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REGIONAL INJURIES1. NECK INJURIESVarious types of injuries occur in the neck:abrasions and contusions, caused by throttling, strangulation and hanging.- stab wounds, almost always homicidal- incised wounds ( cut throat) which are either suicidal or homicidalDifferentiation Between Homicidal and Suicidal Cut ThroatSuicidal cut throatHomicidal cut throat1.Circumstantial evidence .History of emotional troubles or chronic disease.? The body is usually found indoor, may be in front of a mirror.? Furniture not disturbed.? History of quarrel? The body may be found indoor or outdoor.? Furniture usually disturbed.2. Examination of the bodyNo signs of resistance? Other methods of attempts suicide e.g. cut wrist.? The hand of the victim may grasp the knife (cadaveric spasm).? Blood is found in front of the victim's clothes.Signs of resistance ++? No other methods,? The hand of the victim may grasp hair or fibers from the assailant.? Blood is found on the back of the victim's clothes.3. Examination of the wound:- Site- Direction- Depth- Hesitation marks- It is slanting? High up in the neck.? Oblique from left to right in right handed person.? The beginning is deep and the end superficial.? Present at the beginning of the wound.? The skin is cut at a higher level than the deeper tissues.? Lowdown in the neck,? Transverse,? Deep all through.? Absent.? The skin is cut at the same level of the deeper tissues.4. Examination of weapon? As regards finger prints, blood of the deceased only? As regards finger prints, stains, hair, fibers of assailantCauses of death In cut throat1. Reflex vagal inhibition due to fright or due to injury of the carotid sinus.2. Severe hemorrhage (external).3. Asphyxia (blood trickles into the trachea).4. Venous air embolism.2-CHEST INJURIESchest injuries may be penetrating (open) or non penetrating (closed) 1. Penetrating chest injuries = Open:They are caused by stab puncture or firearm injuries. They may involve the internal organs.2. Non penetrating chest injuries = Closed:Closed chest injury is an injury in which the skin and subcutaneous tissues are intact or at least neither the pleura nor the pericardium were opened to the outside. Most closed chest injuries are caused by application of blunt force.A ) injuries of chest wall: In the form of abrasions, bruises.B ) Ribs: These may be fractured by direct (e.g. a blow) or indirect force (e.g. chest compression)Rib direct force indirect force fracture At site of trauma . along mid axillary line at the posterior angle. number Usually single, masked by contusion Multiple, usually bilateral : Fracture ends ? Driven inside, thus liable to injury heart or lung Rent outwards c. Injuries of the lungsIn the form of lacerations and contusions:- Lung lacerations are produced by penetration of the lung tissue by fractured rib ends.- Lung contusions may be due to direct blow (under the site of application of force) or contrecoup injury following sudden compression of the chest (usually over the posterior surfaces of the lungs) leading to violent displacement of air in the lungs.d- Injuries of the heart- Puncture stab wound of the heart may reach the muscles, or penetrates into the cavity, or transfixes the heart. If the injury is in the atria, which is similar to big vessels, death is very rapid contrary to the ventricles where the severe contraction may close the injury and death may be delayed.- The heart may rupture from fracture ribs or in case of rapid increase of intracardiac pressure due to sudden reflux of blood from the abdomen and the limbs in cases of falling from height or severe compression of abdomenComplications and sequelae of chest injuries:I. Flail chest injury:. when more than 3 adjacent ribs are fractured along two places of each rib leading to “mediastinal flutter” or paradoxical movement of the mediastinum where the lung is poorly ventilated.2. Pneumothorax: which may be:- Opened pneumothorax: air enters the pleural cavity through an open wound in the chest wall.?- Closed or tension pneumothorax: air enters the pleural cavity through a wound in the lungs. The air is allowed to go in but not? out thus the pressure is rising all the time pressing on the mcdiastinum.If pneumothorax is suspected during PM, the chest should not be opened except under water.3. Hemothorax i.e hemorrhage into a pleural cavity whi comes from penetrating wound of the lung (small in amount) or of the heart or large blood vessels (large in amount).4. Chylothorax i.e. effusion of chyle from thoracic duct into the right pleural cavity.5. Cardiac tamponade. due to accumulation of blood in the perieardial sac (200-300 cc). It interferes with ventricular dilatation during diastole - progressive failure of circulation.6. Arterial air embolism due to entry of air into the pulmonary veins.3. ABDOMINAL