Transcript WOUNDS - UMF IASI 2015

INJURIES
Assoc. Prof. Beatrice Ioan
MD, PhD, MA
Definition & classification
Definition → damages to the tissues of the body caused
by mechanical forces
I. Intact skin
- Traumatic eritema
- Bruise (contusion)
- Hematoma
II. Injured skin
- Abrasion (scratch, graze)
- Wounds
Traumatic eritema
• produced by a light slap or a continuous
pressure against the tissues
• transient irritation of the nervous endingsdilatation of the vessels
• pain, redness of the skin/ red points on the skin,
tumefaction
• all signs and simptoms dissapear in a few hours
Bruise/contusion
- Blunt injury to the tissue- strike or compression
Blunt objects: rock, stick, club, hammer, fist,
leg
↓
- Damage of the small and middle blood vessels
beneath the skin- the blood leaks into the
surrounding tissues
- Most frequent under the skin
- Possible deep bruising- any organ, tissue
Bruise/contusion
- Usually it does not reproduce the pattern of the
causative object- the blood leaks in a diffuse manner
Bruise changes with time and position
- The bruise may become visible at a later moment from
the trauma - repeated examinations
- The bruise may appear at a different site than the injury
site
Bruise/contusion
Timing → colour changes
Chemical changes of hemoglobin
• the first hours- red (HbO2)
• few hours- bluish (reduced Hb)
• 3-5 days- green-yellow (biliverdin)
• 7-8 days- yellow- brownish (hemosiderin)
• 7-20 days- normal skin colour (depend on the size and
depth of the bruise).
Bruise/contusion
The speed of the changes is variable- 7-10 days
Recognition of bruises of different colours in the same
person- inflicted at different times- repeated
aggressions- child/adult abuse
Differentiated from postmortem lividities
Bruise/contusion - Size
• space outside the vessels for free blood to accumulate;
• gravity of the bleeding, depending on:
* the intensity of the traumatism;
* the size and the density of the vascular network in
the damaged region;
• presence of the bone directly under the skin;
• depth of blood accumulation;
• fragility of blood vessels;
• coagulability of the blood
Bruise/contusion
Particular types of causation- mark bruises
- “Tram-line”/”railway-line
- Bilateral ovalar bruises on the throat- manual
strangulation
- Envelope imprint
“Tram-line”/”railway-line” - two parallel lines of bruising
with a pale undamaged area between- rod-like weapon,
either cylindrical or square-sectioned
Hematoma
Definition- an important collection of blood- the rupture of
a big vessel- blunt injury
Localization: tissues, organs, natural cavities
• Superficial hematoma- the covering skin is bruised;
• May compress the muscles, nerves, vessels- surgical
treatment to evacuate the blood;
• Hematomas in the natural cavities or inside the organs
have, frequently, a severe evolution- even death
Abrasion
- The most superficial type of injury which destroys the
integrity of the skin
Mechanism:
- Friction of a sharp or irregular object against the surface
of the skin, determining the abrasion of the superficial
layers.
