Injuries

Chapters 8-10 & 14

Done by:
Sarah Julaidan & Asmaa Alrusaies

Revised by:
Sara Aljebrin & Abdulaziz Alsaud
Correction file
Chapter 8
Assessment classification and
documentation of injury

❖ One of the most important aspects of forensic medicine is the assessment,

classification and documentation of injury.
❖ Offences against individuals of a physical nature that may result in criminal
prosecutions have a great variety of types and origins, not all of which may
cause visible evidence (e.g. poisoning, infection)
❖ The role of the forensic pathologist and forensic physician is to ensure that the
medical relevance of findings, or lack of them, is understood by the
investigating authority.
n the legal context, a wound is an injury that breaks the continuity of the skin. There
must be a division of the whole skin structure and not merely a division of the cuticle
or upper layer. As the skin is not broken, a bruise or internal rupturing of blood vessels
is not a wound. A broken bone is not considered a wound, unless it is a comminuted
fracture.
Types of injury:
1. By physical force : divided into two main groups: blunt force and sharp force.
2. By non-physical forces, which can be thermal, chemical, electrical or
electromagnetic
Blunt-force injury :
Blunt-force trauma is that trauma not caused by instru- ments, objects or implements
with cutting edges. The nature of the force applied may include blows (impacts),
traction, torsion and oblique or shearing forces. May have a number of outcomes:
■ no injury ■ reddening ■ abrasions (grazes)
■ tenderness ■ swelling ■ lacerations
■ pain ■ bruising ■ fracture

Both pain and tenderness are subjective findings and are thus dependent on
(1) The pain threshold of the individual. (2) Their truthfulness.
 ...continue Chapter 8

Bruises : leakage of blood into underlying tissues from damaged blood vessels. Two
events must occur before a bruise can form: 1- damage to a blood vessel 2- the
leakage of that blood into surrounding tissues.
Compression may produce petechiae at the level of or above the compressing force
(e.g. in ligature strangulation). Bruises evolve and can ‘migrate’. Gravity and tissue
planes are two of the factors that may determine how the appearance of a bruise might
change . Thus the presence of a bruise at a particular site does not necessarily imply
that the blunt impact was applied at that site.
Age estimation based on the colour of bruising is not now considered appropriate, with
one excep- tion – a yellow-coloured bruise may be more than 18 hours old. The
colouring must not be taken from photographic images were colour reproduction may
be inaccurate
Abrasions :
a superficial injury involving (generally) outer layers of skin without penetration of the
full thickness of the epidermis.
Types:
1. scratches (linear abrasions, e.g. caused by fingernails )
2. scuff (brush) abrasions (very superficial abrasions )
3. point or gouge abrasions (deeper linear abrasions caused by objects such as
metal nails)
4. Crush abrasions – often associated with ‘intradermal’ bruising - are important
because they may retain the pattern of the causative object.
Lacerations :
Cuts, splits or tears’ in the skin and are the result of a blunt force compressing or
stretching the skin; they may extend through the full thickness of the skin and can
bleed profusely.
❏ Lacerations are most common where the skin can be compressed between the
applied force and underlying bone (i.e. over the scalp, face, elbows, knees,
shins, etc.).
❏ The shape of the laceration (e.g. linear, curvilinear or stellate) rarely reflects the
nature of the impacting object (unless accompanied by other patterned
blunt-force injury).
Sharp-force injury:
❏ Incised and slash wounds :
❏ caused by objects with a sharp or cutting edge, most commonly a knife. An incised injury is dis-
tinguished from a stab wound by being longer on the skin surface than it is deep.
❏ Incised wounds, by their nature, are only life- threatening if they penetrate deeply enough to
damage a blood vessel of significant size. Thus, incised wounds over the wrist or neck, where
major arteries lie in more superficial tissues, can prove fatal.
❏ Stab wounds:
❏ caused by a sharp implement and is deeper than it is long on the skin surface. For penetration of
the body to occur, a variety of factors determine how much force is required, including:

1. the sharpness of the tip of the weapon: this is often the most important factor
2. the sharpness of the ‘cutting edge’ of the implement
3. the nature of the force applied
Chop injury :
caused by a variety of implements that are generally heavy, and relatively blunt, bladed instruments.
These include some machetes, Samurai swords and axes.

