HEAD INJURIES

Injuries to the scalp

Scalp injuries are very common from accidents, falls and assaults aimed at the head. Self
inflicted scalp injuries are rare, but possible.

Scalp injuries bleed a lot but heal rapidly. Scars are not seen as they are hidden by hair.
These injuries are potentially dangerous to intracranial structures – e.g. infection.

When there are scalp injuries one must look for a fracture of the skull. This should be done
when cleaning the wound before suturing. The possibility of brain damage is always there in
scalp injuries caused especially by blunt weapons. So a complete CNS examination is
necessary and the patient should be observed in the ward for about 24 hours.

A contusion may appear in a site away from the site of force.

Laceration of a scalp may be mistaken for incised wounds.

In burns, scalp may split due to heat.

Colour change in scalp is difficult to observe in dark skinned people. Therefore contusions
may be hidden. Separate the hair and look for contusions. At postmortem shave the hair.

Hair from the victim may get attached in the weapon helping in identification.

Injuries to the cranium, brain and meninges

Head injury may cause transitional functional damage or massive damage to brain ending
fatally. Brain injury is a common cause of rapidly occurring death. In between these two
extremities concussion may be caused. Oedema, haemorrhages, infection are the other
sequelae.

The symptoms and signs following head injuries can occur later e.g. extra-dural
haemorrhage. So every case of head injury must be treated as potentially dangerous and the
patients must be observed.

Skull injuries

These are common and important. Large amount of forensic data may be obtained by
examining an injured skull. Generally, where there is gross brain damage fractures may be
invariably present. Sometimes, brain damage is possible without the skull fracturing at all.

Skull fractures

Shape distribution etc. of skull fractures depend on the area of the skull, the weapon and the
force.

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The degree of force is important. Striking area is also important. The fact whether the head
is fixed and immobile or unsupported and free to move determines the extent of injury. The
fragility and thickness of bones, the points of weakness, strength etc. are important.

A small striking surface at a very great force:

This will drive a neat hole through the skull. There is no side fracturing on the outer table,
But there is bevelling in the inner table, as the force now traverses transversely also (force
spreads)

A larger striking surface and a moderate force:

A limited but depressed, fairly well defined fracture is seen. The damage to the inner table is
more due to the spreading of force e.g. hammer edge or iron rod.

A large striking area and substantial force:

There will be depressed, widespread, fractures.

A linear force:
E.g. Blow with a club.

The vertical component will act like a small striking surface and cause a depressed,
comminuted fracture. The force traveling forwards create a linear fracture going forwards.
The fracture caused by this forward component in called a ‘pointer fracture’. It points to the
forward component. This indicates the direction of the blow and important in reconstructing
the crime. (Pointer fracture is not talked of in cut injuries) Pointer fracture is a linear
fracture.

When a flat fairly large striking force is alighted on the skull, as the vertical force is not so
powerful a depressed fracture may not be present and only a linear fracture may be seen. But
this depends on the weapon. It should be soft and pliable. If the weapon is hard enough, the
injury may be furrow like, due to the shape of the weapon.

Linear fracture goes forward usually. There are exceptions. If there is a huge buttress of
bone present in the front this cannot occur fracture steps at this point or deviated to some
other direct or might come back. This condition is very rare. If there is a point of weakness
round about the linear fracture it may deviate through this. If a suture line is met it may do
several things. This depends on the degree of force and how much the suture line had been
joined.

When a blow alights on the skull there can be temporary bending of skull bone. If the blow is
severe it will crack the skull but two pieces will remain there giving a depressed fracture. If
the blow is not severe and the skull is pliable the bone will jump back from that temporary
bending. In elderly and diseased, the skull bone is not pliable. Therefore, the skull (1)
should be pliable; (2) the force should not be too much (3) and the area where the force
alights should be fairly big for the temporary bending to occur. But there can be local brain
effects at that point and effects due to temporary compression of whole brain. There may be
no marks whatever visible from outside.

Generally the fracturing in the inner table is more widespread than the outer table. This is
because the stress at inner table is more than at the outer table. Another possibility is that
pieces of outer table may be driven into inner table causing more fractures.

