Head Injury from Blunt Force Trauma PDF

**OUTLINE** I. **Head Injuries** A. Direct or Coup Injuries B. Indirect Injuries C. Coup-Contre-Coup Injuries II. **Fractures of the Skull** A. Fissure/Linear Fracture B. Localized Depressed Fracture C. Penetrating Injuries D. Comminuted Fracture E. Gutter Fracture F. Bursting F...

**OUTLINE** I. **Head Injuries** A. Direct or Coup Injuries B. Indirect Injuries C. Coup-Contre-Coup Injuries II. **Fractures of the Skull** A. Fissure/Linear Fracture B. Localized Depressed Fracture C. Penetrating Injuries D. Comminuted Fracture E. Gutter Fracture F. Bursting Fracture G. Ring Fracture III. **Meningeal Hemorrhage** A. Extradural/Epidural Hemorrhage B. Subdural Hemorrhage C. Subarachnoid Hemorrhage IV. **Traumatic Brain Injuries** A. Concussion B. Cerebral Contusion C. Cerebral Laceration D. Intracerebral Hemorrhages V. **Coup and Contre-Coup Injuries** VI. **Distinction between Cerebral Apoplexy and Post-traumatic Intracerebral Hemorrhage** +-----------------------+-----------------------+-----------------------+ | **LEGEND** | | | +=======================+=======================+=======================+ | ⭐ | 🖊️ | 📖 | | | | | | Must | Lecture | Book | | | | | | Know | *\[lec\]* | *\[bk\]* | +-----------------------+-----------------------+-----------------------+ HEAD INJURIES {#head-injuries.TransOutline} ============= Head injuries are classified as to the **site of the application of force**. 📖 the absence of an external wound on the head does not itself permit a conclusion that there is no internal damage. 📖 Contusion and hematoma of the scalp may only be appreciated during post-mortem examination. 📖 Presence of bleeding from the ear, nostrils, and mouth may be associated with basal fractures. +-----------------------------------------------------------------------+ | **GUIDE QUESTION:** | | | | Differentiate direct from indirect head injuries due to blunt force | | trauma | +-----------------------------------------------------------------------+ A. DIRECT OR COUP INJURIES {#a.-direct-or-coup-injuries.TransSubtopic1} -------------------------- Injuries which occur at the **site of the application of force** Will develop as a natural consequence of the force applied 📖 Direct injuries may result from: Compression of the head by the wheel of a vehicle When the head strikes an object in motion, such as bullets When the head is in motion and strikes an object, as in vehicular accidents B. INDIRECT INJURIES {#b.-indirect-injuries.TransSubtopic1} -------------------- Injuries **NOT found at the site of the application of force**. 📖 The injury may be at the opposite, or in some areas offering the least resistance, or in areas that have no relation with the site of impact. CONTRE COUP INJURIES {#contre-coup-injuries.TransSub-subtopic2} -------------------- Injuries that develop **opposite the side** of the application of force 📖 This is observed when the head is free and mobile 🖊️ E.g. A blow to the occiput may produce laceration or contusion of the frontal lobe of the brain REMOTE INJURIES {#remote-injuries.TransSub-subtopic2} --------------- Produced in cases where the force is applied in **some areas of the body which have no relation to the head.** 🖊️ E.g: A fall on the feet or buttocks may cause basal fracture of the skull. LOCUS MINORIS RESISTENCIA {#locus-minoris-resistencia.TransSub-subtopic2} ------------------------- Injury is found in some areas of the skull **offering the least resistance** E.g: A blow to the head may cause a linear fracture of the roof of the orbit which may manifest as "raccoon eyes" A close-up of a person\'s face Description automatically generated **Figure 1**. Basilar Skull Fracture C.COUP-CONTRE-COUP INJURIES {#c.coup-contre-coup-injuries.TransSubtopic1} --------------------------- Direct AND Indirect injuries The injuries may be at **the site of impact and at the same time found in some other parts of the head** which may be the opposite of the site of application of force, or elsewhere. E.g: a Hammer blow in the frontal portion of the head may cause a depressed fracture of the frontal bone and at the same time fracture of the roof of the orbit and laceration of the posterior lobe of the cerebellum. FRACTURES OF THE SKULL {#fractures-of-the-skull.TransOutline} ====================== +-----------------------------------------------------------------------+ | **GUIDE QUESTIONS:** | | | | Skull fractures | | | | What are the different types? | | | | How are they produced and identified? | +-----------------------------------------------------------------------+ A. FISSURE/LINEAR FRACTURE {#a.