 ml is required
to cause neurological
signs

Acute Subdural hematoma:

Clinical Features
The onsets of symptoms are delayed
as the
bleeding is of venous origin and take
longer
time to accumulate.
Lucid interval may be present
There is gradual decline in
consciousness and
may have speech defects
contralateral hemiparesis

Chronic Subdural
Hematoma
The lesion is found commonly in old
people or chronic
alcoholics(Atrophy of brain)
SDH from natural causes is often
bilateral while traumatic variety is
usually unilateral.
- Recent lesions (up to weeks) are redbrown with a gelatinous membrane
covering the surface
- Older hematoma up to months is firm
with tough membrane on both

2. Subdural hematoma:

2. Subdural hematoma:

2. Subdural hematoma: