CHAPTER 13

Regional Injuries

Definitions „ Craniocerebral injuries to the head can be grouped

„ Traumatic brain injury (TBI): Traumatically induced into two types: ‘focal’ or ‘diffuse’ in the sense that
structural injury and/or physiological disruption of they are localized or widespread (Table 13.1).
brain function as a result of an external force.
„ Closed head injury (non-penetrating): Damage to Biomechanics of Head Injury
the brain without any fracture of the skull and/or
Head injury can be broadly classified into two types
penetration of dura; most often results from blunt
based on mechanical loading: (Flow chart 13.1)
trauma.
i. Static
„ Open head injury (penetrating): Disruption of
ii. Dynamic
cranial vault with opening through skin and cranial
bones to expose damaged brain; most often associated „ Static/Contact injuries: Contact injuries occur both
missile wounds, stab/chop wounds, and motor at the site and remote from the point of impact on
vehicle or occupational accidents. the head. It results in skull fractures and contusions.
„ Missile injury: Injury produced by moving object The length and direction of a skull fracture depends
striking cranium; most often refers to bullet injury. on the amount of contact energy absorbed by the
„ Acceleration/deceleration injury: Damage produced skull and its thickness at the impact site.
by movement of brain within confines of cranial vault „ Dynamic/Inertial injuries: Dynamic loading is
(tearing during violent movement or from impact of usually the result of an impact, such as the head being
striking interior of skull or dural folds). struck a blow by a moving object or the head itself
striking a relatively stationary surface. Inertial injuries
Craniocerebral Injuries are commonly called ‘acceleration’ or ‘deceleration’
injuries which biomechanically can be considered
„ There are three main components of the head: scalp, as the same phenomenon. The brain is damaged by
skull and brain (Fig. 13.1). one or both mechanisms: through strains produced
„ The term ‘craniocerebral injuries’ can be used to within the brain tissue itself, and through differential
describe the presence of skull (‘cranio’) and brain movements between the brain and the skull. Three
(‘cerebral’) injury. types of acceleration are recognized:
i. Angular acceleration is most common and most
serious in which rotation is usually centered in
the low cervical region. Angular acceleration

Table 13.1: Classification of craniocerebral injury

Focal Diffuse
� Scalp lacerations � Axonal injury (DAI)
� Skull fractures � Ischemic injury
� Contusions/lacerations � Vascular injury
� Intracranial hemorrhage � Brain swelling
� Lesions secondary to raised
Fig. 13.1: Cross section of the scalp, skull
intracranial pressure
and meninges
 Regional Injuries 233

Flow chart 13.1: Pathological changes depending on mechanism of injury

alone is capable of producing almost every they appear as localized swelling due to the dense
known traumatic brain lesion, except for a skull fibro fatty tissues, but contusions deep into the
fracture or an epidural hematoma. galea aponeurotica are diffuse on account of loose
ii Translational acceleration (e.g. anterior to posterior) aponeurotic tissues, and difficult to make out on
does not produce diffuse brain damage but may examination.
cause a variety of focal surface lesions. z The easiest way to detect scalp injuries is by

iii. Rotational acceleration in the horizontal plane is palpation, but shaving is necessary for proper
a very damaging mechanism, producing both documentation and photography.
high surface forces and intracerebral damage, z During postmortem examination, autopsy

but it usually occurs in association with angular surgeons are able to visualize this subscalpular
acceleration. (subgaleal) hemorrhage after reflection of the
scalp.
Strain within the brain tissue is the deformation that
z Scalp hematoma may be associated with an
it undergoes when a mechanical force is applied. Tensile
underlying linear skull fracture.
strain refers to elongation of neural tissues and is the
iii. Lacerations: They resemble incised wounds (incised
most important mechanism in head injury. Compression
looking lacerations). Careful examination in the
wherein constituent units are being forced together
depths of the wound will reveal the bridging fibers
and shear or sliding strains which move adjacent strata
with surrounding band of abrasion.
of tissue laterally also occur. The brain is virtually
iv. Incised wounds: They have clean cut margins;
incompressible, and has a low tolerance to tensile and
hair bulbs are cleanly cut.
shear strains.
„ An effusion of blood over the top of the head or

Soft Tissue Injury forehead may gravitate down to the loose tissues
causing black eyes (periorbital hematoma).
„ Injuries: Scalp wounds are caused by falls, blows,
Causes of black eyes (spectacle hematoma or raccoon eyes)
sharp cutting instruments or discharge of a firearm.
(Fig. 13.2)
It can be: i. Most commonly due to local violence causing
i. Abrasion: It caused by a lateral rubbing action subcutaneous extravasation of blood into the lids,
by a blow, a fall on a rough surface or by being occurs soon after injury to upper and lower eyelids.
dragged in a vehicular accident. They are simple ii. Bleeding into the layer of loose connective tissue after a
injuries, bleed slightly, and heal rapidly. blow on the skull; the blood gravitates under the frontalis
ii. Contusions: Presence of scalp contusion is muscle and appears first in the upper eyelid and then
indicative of contact injury. In superficial fascia, the lower eyelid over the course of a couple of days.
234 Review of Forensic Medicine and Toxicology

„ The fracture of skull can occur either by direct or

iii. Fracture of the orbital plate of the frontal bone results in indirect violence.
hemorrhage into the orbit, the blood tracks under the i. Direct violence: The forces act directly on the
conjunctiva, appearing as a triangular, flame-shaped
bone to produce a fracture, e.g. head crushed
hemorrhage, the apex of which is at the margin of the
cornea and the posterior limit cannot be seen, which under the wheels in road traffic accidents or an
distinguishes it from the subconjunctival hemorrhage. object like stick/rod/bullet striking the head.
ii. Indirect violence: The forces act indirectly on
„ Wounds of the scalp bleed freely (blood vessels in the skull through some other structure, which
the fibrous layer, superficial to galea aponeurotica, receives primary impact, e.g. fall on buttocks
being held open once cut), but heal rapidly. If an from height which transmits the force to occipital
injury extending through the galea gets infected, it bone through vertebral column or a blow to the
may spread through the emissary veins to involve chin resulting in fracture of base of the skull.
the sagittal, lateral and cavernous sinuses causing During autopsy, prior to cutting the skull cap off,
septic complications, like meningitis and brain the skull should be visually inspected and palpated
abscess. for the presence of fractures.

Skull Fractures Types (Fig. 13.3)1

Motor vehicle accidents and falls are the most common 1. Fissure/linear fractures: These are linear cracks
causes of skull fractures. passing over the vertex or across the skull base
without any displacement of the fragments, and
Mechanism: The skull is not a completely rigid either involves the whole thickness of the bone or
structure, and it is able to bend and distort when force the inner or outer table alone.
is applied to it. A blow to the skull causes ‘inbending’ z These fractures are usually caused by:
of the bone at the site of impact, and asymmetric and i. Forcible impact against a broad resisting
variably localized ‘outbending’ at a distance from the surface, like hard ground surface, as in road
impact. If the forces applied exceed the elastic properties traffic accidents.
the skull, fracture will occur. ii. When knocked to the ground by the blow
„ In general, if force is applied over a small area (e.g. of a fist.
a blow from a weapon) a fracture occurs at the site iii. Blows with a hard blunt object having a
of inbending, whereas an impact over a larger skull relatively broad striking surface.
area leads to fractures at the site of outbending. z The fracture line tends to follow an irregular
„ Fractures also represent the point of maximum stress course, and is no more than a hair’s breadth.
upon the skull, which may not be at the immediate z They are difficult to detect, may not be seen on
site of impact. X-ray, and can only be detected at autopsy.
„ Skulls of infants and children are thinner than those z The line of fracture runs parallel with the axis
of adults and may be able to distort more before of compression.
fracturing. z Depression of bone fragments is not seen.

z An injury of the head sustained by a fall is

mostly situated at the level of the margin of the

hat, while an injury due to blow is commonly
situated above this level.
2. Depressed fracture: When a portion of fractured
bone is driven inwards to a distance equivalent
to the thickness of the skull table, it is known as
depressed fracture. It is also called ‘fracture a la
signature’ (signature fracture), as the shape often
points towards the shape of the offending weapon.2
z They are caused by blows with a heavy weapon

having small striking surface, such as hammer,

Fig. 13.2: Causes of black eyes axe, brick or chopper.
 Regional Injuries 235

Fig. 13.3: Types of skull fractures

z The part of the skull which is first struck shows – These fractures are rare, and are usually
maximum depression; usually seen in the left associated with injury to the dura also.
frontal region. b. Pond or indented fracture: This is a smooth
z This type of fracture often suggests the probable concave depression without a fracture line,
manner of application of violence, and also the resulting from in-buckling of skull, occurring
relative position of the victim and the assailant only in the elastic skull of infants and children
at that moment. (prior to 4 years of age).3,4
z Depressed fracture is considered to be compound – Inner table is not fractured, meninges and
if an associated scalp laceration extending brain are not damaged.4
through the pericranium is present, and – It may also be caused by forcible compression
with an obstetric forceps or impact against
penetrating if a dural laceration exits.
some protruding objects, e.g. sacral promontery
z The soft fluctuant centers of scalp hematomas
during delivery.
can masquerade as depressed skull fractures
– It is also known as ping-pong fracture, as it
(Diff. 13.1).
looks similar to a dent in ping-pong ball.
z The risk of post-traumatic epilepsy following
3. Comminuted fracture (spider-web/mosaic
depressed skull fracture and cortical laceration fracture): Two or more intersecting lines of fracture
is about 15%. divide the bone into three or more fragments
Some variants: resembling a spider web or mosaic pattern.
a. Elevated fracture: One end of fractured z Skull bone gets broken into multiple pieces
fragment is elevated above the surface of skull, by fracture lines, which are haphazardly or
while the other end may dip down into cranial concentrically arranged, or stellate if they radiate
cavity resulting in injury to the brain. from the site of impact.
– It is caused by a blow from sharp, heavy z It is caused by vehicular accidents, fall from
object (e.g. an axe) which elevates the skull height on a hard surface or by blows with
fracture by lateral pull of the weapon while weapons having large striking surface, such as
retrieving it. heavy iron bar, or from a bullet.
236 Review of Forensic Medicine and Toxicology

Differentiation 13.1: Hematoma and depressed skull fracture

[Link]. Feature Hematoma Depressed skull fracture
1. Relation with skull surface Raised above the surface At or below the level of skull surface
2. On pressure Will pit Will not pit
3. Pulsation May have pulsation, if any artery is involved No arterial pulsation felt
4. Shape Circular in shape and movable over skull surface Margins sharper, irregular, less evenly circular

zComminuted fractures may be a complication z They occur after an occipital, parietal or

of fissure fracture, and the fragments of bone if temporal impact along with fracture at the site
displaced inward, form a depressed skull fracture. of impact.
4. Gutter fracture: It is formed when part of the 8. Blow-out fracture: This is due to blunt trauma to
thickness of the bone is removed so as to form the eye wherein the forces are transmitted via the
a gutter, e.g. oblique bullet wounds. It is usually globe to the bony orbit, causing disruption of the
accompanied by comminuted depressed fracture of orbital walls.5
the inner table of skull, and the fragments causing
Teardrop sign: The fracture is most commonly involves the thin
injury to the meninges and brain.
medial wall and/or orbital floor that results in orbital contents such
5. Ring fracture: This is a type of fissure fracture that as periorbital fat and inferior rectus muscle herniate downwards
encircles the base of skull around the foramen into the maxillary sinus resulting in pain, restricted eye movements
magnum, running from the sella turcica, partly and diplopia.5,6 Radiographically, a soft tissue ‘teardrop’ or polypoid
through petrous ridges and then going posteriorly mass in the roof of the maxillary antrum may be seen.
and medially, joining in the posterior fossa. In the
front, the fracture may pass through the middle 9. Basilar fracture: The base of the skull is weak,
ear and roof of the nose. As a result, the skull gets and hence any diffuse impact to the vertex of the
separated from the spine. These fractures do not skull will produce basilar fracture. These fractures
occur commonly. may be missed on X-ray examination.
Seen in: z Fracture of anterior cranial fossa: Usually due

z Fall from a height on feet or buttocks, when the to direct impact, although fissure fractures
force of the fall is transmitted upwards through in orbital or cribriform plate may be due to
the spinal column. contrecoup injury. The patient presents with
z Vault of skull being driven against vertebral epistaxis, CSF rhinorrhea (at times from mouth),
column by fall of heavy load or by a heavy anosmia, nasal tip parasthesiae, black eye, or
blow over the vertex. occasionally caroticocavernous fistula.7-10
z Violent twisting of the head on the spine, z Fracture of middle cranial fossa: It is seen due to

shearing the vault from base. direct impact behind the ear or crush injuries of
z Heavy blow directed underneath the occiput the head. It manifests by CSF otorrhea if petrous
or chin. part of temporal bone is fractured (or rhinorrhea
6. Diastasis or sutural fracture: Usually occurs in via Eustachian tube), hemotympanum, ossicular
young children following a forcible blow on the disruption, Battle sign, or VII and VIII nerve
head with a heavy hard blunt object where the palsy.11,12
fracture line passes through the sutures. It occurs z Fracture of posterior cranial fossa: It is commonly

alone, but is often associated with fissure fracture. due to direct impact of the back of the head on
7. Contrecoup fracture: Occurs exactly opposite to the ground, and clinically diagnosed by escape
the site of primary impact or ‘coup violence’. This of blood and CSF through the mouth.
is due to shear strain. 10. Hinge/transverse fracture: Fracture of the base
z It is usually seen in the anterior cranial fossa of skull occurs that completely splits it, creating
involving the bones of the orbital or ethmoid a hinge (‘nodding face’ sign); frequently occurs
plates with associated periorbital hematoma. with side impacts.13 It is sometimes referred to
 Regional Injuries 237

as ‘motorcyclists fracture’. Most common form is iii. Infections: It may be direct spread from compound
the one which extends from the petrous bony fracture or spread from fracture of paranasal
ridge through sella turcica to lateral end of the sinuses, like frontal or ethmoidal.
contralateral petrous ridge. iv. Traumatic epilepsy: More common with open head
injuries. Usually seen 1–2 years after the episode,
 Compound skull fracture: Laceration of scalp associated with and manifests as tonic or clonic fits.
skull fracture.
Growing skull fracture: Expanding linear fracture (usually
Brain Injury


in young children) associated with dural tear which allow

leptomeninges to herniate into fracture site and expand with
cerebrospinal fluid pressure (leptomeningeal cyst). „ Traumatic brain injury (TBI) is usually caused by
 Halo or ring sign: Blood from head injured patients may mix motor vehicle accidents, falls and assaults.
with CSF and mask the recognition of a leak. CSF will separate „ TBI can be classified based on severity (mild,
from blood when the mixture is placed on filter paper resulting moderate or severe, Table 13.2) mechanism (missile
in a central area of blood with an outer ring or halo.14 or blunt) and pathology (primary or secondary,
 Glucose estimation: CSF has a greater concentration of
glucose than mucus or lacrimal secretions. The quantitative Flow chart 13.2).
determination of a glucose level in nasal fluid not contaminated Flow chart 13.2: Classification of brain injury
by blood can be diagnostic of CSF rhinorrhea, if the nasal fluid
contains > 30 mg/dl.10,14
 Immunoelectrophoretic identification: β-2-transferrin assay
is the most widely used test and is considered the standard
criterion for diagnosis of CSF rhinorrhea.14,15
 Battle’s sign: Bruising behind the ear appearing 36 h after
head injury; may be confused with retro-auricular scalp bruise
(Fig. 13.4).16
 With basilar fracture, intracranial passage of a nasogastric tube
or nasopharyngeal airway can happen. These fractures may be
visible on plain radiographs or on bone window axial CT scans,
but confirmed radiologically by pneumocranium or air-fluid
levels in the sinuses.
 Skull X-rays have a limited role in head injuries, since they
do not identify intracranial injury. However, it may be helpful
when CT scan is not available. Plain X-rays can detect a skull
fracture, and its presence is helpful in predicting the presence
of intracranial injury. However, a normal skull series does not
rule out a brain injury. „ Primary brain injury is the injury caused at the time
of impact (e.g. contusion, laceration).18
„ Secondary brain injury is brain damage arising from
Complications of Skull Fractures events developing subsequent to primary injury.
z Some secondary injuries occur almost instantane-
i. Injury to the brain which may be dangerous to
life. ously (e.g. hemorrhage as a consequence of tear-
ing of vessel), whereas others evolve over hours
ii. Hemorrhage: If middle meningeal artery is
ruptured, fatal hemorrhage may occur. to days (e.g. delayed hemorrhage, inflammation,
brain swelling, and axonal swelling secondary to
paralysis of axonal transport or tearing of axons).19
z Excitatory neuropeptides, cytokines, free radicals,

metabolic and oxygenation insufficiencies cause

this injury.
z Little can be done about primary injury once it

has occurred. However, medical management

attempts to minimize the damage caused by
secondary injury.
z Acute injury to the brain causes increase in

glumatate, potassium and calcium levels with

Fig. 13.4: Battle’s sign: Blood in soft tissue decrease in glucose metabolism and level of
over mastoid magnesium.
238 Review of Forensic Medicine and Toxicology

Table 13.2: Severity of brain injury stratification

Criteria Mild/concussion Moderate Severe
Structural imaging Normal Normal or abnormal Normal or abnormal
Loss of consciousness 0–30 min > 30 min and < 24 h > 24 h
Alteration of consciousness/mental state A moment upto 24 h > 24 h Severity based on other criteria
Post-traumatic amnesia ≤ 1 day > 1 and < 7 days > 7 days
17
Glasgow Coma Scale 13–15 9–12 3–8
(best available score in first 24 h)

Cerebral Concussion leading to the condition known as chronic traumatic

encephalopathy syndrome.
Definition: Concussion (Latin concutere: to shake) is
physiological disruption of brain function as a result Signs and Symptoms
of a traumatic event which is manifested by at least Unconsciousness, bradycardia, hypotension and sweat-
one of the following: alteration of mental state, loss of ing, and is always followed by retrograde or post-
memory or focal neurological deficit, that may or may traumatic (antegrade) amnesia, temporary lethargy,
not be transient.20 irritability and cognitive dysfunction.21 Muscles are
„ Concussion, also known as mild traumatic brain
flaccid, pupils are dilated and unreacting, pulse is weak
injury is a clinical diagnosis (Table 13.2). and slow, and respiration is shallow.
„ It results from acceleration/deceleration of the head.
„ Violent head movement causes shearing or stretching
Severity of concussion: It is given in Table 13.3.
of nerve fibers and axonal damage. Findings: Gross and light microscopic changes in
„ It may resemble drunkenness (Diff. 13.2). the brain are usually absent, but biochemical and
„ Concussion is common among contact and collision ultrastructural changes—mitochondrial ATP depletion,
sports participants. Football players and boxers local disruption of blood-brain barrier occur. CT and
are particularly exposed to repetitive concussions, MRI scans are usually normal.

Differentiation 13.2: Drunkenness and concussion

S. No. Feature Drunkenness Concussion
1. Skin Flushed, congested and warm Pale, cold and sweating
2. Pulse Rapid and bounding Slow and feeble
3. Pupils Dilated; contracted in coma Contracted in pontine hemorrhage
4. Light reflex Sluggish May be brisk
5. Respiration Sighs, puffs, eructates Shallow, irregular, slow
6. Memory Confused, disoriented Retrograde amnesia, unrelieved by time
7. Behavior Uncooperative, abusive, talkative, sulky Quiet and retracted, curled up in bed, photophobia
8. Urine/blood Examination will be helpful Retention of urine, urine may contain albumin
9. History History of having consumed alcohol, smell of alcohol History of head injury with features of concussion

Table 13.3: Concussion grading scale

Grade 1 Grade 2 Grade 3
Transient confusion Transient confusion —
No loss of consciousness No loss of consciousness Brief or prolonged loss of consciousness
Concussion symptoms or mental status Concussion symptoms or mental status —
change resolves in ≤ 15 min change resolves in > 15 min
 Regional Injuries 239

 Post-traumatic automatism: It is intimately associated with Table 13.4: Grading of diffuse axonal injury (DAI)
amnesia. After an accident, the patient may speak and act in a Severity Axonal injury Hemorrhage in Lesions in cerebellar
purposive manner, but does not remember anything later on. corpus callosum peduncle
 Retrograde amnesia: Loss of memory preceding the event.
Grade I Present Absent Absent
 Anterograde amnesia: Loss of memory subsequent to the
event that caused the amnesia. Grade II Present Present Absent
 Post-concussion syndrome: Seen in patients who returned Grade III Present Present Present
to work too early after head injury. It consists of headache,
vertigo, lassitude, irritability and depression which may persist
for months. Autopsy Findings
 Second impact syndrome is characterized by rapid death due
to a second concussion prior to a return to baseline functioning i. Contact injuries to the scalp and skull may be
after an initial one. absent.
 Punch drunk syndrome (dementia pugilistica or boxer’s ii. Thin subarachnoid hemorrhage may be seen.
encephalopathy): A condition occurring late in boxer’s career or iii. Brain: Cut sections may be normal to the naked eye
years after retirement which is the cumulative result of recurrent
or there may be minimal gross alterations—focal
cerebral concussions.
necrosis or petechial hemorrhages in the corpus
Signs and symptoms: There may be deterioration of speed and
reflexes, and incoordination along with personality change callosum, focal lesions in the dorsolateral aspect
associated with social instability and sometimes paranoia and of the rostral brainstem in the vicinity of the
delusions. Later, memory loss progresses to full dementia, often superior and middle cerebellar peduncles. Gliding
associated with Parkinsonian signs, ataxia or intention tremors, contusions are common, and hemorrhages in the
shuffling, broad-based gait and dysarthria. thalamus and basal ganglia are frequent.
Autopsy: Chronic SDH, attenuation of corpus callosum, DAI and
cortical atrophy may be seen. Diagnosis
 CT scan: Characteristic CT findings may be absent but in severe

DAI focal lesions are seen as petechial hemorrhages in the

There are four forms of diffuse TBI: axonal injury, corpus callosum, cerebellar peduncle and evidence of diffuse
vascular injury, hypoxic ischemic encephalopathy and injury to axons.24
 MRI with its high sensitivity for parenchymal injury, DAI is
brain swelling. These categories overlap and they are
diagnosed in patients with non-hemorrhagic areas of T2 signal
often accompanied by various forms of focal TBI.
within the white matter or at the gray-white junction.
 Histologically, it is diagnosed by demonstrating scattered
Diffuse Axonal Injury (DAI) microglial accumulates and debris-laden macrophages along
with numerous axonal swellings (‘retraction balls/bulbs’) in
Definition: Diffuse axonal injury (DAI) is a condition the internal capsule, corpus callosum and superior cerebellar
representing a spectrum of severity in which the victim peduncle (Fig. 13.5).25 They can be seen as eosinophilic-pink
swellings on H&E stained sections and can be also detected by
is unconscious from the time of injury, and then either silver stains, but a survival of 15–18 h is required before they
remains in a coma or enters a persistent vegetative state. can be identified using this technique.
„ In severe cases, patients may expire depending on  Immunohistochemistry is the most sensitive technique, and

the severity of concurrent secondary injury. currently immunostaining for β-amyloid precursor protein (BAPP)
has proven to be a sensitive and specific method of detecting
„ DAI is a clinical syndrome with supporting neuro-
axonal swellings.
radiological changes.
„ Cause: It results from relative movement (shearing)
at the gray-white matter interface following sudden Cerebral Contusion and Laceration
rotational acceleration/deceleration forces which
Definition: Areas of hemorrhagic disruption (tearing
cause disruption and tearing of axons, myelin sheaths
lesions) of the CNS that are superficially located in the
and blood capillaries.22,23 With concussions, the
brain are called contusions if the pia mater is intact, and
axonal damage is considered as reversible; however,
lacerations if the pia is torn.
when sufficient vital axons are severely injured then
death can occur. Location: Contusions occur usually in the frontal and
„ Ninety percent of cases are due to road traffic temporal poles, inferior surfaces of the frontal (orbital
accidents and 10% due to falls and assaults. gyri) and temporal lobes, and the cortex above and
Severity of DAI is given in Table 13.4. below the Sylvian fissure.
240 Review of Forensic Medicine and Toxicology

Fig. 13.5: Axonal swelling/ballooning Fig. 13.6: Location of contrecoup contusions on undersurface of
frontal and temporal lobes (shaded areas)

„ Typically, it involve the crests of gyri and often ii. Contrecoup contusion: It is associated with falls
involve the gray matter only; may extend into and occurs at a site diametrically opposite to the
underlying white matter and form a hematoma. point of impact. It is due to the brain rebounding
„ In severe cases, extensive laceration with underlying backward from the skull following impact. It is
parenchymal hemorrhage may be associated with seen most commonly in the frontal (orbital gyri)
subdural hemorrhage, forming a so-called burst and temporal lobes (Fig. 13.6).
lobe—often seen in the temporal lobes. iii. Fracture contusion: Related to fractures of the skull
Pathogenesis: Contusions are the sites where the brain and bears no relation with the point of impact.
tissue comes in contact with the bony protuberances iv. Intermediary coup contusion: Present in deeper
and dural coverings, sites of forcible separation of the structures of the brain, like the white matter or
brain from the dura, and sites of differential movement basal ganglia. It is present along the line of impact
between the brain and dura and between adjacent areas between coup and contrecoup points.
of the brain. v. Gliding contusion: Usually associated with DAI,
„ Contusion produces focal neurological deficits that
and independent of site and direction of impact. It
persist for > 24 h. Since, the damage is focal, patients is a focal hemorrhage in the cortex and underlying
may recover uneventfully, provided that they did white matter of the dorsal surface of cerebrum,
not develop complications leading to other types particularly the frontal region. It is seen in falls
of brain damage, and did not sustain DAI at the and road traffic accidents.
time of injury. vi. Herniation contusion: It is due to the impact of
„ Intoxication by alcohol is associated with unduly medial side of temporal lobe with the edge of
large contusions as they tend to fall more heavily the tentorium, or the cerebellar tonsils against the
because of their blunted protective locomotor foramen magnum. It is independent of the site and
reflexes. Moreover, associated liver disease and acute direction of impact.
alcohol intoxication hinder hemostasis. Clinical features: The GCS is often low, and
Types: There are several types of brain contusions based focal neurologic symptoms, loss of consciousness and
on location and/or mechanism of injury: visual changes are present. Secondary injury may
i. Coup contusion: Occurs at the site of impact due further complicate the clinical picture by producing
to inbending bone rebounding and injuring the infarcts due to local vasospasm. Prognosis is usually
brain. They have a wedge-shaped appearance whose poor.
base is at the pial surface and the tip pointing Diagnostic tool: CT scan shows a mixture of hypo-
towards the white matter. and hyperdense lesions within the brain parenchyma.
 Regional Injuries 241

Autopsy Findings occipital lobes (coup injury) and a more prominent

i. In early stages, small contusions appear as linear injury to the frontal lobes (contrecoup injury)
hemorrhages perpendicular to the pial surface (Fig. 13.7).
and associated focal swelling. Large contusion-
lacerations appear as fragmented and irregularly Mechanism
shaped hemorrhagic areas. Frequently, there is There are several hypotheses to explain this phenomenon
associated subarachnoid hemorrhage. and most are correct in some aspect.
ii. With time, it shrinks and takes a golden brown „ When head strikes the ground, a transient deformation
color secondary to hemosiderin deposition. of the skull occurs with increase in pressure which
iii. Old contusions are frequent incidental autopsy may impinge on the underlying brain causing
finding, particularly in chronic alcoholics, which
compression—coup injury.
are seen as depressed yellow gliotic scars (plaque
„ Simultaneously, opposite area of the skull will bulge
jaune).
outward to accommodate the deformation—the
so-called ‘struck-hoop’ action. There is formation of
Coup and Contrecoup Injury
vacuum or rarefaction (due to negative pressure
„ Coup injury is one which occurs immediately gradient) as brain lags behind the moving skull.
beneath the area of impact, and results directly by The vacuum exerts a suction/cavitation effect that
the impacting force. causes tension and shear strain by pulling apart of
z Smaller the impact area, greater is the likelihood the constituent of the brain—contrecoup injury.
of a coup injury.
z Effects are immediate, resulting in contusion and
The following points should be considered:
hemorrhage. i Contrecoup injury is rare before the age of 3 years.
z For example, if the head is fixed (person standing
ii. There may be only contrecoup injury without any
still) and there is violent impact over the frontal coup injury.
bone, fracture and underlying brain damage will iii. There may be no fracture of skull, even in the
be located beneath the site of impact (Fig. 13.7). presence of severe coup and contrecoup lesions.
„ Contrecoup injury (French contre: opposite, coup: iv. Though, contrecoup contusion is typically caused
blow) means that the lesion is present in the brain by deceleration of a falling head (head is free to
opposite to the site of impact. move), it can also occur when a fixed head is struck.
z It is caused when the moving head is suddenly If the victim is lying on the ground, a heavy blow
decelerated by hitting a firm surface, e.g. striking on the upper side may cause typical contrecoup
of the head on the ground during a fall, usually lesions either in the contralateral temporal or
seen in road traffic accidents. parietal cortex, or against the falx on the inner
z For example, when a person falls with his occiput side of the ipsilateral lobe. In such cases, there is
striking the ground, he may sustain injury at the often coup injury as well.

Fig. 13.7: Mechanism of coup and contrecoup injury of the brain

242 Review of Forensic Medicine and Toxicology

Site
constituent particle of brain that are roughly opposite to
„ The most common site for contrecoup injury is the the original site of impact.
frontal lobes (tips of the frontal poles/orbital surface)  Bony irregularities theory: Most contrecoup injuries occur in
and may be symmetrical, if a fall on the occiput has frontal, temporal and parietal areas of the brain. The occipital
occurred. lobes lying in the rounded capacious posterior fossa are less
„ In temporal or parietal impacts, the contrecoup often involved. This suggests the impact of frontal and temporal
lesions are usually on the contralateral surface of poles in against the irregular floors and borders of the anterior
and middle cranial fossae.
the brain.
 Transmitted wave theory: Energy of impact in a hollow organ
„ It is rare for a fall on the frontal region to produce propagates by radiating waves along the meridional lines that
occipital contrecoup. This is thought to be due to the damage as they leave the site of impact and converges as they
anatomical configuration of the floor of the cranium. approach the opposite side.

Medico-legal Importance
i. On the basis of localization of injuries, it is possible to Intracranial Hematoma
conclude if they resulted from a fall or from blows.
z With blows (assault), brain shows much larger Intracranial hemorrhages are classified by anatomical
contusions underlying the area of impact (coup) location:
than on the site opposite to impact (contrecoup). Types of intracranial hematoma
Contrecoup lesions are rare.
 Extradural  Subarachnoid
z But, in head injuries caused by falls (e.g. road
 Subdural  Intracerebral
traffic accidents), the contrecoup injuries are
usually located in inaccessible portions and are „ Intracranial hemorrhage is a common complication
larger than the coup contusions. Coup lesions of head injury, and is the most common cause of
may be absent or minimal. death in patients who experienced a lucid interval,
ii. With severe frontal contrecoup from a fall on the ‘talk and die’, or ‘talk and deteriorate after injury’.
occiput, the transmitted force may cause fracture „ Clinical complications associated with a hematoma are
of the floor of the anterior fossa resulting in ‘black related to the size/volume of the lesion, the anatomical
eyes’. In assaults where a fall has occurred, care location and the rapidity with which it develops.
must be taken not to attribute such periorbital „ Hypovolemic shock cannot happen from intracranial
bleeding to direct punches.
bleeding; there is not enough space inside the head
for the amount of blood loss needed to produce
Various theories that have been proposed to explain contrecoup
shock.
injuries:
 Skull deformation/Struck hoop theory: It likens the skull on
„ Expanding hematomas should be distinguished
impact to a deformed hoop. The ovoid shape of the skull is from delayed hematoma, which are as lesions that
exaggerated and the brain opposite to the point of impact occurs 24-48 h after the time of injury and are not
collides with the deformed skull. evident on initial imaging studies. It reflects increased
 Brain displacement theory: There is continued movement of
blood flow or pressure through a vascular capillary
the brain within the skull in the direction of impact after the
network that was focally damaged, compounded by
bony case has been brought to a halt. The reverse impact of
the brain to the internal surface when it returns to its primary post-traumatic coagulopathy.
position results in contrecoup damage. „ In several cases of death due to blunt force head
 Pressure gradient theory: At the site of impact the pressure trauma, the only intracranial injuries that are evident
is raised whereas on the opposite side, the pressure is lowered. at autopsy include subdural and subarachnoid
Contrecoup injury is due to formation of cavity or vacuum hemorrhage.
in cranial cavity on the opposite side of impact as brain lags
behind the moving skull. The vacuum exerts a suction effect  Hemorrhage: Copious discharge of blood from the blood
that damages the brain. vessels.
 Rotational shear force theory: Contrecoup lesions are  Hematoma: Localized collection of blood in the tissues, usually
chiefly due to local distortion of blow that causes shear clotted or partially clotted.
strains (rotational forces, either deceleration or acceleration)  Apoplexy: Sudden large effusion of blood in an organ or tissue.26
in the direction of the force applied due to pulling apart of The term is synonym for cerebral hemorrhage.
 Regional Injuries 243

Extradural/Epidural Hematoma (EDH) „ It forms a circumscribed ovoid or disk-shaped

blood clot that progressively indents and flattens
Definition: It is the bleeding occurring between the the adjacent brain.
inner table of the skull and meninges (dura) (Fig. 13.8A). „ Size and extent of an EDH is determined by the
source of bleeding (venous or arterial) and the
Causes strength of attachment between the outer layer of
Mostly traumatic in origin, and unilateral. It is seen the dura and the cranium.
in falls and road traffic accidents (upto 10% of severe „ Artifactual epidural hematomas can occur in fire
head injury cases). victims, related to heat-induced postmortem skull
fractures.
Salient Features
„ It occurs usually on the side of the impact, and
Site and Vessels Involved
common in adults between 20–40 years as the dura i. It may be due to impact over:
is able to strip more readily off the underlying bone. z Lateral convexity of head, resulting in fissure

„ It is infrequent in the elderly and young (< 2 years) fracture of squamous temporal bone with
due to greater adherence of dura to the skull in both rupture of underlying middle meningeal artery
these age groups, and absence of a bony canal for which is a direct branch of internal maxillary
the artery in the young. artery (commonest cause).28-30
„ It shows typical limitation due to the dural attach- z Forehead that may tear the anterior ethmoidal

ments at the suture lines.27 artery.

„ Fracture (fissure type) is present in most of the cases z Occiput that may tear the transverse sigmoid

(90–95%). sinus.
„ In children, EDH may be seen even without skull z Vertex that may cause hemorrhage from sagittal

fracture. sinus.

Fig. 13.8: Intracranial hematomas

244 Review of Forensic Medicine and Toxicology

ii. Fracture of skull with tear of diploic veins and bone and a small thrombus on the surface of the
middle meningeal veins. middle meningeal artery may be seen.
iii. Diffuse brain swelling and cerebral contusions may
Types be seen.
i. Acute onset is within few minutes to few hours or iv. Subfalcine herniation extending from the side of the
even a day (arterial bleeding). hematoma to the opposite side, and transtentorial
ii. Chronic: Symptoms are slower in onset (48–72 h) herniation which is usually more marked on the
after trauma. It is rare, and commonly associated side of the hematoma (effects of intracranial ‘space
with tears of venous structures. occupancy’).
v. Swelling of the cerebral hemisphere under the
Clinical Features31,32 hematoma causes effacement of sulci and flatness
of the crests of the gyri, which gives a smooth
i. Loss of consciousness due to concussion.
appearance of the brain.
ii. Dilation of pupil on the side of hemorrhage with
conjugate deviation of eyes to opposite side. Medico-legal Aspects
iii. Bilateral fixation of pupils.
iv. Lucid or latent interval is seen.* It is a state of „ Prognosis is good with proper treatment. Hematoma
consciousness between two episodes of uncon- on the contralateral side should be carefully excluded.
sciousness.33 „ Patient may be discharged from hospital during lucid
Mechanism: Since, the initial brain injury is only a interval and die at home; doctor may be charged
concussion, subsequent middle meningeal bleed with negligence.
cause the ensuing decompensation from the „ Most complications occur within the first 24 h
expanding blood collection, causing increased following the injury. Patient’s attendants should be
intracranial pressure and a reduction in cerebral instructed on what signs to look for and when to
perfusion (a secondary injury). return for further care.
v. Features of cerebral compression supervene and „ The condition may resemble drunkenness and patient
may lead to coma. may die in police custody.
vi. Decerebrate rigidity, and death due to respiratory „ Presence of an EDH may or may not cause death—
failure. the possibility increasing with increasing volume
Frequently, patient presents in coma and requires an of blood, duration of injury and the presence of
urgent craniotomy. It is a surgical emergency, and early herniation phenomenon.
diagnosis and intervention usually saves the patient,
since the brain itself is not significantly injured, and the Non-traumatic spontaneous EDH may be seen in sickle cell
bleeding originated from outside the brain parenchyma. anemia, coagulopathies, infectious diseases of the skull like sinusitis,
vascular malformations of the dura, metastasis to the dura or skull,
Diagnostic tool: CT scan. and chronic kidney disease. In this category of patients, typically
„ It produces a biconvex lenticular-shaped hemorrhage, there is no evidence of head trauma, skull fracture or lucid interval.
due to adherence of the dura to the inside of the
cranium. Subdural Hematoma (SDH)
„ Isolated EDHs of ≥ 2 cm or about 30 ml in volume
may cause an alteration in the level of consciousness Definition: It is the bleeding occuring between the
or a focal neurologic deficit. under surface of dura and outer surface of arachnoid
mater (Fig. 13.8B). It is essentially a venous or capillary
Autopsy Findings bleeding, and not an arterial bleeding.
i. Temporal scalp contusion on the side of the
hematoma. Cause
ii. Hematoma in the epidural space on removal of the It is usually traumatic, following an assault or fall
skull cap along with fissure fracture of the temporal (70–75%), accidents account for another 20–25% of