-fissurelinear-fracture.TransSubtopic1} -------------------------- **Straight or curved fracture lines** 🖊️ Most common type of skull fractures and most seen in traffic accidents and falls Usually caused by the **impact of a blunt object** and may appear as a radiating crack 📖 from the site of the application of force and may involve the base of the cranial fossae Most of the time, it will tell you where the site of impact is but don't be surprised if the site is elsewhere. Generally, results from lower energy blunt trauma over a large surface area of the skull. Blunt force trauma may not have been severe. You can have a linear fracture from falling on the back side of your head.  **Figure 2.** Linear fracture of the posterior fossa, due to a fall on the occiput. The fracture typically crosses the thinner bone, avoiding the central buttress, and ends near the foramen magnum. Source: Knight's Forensic Pathology B. LOCALIZED DEPRESSED FRACTURE {#b.-localized-depressed-fracture.TransSubtopic1} ------------------------------- 📖 Sometimes called "Fracture a La Signature" Invariably **shows the nature of the instrument that causes the fracture.** E.g: the Round face of the hammer may show a round depressed fracture in the cranium A close-up of a bloody head Description automatically generated **Figure 3.** Depressed fracture of the skull from a blow with a heavy club hammer. The defect is wedge-shaped with a curved anterior border caused by the hammer striking at an angle. The depression is concentrically terraced, with the lowest fragments lacerating the surface of the brain. Source: Knight's Forensic Pathology C.PENETRATING INJURIES OF THE SKULL {#c.penetrating-injuries-of-the-skull.TransSubtopic1} ----------------------------------- Can be **from stab wounds to the head or gunshot wounds** 🖊️ Gunshot produces an oval or round hole with beveling at the entry point. Remember that in other gunshot injuries, there may be an entry wound without a corresponding exit wound even if there is a penetrating injury to the skull. Caused by a **sharp-edged instrument that produces a clean-cut fracture of the skull**. The size and shape of the fracture may correspond to the shape of the wounding instrument. D.COMMINUTED FRACTURES {#d.comminuted-fractures.TransSubtopic1} ---------------------- **The skull is broken into several sections** May develop as a result of a fissure or a depressed fracture Indication of the severity of force applied or the use of a heavy weapon to the point that the **skull is broken into several sections** Examples of this include motor vehicular accidents, head trauma from a heavy weapon or a near shot from a firearm 📖 In a near shot with a firearm, there is usually a radiating fissure fracture from the point of impact which forms a "spider web" comminution of the cranium.  **Figure 4.** Comminuted skull fracture with depression of the central area. The head was struck with a heavy piece of wood along the line of the depressed area. Source: Knight's Forensic Pathology E. POND OR INDENTED FRACTURE {#e.-pond-or-indented-fracture.TransSubtopic1} ---------------------------- ⭐ More common in infants 📖 in the skull of infants wherein there is **undue elasticity**, the production of a pond or indented fracture is common. Compression of the skull caused by the inner buckling of the calvarium ⭐ **"ping-pong ball" appearance** The is an indentation or inner buckling like a squeezed pingpong ball Two main categories Congenital 🖊️ Usually are either antenatal due to in-utero pressure of the limbs on the surface of the skull or during birth due to the pressure on the mother's symphysis pubis Acquired 🖊️ Usually related to obstetric interventions such as using forceps or postnatal trauma 🖊️ Clinically, the fracture appears as a deformity on the surface of the skull, usually without any associated symptoms, unless there is an associated intracranial injury that caused the depression or indentation of the calvarium of the baby. A close-up of a baby\'s head Description automatically generated **Figure 5.** "ping-pong ball" appearance. Source: Nicolet, J., & MacVane, C.Z. (2012). An infant with a head injury. Ping-pong fracture. Annals of Emergency Medicine, 59 5, 442, 450. F. GUTTER FRACTURES {#f.-gutter-fractures.TransSubtopic1} ------------------- **Furrows in the skull** caused by the tangential or glancing approach of a bullet 📖 The furrow may cause injury to the blood vessels causing intracranial hemorrhage or laceration of the brain. G. BURSTING FRACTURES {#g.-bursting-fractures.TransSubtopic1} --------------------- There are usually two points of contact **Mechanical force on one side while the head is pressed on another hard surface** 🖊️ This may not always be true The force applied is severe for the calvarium of the skull to burst and it may extend transversely into the base of the skull E.g., When the wheel of a heavy vehicle runs over the head of a person. H. RING FRACTURE *(2025 Trans)* {#h.