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Wounds

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by

Reham Sedie

on 22 November 2016

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Transcript of Wounds

Wounds
Stab wounds
factors affecting the severity/extent/appearance of the wound :
Classification of wounds
Outlines ..
Artifacts ..
Scrape abrasion


age,

sex,

the condition and health of the victim,

the site and type of tissues struck.

Dating of Bruises
The method most commonly employed in dating contusions is based on the changes in color a contusion undergoes as it heals.
As a bruise ages, it undergoes an evolution in its color due to the degradation of the

hemoglobin
.
As the hemoglobin in the bruise is broken down, the color gradually changes to

violet
,
green,

dark yellow
,
and

pale yellow

before disappearing.
These changes can occur over a matter of days to weeks.
Laceration
Incised wounds

Incised wounds or cuts or slashes are
clean cut
wounds produced by sharp-edged weapons or instruments.

The sharp edge of the instrument is pressed into and drawn along the surface of the skin, producing a wound
whose length is greater than its depth.

A
knife
is the classical example of a weapon used to inflict an incised wound, though, in fact, any instrument with a sharp edge can do so e.g., a piece of glass, sword, razor, scalpel, etc.





The edges of an incised wound tend to
separate or gap
.
The extent to which the wound gaps and the shape it subsequently assumes depend on whether it is parallel, transverse, or oblique to the direction of the elastic fibers in the skin
(Langer’s lines)
In rare instances, a fatal self-inflicted incised wound of the neck may be accompanied by
cadaveric spasm
with the knife or razor found firmly clenched in the victim’s hand.




Stab wounds are produced from penetration with long narrow instruments having
pointed
ends.

A stab wound is an incised wound that is
deeper than its wide.

Extremely common in homicide.




Reham Sedie
Blunt forece wounds :
Abrasions
- 'grazes or scratches'.
Contusions
- 'bruises'.
Lacerations

- ‘ tears'.

Sharp force wound :
Incised wounds

- 'cuts', 'slashes'.
stab wounds
-

Chop wounds




Impact abrasion
Patterned abrasion

Is a variation of an impact abrasion, Where The
pattern of the object
, or intermediary material,such as
clothing
, is imprinted or stamped on the skin underlying the point of the impact



Bruises
A
(Contusion)
Or

bruise
is an infiltration of extravasated blood into soft tissue due to rupture of small blood vessels caused by blunt trauma.

Contusions may be present not only in skin, but also in internal organs.

A large focal collection of blood in an area of contusion is referred to as a
hematoma
.

A contusion can be differentiated from an area of livor mortis (hypostasis) in that,
...

Eye and Eyelids

Surgical removal of corneas
or the globes of the eyes shortly after death can result in hemorrhage into the eyes indistinguishable from antemortem traumas .

Removal of vitreous
shortly after death can result in scleral hemorrhage at the puncture site .



Is a tear or split of the tissue pruduced by blunt force injury such that tissue is sheared,crushed or avulsed.

They are caused by blows from
blunt objects
,
falls
, or
impact from vehicles
, most commonly over bony prominences, such as in the head, where the skin is fixed and can more easily be stretched and torn.

Lacerations of the skin tend to be
irregular
with
abraded contused margins
, they may extend deep and bleed profusely.

one can have lacerations of internal organs as well as the skin.















































Definition :











An injury produced by a blunt object
striking the body or impact of the body against blunt object or surface
.



Blunt trauma wounds

The
bruising and crushing of the margins
.

The persistence of tissue strands across the interior of the wound
(bridging)
, including fascial bands, vessels and nerves, in a wound from a sharp weapon these are divided.

The
absence of a sharply linear injury in the underlying bone
, especially if it is the skull. A knife or axe is likely to chip or score the base of the wound

If the area is covered with hair, as on the scalp,
intact
hairs will survive to cross the wound
; an incised injury would divide them.

A laceration can be distinguished
from an incised wound by:


The term refers to the tearing away of tissues from their attachment, Tires passing over an extremity may avulse soft tissue off the bone, Internally, organs can be avulsed or torn off in parts.