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Generally, deficiencies of the skull bones take the shape of the weapon.

Long cut injuries (e.g. by swords) have tailing ends with a deeper centre. When there is a
stab, there will be a clean cut injury and the shape of weapon and the sharpness of the edges
may be predicted accurately. As a rule, there is a greater tendency for comminution when the
skull is supported and the base of the skull may be involved. Damage to ethmoid bone opens
the nasal passages directly to the brain resulting in infection. In nasal fractures aspiration of
blood through nasopharnyx may be fatal.

Intracranial Structures

Brain damage could occur without much visible damage outside (in the scalp or skull). Brain
damage may be momentarily or persistent. There are grades of damage – concussion,
cerebral contusion, cerebral laceration, intracranial haemorrhages.

Sudden start of moving the brain is called acceleration and sudden stop is called deceleration.
These occur in head injuries. Injuries can occur in either due to acceleration or deceleration.

When a blow alights from a larger striking surface, the head moves forwards and there will be
slight rotation. Due to inertia, skull moves a split second earlier than the brain and brain is
left behind for a moment. The greatest force is exerted on the brain stem due to this.

(Inertia is the resistance of any physical object to a change in its state of motion or rest, or
the tendency of an object to resist any change in its motion. It is proportional to an object's
mass)

A similar phenomenon occurs when skull suddenly comes into a stop, but in a reverse
manner. Now the brain moves for a split second more than skull movement. This can cause
local damage at a point diametrically opposite to the point of impact. This is called a
“Contre-coup” injury. This may be more damaging than the impact injury, which is called a
coup injury.

“Contre-coup” injury occurs in a mobile skull. Almost never in a fixed skull. Concussion
may be due to this.

Concussion: This is a transient loss of consciousness due to a blunt impact on the head.
Duration of the unconsciousness depends on the amount of shake up of the brain. It is a
complex pathophysiological process affecting the brain, induced by traumatic biomechanical
forces. Concussion typically involves temporary impairment of neurological function that
heals by itself within time. Neuroimaging normally shows no gross structural changes to the
brain.

The brain is surrounded by cerebrospinal fluid, one of the functions of which is to protect it
from light trauma. But more severe impacts or the forces associated with rapid acceleration
may not be absorbed by this cushion. Concussion may be caused by impact forces, in which
the head strikes or is struck by something, or impulsive forces, in which the head moves
without itself being subject to blunt trauma.

Forces may cause linear, rotational, or angular movement of the brain, or a combination of
these types of motion. In rotational movement, the head turns around its centre of gravity, and

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in angular movement it turns on an axis not through its centre of gravity. The amount of
rotational force is thought to be the major type of force to cause concussion and the largest
component in its severity.

The parts of the brain most affected by rotational forces are the midbrain and diencephalon. It
is thought that the forces from the injury disrupt the normal cellular activities in the reticular
activating system located in these areas, and that this disruption produces the loss of
consciousness often seen in concussion. Other areas of the brain that may be affected include
the upper part of the brain stem, the fornix, the corpus callosum, the temporal lobe, and the
frontal lobe.

Concussion might terminate in death. Therefore the life is in danger. In the mild degrees
recovery is 100%. In moderate degrees may have neurological lesions, drowsiness etc.

Signs and symptoms of concussion:

Physical: Headache, dizziness, vomiting, nausea, lack of motor coordination, difficulty in

balancing, problems with movement or sensation, light sensitivity, seeing bright lights,
blurred vision, double vision, tinnitus, convulsions.

Cognitive and emotional: Confusion, disorientation, difficulty focusing attention, loss of

consciousness, retrograde and post-traumatic amnesia, confusion (repeatedly ask the same
questions, slow to respond to questions or directions, have a vacant stare), slurred or
incoherent speech, changes in sleeping patterns, difficulty with reasoning, concentrating, and
performing everyday activities, loss of interest in favourite activities or items, tearfulness,
and displaying emotions that are inappropriate to the situation. Common symptoms in
concussed children include restlessness, lethargy, and irritability.