* Patients with lucid interval are often not associated with other types of brain injury. If the patient is in coma from the time of injury,
other types of brain injury are likely to be present.
 Regional Injuries 245

cases, but it can be due to secondary causes including „ It causes displacement of the cerebral hemispheres
alcoholism and anticoagulant therapy (Table 13.5). with flattening of the convolutions of the opposite
hemispheres.
Table 13.5: Causes of SDH
Causes Comment Types
Trauma Blunt force head injury (accident/assault) SDHs are classified in clinical terms as acute, subacute,
Neurosurgical Neurosurgical management of hydrocephalus chronic or acute on chronic depending on the length of
complication history, the neuroimaging findings and the appearance
Perinatal Following labor (rarely significant) of the blood when the hematoma is drained.
Vascular Aneurysms, a rare childhood cause i. Acute SDH: Signs are evident within 3 days of injury.
It occurs due to rupture of large bridging veins or
Hematological Inherited and acquired coagulation disorders,
disorders and hematological malignancies the cortical artery or due to cerebral laceration.
z It is mostly unilateral, may be bilateral with
Metabolic Glutaric aciduria, Menkes disease, and galacto-
disorders semia
mortality—90%.
z Clinical features: Drowsy or comatose (one-third
Hypernatremia Associated with intracerebral hemorrhages patients have a lucid interval) from the moment
Raised central Intradural bleeding may lead to subdural collec- of injury. Unilateral headache, hemiparesis,
venous pressure tions enlarged pupil on the same side are frequent.35
z It is a rapidly evolving lesion and burr (drainage)

Salient Features holes or emergency craniotomy is mandatory.

z Blood tends to accumulate in the base of skull,
„ One of the most common head injuries ending fatally. especially in the middle cranial fossa, is reddish
SDH is caused due to acceleration-deceleration injury in color and clotted.
in which there is significant primary damage to ii. Subacute SDH: The signs are evident between
brain parenchyma. 4–21 days.
„ Hematoma often not associated with a fracture of z It is due to rupture of smaller bridging veins.
the skull. z It is associated with minor cerebral contusions
„ Commonly seen in elderly and alcoholics. or swelling.
„ Location of a SDH does not necessarily correlate to
z Clinical features: Drowsiness, headache, confusion,
the location of the blunt force impact site.
forgetfulness or mild hemiparesis.
„ In infants < 1 year, the subdural space is narrower
z It may be mistaken in the young for schizophrenia
and less tolerant of space occupying lesions.
and in the old for presenile and senile dementia.
z Mortality is less.
Vessels Involved
z Blood is partly clotted and partly fluid due to
i. Rupture of bridging or communicating veins traver- hemolysis or dilution with CSF.
sing the subdural space to drain into parasagittal iii. Chronic SDH or Pachymeningitis hemorrhagica
sinus.34 interna chronica
ii. Tears in the dural venous sinuses. z Signs and symptoms of alteration in mental state
iii. Cerebral contusions/lacerations after a fall. or progressive focal neurological deficits (usually
iv. Fresh tear of old adhesion between dura and brain headache, cognitive decline, gait abnormalities
with bleeding. and hemiparesis) appear > 3 weeks after trauma.
z It is most common in infants (< 6 months) and
Site in the elderly (> 60 years). A history of head
„ It is commonly seen over the upper lateral surface trauma may be elicited.
of cerebral hemispheres and most commonly supra- z Blood is liquefied, mixed with proteins and CSF.

tentorial (frontotemporal region). z Risk factors: Cerebral atrophy, alcohol abuse,

„ The blood presses on both the crests and depths of seizures, coagulopathies, subdural structural
the gyri, hence the cerebral convolutions retain their abnormalities, intraventricular shunts, CSF
normal contours. fistulae and dehydration.
246 Review of Forensic Medicine and Toxicology

z It is usually seen over the parietal lobe and Autopsy Findings

near the midline. i. Externally, evidence of blunt force injury, more
z It is frequently an incidental finding during commonly to the face than to the head may be
autopsy in old persons. seen.
Diagnostic tool: CT scan. It appears as concavoconvex ii. Skull fractures may be present.
crescentic opacity.36 iii. Clotted or partly liquefied hematoma extending
for a considerable distance in the subdural space,
 Acute SDH appears hyperdense to brain tissue, subacute appears producing an accentuation of the gyral pattern on
isodense and chronic appears hypodense on noncontrast CT. the affected side with flattening of the opposite
 Acute SDH > 120 ml is invariably fatal, between 50–120 ml is
likely to cause death (particularly if there is significant subfalcine side (in contrast to the smooth brain surface under
herniation and uncal herniation), and < 50 ml is unlikely to be an epidural hematoma).
fatal. Usually 50 ml of rapidly accumulating subdural blood is iv. In acute SDH, there are no enclosing membranes.
su%cient to be life-threatening. Chronic SDH may present ‘classically’ as typical
 ‘Acute on chronic’ SDHs are chronic SDHs into which there hematoma surrounded by a clearly defined membrane
has been recent bleeding to the extent that new neurological
symptoms are precipitated in a patient who previously had no
that includes original dura, and an inner and outer
symptoms or trivial symptoms. ‘neomembrane’ which contains bloodstained fluid of
 When a child presents with unexplained vomiting, lethargy and/ variable color (usually yellow).
or head trauma, and subdural hematoma is found, the possibility v. Transtentorial herniation (more marked on
of non-accidental injury (child abuse) must be explored. the same side of the hematoma), and tonsillar
herniation and subfalcine herniation directed away
Age of Subdural Hematoma from the side of the hematoma may be seen.
„ Grossly, during the first 4 days, hematoma undergoes
Medico-legal Aspects
clotting, and gradually becomes dark red to brownish
in color by 5–10 days. Discrete fragile membrane „ The presence of any amount of SDH is usually
becomes obvious by 2nd week. Liquefaction of clot interpreted by forensic experts as an indicator that
occurs by 3 weeks. After 1 month, a firm capsule the amount of force sustained by the individual
containing a dark brown watery fluid is formed. was likely sufficient to cause lethal brain injuries.
„ Histologically, age of subdural hematoma can be However, it is possible for individuals to survive
estimated as given in Table 13.6. a SDH.
„ Histopathology of SDH, both acute and chronic, is
used as a basis for estimating the period between
Table 13.6: Histological timing of subdural hematoma injury and death which helps in correlating the
Interval Features events prior to death.
36 h Intact RBCs, fibroblastic activity at the margins.
Subdural Hygroma
4–5 days Loss of RBC contour, neomembrane adjacent to dura
is 2–5 layers of thickness. It is an accumulation of CSF in subdural space. When
arachnoid is torn, CSF may pass from subarachnoid
6–10 days Laked RBCs, clot liquefies, 12–14 layers of fibroblasts,
hemosiderin laden phagocytes seen, neomembrane space into subdural space. A large collection of fluid
visible grossly. may accumulate and cause cerebral compression.
„ It is usually seen in infants and children.
11–14 days Fibroblasts, capillaries and fibrin subdivide the
clot, fibroblasts migrate around the edges of clot, „ This chronic lesion has all the features of subdural
siderophages present on arachnoid side. hematoma, except trauma is not recorded and
15–20 days Capillary formation, original RBCs lysed, membrane 1/3 amount of blood is minimal.
to & dural thickness on the side of dura, but variably „ It may develop as a complication of meningitis,
thin on arachnoid side. hydrocephalus and head trauma with/without skull
3–4 weeks Liquefied clot, membrane same thickness as dura on fracture.
dural side and & dural thickness on arachnoid side.
Siderophages in membranes. Subarachnoid Hematoma (SAH)
1–3 months Hyalinization of membranes, more of collagen and of
same thickness as dura on arachnoid side.
Definition: It is the hemorrhage in the subarachnoid
space between the arachnoid and pia mater, mixed
3–6 months Hyalinized neomembrane resembling dura.
with CSF (Fig. 13.8C).
 Regional Injuries 247

Causes In acute alcoholism, traumatic SAH is common due to:

It is mostly venous in origin.  Loss of muscular coordination resulting in excessive rotational

a. Non-traumatic/natural causes forces within the head

 Increased bleeding from congested vessels
i. Rupture of a developmental aneurysm of the  Bounding pulse of the drunken person
vessels in the Circle of Willis [Berry (saccular)
aneurysm].37 Excluding head trauma, it is the
most common cause (70% of cases) of SAH Salient Features
especially in young adults (Fig. 13.9).38 Aneurysm „ SAH is common in TBI. Even in minor head trauma,
size and site are important in predicting risk of small amount of localized SAH over the cerebral
rupture. Rupture is likely with aneurysms that convexities is almost invariably seen.
are large (7–10 mm in diameter). „ Like SDH, the location does not correlate with the
ii. Arteriovenous malformations (10%). site of impact in blunt force trauma, but usually SAH
iii. Atherosclerotic changes in blood vessels is most prominent close to its source.
associated with hypertension in elderly subjects. „ SAH is extensive because CSF and unclotted sub-
iv. Leaking intracerebral hemorrhage. arachnoid blood flow freely in the subarachnoid space.
v. Disease conditions, like purpuric states and „ When the brain is removed at autopsy, the arachnoid
leukemia. membrane remains covering the brain.
b. Traumatic causes
i. Cerebral contusions or lacerations. Site
ii. Explosive blast.
iii. Asphyxia by strangulation. „ SAH has a predominantly basal distribution.
„ It is usually found over the orbital surface of the
iv. Traumatic asphyxia.
frontal lobe, parietal lobe and anterior third of the
v. Blows to the neck, accidents, falls, and cervical
temporal lobes.
manipulations causing damage to the vertebral
„ It can be unilateral or bilateral, localized or diffuse.
or basilar arteries.
vi. Rupture of a traumatic ICH into the subarachnoid Types
space or into the cerebral ventricles with flowing
i. Immediate.
of the blood through the foramina of Magendie
ii. Delayed/reactionary hemorrhage—until the initial
and Luschka into the subarachnoid space.
contraction and retraction of vessels has subsided
vii. Prolonged hyperextension of the head during
(delayed post-traumatic SAH).
bronchoscopy, bleeding originating from rents
in basilar or vertebral arteries (may lead to a
Clinical Features39
charge of negligence).
i. Sudden onset of severe, unusual headache
(‘thunderclap headache’).
ii. Nausea and vomiting.
iii. Neck stiffness, photophobia, drowsiness or
agitation.
iv. Depressed consciousness.
Physical findings: Meningism and a positive Kernig’s
sign.
Diagnosis: Non-contrast CT scan.40 It shows hyperdense
blood collections along the falx, and in the basilar
cisterns. Lumbar puncture (LP) should be performed,
if CT scan is not yielding sufficient information. LP
will reveal CSF intimately mixed with blood coming
under increased pressure.
Fig. 13.9: Common sites of Berry aneurysms in circle of Willis Differential diagnosis: Bacterial meningitis.
248 Review of Forensic Medicine and Toxicology

Medico-legal Aspects Important differentiating features of extradural, subdural and

„ Atherosclerotic vessels in older persons with high subarachnoid hemorrhages are given in Diff. 13.3.
blood pressure rupture more easily than normal
ones. The condition of blood vessels must therefore Intracerebral Hematoma (ICH)
receive most careful consideration.
Definition: Hemorrhage found within the cerebral
„ It is possible to testify that trauma has caused or
parenchyma that is not in contact with the surface of
precipitated the rupture of developmental Berry
the brain (Fig. 13.8D).
aneurysm when head injury is followed at once by
symptoms of unexplained acute neurologic deficit Causes
(headache, hemiparesis, stupor or confusion).
„ SAH can be produced postmortem, secondary „ Hypertension, trauma and cerebral amyloid
to decomposition, with lysis of blood cells, loss angiopathy cause the majority of these hemorrhages.43
of vascular integrity and leakage of blood into „ Advanced age, and heavy alcohol and cocaine use

subarachnoid space. It can also be produced during increase the risk.

the process of removing the brain. „ Usually, it is due to disease of cerebral vessels;
hypertension is often a contributory cause.
 Berry aneurysms usually occur at a point where an artery is „ Common causes are:
branching from a parent artery close to the circle of Willis, and i. Spontaneous hemorrhage in the region of basal
develop where the vessel wall is abnormal due to congenital ganglia by rupture of lenticulo-striate artery
defect or a degenerative change producing a thin-walled out-
(Charcot’s artery) which is a branch of middle
pouching. The wall of an aneurysm lacks an internal elastic lamia
and muscularis layer. Only the intimal layer and adventitia of cerebral artery.
the artery form the dome of the aneurysm.41 ii. Capillary hemorrhage in anoxia, arterial thrombosis,
 Thunderclap headache: Headache that reaches its maximum blood dyscrasias, fat embolism and asphyxial states.
intensity in < 1 min. SAH is the most common cause.42 Other iii. Angioma or malignant tumor of the brain.
causes: Sentinel headache, cerebral venous sinus thrombosis,
iv. Hypertensive cerebral vascular disease.
unruptured cerebral aneurysm, cervical artery dissection,
pituitary apoplexy and ischemic stroke. v. Laceration of the brain.
vi. Puerperal toxemia.