Other types of injury pattern:

1. Punching :
❏ A punch is a blow delivered by the clenched fist.
❏ Visible injury is more likely to be seen over those areas of the body where the skin is
closely applied to bone, as in the face and skull.
❏ The entire range of blunt force injuries can be caused, including bruises, abrasions,
lacerations and fractures.
❏ Any examination following a blow to the face or mouth requires intraoral examination.
2. Kicking and stamping :
The victim is often on the ground when these injuries are inflicted, and blows from the foot are
commonly directed towards the head and face, the chest and the abdomen.
3. Bite injuries:
Bite marks can be seen in sexual assaults ( The neck, breasts and shoulders), child abuse (arms and the
buttocks) a swab of the area should be taken for DNA and the bite should be photographed with a scale.
4. Defence injuries:
❏ When a knife or a stabbing implement is directed at an individual, blows to the head and
face may be defended by raising the hands and arms to cover the head and face.
❏ Defence injuries may be absent following an assault. This may be for a number of
reasons including unconsciousness from assault, or incapacity through drugs or alcohol
or restraint by another person
Survival after injury :
The length of survival following infliction of an injury is difficult to determine: every
human being is different

Self-inflicted injury :
in suicidal individuals, self-inflicted sharp-force injuries are most commonly found at
specific sites on the body called ‘elective sites’;
incised wounds : most commonly on the front of the wrists and neck
stabbing injuries are most commonly found over the precordium and the
abdomen.(Generally, the eyes, lips, nipples and genitalia tend to be spared.)
in suicidal acts, the more superficial injuries are referred to as ‘hesitation’ or
‘tentative’ injuries
The staging of assault or injury may also involve other individuals complicit in the
process. In such a setting, injuries that are unusual as ‘self-harm’ injuries (e.g. black
eyes or deep abrasions) may have been inflicted by an accomplice.

Torture :
Specific torture techniques that may be described include:
1. Beating of the soles of the feet amputation electrical burns
2. Positional torture – e.g. cheera (legs stretched apart) or Parrot’s Perch (wrists
tied over knees)
3. Suspension, which can result in disruption of shoulder joint complexes and
subsequent deformity.
4. Wet submarine – immersing the victim’s head in a container full of water until
the person almost drowns
5. Dry submarino – placing the victim’s head inside a plastic bag until nearly
suffocated.
 Documentation of injury or marks of injury :
Important point should be considered when taking history:
1) Time of injury
2) Has injury been treated
3) Pre-existing illness
4) Regular physical activity
5) Regular medication
6) Handedness of victim & suspect
7) Use of drug & alcohol
8) Weapon used
9) Clothing worn

The following characteristics should be recorded wherever possible for each

injury:
7) Shape
1) Location 8) Colour
2) Pain 9) Orientation
3) Tenderness 10) Age
4) Reduced mobility 11) Causation
5) Type 12) Handedness
6) Size 13) Time
14) Transience of injury

The recording of such information in the clinical setting should ideally be in three
forms :
1) Written form
2) Hand-drawn body diagram
3) Digital image
 Chapter 9
Regional injuries
Specific regions of the body may be particularly susceptible to types of trauma that may not
cause serious or fatal injury elsewhere. A good example of this may the single stab wound. If
this penetrates the limbs then a serious or fatal outcome is unlikely, unless a large artery is
injured. If a single stab wound penetrates the heart or the abdominal aorta a fatal outcome is
much more likely. Consideration of patterns of injuries according to the body region, and the
potential complications of those injuries, is therefore an important component in both the
clinical and pathological evaluation of trauma.

1) Head injuries
There are three main components of the head: the scalp, the skull and the brain.
Scalp
❏ The scalp is vascular, hair-bearing skin; at its base is a thick fibrous membrane
called the galea aponeurotica
❏ The easiest way to detect scalp injuries is by finger palpation, but shaving is
often required.
❏ Lacerations of the scalp can usually be distinguished from incised wounds, its
relative ‘thinness’ and tethering to the skull, contributes to the appearance of an
incised wound following blunt impact.
Skull fractures
❏ the human head is divided into three main parts: the mandible, the facial skeleton and
the closed container that contains the brain, the calvaria. The calvaria is made up of
eight plates of bone
❏ The complexity of the skull structure means that mechanisms of skull fracture can be
extremely complex
❏ The skull’s capability to distort before fracturing varies with age, and an infant skull
may permit significant distortion following impact without fracturing.
❏ Fatal brain injury can occur in the absence of externally visible scalp injury, or skull
fracture and, conversely, however, intracranial injury should always be suspected in
the presence of skull fracture.
❏ Scalp abrasions, bruises or lacerations represent contact injuries, and their presence
will assist in the identification of the point of contact/impact. Bruises, however, may
evolve, and ‘move’ in tissues planes, and may not precisely represent the site of
contact/ impact by the time the scalp is examined. Abrasions to identify sites of impact
 ...continue Chapter 9