- Less often- vertical impact- crushed injury
Two possibilities:
- An object strikes the skin (a bite from a tooth)
- The body hits a stationary object (fall)
Abrasion
- Usualy confined to epidermis- no bleeding
- Some abrasions enter the dermis- slight bleeding
(dermal papillae)
Shape:
- Linear
- Broader- brush abrasion
E.g., dragging across a rough road in traffic
accidents- multiple parallel linear abrasions
When the skin is protected by clothing- “friction
burn”- reddened, excoriated area
Abrasion
Evolution
• the first 12- 24 hours- crust (yellow or redish-brownish);
• 3-4 days- the crust begins to detach;
• 7-8 days- a white track on the skin - dissapears without
any traces
Fingernail abrasions
- strangulation by hand- curved /on the neck;
- linear abrasions- the finger are dragged down the skin (sexual
attacks, child abuse)
Marker- abrasion
- usually when the impact is vertical to the surface of the skin (crushing
abrasion);
Draging
- linear, thin, parallel abrasions
- direction of the force causing the abrasion- close examination- the
torn epidermis will be pulled towards the distal (final) end of the
abrasion
Laceration
- Blunt injury- the weapon crushes the tissues
↓
- Penetrates the full thickness of the skin
Laceration- characteristics
• irregular edges;
• blood infiltration in the edges;
• bruises and abrasions in the surrounding tissues;
• persistance of tissue strands across the interior of the
wound;
• the hair is not destroyed / may be crushed;
• content- crushed tissues, clots of blood, small pieces
from the clothes, dirt;
• main complication- infection
Laceration- particular types
Crack wound
• the skin is compressed between the bone and the blunt
object- e.g. scalp;
• the margins are regular, sharp;
• must be differentiated from the cut wounds
- the crack wound presents tissue strands
across the margins
- injuries in the surrounding tissues
Bite wound
- preserve the shape of the teeth
- samples of saliva- identification of the aggressor
Sting- pricking wound
Mechanism
Lateral compression of the tissues by a thin object with
acute point - needle, screw driver (pricking object)
Characteristics
Entry wound
•
on the skin/mucosal surface
•
a red point if the weapon’s diameter is small (sharp
needle) or a small wound with sharp edges if the
weapon’s diameter is bigger
Sting- pricking wound
Channel
•
in the depth of the tissues
Exit wound
•
rare
•
the damaged part of the body is small/thin
•
the weapon is long enough
Sting- pricking wound
Complications
• severe, even lethal bleeding when blood accumulates
inside a natural cavity (e.g. pericardium)
• death- when the heart or fontanel (infanticide) are
damaged
Cuts
- Sharply cut injuries
- Produced by objects with at least one cutting edgepressure and movement of a sharp edged object against
the tissues
Classification
• cuts (slashes)- larger than deeper, usually linear;
• partial detachment of the tissues- the cut is oblique;
• complete section of a part of tissue, an organ (nose) or a
part of a limb
Cuts - characteristics
• regular edges;
• surrounding tissues- intact;
• no tissue strands in the interior of the wound;
• the hair is divided;
• the cut is deeper at the entry, becomes progressively
shallower as the wound approaches the distal end →
linear abrasion - mouse tail
• content- blood (liquid or clots);
• main complication- bleeding
Cuts
Defence wounds
• passive defence- cuts on the dorsal part of the hands
and forearms;
• active defence- cuts on the palms (the victim tryes to
catch the knife).
Stab wound
Mechanism: pricking and cutting the tissues, by an object
with an acute point and sharp edge/edges
Characteristics
Entry wound
•
on the skin;
•
characteristics of a cut wound;
•
according to its aspect, is possible to determine if the
knife has one or more cutting edges edges
* buttonhole- two cutting edges
* triangle- one cutting edge
Stab wound
Channel
• In the depth of the tissues
• its direction shows the weapon’s direction
inside the tissues;
Exit wound
• characteristics of a cut wound
According to the aspect of the entry wound and
channel is possible to estimate the
dimensions of the knife in the cavities with a
bony wall
Split wound
Mechanism: heavy objects with a sharp
edge- axe, hoe, heavy sword
Appearance - combination between cut wound on the
surface of the skin and laceration in depth
Frequent
- Bone fractures
- Damages in the vital organs
- danger for life
Description
• Location
• Dimensions
• Shape
• Direction
• Aspect
- bruise – colour
- abrasion – crust
- wound
- margins
- surrounding tissues
- ends
- content
- stage of healing
Injuries - forensic relevance
• The damaging weapon → marker injury
• Producing mechanism
- injuries located on the prominent parts of the body
→ fall
- bruises and abrasions on the neck – strangulation
by hand/ligature
• Timing of trauma
- bruise - colour
- abrasions - aspect of the crust
- wounds – stage of the healing – aspect of the scar