Week 11

Blunt and sharp Force Injuries

              Violence is the mainstay in criminal activity, and trauma is the end result of violence to
a person. Trauma can also be the outcome of accidents or self-inflicted injuries, and in forensic
pathology, the pathologist must be able to not only see the trauma and infer what may have
caused it but also determine the manner in which it was inflicted. Old, healed trauma must also
be studied so that the pathologist can assess whether the wound was antemortem, postmortem or
perimortem. Again, reconstructions and a focus on timelines are central to the work of any
forensic professional.
        Blunt trauma is defined as a damage to the body due to mechanical force applied either by
the impact of a moving blunt object or by movement of the body  against a hard surface, both
mechanisms resulting in the transfer of kinetic energy high enough to produce an injury (mainly
by compression, traction, torsion, and shear stresses). The kinetic energy associated with a
moving object is equal to one half the mass of that object multiplied by the velocity of the object
squared (1/2mvsquared). In general somewhat lighter object  traveling at hush speed will cause
more damage than a heavier object traveling at a slow speed. Blunt injuries occur in criminal
assaults (e.g., a blow with a blunt edged instrument, a punch, or a kick), in physical abuse, in
traffic and industrial accidents, in suicides, and in accidental falls brought by the victims
themselves.
Blunt Injuries to the Integument:

Abrasions
    Abrasions are superficial injuries to the skin characterized by a traumatic removal,
detachment, or destruction of the epidermis, mostly caused by friction. In tangential or brush
abrasions, a lateral rubbing action scrapes off the superficial layers of the skin. In fresh grazes,
the direction of the impact can often be determined by the abraded epidermal shreds that remain
attached to the end of the scrape. At a later time, the tissue fluid dries out and forms a brownish
scab. If the lesion does not reach the dermis, it heals in several days without scarring. Infliction
just before or after death results in leathery (parchment-like) appearance with a yellowish-brown
discoloration.
     Another type of abrasion is caused by a vertical impact to the skin (pressure or crushing
abrasion). In such cases, the injuring object may be reflected by the shape of the skin injury so
that the patterned abrasion can be regarded as an imprint of the causative object.
Contusions
     Contusions or bruises are extravasations of blood within the soft tissues originating from
ruptured vessels as a result of blunt trauma differentiated between intradermal and subcutaneous
bruises.
      Intradermal bruises, the hemorrhage is located directly under the epidermis, usually sharply
defined and red in color, whereas the more common bruises of the deeper subcutaneous layer
have blurred edges and, at least initially are in bluish-purple color. 
     Intradermal bruises may reflect the surface configuration of the impacting object. The skin
that is squeezed into grooves will show intradermal bleeding, whereas the areas exposed to the
eleatedf parts remain pale. In falls from a height, the texture of the clothing may produce a
pattern of intradermal bruises corresponding to the weaving structure. Patterned extravasations of
this type are also seen in tire tread marks when an individual is run over by a wheel, and in
bruises from vertical stamping with ribbed soles.
      Subcutaneous bruises are usually non patterned. Victims of blunt force violence often sustain
contusions from self-defense, typically located on the ulnar aspects of the forearms and on the
back of the hands. A periorbital hematoma (“black eye”) is induced either by a direct impact
(e.g., a punch or kick) or an indirect impact (due  to seepage of blood from a fractured orbital
roof, a fractured nasal bone, or from a neighboring scalp injury of the forehead.
      In general, bruises are regarded  as a sign of vitality indicating that the contusion was
inflicted prior to death. During life, the blood from ruptured vessels is forced into the soft tissue
by active extravasation.
       In a living person, the contusion undergoes a temporal series of color changes. Initially, most
subcutaneous bruises appear purple-blue. As the hematoma resolves during the healing process,
the hemoglobin released from the red blood cells is chemically degraded into other pigments
such as hemosiderin, biliverdin, and bilirubin. The color changes-usually over the course of
several days - to green and yellow before it finally disappears. However, the rate of change is
quite variable and depends on numerous factors, above all, the extent of the bruise.
     A special type of blunt injury to the soft tissues is frequently seen in pedestrians who have
been struck or run over by motor vehicles.Both the skin and subcutaneous layer may be  avulsed
from the underlying fascia or bones by shearing forces so that a blood-filled pocket is forme,
typically in combination with a crush damage to the adjoining fatty tissue.
Lacerations
Lacerations are tears of the skin or internal organs. They may be caused by blows from blunt
objects (such as hammer, a whipped pistol, a rod, the toecaps of heavy footwear, or a fist); other
lacerations are produced by an impact from vehicles or by a fall to the ground, Lacerations  occur
most commonly in body regions where the integument directly overlies a firm boney base acting
as support (scalp, face, back of the hand, and shins). When the force acts on the skin, the
subcutaneous tissue is squeezed between the injuring object and the bony platform so that the
integument is compressed and  crushed until it tears and splits sideways.
Lacerations are characterized by abraded, bruised, and crushed wound margins. The edges of the
tears are typically irregular and ragged with bridging  tissue strands (vessels, nerves, and fibers)
running from side to side. The wound slits may be linear (especially with blows with a narrow,
edged instrument), Y-shaped, or star-like. If the impacting object hits the skin at an oblique
angle, one of the edges will be ripped away resulting in unilateral undermining (undercutting and
avulsion), which indicates the direction of the force. Sometimes foreign material from the
causative instrument /surface is deposited in the depth of the wound slit. The abrasion
surrounding the tear may correspond to the shape and dimensions of the impacting blunt-
surfaced instrument or- in the case of a fall to the ground- the area of contact.
Head Injuries
The head is a common target in assaults with blunt objects; other common causes of head
injuries are traffic accidents, falls from a height, and fall from a standing position. The area of
impact usually reveals injuries of the scalp or the facial skin, but severe and even lethal
traumatization may not necessarily be associated with scalp bruising, marked swelling,
excoriation, and/or laceration.
Skull Fractures
These may involve the cranial vault, the base of the skull, and the facial skeleton. There are
several types of skull fractures to be distinguished.
Single or multiple linear fractures are caused either by a blow with an object with a broad
surface area or by a fall on the head so that the skull is deformed (flattening/indenting at the
point of impact and outward bending/bulging in the periphery). The fracture line originate where
the bone is sent outward and therefore exposed to traction forces exceeding the limits of the
bone’s elasticity; from these extruded parts of the skull, the fractures extend toward the area of
impact, and also in the opposite direction.For this reason, either of the ends is often in congruity
with the impact injury of the scalp. Several fracture lines  may radiate outward from a central
point of impact where the skull is often depressed and/or shattered to pieces forming a spider’s
web or mosaic pattern consisting of circular and radiating linear fractures.
Before fusion of the cranial sutures (i.e., in children and young adults), a fracture may travel
along the seam resulting in diastasis (diastatic fractures). If a gaping fracture runs from one side
of the cranial base to the other (mostly after lateral impact or side-to-side compression), this
transverse type is called a hinge fracture because of the independent movement of the front and
rear halves of the  skull base.
Longitudinal fractures of the base of the skull often occur due to a fall on the occiput, on the
other hand they can also be produced by impaction of the frontal region.
Depending on its course and location, a base fracture may be followed by several clinical signs:
bleeding from the ear (in fractures of the temporal bones with concomitant hemotympanum and
rupture of the eardrum); bleeding from the nose and mouth (in fractures involving paranasal
sinuses, which provide a communication with the nasopharynx); periorbital hematoma (from
fractures of the orbital roofs); leakage of cerebrospinal fluid coming out of the nose or the ear (if
the dura is injured along the fracture); and bacterial infection of the meninges (by spread from
the nasal cavity, the  paranasal sinuses, and the middle ear, especially when the fracture is
accompanied by a tear of  the dura).
A ring fracture is located in the posterior fossa and encircles the foramen magnum. It occurs
mostly in falls from a height onto the victim’s feet or buttocks so that the cervical spine is driven
into the skull. This is also seen in deceleration traumas, in head-on collisions, in passengers with
fastened seat belts; due to inertia, the non restraint head will continue to move forward exerting
traction forces on the base of the skull.
Bone impressions and depressed fractures are always localized at the point of impact where the
head is struck with an object having a relatively small surface area such as a hammer or a
protruding corner of a piece of furniture.
Hole fractures from bullets perforating a flat bone of the skull are mostly roundish and clean-cut
at the site of entrance, but beveled out in a craterlike manner, at the exit site.
Blunt force applied to the occiput, mostly as a consequence of a fall on the back of the head,
often causes independent fractures of the anterior cranial fossa such as cracks of the thin orbital
roofs (secondary fractures at the site of the contrecoup).
Intracranial Hemorrhages
Space occupying bleeding into the brain membranes is followed by a local displacement of the
brain and raised intracranial pressure with concomitant flattening of the cerebral hemisphere.
Intracranial hematomas as well as traumatic brain swelling, which often accompanies head
injuries may result in: transtentorial (uncal) herniation (in cases of supratentorial mass lesion)
and/or herniation of the cerebellar tonsils, which are forced into the foramen magnum leading to
compression of the brain stem with secondary damage and failure of the medullary respiratory
centers.