Differentiation 13.3: Extradural, subdural and subarachnoid hemorrhage

S. No. Feature EDH SDH SAH
1. Location Between skull and dura Between dura and arachnoid Between arachnoid and pia
2. Cause Always due to head injury Mostly due to injury but not always Both natural and traumatic
3. Incidence 2% of head injuries 5% of all head injuries; 50% of fatal Extremely common in head injuries
head injuries
4. Vessel involved Middle meningeal artery Bridging veins, cortical contusions Leakage from vessels on brain surface
5. Externally Often swelling under the scalp Often no external manifestation No external manifestation
6. Confusion with Can be confused with heat Seldom confused with other bleeding Can be artifact from opening the skull
other condition artifact
7. Space occupying Can be space occupying Often space occupying Space occupying, if it is arterial
8. Effect on brain Brain surface ironed out by dura Brain compressed, but less ironed out Brain surface not distorted
(ruler straight appearance) (undulating appearance)
9. Situation Usually on one side, but can be Unilateral or bilateral Focal, diffuse, or bilateral
bilateral
10. Clinical course Classic lucid interval Less well-defined Depends on cause, location, vessel
11. Autopsy Save a portion for alcohol and If fresh, save a portion for alcohol Blood seldom sufficient or helpful for
drugs and drugs analysis
 Regional Injuries 249

Traumatic and Nontraumatic ICH (Diff. 13.4) Diagnostic tool: CT scan. ICH appear as hyperdense
The cause of ICH is at times remains uncertain, and a coincidental lesions (small foci, typically at gray/white matter
hypertensive hemorrhage or a hemorrhage associated with cerebral interface or more centrally in the white matter) and are
amyloid angiopathy may be di%cult to exclude. associated with mass effect and midline shift.
 The exclusion of a hypertensive hemorrhage is presumptive,
based on the lack of a history of hypertension and the absence
of gross (e.g., cardiomegaly and renal tubular atrophy) and Intraventricular Hemorrhage (IVH)
microscopic features (hypertensive vascular changes in the basal
The presence of copious blood in the fourth ventricle, seen
ganglia and dentate nucleus) of hypertension.
through the foramina of Luschka and Magendie before the brain
 Hemorrhage owing to cerebral amyloid angiopathy is excluded
when microscope sections stained with Congo red do not show is sectioned, can be taken as indirect evidence of IVH which is
amyloid in the cerebral vessels. confirmed when the brain is sectioned. Traumatic IVH can be
primary or secondary.
 Primary traumatic IVH is rare, but occurs after motor vehicle
Salient Features
accidents and assaults.
„ Traumatic ICH is seen in 15% of all patients who  Nontraumatic primary IVH originates from a ruptured Berry
sustain fatal head injuries. aneurysm or vascular malformation, or can be associated with
„ Most likely result from a direct rupture of intrinsic hypertension, anticoagulant therapy or methamphetamine
cerebral blood vessel in relation to contusions at the abuse.
time of injury.  Secondary IVH is common after trauma which is usually self-

„ May be single or multiple. evident when the brain is sectioned and a hematoma is found
in continuity with the ventricles.
Sites
ICH are well demarcated homogenous collection of
blood seen most frequently in the white matter of the
frontotemporal lobes when superficially located and  Most common type of intracranial hemorrhage: Intra-
are most likely related to extensive contusional injury; cerebral hemorrhage.
more deeply seated hematomas are seen in impacts of  Least common type of intracranial hemorrhage: Epidural
hemorrhage.
greater force, such as road traffic accidents.
 Most common non-traumatic intracranial hemorrhage:
Clinical Features Intracerebral hemorrhage.
 Most common intracranial hemorrhage following head
i. Abrupt onset of focal neurologic deficit. trauma: Subdural hemorrhage.44
ii. Diminished level of consciousness.  Most common cause of subarachnoid hemorrhage: Head
iii. Signs of increased intracranial pressure, such as trauma.
vomiting and headache.  Second most common cause of subarachnoid hemorrhage:
iv. Seizures are uncommon. Rupture of Berry (saccular) aneurysm.
v. Contralateral hemiparesis.  Most common cause of intraparenchymal hemorrhage:
Large intracerebral hematomas should be evacuated, Hypertension.
Most common artery involved in intraparenchymal
unless the patient’s neurological state is improving.


hemorrhage: Lenticulostriate artery.

Small multiple hematomas need not be removed.

Differentiation 13.4: Post-traumatic intracerebral hemorrhage (PTICH) and spontaneous cerebral hemorrhage (apoplexy)
[Link]. Feature PTICH Apoplexy
1. Cause Head injury Hypertension, atherosclerosis or aneurysm
2. Age Young individuals Adults (past middle age)
3. Onset Distinct interval after injury Sudden
4. Position of head In motion Any position
5. Mechanism Blunt force injury, coup and contrecoup Rupture due to disease
6. Site/location White matter of frontal or tempero-occipital region Ganglionic region
7. Concussion May be seen Not present
8. Coma Variable; coma from beginning, or concussion → Deep unconsciousness and no such sequence
consciousness → coma
250 Review of Forensic Medicine and Toxicology

 Most common sites of hypertensive hemorrhage: Basal Differential diagnosis of multiple brain petechiae
ganglia [putamen (most common site, 55%), thalamus The petechiae of diffuse vascular injury may be confused with
vascular congestion which is common and often marked in the
(15%) and adjacent white matter (10%)], deep cerebellum
brain after fatal TBI.
(10%), and pons (10%).45  Petechiae in vascular congestion can be identified by its
 Sites of hemorrhage following head trauma: Intra- preference for dependent areas of the brain, its localization to
parenchymal (inferior frontal lobes, anterior temporal the walls of the third ventricle, and its tendency to be absent
lobes), subarachnoid, subdural and epidural spaces. or inconspicuous in the brainstem.
 Widespread petechiae are also seen in many non-traumatic
 Commonest sites of rupture of Berry aneurysm: Anterior
conditions including DIC, thrombotic thrombocytopenic purpura,
circulation (85%), with the most common locations at the air and fat embolism, and cerebral malaria.
origin of the anterior communicating artery, origin of
the posterior communicating artery and the bifurcation
Brain Swelling
of the middle cerebral artery (Fig. 13.9). Vertebral artery
is the least common site.46 „ Swelling may be severe enough to raise the ICP
and cause death from brain shift, herniation and
secondary damage to the brainstem.
„ The unmyelinated infant brain with its higher water
Diffuse Injury to the Brain
content more rapidly produces life-threatening
DAI has already been discussed. Ischemic and hypoxic cerebral edema.
„ Types: It can be classified into three types:
brain damage, and an increase in the volume of all
or part of the brain are common pathology seen in a. Swelling adjacent to contusions (focal).
autopsy of fatal TBI. b. Diffuse swelling in one cerebral hemisphere seen
in association with ipsilateral acute SDH which
becomes evident after surgical removal of the
Diffuse Ischemic Injury
hematoma.
„ Diffuse ischemia injury can develop as a consequence c. Diffuse swelling involving both cerebral
of increasing cerebral swelling secondary to cardi- hemispheres due to global ischemic injury which
orespiratory arrest, or as a consequence of profound tends to occur in young patients.
hypotension due to other injuries, particularly frac- „ Pathogenesis: It is caused by vasodilation secondary

ture of long bones. to loss of cerebrovascular autoregulation causing

increase in the cerebral blood volume (i.e. congestive)
„ More common in patients with high intracranial
or an increase in water content of the brain tissue
pressure [(ICP), > 60 mmHg is fatal].
(cerebral edema).
„ Ischemic damage is another cause of traumatic coma
„ Features: Flattening of the surface of the gyri and
in the absence of an intracranial mass lesion. narrowing, effacement of the sulci causing a smooth,
„ Histologically, neuronal ischemic injury can be flat outline on the normal undulations of the surface
identified using H&E stain: neuronal nucleus is of the cerebral hemisphere. Brain swelling also causes
shrunken and the cytoplasm undergoes eosinophilic narrowness of the cerebral ventricles, and when it is
change, appearing red. localized, it may cause herniation (Fig. 13.10).
„ In rare cases, the only intracranial injury identified

Diffuse Vascular Injury at autopsy is a markedly swollen brain. The swelling

may be diffuse or it may be localized to a single side
„ Diffuse vascular injury is caused by the same type of with an associated ‘midline shift’ which is referred
forces that cause DAI, but the force is more severe to as ‘malignant cerebral edema’.
and produces extensive disruption of neuronal
function, so that death occurs before axonal swellings  Cushing ulcer is one of the complications seen in 50–75% of
patients with TBI. It is a form of gastroduodenal stress ulceration
can develop. similar to Curling’s ulcer seen in severe burns. The ulcers are
„ Autopsy findings: Contact head injuries may not usually small and multiple.
be apparent. Brain reveals thin SAH and widely  Brain herniation may extend under the falx cerebri damaging
the cingulate gyrus (subfalcine or supracallosal hernia), under
scattered petechial hemorrhages. The hemorrhages the tentorium cerebelli damaging the parahippocampal gyrus/
are prominent in subependymal regions, lateral pons medial temporal lobe (tentorial or uncal hernia), and through
and midbrain, and midline of the hypothalamus and the foramen magnum damaging the tonsil of the cerebellum
(tonsillar hernia).47
rostral brainstem.
 Regional Injuries 251

Fig. 13.10: Features of brain swelling Fig. 13.11: Effect of brain herniation and midline shift

 An intracranial mass lesion is usually associated with a Facial Injuries

contralateral hemiplegia due to either cortical dysfunction or
compression of the ipsilateral cerebral peduncle. However, a Facial injuries are also seen along with head injury.
supratentorial mass lesion can cause shift of the midbrain to However, they are rarely fatal by themselves, unless
the opposite side. The contralateral cerebral peduncle can then
impinge on the tentorium cerbelli, causing the unexpected the victim has asphyxiated from the blood entering
finding of an ipsilateral hemiplegia. At autopsy, this can be seen into the air passages. The face has many prominences
as the Kernohan-Woltman notch indentating the midbrain with complex contours such as chin, nose, cheekbones,
(Fig. 13.11).47 This can be seen in SDH, EDH and cerebral tumors eyebrows, ears and lips. They may be the first ones
with midline shift. The process explains how clinical signs may
appear on the same side of damaged cerebral hemisphere and to receive the blows directed at the face producing
has been referred to as false localizing sign. characteristic injuries.
 Duret hemorrhages are delayed, secondary brainstem „ Eyebrows are injured during falls and blows
hemorrhages (seen in midbrain and pons) (Fig. 13.11). They producing abrasions, lacerations and fractures of
occur in cranio-cerebral trauma victims with rapidly evolving
descending transtentorial herniation.48 Diagnosis: CT brain. the frontal bone and orbital margin.
„ Although the cartilaginous part of the nose escapes
from being damaged, nasal bone is frequently
Evaluation of head injury case fractured causing excessive and serious bleeding
 Initial neurological assessment should evaluate the patient’s
level of consciousness and symmetry of neurologic function into the nasal passages, if the victim is unconscious.
from head to toe. This should include a determination of the „ Direct impacts on the face can cause fractures of the
patient’s GCS, cranial nerve examination that evaluates pupillary mandible and maxilla. This also can cause dangerous
function, extraocular movements, facial symmetry, and vital bleeding into the air passages. Severe impacts like
cranial nerve reflexes, as well as motor examination.
 Noncontrast head CT scan.
49 kicking and road traffic accidents may totally detach
Surgical management the maxilla from the face.
 Patients with an EDH > 30 ml in volume, or EDH in coma (GCS „ Injuries to the mouth and lips are very common in
< 9) with pupillary asymmetry, or an acute SDH with thickness physical assaults, including child abuse and wife
> 10 mm or a midline shift > 5 mm on CT should be surgically
battering. Punching or kicking on the mouth injures
evacuated.
 A comatose patient with SDH < 10 mm thickness and midline
the lips when compressed between the inflicting
shift < 5 mm should undergo evacuation, if GCS score decreases object and teeth.
since admission.
 Patients with parenchymal mass lesions (contusions and
Spinal Cord
intracerebral hematomas) and signs of progressive neurological
deterioration due to the lesion or signs of mass effect on CT
scan should be treated operatively.
Spinal cord may be injured by penetrating wounds;
 Patients with GCS scores of 6–8 with frontal or temporal lesions common sites involved in order of frequency are:
< 20 ml in volume with a midline shift of at least 5 mm and/or „ Lower cervical
cisternal compression on CT scan, and patients with any lesion „ Thoracolumbar
> 50 cc in volume should be treated operatively.
„ Upper cervical
252 Review of Forensic Medicine and Toxicology