INJURIESThey may be divided into two groupsI. Penetrating opened abdominal injuriesthey are either incised or stab puncture wounds. In a fatty person, these may simulate contused wound. Again if the injury is penetrating the lesion in the SI may not coincide with that in the skin owing to the mobility of the intestines.II- Non penetrating = Closed abdominal injuriesThese are caused by blunt force.I. Injuries of the abdominal wallIn the form of contusions. Contusions r appear away from: the site of trauma after sometime, usually in genitalia if they are deeply seated.2. Injuries of the stomach and intestines may be caused by:a. Force of compressionWhen a force is applied to the anterior abdominal wall it may be transmitted through the muscles compressing the stomach or intestines against the rigid posterior abdominal wall. Compression injuries take the form of contusions or laceration, Transmural contusions may slough leading to perforation.b. Traction forceThe force may push these organs leading to overstretching of their attachments with subsequent tearing of the mesentry—> intra-peritoneal hemorrhage and infarcts of the intestine, Rupture of SI may occur at the junction of the fixed and mobile parts e.g. at the duodeno- jejunal junction.c. Bursting forceA blow over the abdomen may cause a violent displacement of the contents of these hollow organs, with sudden increase in the intraluminal pressure —> bursting of the hollow viscus. Rupture in the intestine is usually in the ileum while that of the stomach is along the lesser curvature.Differences between Traumatic. and Pathological rupture of intestine:Traumatic rupturePathologic ruptureHistory of traumaBruises on the abdominal wall.SI is healthy with glistening mm. and mobile villi.Edges of perforation are everted, tear is irregular & mm. bulging out.The tear is surrounded by bruiseAbsence of enlarged lymph nodes.Occur anywhere according to the acting forcesHistory of disease.No bruises, no evidence .of violence.Diseased lusterless mm. & sticking to submucosa.Edges are flat or inverted & tear is funnel shaped.No bruisesPresence of enlarged lymph nodesSite depends on the causative pathology3. Injuries to the kidneysInjuries of the kidneys are not common, as the kidneys are well protected. Injuries may take the form of contusions or lacerations. Certain diseases e.g. pyelonepbrosis may predispose the kidneys to injury after? mild trauma. The application of blunt force to the Join may result in injury of the renal pedicle, partial tears of the renal artery or its spasm —> renal plications of abdominal injuries:1. Shock: either primary (neurogenic) or secondary (hematogenic)2. Internal hemorrhage: hemorrhage from a laceration of the spleen is usually rapid and copious if compared to hemorrhage from the liver.3. Peritonitis: organisms may reach the peritoneal sac from outside or they may enter the cavity through punctured wounds of the small or large intestines. Peritonitis is more likely to follow ruptures of the large intestine. The leakage of gastric contents into the peritoneal sac may result in chemical peritonitis.4. Paralytic ileus.4. PELVIC INJURIESThe pelvis is frequently damaged in toad traffic accidents and in elderly persons following falls. The most common site of fracture is the pubic ramus, where injury to the bladder or urethra may occur. Fracture pelvis is usually accompanied by extraperitoneal rupture of the bladder when fragments of fractured bone penetrate the bladder wall where the urine may extravasate upwards to the level of the kidneys or downwards along the spermatic cord into the scrotum. When the bladder is distended intraperitoneal rupture occurs with extravasation of urine into the peritoneal cavity.5. INJURIES TO THE LIMBSThey may be due to:1. Direct violence (direct blow): it results in injury of the overlying soft tissues. Bone is fractured at the site of trauma. Fracture is commonly comminuted.2. indirect violence (twisting): usually the bone is broken in a region distant from the site of force. It is usually a simple fracture, and less likely to be comminuted..3. Crushing injuries to the limbs: This results in crush syndrome with renal plications of limb injuries:1. Hemorrhage.2. Fat embolism3. Pulmonary embolism.4. Acute tubular necrosis. Crush injuries lead to release of myohemoglobin which will block the distal tubules leading to their necrosis with cellular infiltration. The patient presents with shock followed by oliguria and anuria (crush syndrome).5. Infection: pyogenic infection, gas gangrene or tetanus.HEAD INJUIES(Cranio-cerebral injuries)Head injuries are one of the commonest forms of emergency admissions from accidents as well as from assault. All degrees and types of injury to the head may occur either to the scalp, skull., brain or to any combination of these structures.CLASSIFICATION OF HEAD