At post mortem there is no visible damage to brain. Microscopically, derangement of

neuronal structures and haemorrhages (focal myelin degeneration) may be seen.

Retrograde amnesia: Loss of memory going backwards from the point of impact. Events
immediately preceding the point of injury are forgotten. This may or may not be associated
with concussion and vice versa. Not knowing what happened after an injury may be due to
unconsciousness. It is not amnesia.

Usually people recover from retrograde amnesia. Recovery is progressive. What he says is
absolutely reliable. But he might not remember the exact impact.

Some of the manifestations for head injuries may be seen in alcoholics. Sometimes both are
associated.

Haemorrhage in Head Injuries

Extradural haemorrhage (EDH): Generally, bleeding is due to a fracture which involves a

branch of middle meningeal artery. It is common in the elderly. Sometimes rupture of an
emissary vein or a torn venous sinus can cause EDH. Venous bleeding is less rapid.
(A) When a blow is alighted, a person may become unconscious due to concussion.
Haemorrhage now progresses and cause unconsciousness which merge with the
previous one and results in continuous unconsciousness.

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(B) When a blow is not so forceful, unconsciousness of concussion may be followed
by a period of normality till haemorrhage causes compression of the brain and
unconsciousness. This period is caused ‘lucid interval’. This is the typical
manifestation of EDH.
(C) Sometimes there may be no unconsciousness due to concussion. He may gradually
lose consciousness due to compression from EDH.

During the lucid interval a reliable, rational statement may be made.

Subdural haemorrhage (SDH): This can occur from torn sinuses, emissary veins or
damage to the surface of brain. There are 3 types of SDH.
1. Acute 2. Subacute 3. Chronic

Acute form is associated with severe trauma and usually follows it immediately. It is due
to bleeding from the brain surface generally. This is dangerous as it is associated with
cerebral damage.

Subacute form may be delayed for some hours.

In the chronic form, manifestations occur weeks or months after. This is common in old
people. It may be seen even after trivial trauma. Sometimes SDH occur with a mere
deceleration injury in the elderly.

Subarachnoid haemorrhage (SAH): Traumatic or spontaneous. Occurs from Circle of

Willis (ruptured berry aneurysm), AV malformation etc.

Cerebral haemorrhage: Commonest cause is natural - increased BP, atherosclerosis etc.

Can be traumatic. A person may meet with a head injury, following natural cerebral
haemorrhage. Brain and other systems should be carefully examined to determine what
occurred first. Another example is a fall from height.

Minimal trauma can cause cerebral haemorrhage when arteries are highly diseased.
Raised BP in an emotional situation may rupture a vessel spontaneously. Therefore the
condition of vessels should be always recorded. Other organs should be examined and
abnormalities should be recorded.

Volitional activity after injury - Depends on the site of injury. (e.g.: Frontal lobe injury
– volitional activities not much impaired) During lucid intervals any amount of activity is
possible. Brain stem damage, reticular area damage, and concussion hamper volitional
activity. Generally, blunt injuries are more disabling than sharp injuries.

Other effects subsequent to a head injury:

Post traumatic automatism - phase of automatic activity, the nature of which the victim is
unaware of. This is a valid defence in court if it can be proven.

Epilepsy – Post traumatic epilepsy could occur consequent to a previous head injury.

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Important questions that could be asked in court in a death following head injury:

1. Description of injuries?
2. Category of hurt?
3. Features of the offending agent?
4. Amount of force used and its direction?
5. Position of assailant and victim?
6. Whether victim was able to make a statement after sustaining injury?
7. Whether volitional activity was possible after sustaining the injury?
8. Which injury is likely to have caused death?
9. Sequencing of injuries where possible?
10. Effects of a particular injury on the brain?
11. How long the victim would have survived after injury?
12. If the victim was taken immediately to hospital whether his life could have been
saved?
13. What factors would have contributed to death in this individual?
14. Identification of a similar weapon produced in court?
15. Which injuries were due to an assault and which were due to a fall?