Compression of spinal cord rarely occurs from the cervical spine will be forcibly bent in the frontal
effusion of blood from a fall. The cord is rarely plane or in an intermediate plane (frontal and sagittal)
penetrated in its upper part by sharp-pointed (Fig. 13.12B).
instruments. Firearm wounds may cause cord injury,
Signs and symptoms
even when the missile has not entered the cord.
„ Pain and/or stiffness of neck and lower back
Contusion of spinal cord may occur from direct or
immediately or within 24 h after trauma (cardinal
indirect violence. The hemorrhages usually extend in
manifestation)
the axis of the cord. Bleeding may occur either into the
„ Headache, dizziness, tinnitus, vertigo
spinal meninges (hematorrhachis) or into the substance
„ Irritability, nausea and fatigue
of the spinal cord (hematomyelia).
„ Blurred vision

Whiplash Injury „ Numbness and tingling

„ Pain in the arms, legs, feet and hands
„ Whiplash injury is an acceleration-deceleration
„ Difficulty in swallowing
mechanism of energy transfer to the neck that may
„ Pain between the shoulder blades
result in bony and soft injuries.
„ Concentration and memory problems
„ Commonly seen in road traffic fatalities which are
„ Psychological problems
due to the hyperextension of the neck.50 Hyperflexion
injuries are less likely but can be caused if heavy
Imaging
weights are dropped onto the bent back of an  Plain X-ray: New degenerative changes may be seen.

individual—may be seen in roof collapse.  CT scan: Rotatory instability with increased rotation at C0–C1

„ This injury is sustained commonly by occupants of and/or C1–C2.

 MRI: Disc herniations, ligamentous lesions at the craniovertebral
the front seat in a motor vehicle. junction, especially at the alar ligaments and transverse ligaments.
Causes
„ Rear end or side-impact motor vehicle collisions and Autopsy findings
sometimes in front impact collisions (Fig. 13.12). „ Facet joint (cervical zygapophysial joint), yellow

„ Blow on the chin. ligament, uncovertebral and disc/endplate lesions

„ Blow against the spinous process of upper cervical may be seen.
vertebrae (rabbit punch). „ An area of hemorrhagic discoloration on the surface

Mechanism: Abrupt accelerations of the trunk causing or in substance of the cord, or subthecal effusions
whip-like movements of the head can occur in rear of blood may be found.
end collisions causing a maximal, unchecked backward Medico-legal aspects: A rising percentage of car
thrusting of the head, followed immediately by a accidents result in a refund claim based on whiplash.
forward rebound (Fig. 13.12A), if there is no/poorly This is partly due to an increased awareness and docu-
adjusted head rest. In case of side impact collision, mentation, though few false claims cases are also there.

A B

Fig. 13.12: Acceleration-deceleration injury of the cervical spine in (A) Rear-end and (B) Side-impact collision
 Regional Injuries 253

Concussion of Spinal Cord (Railway Spine) „ Fractured neck by blunt force can cause spinal cord
Causes contusion, laceration or transection. Disruption of the
i. In railway and motor vehicle collisions (most atlanto-occipital junction can result in similar injuries.
common).
ii. Severe blow to the back. Vertebral Column
iii. Compression from dislocation/fracture of vertebrae.
iv. Damage by effusion of blood. „ The spine is commonly injured in major trauma
v. Fall from height. such as road traffic accidents or falls from a height.
vi. Bullet injury. „ The type of injury will depend upon the degree of
force and the angle at which the spine is struck.
Symptoms appear immediately or after some hours and Vertebral column is strong in compression and
includes headache, giddiness, restlessness, sleeplessness, vertically applied forces will result in little damage
neurasthenia, weakness in limbs, amnesia, loss of sexual if the spine is straight. Angulation of the spine will
power and derangement of special senses. alter the transmission of force and the spine becomes
„ It produces paralysis, affecting the arms and hands
susceptible to injury, particularly at the site of the
or bladder, rectum or lower extremities.
angulation.
„ Paralysis is temporary and recovery occurs in about
„ Force applied to the spine may result in damage to
48 h.
the discs or to the vertebral bodies.
Neck „ Fractures of the vertebral column are caused by
direct violence or by indirect violence, as by forcible
The neck can be the site of many different types of bending of the body or by a fall on buttocks or feet.
injury. Its importance in forensic medicine is due to „ Hyperflexion is the most common mechanism of
the presence of a large number of vital structures, fracture of spine. Falling from a height, diving
and the fact that it is of a size that can be grasped and being thrown from automobile are the common
and easily held. causes.
„ Fractures of the hyoid bone or thyroid cartilage may „ The common sites of fracture are upper and lower
occur due to fall injuring the neck, or when the neck cervical regions and the junction of thoracic and
comes in forcible contact with the handlebar of a lumbar segments. Fracture-dislocation and fracture
cycle or the dashboard of a motor car. of the laminae can damage the spinal cord.
„ A blow to the side of the head or face, with a resultant
abrupt twisting or sideways flexion motion of the Fracture of transverse processes: These are common in
neck can result in a laceration of the vertebral artery. the region of the lumbar spine, where the quadratus
„ A blow on the front of the neck may cause uncons- lumborum muscle is attached.
ciousness or even death due to vagal inhibition or by
Fracture of vertebral bodies: Compression (wedging) of
fracture of the larynx, usually involving the thyroid
vertebral body is the commonest fracture of the thoracic,
and cricoid cartilages, and resultant suffocation from
thoracolumbar or lumbar spine. It may occur with a fall
hemorrhage or edema of the larynx.
from a height. Injuries to the atlas and axis are more
„ The mucous membrane of the trachea or larynx may
dangerous than lesions in the lower cervical vertebrae,
be torn producing surgical emphysema and cause
because of involvement of the respiratory center.
death by asphyxia.
„ Suicidal incised wounds are more common than
homicidal, but punctured wounds are usually Chest
homicidal.
„ In wounds of the trachea and of the larynx below the
Injuries of the chest can be:
vocal cords, speech is not possible. Wounds of the „ Non-penetrating or closed, i.e. they do not open

larynx and trachea are not fatal, if the large blood up any part of the thoracic cavity. Usually caused
vessels are not damaged. by blunt force.
„ Wounds of the sympathetic and vagus nerves may „ Penetrating or open. If an injury damages the parietal
be fatal, those of the recurrent laryngeal nerves pleura, it will produce an open pneumothorax,
cause aphonia. communicating directly with the external air.
254 Review of Forensic Medicine and Toxicology

Children and young adults whose chest is elastic, „ After severe head injury, where victim has been
may sustain severe injuries to the intrathoracic viscera maintained for some time in a respirator, areas of
without fractures of sternum or ribcage. collapse and hemorrhage with the formation of
In some cases, absence of injuries may be due to hyaline membrane is seen—’respirator lung’.
clothing worn by the victim. „ A wound of the lung causes frothiness of blood, which
issues from the mouth and nose or during coughing.
Ribs „ Sudden compression of the chest may produce
Blunt injury may result in fractures of the ribs. The contrecoup contusions due to violent displacement
fracture of a few ribs is unlikely to have much effect, of air in the lungs to the posterior surfaces near
other than causing pain in a healthy adult. In children, the angles of the ribs. The contusions may extend
rib fractures are more resilient and they are able to laterally or forwards into the substance of the lungs.
cope better. „ Stab wounds of the lungs are usually not fatal, unless
„ If compression is front to back, lateral rib fractures a major pulmonary blood vessel has been severed.
may occur, and if back to front, the ribs tend to „ Spontaneous pneumothorax may occur following
fracture near the spine. rupture of an emphysematous bulla. Tension
„ If compression is from side to side, the ribs may pneumothorax is seen when the leak in pleura has a
fracture near the spine and sternum. The middle ribs valve-like action, air is sucked into the chest wall
from 4–8th are usually fractured. In fractures due at each inspiration, but cannot escape on expiration.
to direct violence, the fragments are often driven Iatrogenic pneumothorax may occur by external cardiac
inwards and lacerate the underlying structures. massage, percutaneously introduced subclavian
„ In case of run over by a motor vehicle, the ribs are catheters and continuous ventilatory support.
fractured symmetrically on both sides, in front near
Complications of chest injuries
the costal cartilages and at the back near the angles.  Pneumothorax  Chylothorax
„ Multiple unilateral or bilateral rib fractures give rise  Hemothorax  Interstitial emphysema
to a flail or ‘stove-in’ chest, with consequent paradoxical  Air embolism  Cardiac tamponade
respiration (the area of chest around the fractures  Intraparenchymal hemorrhage  Infection
may be seen to move inwards on inspiration) which
interferes with respiratory exchange and also with Diaphragm: Traumatic rupture of diaphragm is seen
return of the blood to the right atrium, resulting with blunt trauma of the lower anterior chest and is
in severe dyspnea. Flail chest occurs when at least more common on the left (right side is protected by
three successive ribs are fractured at two points.51 liver).
Sternum: Fractures of the sternum are not common.
Heart
Complications of rib fracture: Flail chest, lacerations
of intercostal blood vessels with hemothorax, laceration „ Contusions and lacerations of the heart may be caused
of lungs with pneumothorax or hemopneumothorax, by direct violence to the chest or by compression of
impaling wounds of heart, pleurisy and pneumonia. the thorax, or when a driver is forcibly thrown against
Rib fractures can also be artifactual due to cardiopulmonary the steering wheel. Cardiac contusions are usually
resuscitation which may result in sternal and parasternal seen on the anterior surface of either ventricle or the
fractures. interventricular septum. Recent cardiac contusions
z They are usually identified by their symmetrical,
are dark-red, hemorrhagic areas which are usually
parasternal pattern and relative lack of hemorrhage subepicardial.
at fracture site which indicates postmortem origin. „ The commonest pincer lesion is a contusion of the
z Sometimes, fractures are seen in the left side only
right atrium at the entrance of the inferior vena cava.
and may involve the first six ribs and sternal
This is seen in compression injuries. It may cause
fracture may occur at the level of third or fourth
sudden death, several days after the injury.
intercostal space.
„ Contrecoup contusions of the heart are seen over
Lungs the posterior wall of the left ventricle. They are seen
in traffic accidents in which the driver is thrown
„ Compression of the chest or blunt weapon trauma forward against the steering wheel and the heart is
produces contusions or lacerations. compressed against the vertebrae. Contusions may
 Regional Injuries 255

cause sudden death from ventricular fibrillation, or abdominal walls can transmit the force to the abdominal
they may cause progressive circulatory failure and viscera.
death after few hours or days. Injuries of the abdomen can be classified into:
„ Foreign bodies, e.g. bullet, may remain embedded „ Non-penetrating or closed, i.e. peritoneum is intact.
in the myocardium for years without producing It is caused by blunt force; seen in falls, traffic
any symptoms. accidents and assault by blunt weapons.
„ The common sites of traumatic cardiac rupture in order „ Penetrating or open, i.e. when peritoneum is
of diminishing frequency are: right auricle, right
ruptured, it is open to infections.
ventricle, left auricle, ventricular septum and valves.
„ The only natural cause of rupture of the heart is Profuse subcutaneous or deep-seated bleeding of the
softening or thinning by infarction, which invariably abdominal wall may track along the muscular and
occurs in the left ventricle. fascial plane to become more diffuse, and may cover
„ Stab wounds of the heart are dangerous. If the left a large area of abdominal wall, especially in the lower
ventricle is pierced, the thickness of the muscle wall segment. Blood may track down the inguinal canal and
may restrict the bleeding, allowing time for surgical appear in the scrotum or labia.
treatment. A stab of the right ventricle is more rapidly In order of frequency, the structures most likely to
fatal, blood escaping through the wound to cause be damaged in blunt abdominal trauma are: spleen, liver,
hemopericardium and cardiac tamponade. Even 150 kidneys, intestines, abdominal wall, mesentery, pancreas
ml (average 400–500 ml) of blood can cause death by and diaphragm.
increasing intrapericardial pressure and producing
mechanical interference with ventricular contractility. Injuries of the stomach and intestines may be caused by:
The right ventricle is more likely to be wounded, as it i. Compression or crushing forces which produce
exposes its widest area towards the front of the chest. contusions or lacerations.
ii. Traction or tearing forces.
Cardiac tamponade presents with three signs (Beck’s triad). They iii. Disruption or bursting forces.
are—low arterial blood pressure, increased central venous pressure „ Hollow visceral injuries are less common in blunt
and distant heart sounds. Hypotension occurs because of decreased
trauma compared to penetrating injuries.
stroke volume, jugular-venous distension due to impaired venous
return to the heart, and muffled heart sounds due to fluid inside „ Children have proportionally larger solid organs,
the pericardium. less subcutaneous fat, and less protective abdominal
musculature than adults. They suffer relatively more
Cardiac concussion or commotio cordis: It refers to solid organ injury from both blunt and penetrating
sudden cardiac death following a blunt trauma to the mechanisms.
chest. It is often associated with sports and in young „ Small intestine is more commonly injured by forces of
athletes. compression than the stomach and the large intestine.
Mechanism: The impact occurs at an electrically „ The proximal jejunum is the commonest site of
vulnerable phase of the cardiac cycle (during early rupture, followed by the ileum, duodenum, cecum,
ventricular repolarization; 15–30 milliseconds before and large intestine. Transverse colon is usually
the peak of the T wave). involved in case of large intestinal rupture.
„ The small bowel is most common intra-abdominal
Aorta: Wounds of the aorta or the pulmonary artery
are rapidly fatal. The rupture of the aorta commonly organ involved on penetrating trauma (e.g. stab or
occurs at the junction of the arch and the descending gunshot wounds) followed by colorectal injury and
parts, just beyond the origin of the left subclavian artery, duodenal and gastric perforations.
and is due to violent compression of the chest. It is „ The intestinal wound may be situated at some