INJURIES1. According to circumstantial evidence1. Accidental in road traffic accidents, accidental falls and fall of object on head accidentally.2. Homicidal3. Suicidal: in psychoticsII. According to instrument used:1. Blunt instrument: e.g. contusion, contused wound.2. Sharp instrument: either light (knife) or heavy (blade of axe)3. Firearm weapons.III. According to anatomical structures:Scalp injury, skull injury, injuries to meninges, brain injury or any combination of these.IV. Other classification:1. Impact injury: when a localized object strikes the head —> local effects, that affect the scalp, skull, meninges, brain, alone or in combination.2. Acceleration/Deceleration injury due to sudden movement of the head e.g concussion (diffuse axonal injury), subdural hemorrhage in shaken baby syndrome.A. SCALP INJURIESMost wounds of the scalp are caused by application of blunt force to the head e.g. from falls or blows.The scalp consists of five layers of tissues arranged in .the following order.I. Skin2. Subcutaneous tissue is a dense connective tissue which consists of two layers, a fatty layer and a deep membranous layer that contains the major feeding vessels of the scalp.3. Galea aponeurotica: a freely movable aponeurosis of dense fibrous tissue which is structurally designed to absorb the force of external trauma. It is pierced by numerous emissary veins that connect the veins of the scalp with the intracranial venous circulation. Thus can propagate infection from the scalp to the intracranial structures4. Subaponeurotic space: a layer of loose connective tissue between the galea and the periosteum. It is called the dangerous area of the scalp, it contains emissary and diploic veins.5. Periosteum.All types of wounds are present in the scalp:1. Contused wound: as contused wound, cut laceration. This is the commonest injury; it may be accidental or homicidal. Complete avulsion of the whole scalp may occur, this kind of accident occurs in industry when long hair is caught up in moving machinery.2. Incised wound: caused by sharp instrument e.g. knife, blade of axe.3. Firearm wound: in the form of inlet and exit, or only inlet where the missile b retained inside the ku1I or sometimes the missile strikes the skull at an acute angle, so describes a wide arc in the subcutaneous tissue so as to encircle the skull.4. Contusions or hematomas: are a common injury caused by blunt force and are of three types:a. Subcutaneous hematoma: present in the subcutaneous space. It is small and firm.b. Subgaleal hematoma: is present under the galea aponeurotica, it is large, soft and limited by the attachment of the occipito- frontalis muscle.c. Subperiosteai hematoma = Cephalhematoma of the new born. it is common in the parietal bones and is fixed to the bone.A contused wound of the scalp may simu!ate cut wound because:1, There is profuse bleeding due to rich blood supply of the scalp.2. A contused wound may appear regular and linear in shape (splitted contused wound) because the scalp is stretched on hard bone.But careful examination by hand lens will detect irregularity, bruising and abrasions of the margin with crushed end hair in a contused wound.Medicolegal importance of scalp wounds:1. They bleed freely but heal quickly, with less liability to sepsis.2. If got septic, it may affect the bone in the form of superficial necrosis which is limited by the septic scalp area, traumatic osteomyehitis, traumatic meningitis, traumatic encephalitis, brain abscess or sinus thrombosis.You can differentiate between traumatic meningitis, meningitis due to otitis media and meningococcal meningitis by the history, localization of the pus, characters of the pus and the specific organisms in each.B. SKULL INJURIESIn the form of fractures which either affect the base or vault of the skull or both.FRACTURE BASEBasal fractures are fissured (linear) fractures that may be produced by:a. Forces applied directly to the base through the spinal column (e.g. fall from a height on the buttocks) Or face.b. Extension from fracture vault.Fracture Anterior Cranial Fossa (ACF):It is characterized by one or more of the followings: Bleeding from the nose, CSF rhinorrhea, subeonjunctival hemorrhage, cranial nerve involvement especially the olfactory 3rd, 4th & 6111 cranial nerves (occular paralysis).Fracture Middle Cranial Fossa (MC F): Bleeding from the ear, CSF otorrhea, may be facial. paralysis (71h) deafness (8th). Whenever a basal fracture crosses the pituitary fossa there is a danger of stretching or tearing the pituitary stalk.Fracture Posterior Cranial Fossa (PCF)Patients may be comatosed, there are bruises behind the ear, cranial nerve involvement 9, 10 and 11.Factors affecting the production of skull fractures:1. Force of the blow = Momentum: which depends upon the velocity and the weight of the instrument.2. Size of the striking surface area of the instrument Used:- Small e.g. stone or head of hammer —> depressed localized fracture.