Epidural (extradural) hemorrhages are located between the skull and the underlying dura mater,
which is stripped from the bone by bleeding from a torn vessel. Epidural hematomas have a
typical disk- or lens-shaped appearance. The most common site is the temporal and the adjacent
parietal region where branches of the middle meningeal artery are easily lacerated in the course
of a transecting fracture line. Epidural hematomas more frequently originate from arterial
bleeding than from venous bleeding. In the great majority , an extradural hemorrhage is
associated with a cranial fracture
Subdural hematomas are intracranial bleedings located beneath the dura mater and above the
arachnoid. Most often, results from the tearing of overstretched bridging veins that traverse the
subdural space between the surface of the cerebral hemispheres and the superior sagittal sinus.
Other possible sources of subdural bleeding are injuries to venous sinuses or to the cerebral
parenchyma (such as cerebral contusions with concomitant laceration of the arachnoid).  A high
percentage of subdural bleedings are caused by acceleration or deceleration of the head, for
instance, in falls when the head impacts a hard surface, and also in traffic accidents and physical 
child abuse (battered child and shaken baby syndrome).There are also prolonged cases of
hematoma formation and organization, mainly in the elderly people and sometimes without a
history of previous traumatization. Such chronic subdural hematomas typically consist of brown
and gelatinous blood accumulations adherent to the meninges and sometimes covered with a
tough membrane.
Traumatic subarachnoid bleeding may result from damage to the cortex such as brain contusion
(e.g., contrecoup lesions), from penetrating injuries to the brain, and as a consequence of
vessel tears within the subarachnoid space.
Cerebral Injuries
“Concussion of the brain” is a clinical diagnosis which means a disorder of cerebral function
following immediately upon a (blunt) head injury. It is usually characterized by a transient loss of
consciousness (initial coma) with subsequent amnesia from the actual moment of trauma; it is
often combined with retrograde amnesia and vegetative signs such as nausea and vomiting. In
mere concussions, the unconsciousness lasts only for a relatively short time (<1hr) and the 
brain tissue does not show any evidence of structural damage.
Cerebral contusions are traumatic lesions of the brain frequently seen in the cortex and
sometimes extending into the underlying white matter. Due to the injuring mechanism, most
cerebral contusions occur in brain regions that are directly opposite to the point impact
(contrecoup type of contusion).
Diffuse axonal injury (DAI) is considered a consequence of shear and tensile strains from
sudden acceleration/deceleration or rotational movement of the head. Overstretching of the
nerve fibers in the white matter leads to axonal injury varying from temporary dysfunction to
anatomical transection, the latter being followed by microscopically visible club-shaped
retraction balls on the axons. In victims of substantial head injuries, especially after traffic
accidents, DAI may be responsible for prolonged coma and a fatal outcome even in the
absence of an intracranial mass lesion.
Cerebral edema is a frequent finding in significant head injuries. The formation of the edemais
due to an increase in the fluid content of the brain, predominantly in the white matter. Post
traumatic edema may be generalized (diffuse) or related to focal tissue damage (e.g., adjacent
to an area of cerebral contusion or laceration). At autopsy the weight of the brain is increased
and the gyri are pale and flattened with shallow sulci in between. From the pathogenetic point of
view, edema is attributed to a heightened vascular permeability which in turn may be worsened
by additional hypoxia.
Injuries of the Chest
Non penetrating blunt force may damage the thoracic wall and/or the chest organs. Rib
fractures are caused by either direct or indirect violence. In the first case, a localized force is
applied and the underlying ribs are broken in the contact area; the indirect type of rib fracture
occurs away from the impact, mainly due to compression of the chest.
Rib fractures are frequently associated with complications that may be dangerous or even life
threatening.
a. If a victim sustains numerous fractures, the rib cage loses its rigidity  so that the injurd
section of the chest wall will not participate in the expansion of the thorax during
inspiration with the result of paradoxical respiration (flail chest) and concomitant hypoxia.
b. sharp, pointed ends of the rib fragments may penetrate the pleura and lacerate the lung
and/or the intercostal blood vessels with consecutive bleeding into the chest cavity
(hemothorax).
c. A leak in the visceral pleura permits air to enter the pleural cavity (pneumothorax) so that
the lungs collapses, if it is not fixed to the chest wall by preexisting pleural adhesions.  A
valve-like leakage in the pleura leads to a so-called  tension pneumothorax caused by
an increasing pressure of trapped air in the pleural cavity and followed by a complete
collapse of the affected lung and a shift of the mediastinum to the opposite side.
d. the presence of air bubbles in the subcutis or in the mediastinum
(subcutaneous/mediastinal emphysema) may derive from injuries of the trachea, the
bronchi, the thoracic wall, or the lungs by air entering the adjacent tissues.