common in traffic accidents, and less common in fall distance from the external wound due to the
from height and crushing chest injuries. Spontaneous compression and mobility of the intestines, and the
rupture of the aorta may occur from local disease. depth of the wound is greater than the length of the
penetrating object.
Abdomen
Pancreas: Wounds of the pancreas are very rare. The
Abdominal organs are vulnerable to a variety of injuries pancreas may be injured by compression forces usually
from blunt trauma because lax and compressible where it overlies the second lumbar vertebra.52
256 Review of Forensic Medicine and Toxicology

Spleen „ The right lobe is five times more commonly affected

„ Most common organ to be injured in blunt abdominal than the left.
trauma.53 „ Convex surface and inferior border are commonly
„ Penetrating wounds of the spleen are less common involved.
than those of liver, but bleeding is more profuse. „ Mild degree of external violence may rupture the
The spleen may be injured by forces of compression liver, if it is diseased, e.g. fatty change, abscess
or traction forces. Compression forces produce formation, malaria or bilharziasis.
lacerations. Traction forces may tear the spleen from Complications of abdominal injuries
its pedicle.  Laceration of the liver produces slow, but considerable
„ The spleen is ruptured usually in its concave surface, bleeding over a period of time.
and is generally associated with injuries to other  Laceration of the spleen produces rapid and profuse

organs and rib fractures. Lacerations are usually hemorrhage leading to hypotension.
 Peritonitis is more common in rupture of the large
transcapsular and may occur at the hilar or convex
intestine than with rupture of the small intestine due
surfaces. They are often multiple and may simulate
to the presence of pathogenic organisms in the colon.
the alphabetical figures, Y, H or L. Death from  Chemical peritonitis is caused by leakage of gastric contents
rupture of spleen is usually rapid due to profuse or pancreatic juice into the peritoneal cavity.
hemorrhage.  Multiple contusions of the intestines may produce

„ A relatively mild trauma or even the contraction of paralytic ileus.

the abdominal muscle may predispose the spleen to
rupture, when it is diseased and enlarged, e.g. infectious Kidneys
mononucleosis, malaria, kala azar or leukemia.
Injuries to the kidneys are uncommon as they are
Liver situated in relatively well-protected part of the body.
„ It is the second most frequently damaged abdominal Contusions and lacerations usually result from blunt
organ in blunt trauma. The liver is commonly force applied directly to the posterior or lateral aspect
ruptured by motor accidents, blow, kick or by a of the kidneys, such as blows to the loins or in motor
vehicle accidents and fall from a height.
sudden contraction of the abdominal muscles.
„ Lacerations of the kidneys may be transcapsular,
„ The liver is more susceptible than spleen to pen-
subcapsular and transrenal (tear extending from
etrating injury.54
the capsule to the renal pelvis). These may cause
Blunt force to the abdomen may produce the following hemorrhage into the perinephric fat and form a large
lacerations: perirenal hematoma.
i. Transcapsular laceration: Both capsule and „ Penetrating wounds are produced by bullets or
parenchyma are torn, and the laceration is present pointed weapons, usually through the loin, and
over the convex surface of the liver. It may cause other viscera are also injured with retroperitoneal
rapid death from hemorrhage and shock. hemorrhage.
ii. Subcapsular laceration: Capsule is intact and injury „ Complications may be sepsis and the extravasation
is beneath the capsule or intraparenchymal, and of urine into the surrounding tissues with the
present over the convex surface of the liver. It may development of urinary fistula.
rupture few days after the injury and cause fatal
delayed intraperitoneal hemorrhage. Bladder
iii. Non-communicating or central lacerations are seen in The bladder may be lacerated from a fall, a kick or a
the substance of the liver. blow on the abdomen.
iv. Coronal lacerations are seen over the superior surface Ruptures are of two types:
due to distortion. i. Extraperitoneal: It occurs when the bladder is empty
v. Lacerations of the inferior surface are due to or contains little urine and lies within the pelvis. It
distortion. is usually associated with pelvic fractures. The urine
vi. Contrecoup laceration involve the posterior surface may extravasate upwards to the level of the kidneys
of the right lobe, at the point where it rests against or downwards along the spermatic cord into the
the vertebral column. scrotum which may produce cellulitis and death.
 Regional Injuries 257

ii. Intraperitoneal: It occurs when the bladder is full „ Partial or green-stick fractures: These occur because
of urine. Any blunt trauma to the lower abdominal bones in children are very flexible and bend or
wall can compress the bladder against the sacrum, partially break, instead of breaking cleanly when
resulting in rupture due to increased pressure with overloaded. There may be discontinuity in one cortex
the urine entering the abdominal cavity. of the bone, but not in the other.55
Stab wounds of the lower abdomen may penetrate „ In childhood, slipping of an epiphysis is common,
the bladder and cause rapid death from hemorrhage. e.g. in distal end of the radius, medial epicondyle of
There may be extraperitoneal extravasation of urine. the humerus, capitulum and distal end of the tibia.
The male urethra may be ruptured usually under „ Fracture at the neck of the fifth metacarpal bone
the pubic arch by a kick in the perineum, fall on a occurs, usually by striking the closed hand (fist)
projecting substance, fracture of pubic bone or a foreign against a firm surface (boxer’s/brawler’s fracture).56
body. Forcible catheterization or cystoscopy, especially
in the presence of some obstruction can cause rupture  Fractures of the mandible, maxilla, zygoma and zygomatic arch
of urethra from within. are produced by assaults and motor vehicle accidents.
 The frequency of fracture of different parts of mandible in
Reproductive Organs decreasing order is: condyle (36%), body (21%), angle (20%),
parasymphyseal (14%), alveolar (3%), ramus (3%), coronoid (2%)
Female genital organs: Contusions and lacerations of the
and symphysis (1%).57
vulva and vagina may be due to kicks during assault or  Maxillary fractures can be divided into five categories:58
fall on a projecting substance. Wounds of vulva caused i. Dentoalveolar: Separation of fragment of maxilla containing
by a blunt weapon may resemble incised wounds. number of teeth.
Lacerated wounds of the vulva may bleed profusely. ii. LeFort I: Transverse fracture of maxilla, above the apices of
„ The non-gravid uterus is usually not injured. the teeth, through nasal septum and maxillary sinuses, the
„ The gravid uterus may be ruptured by a blow palatine bone and the sphenoid bone.
iii. LeFort II: Fracture has same track posteriorly, anteriorly
or kick on the abdominal wall, by instrumental
it curves upwards near the zygomatic-maxillary suture,
criminal abortion, or in obstructed labor. Placenta through the inferior orbit rim onto the orbital floor, across
may separate from uterus causing death of fetus. the nasal bones and septum.
Male genital organs iv. LeFort III: High transverse fracture of the maxilla that goes
through the nasofrontal suture, through the medial orbital
„ The penis may be injured by a squeeze or crush,
wall and fronto-zygomatic suture, across the arch and
and the engorged erected penis may be completely through the sphenoid.
avulsed from the pubes by forceful pull. v. Sagittal: Fracture line runs through a sagittal plane through
„ Accidental injuries are rare, but the penis may be the maxilla.
injured or amputated in revenge.
„ Penile strangulation may occur by application of a Fracture of the extremities caused by direct application
constricting apparatus around the penis. of force (Fig. 13.13):
„ Compression or crushing of the testes may cause
i. Penetrating fractures are caused by large force acting
sudden death from cardiac inhibition. on a small area; seen in gunshot wounds.
Bones and Joints ii. Focal fractures are transverse fractures results from a
small force applied over a small area. It is usually
Fractures may occur from falls, blows or by muscular seen in the forearms produced by weapons, like
hyperactivity. rods, when the person tries to ward off blows.
„ In simple or closed fracture, there is no communi- Overlying soft tissue injury is relatively minor.
cation between the bone and the air. A fall on the iii. Crush fractures result from large force applied over
outstretched hand will cause Colles fracture (fracture a large area with extensive soft tissue injuries and
of the distal end of radius). often comminuted fractures of the bone. Mostly seen
„ In compound or open fracture, there is a communi-
on the legs in motor vehicle-pedestrian accidents.
cation between the bone and the air through a
wound. Indirect fractures result from a force acting at a distance
„ Comminuted fractures: The bone breaks into from the site of fracture, e.g. a fracture of the head of
fragments which may impact into each other or the radius or of the lower end of the humerus caused
separate and become displaced. by a fall on the extended palm.
258 Review of Forensic Medicine and Toxicology

Fig. 13.13: Classification of fracture

It is classified into (Fig. 13.13): „ Histologically, signs of clot organization is seen in

i. Avulsion or distraction fracture: In this, the bone is about 48 h, the formation of osteoid matrix in about
pulled apart by traction, e.g. transverse fracture of 3 days and formation of soft callus by about 1 week.
patella due to violent contraction of the quadriceps „ In comminuted fractures, where edges are not in
muscle. apposition, bone formation does not occur. The gap
ii. Spiral fracture: The bone is twisted and a spiral is filled by fibrous tissue in 1–3 months depending
fracture is produced. It occurs only when the bone on the size of the gap. The fracture line remains
is subjected to torsional force. permanently visible on X-ray.
iii. Vertical compression fracture produce an oblique „ Age of skull fracture can be estimated as given in
fracture of the body of long bones with the hard Table 13.7.
shaft driven into the cancellous end. „ In case of fracture of the skull, healing occurs
iv. In angulation and compression fracture, the fracture without formation of a visible callus, because the
line is oblique. injured periosteal vessels impede the formation of
v. Angulation, rotation and compression fracture causes an external callus.
fracture with a triangular butterfly fragment. „ In case of tooth being knocked out, age is estimated
Pelvic fractures as given in Table 13.8.
Classified by the direction of force:
Table 13.7: Estimation of age of skull fractures
i. Anterior-posterior compression.
Features Age (weeks)
ii. Lateral compression.
iii. Shear. Edges stick together 1
iv. Complex fractures. Calcification of inner table and rounding of sharp 2
edges

Healing of Fracture Bands of osseous tissue running across 3–4

„ Fractures of cancellous bone unite faster than those

Table 13.8: Estimation of age of tooth dislocation
of cortical bone.
„ In children, a callus (osteogenic granulation tissue) is Features Age
visible on X-ray within 2 weeks of fracture, and the Bleeding stops from its socket, edges sharp and 1–2 days
feathered
bone is consolidated in 4–6 weeks, though it takes 2–3
months to solidly. In adults, callus formation is visible Clot obliterated by fibrous tissue 14 days
on X-ray by about 3 weeks, consolidation takes about Socket completely filled with new bone (as seen 1 year
3 months, and for femur it may take 4–5 months. on X-ray)
 Regional Injuries 259

Complications of fracture Antemortem or Postmortem Fracture

 Shock  Crush syndrome „ Fracture produced just before death or just after
 Hemorrhage  Fat embolism
death will have similar characteristics, except in the
 Infection  Venous thrombosis

with pulmonary embolism former there may be comparatively greater effusion

of blood which will infiltrate the surrounding
 Teeth most often affected by trauma in order of decreased tissues.
frequency: Maxillary central incisors (60%), maxillary lateral „ Antemortem fracture few hours prior to death will
incisors (22%), mandibular central incisors and mandibular show edema and active cellular infiltration into the
lateral incisors.
 In permanent dentition, tooth fractures result from trauma adjacent tissues and between the fractured edges
whereas dislocation is common in primary dentition (due to of the bones.
elastic structures of the alveolar process). „ Antemortem fracture of long bones may result
At autopsy, a fracture may be suspected when there in fat emboli traveling to distant parts of the
is extensive swelling and discoloration of the skin, or body producing characteristic lesions (punctate
when there is abnormal mobility or crepitus is found. hemorrhages in skin, eyelids, conjunctiva) which
The tissues surrounding a suspected fracture should be are seen grossly and microscopically.
dissected to determine injuries to the soft parts. These changes are not seen in postmortem fractures.