- Large e.g. stick or iron bar —> depressed comminuted fracture.3. Position of the head at the time of the blow: whether the head is supported or not. When the head is supported the damage is more because when a force is applied to the unsupported head, part of the force is absorbed in accelerating the head. When the head is supported a polar fracture (fissured fracture) occurs between the supporting point and the striking point.4. Site of the blow: the eminences resist more than in between, also thick bones resist more.5. Covering of the head: including the hair will affect the severity of injury.If these factors were applied soMomentum . Size of striking surface area Result . -High Very small (bullet) Clean hole -Less Small (head of hammer) - Depressed loealised fracture -Less Wide (fall from a height) Fissured fractured Big Wide Depressed comminuted fracture FISSURED FRACTURE OR LINEAR FRACTURE ????? ??????1. Instrument: heavy blunt instrument with wide striking surface area and less momentum.2. Might Occur alone or accompanied with other fractures.3. May be single or multiple. If multiple a complete one results from thefirst blow. :4. Site: usually starts at the site of application of force and runs parallel to its direction. Its extent is governed by weakness of bone e.g. suture or thin plates of bone. Exception of fissured fracture which does not start at the site of application of force:a. Polar fracture occurs when the head is supported.b. Ring fracture at two sitesi. Base of the skull around the foramen magnum, when a person falls from a height on his buttocks.ii. Around the head of the mandible if the force is applied to the chin (in boxers).5. The beginning of fissured fracture is more wider than its end, this indicates the position of the assailant.6. The common site of fissured fracture is the base of the skull.7. Traumatic separation of suture (traumatic diastasis of a suture): common to occur in the coronal and lambdoid sutures.8; Fissured fracture is usually accompanied by signs of brain concussion or compression due to extradural hemorrhage.9. Healing of fissured fracture: complete union of fissured fracture occurs from 3-6 months.DEPRESSED FRACTURE ????? ??????? A fracture is called depressed if the inner table of the skull was depressed by more than the normal thickness of the skull (2-6 mm).Mechanism of depressed fracture:At the site of impact the bone is indented (depressed) in the form of a shallow cone. At the apex of the cone, the inner table is stretched and fractured first while the outer table is compressed. As the force continues to act the outer table is fractured. Occasionally fractures restricted to the inner table, unless revealed by radiography, passes unrecognized at the time of injury, although later they may give rise to traumatic epilepsy if a spicule of bone has happened to pierde the dura. At the periphery of the indentation the reverse will occur where the outer table is stretched and fractured first followed by fracture of the inner table Depressed localized fracture = fracture a Ia signature:It is a medicolegal term as it takes the shape of the. causal instrument. It is caused by heavy blunt instrument with small striking surface area with less momentum. eg. the head of a hammer.Depressed localized fracture is of three types:a) Depressed localized where the bones are depressed and intact.b) Depressed localized with partial comminution,c) Depressed localized with comminution: . . ..The position of the assailant can be known from the site of fracture, the most epressed part and from the fissured fracture if present..Healing of depressed localized fractureThe bones of the vertex develops in the embryo from membrane , not from cartilage thus a bone defect in the vault never fills with bone but heals with fibrous membrane leaving permanent infirmity. There is complete smoothness or eburn of the edges in 3 months and filling of the gap by fibrous membrane in 6l 2 months.Depressed comminuted fracture:It is caused by heavy blunt instrument with wide striking surface area and big momentum e.g. stick, iron bar.Gutter fracture is a depressed comminuted fracture but has the shape of a gutter.. . .CUT FRACTURE . . . . .It is caused by heavy sharp cutting instrument e.g. the blade of a fass (grubber) or axe. It may be caused by a light sharp cutting instrument e.g. knife.CHIPPED FRACTUREIt is caused by the blade. of a heavy sharp cutting instrument passing tangentially at special sites e.g. the eminences and the mastoid processPOND FRACTURE .it is a depressed fracture, occurs in. infants where the bones are thin and elastic. It results from a blow, by a blunt object, or caused ‘by the blade of obstetric forceps. The inner table does not fracture and spontaneous