WOUNDS

Definition: A wound is a discontinuity of

any tissue produced by trauma or violence.
I- Legal classification of wounds:
1- Simple wounds: Which heal in less than 20 days without leaving
permanent infirmity.
A permanent Infirmity is the loss of organ or loss of its function.

2- Dangerous wounds: Which heal in more than 20 days and/or leave a

permanent infirmity.

3- Fatal (mortal) wounds: Which lead to death.

II- Medicolegal Classification:

(1) Abrasions

•Definition:

They are the superficial wounds in the form of destruction of the cuticle
due to friction by a blunt rough object.
• Medico-legal importance:
a-Shape:
Abrasions take the shape of the instrument.

•1-Finger nail abrasions are semilunar or crescentic, may be linear if the

nails are dragged on the skin.

•2-Rope abrasions show the pattern of the rope in cases of strangulation

or hanging, or tying the wrists and ankles in torture.

•3-Car abrasions are imprinted on the body as that of the radiator or

specific metallic designs on hitting part of the car.

• 4-Ground abrasions in falling down are oval or rectangular, in the

form of parallel lines and are opposite boney prominences.
b-Site:
May identify the sort of the crime.

•1-Rope abrasions around the neck point to either strangulation or

hanging. If around wrists and ankles they denote torture.

•2-Finger nail abrasions around the neck are present in throttling, and
are present around nose and mouth in smothering.

•3-In rape, finger nail abrasions are found around mouth, on the neck,
wrists and the inner sides of thighs of the victim.
c-Age of abrasions:
•Fresh: There is hyperemia, oozing serum, usually no bleeding

•Up to36 hours: Hyperemia, soft yellow scab of dried serum.

•2-3 days: Dry brown scab.

•6 days: Falling of the scab, leaving a red surface which disappears

without leaving a scar in about 3 weeks.
•d-Other medico-legally important items:
•1- Always indicate struggle, or accidents.

•2- Differentiate between hypostasis and bruises.

•3- Differentiate between contused and cut wounds

•4- Abrasions are present around the inlet of missiles.

 (2) Contusions or Bruises
• Definition:
A contusion is the collection of blood under the intact skin due to a
trauma by a blunt object.
• Medico-legal importance:

1-Shape of contusions:

They take the shape of the causative instrument.

They are rounded or oval in trauma by a localized surface and elliptical

in human bites.

A stick causes two parallel lines and the whip gives curved bruise
around the body.
• 2-Size of contusions:

It is big with severe trauma and heavy instruments in general.

On the other hand, lax tissues as the eye lids, buttocks & labia majora in
females bruise more easily tough tissues as those of the palm of the
hand or sole of foot.

Patients suffering from hemorrhagic blood diseases show extensive

contusions after mild traumata.
•3-Age of bruises:

They show gradual change in color due to destruction of the

extravasated blood by enzymes and histiocytes to hematoidin and
biliverdin (green) and bilirubin (yellow). The color changes start in the
periphery, so a contusion may show more than one color.

•Red = Fresh contusion (oxy Hb).

•Violet after one day (gradual reduction).
•Blue (reduced Hb) in 3 days.
•Green (biliverdin) in 6-7 days.
•Yellow (bilirubin) in 14 days.
•Normal skin color in about three weeks.
•4-Site of bruises:

A bruise may not appear at the same site or time of trauma due to
gravitation of blood through tissues.

A trauma on the head may appear after 2-3 days as a bruise in the eye-
lid (black eye), a blow on the calf may later cause a bruise around the
heal.

Deep contusions as in the thick tissues of the buttock may not appear
under the skin except after 4-6 days.

Accordingly, victims of assaults who do not show contusions, should

be re-examined after few days for evidence of contusions.
•5-Type of crime:

Bruises indicate violence or struggle, so they occur homicidally or

accidentally. Also, bruises should be differentiated from hypostasis.

•6-Dangers of contusions:

These are: shock, reflex vagal inhibition, sepsis or injury to internal

organs as rupture of liver or spleen.
 (3) Cut or Incised wounds

• Definition:

It the linear wound, longer than broad or deep, which is caused by

drawing the edge of a sharp instrument (razor or knife) on the skin.
• Medico-legal importance:

1-Shape and character:

The length of a cut wound does not correspond to the size of the
instrument, so a small razor may be used to cause a very long wound.
The characters denote that the instrument is sharp, these are:

a) length more than depth.

b) Edges are sharp and linear, but may be irregular in areas with corrugated
loose skin as scrotum or axilla.
c) Angles are sharply cut.
d) No abrasions or contusions are present.
e) Gapping occurs, specially if the skin and muscle fibers are cut
transversely.
f) All tissues are cut to the same degree on the sides and base of the wound,
so there is no bridging of tissues.
g) Hairs are sharply cut as seen under magnification.
h) Bleeding is profuse due to cut vessels.
• 2-Differentiation between a cut and a contused wound:

A contused wound when inflicted opposite bony

prominences may resemble a cut wound and has to be
differentiated from it.
• 3-Type of crime:

Cut wounds occur suicidally as in cut wrist or cutthroat, homicidally in

cutthroat. Numerous cuts may be found in the hands and arms of a
victim while defending himself against an assault by a knife. Incised
wounds may be self-inflicted as fabricated wounds.
 (4) Contused or Lacerated wounds
•Definition:
It is the irregular laceration of the skin and tissues, with
extravasation of blood, following a trauma by a blunt
instrument as stick, stone, hammer, fall from height or
car accident.
• Medico-legal importance:

1-Shape and character:

It may not take the shape of the causative instrument, but its irregularity
shows that it is caused by a blunt instrument
(look table of differentiation between cut & contused wounds).
•2-Differentiation between cut & contused wounds:

When the contused wound is inflicted opposite bony

prominences as scalp, cheek, elbow or shin of tibia, it
may be linear and simulates a cut wound.
Item Cut (incised) wounds
Definition and causal object These are due to drawing the
edge of a sharp object on the
skin e.g. knife, razor or broken
glass.
Examples • Cutthroat (homicidal and
suicidal).
• Cut wrist (suicidal).
Characters (Edges): Regular clean-cut edges and
sharp base except :
• Irregular object: broken
glass
• Corrugated skin: neck,
axilla, wrist and scrotum
Contused (lacerated) wounds
These are due to a blow with
a blunt object e.g. sticks,
stones, car accidents and fall
from a height.
• Scalp wounds by sticks
• Perineal tears due to
delivery
Irregular lacerated edges
except in areas of stretched
skin over a bone e.g. scalp
and shin of tibia.
Item Cut (incised) wounds Contused (lacerated) wounds

Bridges across the edges
Abrasions and bruises at the
edges
Hairs (microscopically)
No bridges (absent), and Bridging of tissues across
gaping edges and no gaping.
Absent Present (seen by a hand lens).
Sharply cut Crushed

Bleeding Free external bleeding (cut Less bleeding (crushed

vessels) vessels) partly closed by
blood clots.
Sepsis Less sepsis (minimal tissues More sepsis (severe tissue
destruction). destruction) and blood clots.

Healing Rapid with a thin scar (1yr Delayed with a thick scar (2yr
intension) intention).
Item Cut (incised) wounds Contused (lacerated) wounds

Varieties and types of wounds • Hesitation marks, • Torn (flap) wounds: by a

indicate suicide. revolving belt of a machine.
• Defense wounds in the • Crushed wounds: due to
palm car accidents.
• Fabricated wounds. • Avulsion by grinding
compression separating the
skin from underlying tissue.
• Rupture of internal organs:
kick or blow to the
abdomen
•3-Varieties of contused wounds:
•a-lacerated wounds:
There is extensive laceration and destruction of skin & tissues as in
major accidents.

•b-Torn or flap wounds:

Occur due to revolving machines pulling clothes then a limb, or the hair
and scalp, tearing them from the body. If a part of the tissue is left
hanging to the body, the torn wound may be called flap one.

•c-Crush wounds:
Occur in train, tram or heavy vehicles passing on the limb, and may
result in amputation.
• 4-Type of crime:
Contused wounds occur mostly in accidents or homicides. Suicidal
cases occur due to jumping from heights or lying on railway tracks.

• 5-Dangers of contused wounds:

These are mainly due to shock, injury to vital organs, hemorrhage, and
infection. Crush syndrome may give rise to myoglobinuria and anuria
with renal failure.
 (5) Stab and Wounds

• Definition:

These are clean edged wounds caused by forcing a sharp pointed object
into the body e.g. knife and dagger.
• Medico-legal importance:

1-Shape and characters of stab wounds:

The depth of the wound is more than its length on the skin. If the
weapon has two sharp edges (double bladed dagger), both angles of the
stab will be sharp. In ordinary knives, with single sharp blade, the
external wound will be wedge shaped, with a single angle and irregular
base.
The length is usually smaller than breadth of the blade due to recoil of
the elastic skin. Puncture wounds with rounded nails or pokers have a
wounded base; and in square instruments it will be star shaped, so it
differs according to the cross section of the instrument.
2-Varieties of stab and puncture wounds:

• They are called penetrating wounds when the instrument penetrates a

body cavity, as the thoracic or abdominal cavities.

• They are called transfixing wounds if they pass through a limb or the
whole body.
3-Type of crime:

These wounds are usually homicidal.

Accidental puncture wounds may occur due to falls on iron fences or

vertical iron bars.
4-Dangers:

Injury to important organs heart, liver, pleura and lung is more liable to
occur.

Tearing of big vessels with massive internal hemorrhage is common, or

even air embolism.

Septic complications are severe due to their depth.

 The General Antemortem Characters of
Wounds
1. Hyperemia, which appears as redness around the wound.

2. Swelling, eversion and gapping of edges.

3. Evidence of bleeding and clotting of blood inside the wound.

4. The presence of external and internal P. M. picture of death from

hemorrhage in wounds causing extensive bleeding.

5. Evidence of infection and septic complications at the site of the

wound, or even healing, if death was delayed.
 Fabricated / Self-Inflicted wounds
•Definition:

o These are simple wounds which are self-inflicted (or fabricated) by

the person on his body.

o These may be inflicted as a desire for revenge, to pretend that the

crime was self-defense, to allege bad treatment by police
authorities, to avoid work in the prison, to obtain illegal
compensation and to escape military service.
•Characters of Fabricated Wounds:

1. Superficial and relatively harmless.

2. In an area readily accessible to the victim and in a safe site e.g.

extremities, forehead, etc.

3. They are inflicted on bare skin, so no corresponding tear on clothes.

4. The age of the wound does not usually correlate with the date
stated by the fabricator.

5. Careful examination and interrogation about the manner of assault

or type of weapon will prove that allegation was false, e.g. firearm
wound: punctured by a nail and burned with a cigarette.
 Defense Injuries

These are injuries sustained by the victim to defend himself.

In case of punching, kicking there will be abrasion or bruises on the

outer side of the forearm, back of hands and fingers may be broken in
an attempt by the victim to shield himself. In kicking, defend bruises
may occur on the outer side of the thigh as the victim tries to protect his
genital region.

In attacks by knife, its blade may be gripped by the victim, so that cut
wounds may occur across the flexors of the fingers and in the palm.
 Causes of Death in wounds

A) Early: B) Delayed:
I. Sepsis.
I. Hemorrhage.
II. Complications of surgical
interference.
II. Traumatic shock (primary
and secondary) III. Crush syndrome.
III. Embolism (Air embolism,
Venous and arterial, fat
embolism, bone marrow
embolism and
Thromboembolic)
 A) Early causes
I- Hemorrhage:
• Amount causing death:
a)External hemorrhage: 1.5-2 liters (1/3 blood volume).
b)Internal hemorrhage: According to its site :
10-20 ccs in the brain.
100 ccs in the pleural cavity.
200 ccs in pericardial sac  cardiac tamponade.

• Rate of bleeding is important: If It is gradual, it may be

compensated (e.g.: piles), but if the loss is rapid, it will be fatal.

• Clinical picture: Weak and rapid pulse, low bl. p., rapid and shallow
respiration and cold clammy skin.
• P.M.P.

 External:
Blood on the ground and clothes, pale body and pale (ill defined)
hypostasis.

 Internal:
Pale organs, contracted empty heart with subendocardial hemorrhage
as the heart squeezes itself to supply the last drop of blood to the brain
thus injuring itself and contracted spleen, being a source of auto
transfusion (Corrugated splenic capsule).
II- Traumatic shock:

1-Primary (neurogenic shock)

a) Parasympathetic inhibition of circulation (reflex vagal

inhibition: R.V.I.):

b) Sympathetic shock:
a) Parasympathetic inhibition of circulation (reflex vagal
inhibition: R.V.I.):
Causes are mainly due to trigger zones stimulation as:

• Sudden dilatation of the cervix in females.

• Blow to the trigger areas (rich in parasympathetic nerve
endings) like the larynx, precordium, external ear, epigastrium
and testes in males.

These conditions may lead to sever vagal stimulation leading to severe

bradycardia  cardiac arrest unless vagal escape occurs
[the ventricles beat by their own rhythm (idioventricular:
=25-30/minute)].
Death is usually rare.
Clinical picture:
• Slow pulse,
• Low pressure,
• Slow and shallow respiration,
• Subnormal temperature,
• Nausea,
• Sweating,
• Vertigo,
• Pallor,
• Finally coma and death.

P.M.P.
Pale organs.
• b) Sympathetic shock: This type occurs after a few minutes.

This occurs after painful wounds or severe fear

Adrenaline release

Rise of B.P. and tachycardia

acute pulmonary Edema or ventricular fibrillation in patients having already

heart diseases (e.g. angina and infraction. )
Clinical picture:
• Rapid pulse,
• High bl. p.,
• Acute pulmonary edema
• Dilatation of pupils
• Death due to acute heart failure

P.M.P.
• Congested viscera,
• cut section of lungs oozes frothy fluid
• and the pre-exciting heart disease (old infraction).
Item Parasympathetic Shock Sympathetic shock

Onset Instantaneous Delayed (few mins.)

Mechanism Blow to the trigger areas. Severe pain or sever fear

(adrenaline).
Pulse and B.P. Slow pulse and low B.P. Rapid pulse and high B.P

P.M.P. Pale hypostasis and pale Dark blue hypostasis and

internal organs congested internal organs.
 2- Secondary (hematogenic or surgical) shock
This occurs due to absorption of histamine-like substances from the site
of trauma which cause vasodilatation which intern decrease venous
return, cardiac output and blood pressure that leads to circulatory failure
and death. This reaction takes few hours to develop.
Clinical picture:
• Rapid and weak pulse,
• Low bl. p.,
• Rapid and shallow respiration and
• Subnormal temperature.
• Finally coma  death (from tissue anoxia)

P.M.P.
• Petechial hemorrhages in tissues and
• Effusion in serous cavities.
III- Embolism:
The most common posttraumatic emboli are: Air embolism, fat
embolism, thromboembolism (95% of posttraumatic embolism).
 a-Air embolism
• Venous air embolism occurs in cut throat, air is sucked in the cut
jugular vein by the negative intrathoracic pressure during inspiration.
• It also occurs in cases of tubal insufflations and criminal abortion
using the douching method.
• If the amount of air is from 100-300 ml., it is rapidly fatal.
• Air fills the right side of the heart and pulmonary arteries  acute
heart failure.

P.M.P.:
• X-ray: Air fills the right side of heart and pulmonary arteries. Filling
the pericardial sac with water then puncturing the right ventricle with a
needle  air bubbles come out.
• Ophthalmoscope: Air bubbles in retinal arteries.
 b- Fat embolism and bone marrow embolism
Causes:
a) Fracture of a long bone with a torn vein.
b) Burns in a fatty area with a torn vein.
c) Trauma to a fatty area.

The fats will reach the right side of the heart and pulmonary artery 
acute heart failure.
Fatal systemic emboli may reach the brain, heart and kidneys.