-ring-fracture-2025-trans.TransSubtopic1} ------------------------------- Depressed fracture with **radial fracture lines.** Not so depressed as to classify it as a locally depressed fracture Results from a local heavy blow. Not just a kind of blow that would result in a fissure fracture but a fairly heavy blow that is fairly concentrated in a small area. But not so focal because if so, it would result in a fracture a la signature. MENINGEAL HEMORRHAGES {#meningeal-hemorrhages.TransOutline} ===================== 📖 It may occur even in the absence of a fracture. 📖 Hemorrhage may be present without trauma. The blood of vessels of the brain may be diseased and may rupture spontaneously. +-----------------------------------------------------------------------+ | **GUIDE QUESTIONS:** | | | | Meningeal hemorrhages: | | | | What are the different types? | | | | How are they produced? | | | | What medicolegal implications may be deduced from them? | +-----------------------------------------------------------------------+ A. EXTRADURAL OR EPIDURAL HEMORRHAGE {#a.-extradural-or-epidural-hemorrhage.TransSubtopic1} ------------------------------------ ⭐ **Almost exclusively due to trauma** Extradural hemorrhage is caused by a fracture of the skull Fracture will cause laceration of the blood vessels Branches of the **middle vessels** are usually involved, the most frequent of which are the branches of the middle meningeal vessels. The laceration is commonly unilateral EXCEPT when the fracture extends to the opposite side. Usually presents as: Headache, vomiting, or drowsiness Pupillary dilatation of one eye Least common type of hemorrhage  **Figure 6**. A large temporoparietal extradural hemorrhage. The undersurface of the scalp on the right shows bruising at the point of impact. There was a linear fracture of the skull passing through the right middle meningeal artery. Source: Knight's Forensic Pathology B. SUBDURAL HEMORRHAGE {#b.-subdural-hemorrhage.TransSubtopic1} ---------------------- Subdural bleeding is essentially **venous or capillary** unlike extradural hemorrhage Most common cause of cerebral compression 📖 This may be a consequence of: Fracture of the skull Laceration of the brain Spontaneous rupture of the blood vessels on the surface of the brain Laceration of the dura and meningeal vessels 📖 The majority of subdural hemorrhages are traumatic in origin Caused by the **tearing of the bridging veins** even in minor trauma. It is not always caused by severe trauma. It can be present in the very old or the very young. A close-up of a brain Description automatically generated **Figure 7**. Chronic subdural hemorrhage in an old person. Brown liquid escaped from the encapsulated lesion adherent to the meninges leaving a gelatinous outer membrane, as seen. The surface of the right cerebral hemisphere is stained brown from old, altered blood and there is some compression of the hemisphere with a midline shift to the left. There was no history of a head injury and no significant neurological deficit. Source: Knight's Forensic Pathology C.SUBARACHNOID HEMORRHAGE (SAH) {#c.subarachnoid-hemorrhage-sah.TransSubtopic1} ------------------------------- ⭐ Presents as a **thunderclap headache** 🖊️ described as the worst headache of your life as if you were kicked on the head Maybe due to trauma or pathology Severe head injury as in contre coup injuries 🖊️ If it is caused by a trauma Ruptured cerebral aneurysm **Basilar, commonly seen at the base of the brain** May be an extension of a spontaneous hemorrhage Which extends to the subarachnoid space 📖 In asphyxia, there may be subarachnoidal hemorrhage in the form of petechial hemorrhage 🖊️ If it is caused by a disease or illness, it's usually **due to a ruptured berry aneurysm or a ruptured arteriovenous malformation (AVM)** and may present itself as a stroke 🖊️ SAH is not always caused by trauma. It can be caused by conditions or pathologies.  **Figure 8.** Subarachnoid hemorrhage from a tiny berry aneurysm (arrow) of the right middle cerebral artery. Source: Knight's Forensic Pathology TRAUMATIC BRAIN INJURIES {#traumatic-brain-injuries.TransOutline} ======================== **By direct intrusion** Foreign objects such as a penetrating weapon, bullets, or missiles. Fragments of the skull in a compound fracture 🖊️ In these types of open wounds, the mechanism of the damage to the brain is of use, though its course may be compounded by the second type of injury that will be described. Most commonly due to laceration or contusion in contrecoup injuries **By deformation of the brain in closed head injuries** 🖊️ The mechanism of injury is complicated and variable with the theories and causation. However, in general, the brain is **shaken in the calvarium** which is an enclosed space. The brain is shaken inside the skull which causes