elevation usually occurs.SEPSIS OF THE CRANIAL BONESIt usually begins from 4-6 week up to 3 months in the form of discoloration, erosion, and roughness of the bone which involves either the outer or inner tables or both, if it continues sequestration of the bone occurs.SURGICAL INTERFERENCE IN FRACTURES1. Burr-bole: previously called trephine done for exploration, on top of fissured fracture or for decompression in depressed fracture or hemorrhage.2. Nibbling: done by the use of bone nibbling forceps, giving the bone serrated edges. It is used to clean the edges of a fracture so as to make them regular, to widen any gap either of a trephine or of a depressed fracture.INJURIES TO THE MENINGES:In the form of tear or hemorrhage. Types of meningeal hemorrhages depend on the site:I. Extradural or epidural hemorrhage: if hemorrhage is present between the inner table of the skull and the dun mater.2. Subdural hemorrhage: if hemorrhage is present between the dura and arachnoid mater i.e. in the subdural space.3. Subarachnoid hemorrhage: if hemorrhage is present between the arachnoid and pia mater i.e. in the subarachnoid space.1. Extradural (Epidural) hemorrhageIt means accumulation of blood between the inner surface of the skulls and the outer surface of the dura. It is always traumatic. Fracture of the skull is not essential.Causes:a. Rupture of the main middle meningeal . vessels or their anterior or posterior branches which is the most common cause.b. Rupture of the Venous sinuses (rare). . . .c. Rupture of diploic veins (bleeding is limited).Site:The common site is the parieto-temporal region and may be in the anterior or posterior fossae. .Symptoms of epidural hemorrhage usually occur 4 — 8 hours after injury, hut it may occur rapidly within half an hour or delayed 24—48 hours.2. Subdural hemorrhage: either traumatic or pathologicala Traumatic subdural hemorrhage:Causes:i. Rupture of the bridging veins: is the most common cause. They are small unsupported thin walled vessels which traverse the subarachnoid and subdural spaces and drain the cortical veins into the venous sinuses. Tear of dural sinuses or cortical veins (less common).Traumatic subdural hemorrhage may be:Acute: within 3 days where loss of consciousness starts early.(ii) Subacute: from 3 days- 3 weeks.(iii) Chronic: from 3 weeks - where signs and symptoms of brain compression start several weeks after head injury, which. is of medicolegal significance.N.B. Chronic subdural hemorrhage may occur in child abuse (Shaken baby syndrome ) in association with subarachnoid hemorrhage and retinal hemorrhage.b. Pathological subdural hemorrhage Pacchy-meningitis hemorrhagicaHere minor trauma is the exiting or precipitating factor. It occurs in elderly persons with hypertension and cerebral arteriosclerosis, in chronic alcoholics, in chronic arsenical poisoning, general paralysis of insane and blood diseases.3. Subarachnoid hemorrhage: eithera. Traumatic: is rare due to rupture of the bridging veins. Often occurs with other intracranial hemorrhages, brain injuries and skull fracture. Also following hyperextension of the neck as in whiplash injury leading to injury of vertebral or basilar artery.b. Pathological: is the most common, is due toi. Rupture of aneurysm in the subarachnoid space (either congenital or acquired).ii, Spread of pathological intracerebral hemorrhage.Intracerebral hemorrhage: it may be:Traumatic: occurs either under, a depressed fracture (coup lesion) or on the opposite side (contercoup lesion). In both, the hemorrhage begins at the surface and passes deeply.b. Pathological: more common in elderly persons due to hypertension and cerebral atherosclerosis. The common site is the internal capsule, less common in the pons ie. pontine hemorrhage( pin point pupil hyperpyrexia and quadriplegia) and cerebellum.BRAIN INJURIESThey may occur with or without skull fractures. It may be:1. Primary brain injuries occur at the time of injury and are either generalized (concussion) or localized (brain contusions or lacerations).2. Secondary brain injuries occur as a complication of the injury e.g. extradural, subdural, subarachnoid hemorrhages, brain swelling (brain edema), infection, respiratory failure and hypoxia.BRAIN CONCUSSIONA state of sudden transient loss of consciousness Eollowing trauma to the head. it is due to momentary arrest of the function of the brain.Theories of brain concussion:a. Disturbance in the reticular activating system (alerting syAtem) in the brain stem and cerebral cortex.b. Recently concussiert is a degree of Diffuse Axonal Injury (DAJ). in which most of the nerve fibers escape permanent structural damage. This is consistent with the persistence of some damage after minor head-injury.Concussion is easily produced if the head is free to move due to rotational brain injury with rotational shear strains and is