In most of the cases of blunt trauma , lacerations , abrasions and bruises will occur in combination with each other.

Combination injuries
Incised wounds of the neck
The wound inflicted from behind is
first shallow
, then
deeper
and then
shallow again
.
The wound generally
starts below the ear
; runs
downward and medially
at an angle, then
straight across the midline
of the neck, and then
upward
, ending on the opposite side of the neck,
lower than
its point of initiation.

Wounds caused by

sharp-edged and pointed
weapons
can be divided into categories:

Incised wounds (cuts or slashes)
Stab wounds
Chop wounds
Therapeutic/diagnostic wounds

Knives
are the weapons most frequently involved and their physical characteristics are important in shaping the wound …

The length, width and thickness of the blade
Whether it is single or double-edged
The face of the hilt guard adjacent to the blade
Any grooving, serration or forking of the blade
Most importantly, the sharpness of the edge and especially of the
extreme tip
of the blade.

Classification :



THE CHARACTERISTICS OF A STAB WOUND
Length and Breadth

An important factor must always be taken into account, when the knife is withdrawn
the elasticity of the skin causes it to retract
, and the
contraction of the underlying muscles.
So, the wound length appears
smaller
than when the blade was in situ.

the breadth is more the thickness of the blade due to
gapping
, so approximation of the edges is needed.


Movement of the knife in the wound


If, however, the knife is
'rocked'
in the wound, the skin defect will be enlarged.

This rocking can occur either by the knife being actively moved in the wound by the assailant - or by the body moving relative to the knife -or by a combination of the two.



The
depth of a stab wound
is the greatest dimension, but its not usually a guide to the lenght of the blade ..

there are pitfalls to be avoided..

the measurement probe may easily pass between fascial planes or within the muscle producing a false track; or more damage.

The
caving-in of the body surface
& the
differences in the position
of internal organs as measured at autopsy in a supine body, compared with their position in the living body in the upright posture.

In the chest and abdomen, visceral relationships vary with the stage of respiration.


Apart from bone or calcified cartilage, the tissue most
resistant to knife penetration is the
skin
,

followed by muscle where large muscle bundles underlay the fascia.

The
sharpness of the extreme tip of the knife
is the most important factor in skin penetration. The cutting edge of the knife, once the tip has penetrated, is of relatively minor importance.

Stretched skin
is easier to penetrate than lax skin e.g: chest wall

Uncalcified cartilage, especially that in the costal cartilages of young and middle-aged persons, is easily penetrated by a sharp knife, Calcified rib and bone provide a much more resistant barrier, but a forceful stab from a strong, sharp knife can penetrate rib, sternum or skull.



Stabbing by a pair of scissors is not uncommon (familiar, near to hand).

The appearances of the wound will differ according to whether the scissors were used open or closed.

If open and one blade is stabbed into the victim, then the appearances will be virtually indistinguishable from a knife wound.

The skin wound made by closed scissors is typically shaped like a flat ‘Z'.

Sometimes, there are small lateral splits in the wound centre from a projecting hinge screw.


Chop wounds are produced by
heavy instruments with a cutting edge
, e.g., axes, meat cleavers.

The presence of an incised wound of the skin, with an underlying
comminuted fracture or deep groove in the bone
, indicates that one is dealing with a chopping weapon .

Usually the lower end (heel) of the axe strikes the surface first, produces a deeper wound than the upper (toe) end.

so, deeper end indicates the position of the assailant.



These are wounds produced by medical personnel during the treatment of a patient.
Common examples are thoracotomy incisions, laparotomy incisions.

Some of these surgical wounds may be mistaken for primary traumatic injury.

Occasionally, a homicidal stab wound is converted to a therapeutic use, e.g., a surgical drain might be placed into the chest cavity through a stab wound of the chest.

To avoid misinterpretation of therapeutic wounds, the
medical records and files should be reviewed
prior to autopsy and, if any questions arise, the treating physicians should be consulted.

In assaults of any kind, the natural reaction of the victims is to protect themselves.