Diagnosis at P.M.:
Sections of the lungs stained with fat stains (osmic acid and Sudan III)
will show fat cells.
 c- Thromboembolism
Causes in trauma:
•Immobilization stasis of blood in veins  thrombus formation.

•Shock, sepsis and hypoxia tissue devitalization thrombus

formation.
 B) Delayed causes

IV- Sepsis: (from2-15 days)

 Sepsis (septicemia, peritonitis, pericarditis…) may cause delayed
death.

 Localized infection may be transmitted to vital organs as the lungs

and meninges resulting in fatal pneumonia or meningitis.

 Tetanus (caused by Cl. Tetani in non-immunized, feeble patient

wounded in the street contaminated with the spore forming
organism). Gas gangrene is another serious infection caused by Cl.
Welchii.
V- Surgical interference:

• Done to save the victim’s life.

• The assailant is responsible for the result of the operation so long as it

was indicated and skillfully done.
VI-Crush syndrome:

• Severe crush injuries liberate the big molecules of the myoglobin of

the muscles, this blocks the glomeruli and renal tubules resulting in
oliguria, or anuria and death from uremia after 7-10 days.
 Cut Throat
Causes of death in cut throat:
1. Neurogenic shock (Vagal) due to injury of the carotid body or
sympathetic due to fear and/or pain.

2. Hemorrhage.

3. Venous (pulmonary) air embolism.

4. Asphyxia due to inhalation of blood.

5. Delayed death (rare) due to edema of glottis, and pneumonia

Differences between suicidal and homicidal
cut throat
Item Suicidal cut throat Homicidal cut throat

I- Circumstantial evidence and examination of the scene of crime:

 History previous  History of previous

attempt at suicide or threatening by an
history of troubles. enemy.
 Door is locked from  Door is locked from
inside. outside.
 No disturbance of  Disturbance of
furniture. furniture.
 Suicide note in his  Anything belonging
own handwriting. to the assailant.
Item Suicidal cut throat Homicidal cut throat
II- Exam. of the victim :
Sex Usually male Male or female
Position Indoors (in front of a Indoors or outdoors
mirror on which blood is
present).
Signs of struggle Absent Present: broken chair, lost
buttons and abrasions or
bruises.
Cadaveric spasm On the knife On hairs or clothes of
assailant.
Site of blood Mainly of anterior parts. Mainly posterior (behind
the neck).
Item Suicidal cut throat Homicidal cut throat

II- Exam. of the victim :

Other injuries Cut wrist + superficial Multiple stabs in chest
cuts in left index and and abdomen.
thumb fingers used to
stretch the skin if he is
right handed.
Item Suicidal cut throat Homicidal cut throat

III- Exam of the wound :

Site High up (above level of Low below thyroid
thyroid cartilage). cartilage as the victim
resists by fixing his neck
down).

Direction Oblique Transverse

Depth Deep at left side and Deep all through and may
tailing superficially to the separate the neck
right side.
Item Suicidal cut throat Homicidal cut throat

III- Exam of the wound :

Character Slanting: cuts the skin at Not slanting (cuts the skin
a higher level than S.C. and muscles at the same
tissues and muscles. level).

Number One May be multiple

Hesitation marks May be present Absent

Item Suicidal cut throat Homicidal cut throat

IV- Exam of the weapon :

Present or absent. Usually present (may be Usually absent (another
grasped by cadaveric one may be left to
spasm) mislead the authorities).

Blood, hairs and finger Blood, hairs and finger Blood and hairs of the
prints on it prints of the victim victim with finger prints
of the assailant.
Item Suicidal cut throat Homicidal cut throat

V- Exam of assailant :
• No assailant. • Signs of struggle
Abrasions and bruises;
N.B. their age = date of the
• Hesitation marks crime.
These are superficial • His clothes: tears or
cuts present at the lost buttons.
beginning of suicidal • His finger prints and
cut wounds. They are blood group must be
done before the victim compared with those
is brave enough to found at scene of
make a deep cut. crime.