rarely produced when the head is fixed.Clinical picture of brain concussion:1. Transient loss of consciousness which ranges from few seconds to few minutes.2, Disturbance of vital signsa. Temperature may be normal or subnormal.b. Pulse weak and rapid.c. Respiration shallow and rapid.d. Blood pressure is low due to transient paralysis of the vasomotor centre.3. Face is pale, skin moist and covered with clammy sweat.4. Pupils are equal.5. Vomiting may occur once or twice (central vomiting).6. Loss of reflexes with general muscular flaccidity Loss of sphincteric reflexes leads to incontinence.7. No signs of lateralization. . .Fate of brain concussion:1. Complete recovery: This is the rule in the majority of patients.2. Death: rarely occurs in severe cases. It is due to prolonged arrest of the function of respiration and circulation. Postmortem picture reveals generalized congestion of the brain with minute petechial hemorrhages scattered throughout its substance.3. Incomplete recovery: the concussed patient regains consciousness but develops a state of post concussion syndrome (PC) within few days or weeks after head trauma. The patient complains of headache, dizziness, irritability, and difficulty in concentration. These symptoms usually disappear when the person takes compensation eog. in industrial accidents or in cases of assault (compensation ncurosis).4, Concussion passing into compression:a. Without lucid interval i.e. concussion passing directly into compression. This occurs in case of depressed bone or in case. of rapid and extensive extradural hemorrhage. .b With lucid interval here the patient recovers from the. coma of concussion and has a lucid interval during which he may be able to walk and to speak. During this interval the blood pressure rises, gradually to reach its normal level (in concussion it is low). Thus any torn vessel in the extradural space will start to bleed. This . leads to gradual unconsciousness due to brain compression by the hemorrhage.Lucid interval:it is the period of recovery of consciousness between the coma of brain concussion and coma of brain compression -due to intra-cranial hemorrhage (especially extradural hemorrhage), during which the patient may be able to walk and to speak. It varies from few minutes to several days.Medicolegal importance of lucid interval:1. The patient may mention the name of the assailant.2. The defence may say that the blow was not the cause of death, so long as the patient recovered after injury.3. The responsibility of the doctor who discharges the patient thinking that he is recovered. So any patient with history of concussion after head trauma must be put under observation in the hospital for at least 24-48 hours, because he might be in the lucid interval and he may enter into a state of cerebral compression. During his hospital stay the state of consciousness, vital signs (temperature, blood pressure, pulse, and respiration) should be recorded every 15 minutes as well as reaction of the pupils and the motor power. X-ray of the skull and brain computed tomography (CT) may be indicated.BRAIN COMPRESSIONDefinition:A state of gradual increase in the intracranial tension, leading to the loss of consciousness.Causes: 1. Depressed cranial bone: .the patient passes directly from concussion to compression without lucid interval . . .2. Intracranial hemorrhage especially extradural hemorrhage: usually there is lucid interval.Mechanism and clinical picture of brain compression:in compression by extradural hemorrhage, the blood is collected in the extradural space leading to displacement of the CSF —> continued rise in the intracranial pressure, this leads to progressive interference with the blood supply of the brain. The vessels suffered first are the thin walled cerebral veins leading to cerebral congestion. This stage is called the stage of cerebral irritation and is characterized by:1. Deterioration in the level of consciousness.2. Pulse slow, full bounding.3. Blood pressure is high.4. Respiration is slow deep (sturtorous).5. Signs of increased intracranial tens ion (headache, vomiting, may be papilledema).6. Signs of lateralization.Affected side Contralateral side a. Pupils . Contracted (irritation stage) Dilated (paralysis) Dilated Normal Contracted (irritation) Dilated b, Reflexes Normal exaggerated c. Conjugate deviation of eyes to the affected side. With persistent increase in the intracranial pressure, the thick walledcerebral arteries are compressed leading to the stage of cerebral paralysiswhich is characterized by:1. Loss of consciousness (coma).2. Pulse slows down, may reach 60/minute.3. Blood pressure is still high.4. Respiration is cheyne-stock.5. Pupils are dilated.6. Absent reflexes.A decompression operation is indicated when the pulse slow down to 60/minutes, the side of lesion is localized by the condition of the pupils, reflexes and not by the wound in the scalp.Later death may occur from progressive respiratory failure due to forcing of the cerebellar lobes and tonsils of cerebellum through the foramen magnum thus compressing the medulla oblongata.BRAIN CONTUSIONA circumscribed area of brain tissue destruction ac byextravasation of blood.Description .