❏ If the vault fractures extend through the skull base from both sides, they may
meet in the midline, at the pituitary fossa, and produce a complete fracture
across the skull base: this is known as a hinge fracture
❏ significant ‘broad surface’ blows to the skull vault, particularly the parietal
bones, may result in a ‘spider’s web’ type of fracture composed of radiating
lines transected by concentric circles.
Intracranial hemorrhage
❏ The anatomy of the blood vessels within the skull has a major influence on the
type of bleeding that will occur following trauma
❏ The meningeal arteries are generally protected from the shearing effect of
sudden movement but are damaged by fracture lines that cross their course.
❏ the connecting veins are at particular risk of ‘shearing’ injury when there is
differential movement between the brain and the skull.
❏ the cerebral arteries and veins, lies beneath the arachnoid membrane and is
generally protected from all but penetrating injuries.
❏ Two main types of haemorrhage within the skull cavity are extradural and
subdural haemorrhage.
❏ Extradural haemorrhage is associated with damage to the meningeal artery,
particularly the middle meningeal artery
❏ Extradural haemorrhages are ones that in the clinical setting may present with
head trauma and then a ‘lucid period’ of half an hour or more, before rapid
deterioration.
❏ Subdural hemorrhage is associated with damage to communicating vein. This
venous damage is not necessarily associated with fractures of the skull.
❏ Recent subdural haemorrhages are dark red in colour and shiny, but begin to
turn brown after several days; microscopically, hemosiderin can be identified
with Perl’s stain
❏ The effects of both extradural and subdural haemorrhages are essentially the
same, at their most severe, causing internal herniation
Traumatic subarachnoid haemorrhage
❏ The vertebral arteries are confined within foramina in the lateral margins of the
upper six cervical vertebrae and are susceptible to trauma either with or without
fracture of the foramina.
❏ Most basal subarachnoid haemorrhages are, however, non-
❏ traumatic in origin and arise from the spontaneous rupture of a berry aneurysm

Brain injury
❏ Whatever the precise cause of the trauma, the effects on the brain, as a whole,
are the same and, as a consequence of the body’s response to primary traumatic
brain injury, cerebral oedema develops (i.e. secondary brain injury).
❏ Penetrating injuries from gunshots or from stab wounds can cause injuries deep
within the white matter, and the tissue adjacent to the wound tracks will often be
contused and lacerated.
❏
Traumatic axonal injury
❏ Shearing is also associated with the so-called ‘gliding lesions’ that occur
predominantly at the junction between cortical grey and white matter.
❏ immunohistochemical staining for β-amyloid precursor protein (ß-APP) may
identify injured axons, given that this stain also highlights axonal injury caused
by non-traumatic phenomena including hypoxia-ischaemia
❏ progressive axonal injury, resulting in the formation of axonal retraction ‘bulbs’,
can easily be recognized by silver staining techniques
 2) Neck injuries
❏ Its relevance in forensic medicine results from :
1. the presence of a large number of vital structures
2. It is particularly prone to injury
❏ The forensic post-mortem examination of the nick is done by : a
Layered, dissection of the anterior (and often posterior) neck structure
❏ Penetrating trauma – sharp force or ballistic – to the neck : Of
particular forensic significance in incised wounds to the neck is the
pattern of injury :
1. Arteria injury : suspicious death
2. Venous injury : possibility of death caused by cardiac air
embolism.

3) Spinal injuries
❏ The spine is very commonly injured in :
1. major trauma
2. more subtle injury, ex: disruption of the atlanto-occipital joint
which can be cause damage to the upper cervical spine
❏ The sequelae of spinal damage will depend upon: the exact anatomical
site - mechanism of injury - the type of injury
❏ Force applied to the spine may result in damage to the discs, the
vertebral bodies, the neural arches and the transverse process
❏ Whiplash injuries associated with road traffic fatalities are caused by
hyperextension of the neck
❏ hyperflexion is less likely to cause damage. Hyperflexion injuries can
be caused if heavy weights are dropped onto the back of a crouching
individual
❏ Forceful flexion of the spine will commonly lead to the ‘wedge’
fracture or compression of the anterior aspect of a vertebral body
 4) Chest injuries
Blunt injury
❏ Result in fractures of the ribs :
1. Few: unlikely to cause effects
2. Numerous: functional integrity of the chest wall may be compromised.
Multiple rib fractures may result in the so-called “flail” chest (the area of
chest around the frac- tures may be seen to move inwards on inspiration )
3. Trauma that has fractured left sided 10th, 11th and 12th ribs may be
substantial enough to cause injury to the underlying spleen.
❏ Rib fractures may have other more serious consequences based on the direction
of the sharp end:
1. inward : pneumothorax, hemopneumothorax
2. Outward : pneumothoraces
❏ Rib fractures in children have a particular place in forensic
medicine, as they can be a marker for non-accidental injury

❏ Rib (and sternal) fractures in adults are frequently identified at post-mortem

examination following cardiopulmonary resuscitation
❏ microscopic examination of rib fractures identified at post-mortem examination
– for evidence of ‘healing changes’
Penetrating injuries
❏ The effect of the penetration will depend mainly upon which organ(s) or
vessel(s) are injured.
❏ Haemorrhage from penetrating injuries to the chest may remain concealed with
little external evidence of bleeding and it is not unusual to find several litres of
blood within the chest cavity at post-mortem examination.
 5) Abdomen
Blunt force injury
❏ blunt trauma, especially in the anterior/posterior direction, may result in
compression of the organs lying in the midline against the vertebral column,
which in order causes injury to intra-abdominal organs, including:
✓ Bruising (or even transection) of the duodenum or jejunum

