Forensic Lecture 6 (Head Injuries) PDF

LECTURE (6) Head injuries ① Scalp injuries. ② Skull Fractures. ③ Meningeal injuries. ④ Brain injuries. ① Contused Wound (The Commonest) ① Meningitis. ② Cut wound ② Brain abscess. ③ Bruises. ③ Sinus thrombosis. ④ Firearm injuries. ④ He...

LECTURE (6) Head injuries ① Scalp injuries. ② Skull Fractures. ③ Meningeal injuries. ④ Brain injuries. ① Contused Wound (The Commonest) ① Meningitis. ② Cut wound ② Brain abscess. ③ Bruises. ③ Sinus thrombosis. ④ Firearm injuries. ④ Hemorrhage ① Direct application of force. ② Indirect violence. ❶ ❷ ❸  Occipital "Frontal "Parietal "Temporal” {Office Party} ❹ e.g. during sleep on ground we may get. ❺ ① Fissure fracture (linear or “diastatic =sutural”) ② Localized depressed fracture ③ Comminuted fracture ④ Cut fractures ⑤ Penetrating fracture ⑥ Basal fractures  Commonest type of skull fracture.  Fissured fracture is a linear fracture involving the whole thickness of skull, or only the inner or outer table.  Suture involved: Most commonly, sagittal suture.  Seen only in young persons [because of non union of sutures] Signature fracture: the injury of outer table take the shape “mirror” of the striking surface of instrument → “weapon identification”.  Mosaic or spider web  Stellate Fracture (Radiating Fracture)  This is a comminuted fracture with fissured fractured fragments radiating from it and held intact  Fall from height on feet or buttocks & force transmission through V. column.  Heavy blow to face and chin.  Extension of vault fissure fracture to the base.  by a bullet   Escape of blood & CSF from nose + sub-conjuctival hemorrhage or black eye (extravasation of blood in orbit).  Escape of the blood & CSF from ear (Eustachian tube) and sometimes nose.  Escape of blood & CSF into neck tissues.  Indirect force transmitted through vertebral column as falls from a height on feet or buttocks.  Severe blow on vortex driving skull downwards onto V. column.  They are usually fissured fractures a. Cerebral concussion. b. Contusions and lacerations. c. Compression of the brain. d. Intracranial Hemorrhage: ① Extradural / Epidural ② Subdural ③ Subarachnoid ④ Intracerebral  State of sudden transient loss of consciousness with a momentary arrest of the brain functions (brain stem reticular formation) following head injury. ① Sudden loss of consciousness. ⑥ Loss of reflexes. ② Pale skin. ⑦ No signs of lateralization. ③ Rapid weak pulse ⑧ Equal pupils ④ Low blood pressure ⑨ Vomiting may occur. ⑤ Hypothermia. ⑩ Diffuse change in EEG. ① Complete recovery (uncomplicated concussion):  In simple or mild cases occurs within 6 hours with no residual signs. ② Incomplete recovery  Post-concussion syndrome "PC":  Headache, vertigo, insomnia, and loss of concentration  Retrograde amnesia:  Patient forgets moment of trauma & period preceding it.  Post-traumatic automatism:  Patient does voluntary acts after the accident but he forgets everything about what he did.  He is not responsible legally ③ Concussion passes to compression a. With lucid interval: initial recovery from concussion then coma from compression b. Without lucid interval: no recovery from concussion. In cases of depressed bone or +++ meningeal hemorrhage.  Period of temporary recovery between coma of concussion and that of compression in which the patient may be able to:  Walk to home unaided.  Talk and tell the events.  Head trauma causes concussion & may tear the middle meningeal artery, or one of its branches.  There is hypotension and the torn artery will not bleed except after patient recovery & regaining of his blood pressure to normal level.  So, the bleeding from torn vessel gradually accumulates and strips off the dura from the bone leading to compression & coma.  Few min., hours, or even few days according to size of torn vessel. ① The patient may mention the name of the assailant. ② The defense may claim that the blow is not the cause of death as the patient recovers after the injury. ③ Observation & follow up & intervention:  Any patient with history of concussion must be hospitalized for 24- 36 h. (even conscious and appears normal) and observed.  Blood pressure, pulse, respiratory rate, conscious state, motor power and size of pupils must be recorded every 15 minutes.  Decompression operation is indicated when pulse decrease to 60.  Lesions may be on the same side of trauma (coup injury) or opposite to it (contre-coup).  Occurs immediately subjacent to the area of impact (blow) due to inbending of bone, with brain compression.  On the contralateral side of the area of impact.  It can occur only if the head is free to move e.g. In falls. It is due to sudden stoppage of head movement against hard surface on the opposite side causing linear & rotational strains producing injury opposite to impact site.  Gradual loss of consciousness due to high intracranial pressure (inside the rigid boundaries of the skull) disturbing brain functions. ① Depressed fracture of the skull. ② Traumatic intracranial Hemorrhage. ① Stage of irritation:  Gradual blood accumulation → press first thin walled cerebral veins → cerebral congestion and edema → cerebral irritation of centers on same side of lesion. ② Stage of paralysis:  With further increase in ICP → the sufficient sized hematoma compress the thick walled cerebral arteries → cerebral ischemia and paralysis of centers on the same side of lesion.  BV on contralateral side of lesion are affected in same sequence i.e. at time ipsilateral paralysis, there is contralateral irritation, which later become paralyzed at terminal stage. ① Gradual loss of consciousness. ② Projectile vomiting ③ Vital signs :  Slow full pulse becomes rapid weak.  Rapid respiration becomes slow stertorous.  Normal temperature then fever.  Hypertension then hypotension. ④ Signs of lateralization:  Unequal pupils.  Exaggerated reflexes on contra-lateral side  Conjugate deviation of both eyes  Muscle twitches  ① Traumatic. ② Middle meningeal artery injury. -  Tearing of vessels in subdural space: Minor or unnoticed trauma (Senile or ① Fracture of cranial bone chronic alcoholics). ② Closed head injury ① Penetrating injury. ① Rupture of Congenital aneurysm in Circle ② Blow on neck causing laceration of of Willis vertebral artery. ② Extension of a pathological cerebral ③ Rupture of bridging veins in hemorrhage. subarachnoid spaces Hypertension and atherosclerosis. Trauma. Pons and corpus striatum. Coup or Contre-coup. Triangular tract, its base at the Triangular tract, its base at outer brain substance and its apex at surface of brain substance. the cranial surface. Thin walled, bluish in color and Thick walled with atheromatous show collapsed end when cut patches and tortuous cut ends. across. No lacerations. Common. ① Post traumatic amnesia ② Retrograde amnesia ③ Post-concussion syndrome ④ Jacksonian epilepsy (post traumatic epilepsy) ⑤ Permanent infirmity ⑥ Sepsis ⑦ Punch drunkness ⑧ Cranial nerve palsies  Bilateral anosmia  Agnosia  Midbrain contusion ① Lucid interval is the period of : A) Concussion B) Amnesia C) Consciousness D) Profound coma E) collapse ② Subdural hemorrhage is due to rupture of: A. Middle meningeal artery B. Dural venous sinus C. Cortical bridging veins D. Rupture of intracranial aneurysms E. basilar artery ③ Skull vault fissure fracture results from a trauma by object having a : A) big striking surface and high momentum B) localized striking surface and low momentum C) big striking surface and low momentum D) localized striking surface and high momentum