The limbs used for protection can be injured and these defence wounds may be of considerable medico-legal significance,
as they indicate that the victim was conscious
, at least partly mobile and not taken completely by surprise.

The classic position for them is on the
forearms
and
hands
.
Other defence injuries may be inflicted on the
thighs
, when attempts are made to shield the genitals.


The victims can do far more than might be expected after injury Bcuz of the adrenaline response of
'fight or flight'.


A cut artery will lose blood faster than a vein of the same general size.


Wound in right ventricle more fatal than in left ventricle.


Other factors, such as the possibility of
air embolism
occurring in a cut jugular vein, might alter the usual pattern of expected events.


TnQ
Sources ..
Spitz and Fisher's Medicolegal Investigation of Death
Knight’s forensic pathology
DiMaio forensic pathology , text and handbook
Dolinak's Forensic Pathology: Principles and Practice
forensic pathology of trauma
Simpson’s forensic medicine
Color Atlas of Autopsy
Color atlas of forensic pathology
emedicne


A wound can best be defined as
'damage to any part of the body due the application of mechanical force'.




In medico-legal practice, wound will include any lesion, external or internal, caused by violence ,
with or without breach of continuity.
Types of
abrasion :
"Brush burn"
, is a term commonly used to describe a scraping injury over a large area of the body (back), such injury when dry it will be very firm .
seen in pedestrians who slide across the pavement after being hit by motor vehicle.
The blunt object scrapes off the superficial layers of the skin, leaving a
denuded surface
.

these abrasions may be fairly deep, extending down to the dermis. there may be leakage of fluids with deposit of a serosanguineous fluid on the surface of the abrasion, This dries, forming the familiar
reddish
brown scab.



..( crushing / pressure) abrasions

The blunt force is directed perpendicular (vertical) to the skin, crushing it.

Seen overlying bony prominences where a thin layer of skin covers bone.
Impact abrasions over the supraorbital ridge and zygomatic arch are commonly seen when the individuals collapse, and strike their heads on the ground.

A contusion at a site does
not
necessarily indicate the point of trauma, since soft tissue bleeding will follow the path of
least resistance
.




In other instances, deep bruises may not become visible externally until hours after death.
" delayed Bruises"



Absence
of a bruise, does not indicate that there was
no blunt force
to that area, This is especially true of the anterior abdominal wall, where there may be massive internal injury in the absence of external evidence of trauma.
Bruises can also be difficult to detect in dark-skinned individuals.
Children and the elderly bruise more easily because of
loose delicate skin and loss of subcutaneous supportive tissue.
Diseases and Drugs :
Alcoholics with cirrhosis, individuals with bleeding diatheses, and individuals taking aspirin bleed more easily.
Not uncommonly, the color change goes directly from violet to yellow with no green coloration.


Unfortunately, the rate of change is quite variable, not only between persons, but in the same person and from bruise to bruise.
Postmortem Bruising
Contusions can be produced postmortem if a severe blow is delivered to a body within a few hours of death.

Identical in appearance to an antemortem contusion.

This is partially caused by continued bleeding from the ruptured vs.

Another factor may be
haemolysis
, when the free hemoglobin is able to stain the tissue in more diffuse way and become more noticeable than intact red blood cells.
This is the reason not only for the well known post-mortem phenomenon of bruises becoming more prominent after death , but of new bruises appearing later.

Since different components of soft tissue have different strengths, there is usually incomplete separation of the stronger elements, such as blood vessels and nerves, so that when one looks into the depth of the laceration, one sees
“bridges”
of tissue running from side to side.

The presence of bridging proves decisively that one is not dealing with an incised wound.


The depths of the laceration should be explored for the presence of foreign material that could have been deposited there by the weapon or surface that caused the laceration.

An avulsion or avulsive injury is a form of laceration;
The essential feature of all incised wounds is
the clean division of the skin and underlying tissues
so that the margins are almost free from any damage ..