✓ Rupture of the pancreas

✓ Rupture of the liver
✓ Disruption of omentum and mesentery
❏ The forces required to cause these injuries in an adult must be considered to be
severe and they are commonly encountered in road traffic collisions.
❏ kicks and stamps are commonly the cause of major trauma.
❏ Kidneys and spleen are susceptible to direct trauma + rotational forces that may
result in avulsion from their vascular pedicles.
❏ Blunt trauma to the spleen is sometimes associated with delayed rupture leading
to haemorrhage and possibly death some hours or even days after the injury.
❏ Intra- abdominal injuries could be caused by CPR but it very rare

Penetrating injuries
❏ Depend almost entirely on the organs and vessels involved
❏ A penetrating injury to the aorta, or inferior vena cava, can result in severe
haemorrhage and may produce rapid death. Peritonitis from a ruptured bowel or
stomach may not be recognized until too late, by which time septicaemia will
have developed.
❏ The presence of peritonitis and blood clots at post-mortem are both factors
which may give indications of how long before death intra-abdominal trauma
had occurred.
Chapter 10
Ballistic injuries

Firearms

-Two main types of firearm:

1- those with smooth barrels, which fire groups of pellets or shot.
2-those with grooved or rifled barrels, which fire single projectiles or bullets.

-They rely upon the detonation of a solid propellant to produce the gases that propel the projectile(s).
-These two types are different than air guns and air rifles where they compressed gas to propel the
projectiles.

-The speed with which the projectile leaves the end of the barrel (the muzzle velocity) varies from a few
hundred metres per second to a thousand or more.

-The energy of the projectile is proportional to the speed at which it travels, so higher muzzle velocities are
more effective at delivering energy to the target than larger bullets.

Watch these for more information of how do guns work

Gunshot injuries
-Discharging a firearm will result in the formation of smoke, flame and gases of combustion.
-These exit the barrel with:
1-portions of unburned, burning and burnt propellant
2-other items such as wadding and plastic containers for the pellets.
-These ‘contaminants’ will usually follow the projectile(s), but in some guns they may precede them.
-They can also escape from small gaps around the breech and will soil hands or clothing close to the breech
at the time of discharge.

Extra: Click the picture for more information of gun parts

 ...continue Chapter 10

Smooth-bore guns injuries

-The shot pattern expands as a long, shallow cone with its apex close to the muzzle of the shotgun.
-The further away from the gun that the victim is situated, the larger the pellet spread, and the larger the area
of potential damage.

A) Contact wounds:
● -They are created when the gun muzzle abuts (touch) the skin.
● -A circular entrance wound that approximates the size of the muzzle.
● -The wound edge will be regular and often has a clean-cut appearance.
● -There will be smoke soiling.
● -There may be a narrow, circular rim of abrasion around the entrance wound, caused when the gases
of the discharge enter through the wound and balloon the tissues upwards so that the skin is pressed
against the muzzle.
● -If the discharge was over an area supported by bone, the gases cannot disperse(distribute) as readily
as they would in soft, unsupported areas such as the abdomen, and the greater ballooning of the skin
results in splits of the skin, which often have a radial pattern.
● -any wadding or plastic shot containers may usually be recovered from the wound track.
● -The tissues along the wound track may be blackened and the surrounding tissues are said to be
pinker than normal as a result of the carbon monoxide contained within the discharge gases.

B) Close discharge:
● -within a few centimetres of the surface
● -produce a wound with a similar appearance, but there is a
space for muzzle gases to escape.
● -there will be no muzzle mark.
● -More smoke soiling can occur, and burning of skin, with
singeing (burn superficially or lightly) and melted hairs
around the wound.
● -There is powder ‘tattooing’ of the skin around the entry
wound. This tattooing results from burnt and burning flakes
of propellant causing tiny burns on the skin and cannot be
washed off.
...continue Chapter 10
Satellite
rat-hole
C) Intermediate range: pellet hole

1-between 20 cm and 1 m.
-diminishing smoke soiling and burning of the skin, but powder tattooing may persist.
-The spread of shot will begin, first causing an irregular rim to the wound. This is often called a
‘rat-hole’ because of the appearance of the wound edge; the term ‘scalloping’ may also be used.
-Separate injuries caused by the wads or plastic shot containers may be seen.

2-At a range of over 1 m.

-smoke damage and tattooing generally do not occur.
-satellite pellet holes begin to be seen around the main central wound
at a range of about 2–3 m.

D) long ranges:
-20–50 m.
-there is a uniform peppering of shot, and this is rarely fatal.