- It is wedge shape with the base toward the surface.- Usually surrounded by numerous petechial.- Pia mater is intact. .Site- Under the site of trauma (coup lesion).- On the opposite side (contre-coup lesion)..Brain contusions are usually surrounded by brain edema, healing of these contusions may result in scar formation —> epileptic seizures.BRAIN LACERATIONSThese are areas of brain, tissue destruction leading to loss ofcontinuity of the brain surface.Description- Are larger than Contusions.- Surrounded by contusions.- The pia mater is ruptured.CausesUnder the site of a blow i.e. coup lesion from depressed bone fragments.- Contrecoup lesion where brain, lacerations present on the opposite side of the blow.Firearm injuries.Healing of lacerations usually leads to adhesions between the brain and overlying dura mater —> post traumatic epilepsy.MECHANISM OF CONTRECOUP LESIONS1. Direct impaction’ of the cortex, of the brain against the bony prominences and rigid dural septa. So common to occur in the under surface of the temporal lobes and orbital surface of the frontal lobes. Hence brain lacerations and contusions are common at the fronto temporal regions.2. Shear strains i.e. sliding of the superficial layers ‘of the brain over the deeper layers —+ stretching and tearing of blood vessels and nerve fibers. This usually occurs in rotational movements of the head.3. Contrecoup by suction occurs in linear movement of the head (e.g. from side to side movement). Where at the pole opposite to the, site of impact the skull is moving and the brain is still lagging. Before this space between the skull and brain is filled by CSF, a zone of diminished pressure results which allows rupture of superficial and even deep vessels.ASSESSMENT OF THE SEVERITY OF HEAD INJURYAssessment of the severity of head injury is by the following:1. State of consciousness using Glasgow Coma Scale2. Duration of coma3. Post-traumatic amnesia:These are of utmost importance as regards the clinicaL management, the prognosis, as well as legal assessment for compensation.The Glasgow Coma Scale (GCS) is based on eye opening (4 scores), verbal response (5 scores) and motor response (6 scores). According to this scale, coma can. be defined as absence of eye opening; absence of motor response and absence of verbal response (i.e. score 3). So the worst score is 3 and the best score is 15.GLASGOW COMA SCALE Mild head injury: GCS 15 — 13 Moderate head injury GCS 12 —9 Severe head injury: GCS 8 - 3 ??Patient response Score I. Eye opening: - Open eyes on own - Open eyes when asked - Open eyes to pain - Not open eyes 4 3 2 I II. Motor response: . : . - Obey commands - Push examiner’s hand away when pinched - Pulls a part of body away when pinched -. Flexion response to pain - Extension in response to pain - No motor response to pain 6 5 . 4 3 2 1 HI. Verbal response . . - Oriented - Disoriented (confused) - Inappropriate words - Incomprehensible sounds -None 5 4 3 2 1 Coma score ? ? = E+M+V = 3 15 (worst score) .... (Best score) . . COMPLICATIONS AND SEQUELAE OF HEAD INJURIES1. Retrograde amnesia where the patient looses memory for the actual occurrence and for sometime before the accident.2, Post traumatic automatism the patient may do voluntary acts after the ?? accident but he forgets everything about what he did.3. Traumatic delirium the patient is often violent with anxiety and fear with hallucinations and confusion. Then he may pass to Korsakoffpsychosis. In this stage false accusation may be made in connection with the accident. So these patients should not be interrogated by thepolice.4. Post traumatic neuroses in the form of anxiety, depression, hysteria. Usually occurs with minor head injuries because of the question of compensation.5. Post traumatic psychoses are rare in the form of schizophrenia or mania.6. Post traumatic personality disorders especially in children e.g. hyperactivity, delinquency, nocturnal enuresis.7. Post concussion syndrome8. Focal brain injury, which differs according to the site of brain injury e.g. hemiplegia, aphasia, epileptic attack.9. Cranial nerve injuries e.g. loss of smell (olfactory) loss of vision, facial paralysis, deafness. . .10. infection: Traumatic osteomyelitis, traumatic meningitis, encephalitis, brain abscess and sinus thrombosis11. Fistula: CSF otorrhea, CSF rhinorrhea.12. Defect in the skull which is a permanent infirmity the compensation depends upon the size of the bone defect. ................
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