MULTIPLE CHOICE QUESTIONS

1. NOT a type of skull fracture: NIMHANS 08 7. Roof of orbit is fractured due to: AIIMS 09
A. Linear B. Depressed A. Blow on forehead B. Blow on lower jaw
C. Diffuse axonal D. Basal C. Fall on back D. Blow in parietal region
2. Fracture-a-la signature is: AI 11; MAHE 12; AIIMS 13 8. CSF rhinorrhea is due to fracture of:
A. Gutter fracture B. Depressed fracture UP 08, 09; DNB 10; Bihar 10;
C. Ring fracture D. Sutural separation AIIMS 10; CMC (Ludhiana) 13
3. Pond’s fractures are common in: AP 09 A. Cribriform plate B. Sella turcica
A. Children C. Petrous temporal bone D. Mastoid
B. Adolescent 9. Characteristic of anterior cranial fossa fracture:
C. Adult WB 07
D. Old age A. Black eye B. Pupillary dilatation
4. All are true of pond’s fracture, except: C. CSF otorrhea D. Hemotympanum
CMC (Vellore) 13 10. True about CSF rhinorrhea: UP 09
A. No brain damage A. Commonly occurs due to break in cribriform plate
B. Seen in infants B. Contains less amount of proteins
C. Depressed fracture of the skull C. Decreased glucose content confirms diagnosis
D. Shearing of the dura is not seen D. Immediate surgery is required
5. Orbital blow-out fracture involves: AIIMS 09; 11. CSF otorrhea is caused by: Bihar 10; WB 11;
FMGE 10; MP 10; JIPMER 11; Bihar 11; PGI 11 CMC (Vellore) 13
A. Lateral wall and floor of orbit A. Fracture of cribriform plate
B. Medial wall and floor or orbit B. Fracture of parietal bone
C. Lateral wall and roof or orbit C. Fracture of petrous temporal bone
D. Medial wall and roof or orbit D. Fracture of tympanic membrane
6. Teardrop sign is seen in: 12. Battle sign indicates: NIMHANS 13
Kerala 08; JIPMER 08; Maharashtra 09 A. Basilar fracture B. Sutural fracture
A. Fracture medial wall of orbit C. Orbital fracture D. Depressed fracture
B. Fracture lateral wall of orbit 13. Hinge fracture is: JIPMER 14
C. Fracture floor of orbit A. Depressed fracture B. Sutural fracture
D. Fracture roof of orbit C. Orbital fracture D. Basilar fracture

1. C 2. B 3. A 4. C 5. B 6. C 7. C 8. A 9. A
10. A 11. C 12. A 13. D
260 Review of Forensic Medicine and Toxicology

14. CSF rhinorrhea is diagnosed by: MP 07 C. Multiple infarcts

A. Glucose estimation B. Halo sign D. Diffuse axonal injuries
C. Immunoelectrophoresis D. All 25. ‘Retraction balls’ after trauma are seen in:
15. Specific for CSF in rhinorrhea: AI 10 PGI 08, 11; UP 12
A. b-2 microglobulin B. Albumin A. Brain B. Spleen
C. Macroglobulin D. b-2 transferrin C. Liver D. Lung
16. Battle’s sign is: TN 11 26. Apoplexy is: DNB 08
A. Hemorrhage around eyes A. Learning disability
B. Mastoid ecchymosis B. Insanity leading to commitment of a crime
C. Umbilical ecchymosis C. Sudden onset of bleeding in the brain
D. Vaginal ecchymosis D. Injury to the brain due to trauma
17. Best prognostic indicator for head injured patients: 27. Brain hemorrhage limited by sutures:
AIIMS 10 BHU 09; Punjab 12
A. GCS B. CT findings A. EDH B. SAH
C. Age of the patient D. History C. SDH D. ICH
18. Primary impact injury to brain: DNB 10 28. Commonest source of extradural hemorrhage: UP 09
A. Concussion B. Cerebral edema A. Middle meningeal artery
C. Hypoxic injury D. Intracerebral hematoma B. Basilar artery
19. Secondary brain injury is: JIPMER 10 C. Charcot’s artery
A. Concussion D. Middle cerebral artery
B. Diffuse axonal surgery 29. Middle meningeal artery is a direct branch of:
C. Depressed skull fracture AI 06; Odisha 09; Punjab 12
D. Intracerebral hematoma A. External carotid artery
20. Concussion causes: Karnataka 07 B. Internal maxillary artery
A. Small hemorrhages and swelling of brain tissues C. Superficial temporal artery
B. Momentary interruption of brain function with/ D. Middle cerebral artery
without loss of consciousness 30. Artery usually torn in temporal bone fracture is:
C. Tearing or shearing of brain structures Odisha 11
D. Bruising of the brain A. Middle meningeal artery
21. Antegrade amnesia is seen in: AIIMS 10 B. Posterior auricular artery
A. Post-traumatic head injury C. Transverse facial artery
B. Drug induced D. Deep temporal artery
C. Electroconvulsive therapy 31. Most common manifestation of increased intracranial
D. Stroke pressure in a patient with head injury: UPSC 07
22. Shearing damage is seen in: CMC (Vellore) 07 A. Change in the level of consciousness
A. Heart B. Liver B. Ipsilateral pupillary dilatation
C. Brain D. Spinal cord C. Retching and vomiting
23. Diffuse axonal injury is characterized by lesion at: D. Bradycardia
AI 08; FMGE 11 32. A rugby player hit his head on the post whilst involved
A. Junction of gray and white matter in a tackle. He was unconscious for 5 min but regained
B. White matter full consciousness and sat on the sideline until the end
C. Basal ganglia of the game. He was then noted to be drowsy and over
D. Corpus callosum the past 30 min became confused and no longer obeyed
24. A male was brought unconscious with external injuries. commands. Most likely diagnosis is:
CT brain showed no midline shift, but basal cistern Himachal 10; AIIMS 13; NIMHANS 14
were compressed with multiple small hemorrhages. A. Extradural hematoma
Diagnosis is: AIIMS 06 B. Subdural hematoma
A. Cerebral contusion C. Subarachnoid hematoma
B. Cerebral laceration D. Cerebral edema

14. D 15. D 16. B 17. A 18. A 19. D 20. B 21. A 22. C

23. A 24. D 25. A 26. C 27. A 28. A 29. B 30. A 31. A
32. A
 Regional Injuries 261

33. Lucid interval is classically seen in: COMEDK 07; 40. Investigation of choice in SAH:
PGI 07; Kerala 08; WB 09; FMGE 10; DNB 10; NIMHANS 07; FMGE 11
NEET 13, 14 A. CT scan B. MRI
A. Intracerebral hematoma C. X-ray skull D. Radionuclide scan
B. Acute subdural hematoma 41. Cause of Berry aneurysm: AIIMS 11
C. Chronic subdural hematoma A. Degeneration of internal elastic lamina
D. Extradural hematoma B. Degeneration of media/muscle cell layer
34. Subdural hemorrhage is due to rupture of: Bihar 11 C. Deposition of mucoid material in media
A. Middle meningeal artery D. Low grade inflammation of vessel wall
B. Dural venous sinus 42. Commonest cause of thunderclap headache:
C. Cortical bridging veins AIIMS 10; NIMHANS 14
D. Rupture of intracranial aneurysms A. Extradural hemorrhage
35. A 14-year-old boy was hit on the side of the head B. Aneursymal SAH
with a baseball bat during practice. A laceration with C. Subdural hemorrhage
palpable bone fragment was found in the wound. After D. Basilar migraine
5 h the boy died. Most likely cause of death is: 43. Traumatic bleeding may include all, except: Kerala 09
Himachal 10 A. EDH B. SDH
A. Subarachnoid hemorrhage C. SAH D. ICH
B. Epidural hemorrhage 44. Commonest hemorrhage following head injury:
C. Subdural hemorrhage KCET 13
D. Intracranial hemorrhage A. Extradural hemorrhage
36. CT of subdural hematoma will show: B. Subdural hemorrhage
Odisha 09; NIMHANS 11; Bihar 12 C. Intracranial hemorrhage
A. Biconvex hyperdense opacity D. Subarachnoid hemorrhage
B. Biconcave hyperdense opacity 45. Most common location of hypertensive intracranial
C. Concavoconvex opacity hemorrhage is: AI 06; NIMHANS 08; DNB 10; WB 11
D. Hyperdense diffuse lesion A. Subarachnoid space B. Basal ganglia
37. Circle of Willis is not formed by: TN 11 C. Cerebellum D. Brainstem
A. Anterior choroidal artery 46. NOT true about Berry aneurysms: AP 08
B. Anterior cerebral artery A. Rupture leading to SAH
C. Posterior cerebral artery B. Most common in posterior circulation
D. Anterior communicating artery C. Developmental anomaly
38. A 18-year-old female presented with severe headache of D. Common in anterior circulation
sudden onset. On CT scan, a diagnosis of subarachnoid 47. Kernohan-Woltman sign (notch) is seen in:
hemorrhage is made. Most common cause is: COMEDK 15
AI 06; UP 10, 12 A. Uncal herniation
A. Hypertension B. Central herniation
B. Berry aneurysm rupture C. Transfalcial herniation
C. Basilar artery rupture D. Foraminal herniation
D. Subdural venous sinuses rupture 48. Duret hemorrhages are found in: PGI 08,10,11; Kerala 11
39. A 40-year-old hypertensive lady is brought to the A. Brain B. Heart
emergency room after being unresponsive following C. Kidney D. Liver
a sudden bout of severe headache, vomiting and neck 49. Investigation of choice for evaluation of acute head
rigidity at work. O/E her BP is 180/100 mmHg and her injury: AIIMS 14
respiration is irregular and of Cheyne-Stokes type. She A. CECT Head B. NCCT Head
is agitated and doesn’t follow commands, but moves C. MRI Brain D. CT Angiography
her extremities spontaneously. Most likely diagnosis 50. ‘Whip-lash’ injury is caused due to: AIIMS 06;
will be: JIPMER 08; AIIMS 13 Karnataka 07; BHU 12; NEET 15
A. Subarachnoid hemorrhage due to rupture cerebral A. Fall from a height
aneurysm B. Acute hyperextension of the spine
B. Hypoglycemic coma C. Blow on top to head
C. Conversion reaction D. Acute hyperflexion of the spine
D. Addisonian crisis

33. D 34. C 35. C 36. C 37. A 38. B 39. A 40. A 41. B

42. B 43. D 44. B 45. B 46. B 47. A 48. A 49. B 50. B
262 Review of Forensic Medicine and Toxicology

51. Flail chest means fracture of: PGI 12 55. A green-stick fracture is:
A. Two ribs on same side TN 06; UPSC 07; BHU 09; NIMHANS 10
B. Two ribs on opposite side A. Seen mostly in the elderly
C. Four ribs on two sides B. Fatigue fracture
D. Multiple ribs on both sides C. Spiral fracture of long bone
52. Organ that does not show countercoup injuries: D. Part of cortex is intact and part is crumpled
SGPGI 12 56. Boxer’s fracture is: MP 11
A. Heart B. Brain A. Fracture of first metacarpal base
C. Lung D. Pancreas B. Fracture of fifth metacarpal neck
53. True about blunt trauma abdomen are all, except: C. Fracture of third metacarpal neck
PGI 14; JIPMER 14 D. Fracture of first metacarpal neck
A. Solid organ injury more common in children than 57. Most common site for fracture mandible: TN 11
adults in blunt trauma A. Condyle
B. Liver injuries are more common than splenic injury B. Angle
C. Diaphragmatic injuries are rare C. Body
D. Intraperitoneal gas shadows are pathognomonic of D. Symphysis
bowel perforation 58. LeFort’s fracture would include all of the following,
54. Most common organ injured in penetrating injury of except: Manipal 10; WB 09; TN 09; Bihar 10;
the abdomen: AFMC 10 NIMHANS 14
A. Liver B. Spleen A. Maxilla B. Mandible
C. Stomach D. Small intestine C. Zygoma D. Nasal bones

51. C & D 52. D 53. B 54. A 55. D 56. B 57. A 58. B