-Shotguns rarely produce an exit wound when fired into the chest or abdomen.
-Exit wounds can be seen when a shotgun is fired into the head, neck or mouth.
-In the head, where the skull may virtually explode with the gas pressure from a
contact wound, ejecting part or even all of the brain from the cranial cavity.

Wounds from rifled weapons

-rifled weapons bullets at a higher velocity than pellets from a smooth-bore weapon.
-cause both an entry and an exit wound.
-However, many bullets are retained within the body because they did not possess enough energy
to complete the passage through it, or energy was expended on contact with other structures (e.g.
bone).
...continue Chapter 10

Entrance and exit wounds from rifled weapons

A) Contact wounds:
-circular, unless over a bony area such as the head, where splitting caused by the propellant gas is
common.
-There may be a muzzle mark on the skin surface.
-There may be slight escape of smoke, with some local burning of skin and hair, if the gun is not
pressed tightly.
-Bruising around the entry wound is common.

B) Close range:
-up to about 20 cm
-smoke soiling and powder burns, and skin and hair may be burnt.

-The shape of the entry wound gives a guide to the angle that the gun made with that area of skin:
1-a circular hole indicates that the discharge was at right angles to the skin
2-an oval hole indicates a more acute angle.

-Examination of the entry wound will show that the skin is inverted; the defect is commonly slightly
smaller than the diameter of the missile because of the elasticity of the skin.
-there is an ‘abrasion collar’ or ‘abrasion rim’ around the hole, which is caused by the friction,
heating and dirt effect of the missile.

-Bruising may or may not be associated with the wound.

C) Over 1 m: no smoke soiling, burning or powder tattooing.

D) At longer ranges: (up to several kilometres), the entrance

hole will have the same features of a round or oval defect
with an abrasion collar

E) At extreme ranges: larger, more irregular wounds.

...continue Chapter 10

The exit wound

- is everted with split flaps, often resulting in a stellate appearance.
-No burning, smoke or powder soiling will be evident.

-If the bullet has been fragmented, or if it has fractured bone,

the exit wound will be larger and more irregular, and those fragments
of bullet or bone may cause multiple exit wounds.

-Where skin is firmly supported, as by a belt, tight clothing or even

a person leaning against a partition wall, the exit wound may be
as small as the entrance and may fail to show the typical eversion.
-There is a rim of abrasion..

Air weapons, unusual projectiles and other weapons

-rely upon the force of compressed air to propel the projectile, usually a
lead or steel pellet although darts and other projectiles may be used.

-The relatively low power of these weapons means that the pellet will
seldom exit, but if it does do so, a typical exit wound with everted margins
will result.

Miscellaneous firearms and weapons

1-The plastic rounds:
-In public disorder situations, for crowd control purposes.

-The purpose of these weapons is to disable and discourage

rioters but not to kill or seriously injure them. .

-They should not be fired at ranges less than about 20 m

and should only be fired at the lower part of the body.

-The mark left on the skin surface by a plastic round is usually

distinctive.
...continue Chapter 10

2-Stud guns:
-Are devices used in the building industry to fire steel pins
into masonry or timber.
-They have been used for suicide and even homicide,
but accidental injuries are more common.
-The skin injury often appears similar to many small-calibre entry wounds,
although the finding of a nail will usually solve the diagnostic problem.

3-Humane killers:
-Are devices used in abattoirs (Slaughterhouse), and by veterinary
surgeons, to stun animals before slaughter.
-These weapons have been used for both homicide and suicide,
but accidental discharges are also recorded and may cause serious injury
or death.

4-Bows and crossbows:

- Are used recreationally but may also be used as weapons of assault.
-These weapons fire arrows or bolts.
-The tips of these projectiles may have many shapes from the simple
point to complex, often triangular forms.
-However, if the projectile has a simple pointed tip, and if it has
been removed from the body, the entry wounds can appear
very similar to those caused by standard bullets, with a central
defect and surrounding abrasion rim.

Determination of accident, suicide or murder

-Death investigators, including pathologists, must be aware of the potential for ‘staging’ of homicide
in order to give the appearance of death having occurred as a result of accident or suicide.

-Those who have killed themselves must generally have wounds the site and range of which are
within the reach of the deceased’s arm, unless some device has been used to reach and depress
the trigger.

-The weapon must be present at the scene, although it may be at a distance from the body
because it may have been thrown away from the body by recoil, or by movement of the individual if
death was not immediate.

-Suicidal gunshot injuries are most commonly in the ‘sites of election’, which vary with the length of
the weapon used.
...continue Chapter 10

● -The weapons can be used in the mouth, below the chin, on the front of the neck, the centre of
the forehead or, more rarely, the front of the chest over the heart.
● -Discharges into the temples are almost unique to handguns and are usually on the side of the
dominant hand, but this is not an absolute rule.
● -People almost never shoot themselves in the eye or abdomen or in inaccessible sites such as
the back.
● -It is unusual for females to commit suicide with guns and females are rarely involved in
firearms accidents.
● -If suicide can be ruled out by the range of discharge, by absence of a weapon or by other
features of the injury or the scene, a single gunshot injury could be either accident or homicide.
● -Multiple firearm wounds strongly suggest homicide.
● -It is most likely that severe damage to the brain, heart, aorta and any vital internal organs will
lead to death; however, many forensic practitioners will have seen cases of survival following a
contact discharge of a firearm into the head.