brain injury so for example, if the head is moving and there is a sudden stop, as in traffic accidents, there is a jarring of the brain inside the calvarium. In cases of child abuse, even if there's no visible external laceration or wound in the head as in shaken baby syndrome, the baby can sustain a traumatic brain injury. +-----------------------------------------------------------------------+ | **GUIDE QUESTIONS:** | | | | Cerebral injuries: | | | | What are the mechanisms involved in traumatic brain injuries? | | | | What are the different types? | | | | What medicolegal implications may be deduced about the mechanism of a | | cerebral contusion/hematoma/laceration? | +-----------------------------------------------------------------------+ A. TYPES OF TRAUMATIC BRAIN INJURIES {#a.-types-of-traumatic-brain-injuries.TransSubtopic1} ------------------------------------ CONCUSSION {#concussion.TransSub-subtopic2} ---------- A **transitory period of unconsciousness** resulting from a blow to the head Violent shaking of the head or the upper body can also lead to a concussion. It is quite common in contact sports, for example basketball. A clinical, not a pathological entity 🖊️ No structural abnormality **A mild form of Traumatic Brain Injury** Lasts from seconds to minutes ⭐ If longer - likely with structural brain damage 🖊️ The longer the period of concussion, it would relate to a poor prognosis. Symptoms depend on the degree of injury 🖊️ May have amnesia or temporary loss of consciousness but not all the time ⭐ Headache, tinnitus, nausea, and vomiting, blurring of vision 🖊️ Usually in concussion, there is a rapid onset of short-lived neurological impairment which resolves spontaneously. 🖊️ Acute clinical symptoms usually reflect a functional disturbance but not a structural injury if it lasts for seconds to minutes but there's a range of clinical symptoms that may or may not involve loss of consciousness. CEREBRAL CONTUSIONS {#cerebral-contusions.TransSub-subtopic2} ------------------- **Bruising of the brain** The cortex retains its shape 🖊️ Can lead to subdural or subarachnoid hemorrhages CEREBRAL LACERATIONS {#cerebral-lacerations.TransSub-subtopic2} -------------------- **Macroscopic tearing of the cerebrum** #### COMMON FOR BOTH {#common-for-both.TransSub-subtopic3} Mostly associated with tears in the **pia and arachnoid matter** Maybe coup or contre-coup Commonly involving the frontal or temporal lobes INTRACEREBRAL HEMORRHAGES {#intracerebral-hemorrhages.TransSub-subtopic2} ------------------------- **Pathologic origins (stroke)** are usually not trauma-related 🖊️ Commonly from natural diseases especially if the person has risk factors such as hypertension, chronic alcoholism, senility, etc. When traumatic in origin, it may be associated with coup or contrecoup or from lacerations ⭐Mobile head is struck -- coup ⭐Moving head with sudden deceleration or fixed head is struck (example: fall from great height) -- consider both coup and contrecoup A skull fracture or scalp injury may be absent COUP AND CONTRE-COUP INJURIES {#coup-and-contre-coup-injuries.TransOutline} ============================= Occipital impact Contre-coup may be symmetrical Severe frontal contre-coup May fracture the orbital roof Temporal or parietal impacts Likely contralateral lesions Temporal Maybe on the opposite side of the ipsilateral hemisphere 🖊️ May be in the temporal area, probably a bit to the front or same side but more front of the injury. 📖 DISTINCTION BETWEEN CEREBRAL APOPLEXY AND POST-TRAUMATIC INTRACEREBRAL HEMORRHAGE {#distinction-between-cerebral-apoplexy-and-post-traumatic-intracerebral-hemorrhage.TransOutline} =================================================================================== In traumatic intracerebral hemorrhage, the interval between the injury and onset of \"stroke\" (symptoms) is usually a week or less. In traumatic intracerebral hemorrhage, the injury to the head must be sustained when the head is in motion and the hemorrhage is the result of the coup-contre-coup mechanism. The location of traumatic intracerebral hemorrhage is in the central white matter of the frontal or temporo-occipital region. Cerebral apoplexy is usually at the basal ganglia, a very uncommon site of traumatic intracerebral hemorrhage. History of hypertension prior to the \"stroke\" and evidence of degenerative disease are present in cerebral apoplexy. There is a history of head trauma in traumatic intracerebral hemorrhage. REFERENCES {#references.TransOutline} ========== - Solis PP: Legal Medicine. Quezon City: R.P. Garcia Publishing Co., 1987 - BERNARD, S. P. J. K. (2023). Knight's forensic pathology. CRC Press. - Lecture Video: Mundin, BN. Lecture on Head Injuries from Blunt Force Trauma - Previous Trans: Batch 2025 APPENDIX ======== No Appendices