Blunt force to the lung is mainly encountered as contusions or lacerations. A contusion typically
caused by  a substantial impact on the chest with consecutive inward bending of the thoracic
cage. In young victims, contusions are not necessarily accompanied by fractures of the ribs or
of the sternum because of the high pliability of the juvenile thoracic cage.
Blunt traumatization of the heart manifests as concussions, contusion or myocardial rupture.
Traumatic aortic ruptures typically occur in vehicular accidents and in falls from a height, the
most important mechanism is sudden deceleration, probably in combination with compression
and/or shearing.
Abdominal Injuries
The abdominal organs most vulnerable to blunt trauma are the solid liver and spleen on the one
side and the mesentery on the other. Substantial injuries to the liver, the  spleen, and the
mesentery have always to be regarded as life threatening and potentially fatal, especially in
cases without rapid surgical treatment. The main reason is internal bleeding into the peritoneal
cavity from lacerations. Ruptures of the liver and spleen can be classified as either
transcapsular or subcapsular lacerations. Transcapsular lacerations, both the parenchyma and
the capsule are injured so that the blood instantaneously pours into the peritoneal cavity.
Subcapsular lacerations are characterized by the initial formation of a subcapsular hematoma
which expands continuously and possibly causes delayed rupture when the covering capsule
tears due to overstretching (mostly several hours or even days after the trauma).

Sharp Trauma
Sharp-force injuries are the second most common cause of injury following trauma by blunt
force. They are caused by sharp-pointed or keen-edged instruments, resulting in incised
wounds, that is, cuts or slashes, stab wounds, or chop wounds, depending on the implement
used and the manner of infliction.
Upon examination of sharp-force injuries, the forensic expert will be asked to differentiate
between suicidal, homicidal, and accidental origins. Diagnostic findings which are essential to
make this distinction, include the following:
a. kind of injury sustained by the victim (incised, stab,  or chop wound)
b. pattern of injuries, that is, their number and their anatomical localization
c. characteristics of the instrument or weapon used
d. sequelae (e.g., from lesions to vessels and inner organs) or cause of death
e. findings at the scene such as blood traces or bloodstain patterns
Wound Morphology and Biomechanics
Blunt- and sharp- force injuries show some fundamental morphological differences allowing
diagnostic  differentiation. Sharp force injuries have clearly severed wound edges, usually
without concomitant abrasions or contusions. Tissue bridges between the wound edges, which
are due to the unequal tear resistance of different types of tissues, are also absent in sharp-
trauma injuries.
Incised Wounds: Cuts and Slashes
Cut wounds occur when a sharp-edged instrument moves in a direction tangential to the body
surface. A cut formally describes an incision of the skin and the underlying  soft tissue, whereas 
a slash implies cutting with a violent sweeping movement.Depending on its position in relation 
to the cleavage lines of the skin, the wound may gape more or less in a spindle-shaped way
with the greatest depth in the middle decreasing toward the wound ends.
Stab Wounds
A stab wound is caused by a pointed object thrust into the body. In stabs to the trunk, the
abdominal and/or thoracic cavities may be affected.
Under certain circumstances, some features of the stabbing instrument are reflected by the
wound morphology. For example, a stab wound from a single-edged blade may show one
sharply pointed end corresponding to the cutting edge of the blade and one rounded end on the
side of the knife’s back.
When the knife has plunged into the body, turning of the victim or twisting of the blade before
withdrawal causes I,Y V-shaped wounds.
Atypically shaped wounds can also result from stabs through skin folds or creases. “Incised stab
wounds” result from a combination of cutting and stabbing movements. The wound may start as
a cut, which terminates as a stab wound; on the other hand, some stab wounds turn into an
incised wound as the knife is withdrawn at a shallow angle.
Stabbing instruments do not necessarily have to be edged, and there is a variety of pointed 
implements that are used to inflict stab wounds, example: ice picks, forks, pens, scissors. and
screwdrivers. (Z-shaped injuries resulting from a closed pair of scissors or the four-point star-
shaped wounds by a Phillips screwdriver).
Chop Wounds
Chop wounds are caused by rather heavy objects with a sharp edge. (e.g., axes, hatchets,
cutlasses, and chopper knives) and/or very long blades (e.g., swords, sabers, and machetes).
These objects sometimes cause injuries showing both sharp- and blunt-force elements, for
example, additional fractures of the skullcap in blows to the head.
Injuries from Glasses
Whenever broken bottles or pieces of glass are used for cutting or stabbing, the wound margins
can show concomitant skin abrasions, notches, or hematomas.