Evidence recovery
-Any foreign objects such as wads, bullets or shot, and any skin removed from the
margin of a firearm wound should be carefully preserved for the police.

-Those arrested for possible involvement in firearms offences will need detailed
examination and taking of samples, including skin and hand swabs, and nasal samples,
to identify any firearms residue.

-The same general rules apply to the post-mortem recovery of exhibits.

-The skin around the wounds may be swabbed for powder residue if this is considered to
be necessary.

-Swabs of the hands of the victim should be taken.

-The pathologist must ensure that accurate drawings and measurements of the site, size
and appearance of the wound are obtained and that distant and close-up photographs
are taken of each injury with an appropriate scale in view.
...continue Chapter 10
Explosives
-Armed conflict, and terrorist activity, leads to many deaths from explosive devices.

-In military bomb, shell and missile explosions, the release of energy may be so great that
death and disruption from blast effects occur over a wide area.

-In contrast, terrorist devices, unless they contain very large amounts of explosive, rarely
compare with military effectiveness and thus the pure blast effects are far more limited.

-However, such devices are often detonated within relatively confined spaces (e.g. subways
and buses).

-The pure blast effects can cause either physical fragmentation or disruption of the victim or
bomber solely from the effects of the wave of high pressure and hot gases striking the body.

-There will be pressure effects upon the viscera and these effects are far more damaging.

-Rupture and haemorrhage of these areas represent the classical blast lesion.

-Casualties & fatalities are caused by secondary effects of explosive devices, especially in
the lower-powered terrorist bombs. These secondary effects include:
■ burns
■ missile injuries from parts of the bomb casing, contents or shrapnel.
■ peppering by small fragments of debris and dust propelled by the explosion;
■ various types of injury owing to collapse of structures as a result of the explosion.
■ injuries and death from vehicular damage or destruction.

-Post-mortem radiology is essential, in order to identify unexploded ordinance, and items

comprising components of the explosive device.

-Identification of deceased individuals is important, not only ethically, but also to enable the
relevant medico-legal authority to discharge their responsibilities.

-The identity of suicide bombers, whose bodies are frequently extensively disrupted
following the explosion, may be extremely challenging
...continue Chapter 10

Mass disasters and the doctor

-Increasingly, such a situation is just as likely to involve a terrorist incident.

-For the non-specialist doctor at the scene of a mass disaster of any kind, the first
consideration is the treatment of casualties, which may involve taking difficult ethical
decisions about triage.

-The police and the usual state agencies (or Coroner) responsible for sudden death.

-All these details are recorded on standard forms and charts and the information is sent
back to the identification teams, who can compare this post-mortem information with
antemortem information obtained from relatives, friends.

-An internal post-mortem examination is usually performed to determine the cause of death,
retrieve any foreign objects that, for example, may be related to an explosive device, and to
seek any further identifying features, such as operation scars and prostheses.
Chapter 14
Transportation medicine

● -All forms of transport (air, water or land) are associated with a risk of harm or
injury.
● -The incidence of those risks is increased when other factors are taken into
account, including lack of experience, fatigue and the effects of drugs and
alcohol.

Every jurisdiction has laws that:

1-control the speed of the vehicles
2-control the amount of alcohol and/or drugs the individual can consume

● They measure the levels of alcohol in blood, breath or urine

‘Driving under the influence’

-In many cases it’s confirmed by the ability, or failure, to pass standardized tests of
sobriety(not a drunk ), or by medical examination to determine whether the ability to drive
may be impaired, following preliminary impairment tests undertaken by police personnel.

-Initial screening may be done by officers at the scene of an alleged offence or accident,
using ‘field impairment tests’.

-Evidential ‘breath alcohol machines’ are used to take breath samples, and if for some
reason (e.g. asthma, oral trauma) it is not possible for an individual to provide a sample,
then blood or urine samples must be sought.

-The aim of the examination in the medical assessment is to determine

(1) whether the individual’s ability to drive is impaired,
(2) which drug/substance is causing this impairment,
(3) whether there is a medical reason for the individual’s apparently impaired status (e.g.
neurological disorder, psychiatric disorder).

-certain procedures that measure psychomotor function and ‘divided attention tests’ are
used.
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Divided attention tests

-which assess an individual’s balance and coordination.
-Also assess the ability to follow simple instructions, include the ‘walk and turn test’, ‘one-leg
stand test’, ‘horizontal gaze nystagmus test’ and Romberg test.

Many individuals will have used a mixture of drugs and alcohol, which make the
results of specific drugs groups inappropriate or wrong.

Field impairment tests (‘preliminary impairment tests’ in the UK)

-They are useful in screening individuals suspected of being impaired as a consequence of
drug use, and provide supportive evidence of impairment.
-They cannot be used with certainty to confirm that drugs have been used, or the particular
drug or drugs that may have Consumed.

Personal transport and road traffic injuries

Those injured by collisions on the road, or offroad using personal transport can be divided
into three broad groups:
1-pedestrians
2-cyclists (pedal or motor)
3-drivers or passengers of vehicles.

-Of these three broad groups, it is pedestrians who are most often injured

- The greater mingling of motor transport and pedestrians the greater risk of injury to the
pedestrian.

-Most road deaths in the world occur in developing countries.

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Pedestrians

Pedestrians struck by motor vehicles suffer injuries:

1-from direct contact with the vehicle (primary injuries) or
2-from contact with other objects, or the ground, after the primary contact with the
vehicle (secondary injuries).

-When an adult is hit by the front of a car, for example, the front bumper (fender) usually
strikes the victim at about knee level.(primary injury)

-The exact point of contact, however, whether on the front, side or back of the leg(s), will
depend on
1-the orientation of the victim
2-the nature of the front of the car
3-whether or not it is actively braking at the time of impact.

-There are often additional primary injury sites on the thigh, hip or pelvis caused by contact
with other parts of the car, such as the bonnet (the hood).

-At low speeds 20 kph the victim thrown off the bonnet either forwards or to one side.
-Between 20 and 60 kph the pedestrian may strike the bonnet (hood) and the head may
strike the windscreen.
- At higher speeds (60–100 kph) pedestrians may be projected up into the air; sometimes
they will pass completely over the vehicle and will avoid hitting the windscreen and other
points on the vehicle.

-Such impacts will cause complex fractures or traumatic amputations.

-Secondary injuries are more serious and lethal.

-Such secondary injuries vary from simple ‘brush abrasions’ to fractures of the skull or axial
skeleton, to hyperextension or hyperflexion fractures of the spine.

-Even in the absence of skull fracture, traumatic brain damage, including traumatic axonal
injury, is frequently observed in fatally injured pedestrians.

-This occurs as a consequence of the rotational, deceleration forces produced when the
rapidly moving head is suddenly stopped at impact, leading to ‘shearing’ injuries to the brain
and its coverings.
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-Fractures of the spine, especially in the cervical and thoracic segments, may lead to cord
damage.
-Fractures of the limbs are common but, apart from those of the legs that are associated
with the primary impact sites, they are somewhat unpredictable because of random ‘flailing’
of the limbs following primary impact.

-When an adult is struck by a larger vehicle, for example a van, truck or lorry, or when a
small child is struck by any vehicle, the typical lower limb primary contact injury site
described above tends to be ‘higher up’ (pelvis, abdomen, chest or head).

-It is likely that the victim will make contact with more of the front of the vehicle or be
projected along the line of travel of the vehicle and ‘run-over’.

-‘Run-over’ injuries are relatively unusual and the effects are variable, depending on
1-area of the body involved 2-vehicle weight 3-surface area of the contact.

-Compression of the chest may result in multiple rib fractures, causing a ‘flail chest’.

-The rotation of the wheel may strip off large areas of skin
and subcutaneous tissue; this is called a ‘flaying injury’.

- patterned injuries are characterised as tyre-treads

Car occupants
● -Most impacts involve the front of the vehicle and the impacts are against either
another vehicle or a stationary object.
● -This type of impact rapidly decelerates the vehicle.
● -Less commonly, the vehicle is hit from behind, causing an ‘acceleration’ impact.
● -The least common impacts are side impacts and ‘roll-overs’.
● -Unrestrained (not wearing the seat belt) front-seat occupants in a vehicle subjected
to rapid deceleration during a collision will continue to move forwards as the vehicle
decelerates around them, and will impact those parts of the vehicle that are in front of
them.
● -The injuries of rear-seat occupants, may not severe such as the front-seat
occupants.
● -In a deceleration impact, the rear-seat passengers will be thrown against the backs
of the front seats and may impact the front-seat occupants.
● -They may be projected over the front seat to hit the windscreen and even be thrown
out through the windscreen.
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The function of seat belts

-The combination of a horizontal lap strap and diagonal shoulder strap was introduced as a
satisfactory compromise between effectiveness and social acceptability. To be effective, a
seat belt must
(1) be worn
(2) worn correctly.
-The use of seatbelts can also cause injuries.

Air bags
Air bags aid the protection of all car occupants following a collision by rapidly deploying a
‘soft method of restraint’ that is only present when require.
-They are designed to provide protection to the ‘average-sized adult’ in the front of the car.
-Air bags can cause injuries, most frequently abrasions or burns.
-Most cars have the option of disabling air bags if those of short stature (generally children)
are occupying such seats.
-Air bags, in general, should never be used in the presence of baby seats.
-The back of the baby seat may lie within the range of the bag when it is maximally
expanded, and fatalities have been recorded following relatively minor vehicle impacts when
the airbag has struck the back of the baby seat.

Motorcycle and pedal cycle injuries

-Most injuries to motorcyclists are caused by falling from the machine onto the roadway.
-Many of the injuries can be reduced or prevented by the wearing of suitable protective
clothing and a crash helmet.
-Abrasions caused by contact with the road surface are almost universal following an
accident at speed, and injuries to the limbs and to the chest and spine occur very commonly
because of contact with other objects or vehicles, entanglement with the motor bike or direct
contact with the road.
-A more unique injury occurs from ‘tail-gating’ (drive too closely behind (another vehicle)),
where the motorcyclist drives under the rear of a truck, causing severe head injuries or even
decapitation.
-This injury has been reduced by the presence of bars at the sides and rear of trucks to
prevent both bikes and cars passing under the vehicle.
-Secondary injuries, especially to the head and chest, are common.
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Railway injuries
-These are most common in countries with a large railway network, such as India and China, and in
countries where rail crossings are unprotected or unmanned.
-Railway lines are a common site for suicide attempts.
-Medically, there is nothing specific about railway injuries except the frequency of very severe
mutilation(amputation).
-The body may be severed into many pieces and soiled by axle grease and dirt from the wheels and
track.
-Where passengers fall from a train at speed, multiple injuries caused by repeated impacts and
rolling may be seen, often with multiple abrasions from contact with the coarse gravel of the line
ballast.

Suicides on railways fall into two main groups:

1-those that lie on the track (sometimes placing their neck across a rail so that they are
beheaded)
2-those that jump in front of a moving train from a platform, bridge or other structure near to
the track.

-they may be localized with black soiling at the crushed decapitation or amputation site if the
individual has lain across the track.
-There is a risk of secondary injury if survival occurs where other factors such as electrified lines are
present.
-On electrified lines, an additional cause of suicidal or accidental injury or death is present in the
form of electric shock from either a live rail or overhead power lines.
-A careful search for unusual injuries inconsistent with the setting, as homicides may be concealed
by staging the scene, with the deceased being placed on the rail track in an attempt to conceal the
true cause of death.
-Railway workers may be injured or killed by falling under, or by being trapped between the buffers
of two trucks while uncoupling or coupling the rolling stock.
-The injuries associated with the squeezing between rolling stock are often those of a flail chest, with
or without evidence of traumatic asphyxia.

Aircraft fatalities
Aviation incidents can be divided into two main groups:
1-those that involve the crew and the large numbers of passengers of a modern,
commercial aircraft.
2- those that involve the occupants of small, relatively slow, light aircraft.
-Large aircraft are pressurized and, if the integrity of the cabin is breached, there can be
rapid decompression and the passengers may suffer barotrauma.
-If the defect in the cabin is large enough, victims may exit through the defect and fall to
their death.
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● -When an aircraft hits the ground, the results will depend on the rapidity of transfer of
the forces, and this is dependent on the speed of the aircraft and the angle of impact.
● -The usual lap-strap seat belt offers little protection in anything but the most minor
accident. -Fire is one of the greatest hazards in air crashes and accounts for many
deaths.
● -In light aircraft crashes, the velocity, and hence the forces, may be less than in large
commercial aircraft, but they are still often fatal.
● -The investigation of air accidents is a task for specialist medical personnel, who are
often available from the national air force or from a civil authority.
● -There should always be a full autopsy on the pilot or suspected pilot, with full
microscopic and toxicological examination to exclude natural disease, drugs and
alcohol.

Marine fatalities
● -Fatalities in the marine setting embrace a range of marine-specific and general
injury types.
● -The range of activities include commercial diving, recreational diving, use of
powered water sport bikes, sailing, motor cruising and commercial marine transport
(e.g. oil tankers, container ships, passenger vessels).
● -The likelihood of dying in a marine environment is enhanced by not wearing
appropriate safety gear.
● -In the recreational setting, fatalities occur when individuals fall from vessels and
drown, or succumb to hypothermia, or cannot be recovered back on board.
● -Physical injuries in recreational sailing are widespread and examples include those
of suffering direct trauma, loss of digits or limbs when caught up in winches or anchor
cable, limb fractures or skull fractures from direct impact from flailing blocks and burn
injury from uncontrolled rope movement.
● -Drowning may occur from being trapped after inversion of the vessel.
● -Motor-powered vessels may cause injury from explosion or fire, or those in the water
may sustain injury from rotating propellers.
● -Commercial vessels may cause their own specific problems, such as asphyxiation in
storage tanks or falls from heights.
● -Most of these scenarios are of an industrial/occupational nature and may involve
potential breaches of health and safety legislation.