No bridging
in the depth of the wound will occur.
Suicidal incised wounds
are generally inflicted on those parts of the body most
accessible
to the victim.
The victim may
expose
the portion of the body to be incised.
Fatal incised wounds of the arm (wrists, antecubital fossa ..)
almost suicidal
unless the scene indicate an accidental manner.
Right handed individual tend to cut his left wrist or arm and vice versa, cuts can be on both sides.
In self-inflicted incised wounds, one will often find
hesitation marks
, these are superficial incised wounds adjacent to, a continuation of, or overlying the fatal incised wound.
Accidental cut throats are extremely rare.

flying sharp objects ex; glass
household accident
The nature of the stabbing weapons
Shape

Blunt end of the wound may have small
splits in the skin
, forming the so-called
'fish-tail' appearance
.

Chop wounds
Determination of Whether a Wound is Ante- or Postmortem ..!?


The presence of bleeding into the tissue !!
Microscopic examination of the injury in search of an inflammatory reaction. !!


Techniques to identify antemortem injuries involving use of histochemistry, enzymology and biochemistry have been developed.










In addition to enzymes, other markers such as vasoactive amines and catecholamines have also been used.

Thus, histamine and serotonin are both increased in antemortem.

Dating of Abrasion
Features


Bright red , oozing of serum and some blood.

Exudation dries to form a reddish scab Composing of blood, lymph, and epithelial cells, polymorphonuclear cells (scab formation)

Reddish-brown scab
Scab is dark brown
Scab is brownish black and starts falling , epith. grows from the margins ( epith. regeneration)

Scab dries, fall off , the area under getting pigmented ( subepidermal granulation)

Epith. become thinner and atrophic, new collagen, less vascularity ( regression).
Duration


fresh



2-24 H



2-3 days
4-5 days
5-7 days



7-12 days


>12 days
wrinkled wounds are
produced where the
skin is wrinkled (folds)
and
more than one
incised wounds may seen.
esp. in obese & elderly
The pattern of arrangement of the dense network of intimately intermingled
dermal collagen and elastic fibres
is called the

cleavage direction
or
lines of cleavage

of the skin and their linear representation on the skin are called
Langer's lines
.
Depth and Direction :


incised wound usually
deeper
at the commencement,
this known as
head of the wound;
towards termenation, the cut become
shallow
, known as
tailing of the wound
.

this may help suggesting the direction in which the force was applied.
Other knife-like weapons include scissors, dagger, piece of glass, screwdrivers, pens, icepicks and fork.
Penetrating wound;
weapon enters into the body cavity produce only one wound (wound of entry).

Perforating wound;
weapon after entering into body will come out through the other side, producing two wounds (entry and exit).

edges of the wounds are
regular-clean-cut
usually no abrasions or bruising of the margins..

but in full penetration of the blade, a
patterned abrasion or bruising produced by the hilt-guard striking the skin.

However, injuries caused by pointed instruments have lacerated edges.
Margins
Direction of a stab wound

Active type
passive type
is an injury to the skin in which there is removal of the
superficial layer of the skin
by friction or sliding motion against a rough surface, or by compression.

Antemortem abrasions appear
reddish
-brown
and heal
without scarring.

Abrasions produced after death are
yellow
and translucent with a
parchment-like appearance.
Abrasion
Postmortem insect bites and diaper rash are occasionally misinterpreted as abrasions.
Another artifact that can be confused with an abrasion is
drying of the skin of the scrotum
and, less commonly, of the
vulva
, The skin in these areas seems to be very susceptible to drying, especially if exposed to the open air..
So; why abrasion bleeds/scars
sometimes ?
Heaped up tags and direction !?
stomping injury
"Blunt force injuries are possibly the most common injuries documented and interpreted by forensic pathologist"
artifact !
The duration of the healing process depends on :


- preexisting medical state
- location& extension of the injury
- presence of 2ry infection
- repeated trauma to the same area
"subconjunctival hmg"
Black eyes " Raccoon eyes"
Patterned Bruising ..



2 parallel lines occurred by a
rod shaped weapon or stick
.
The tissue on each side of the impact get stretched, resulting in rupture of vessels and displacement of blood to the sides with pressure exerted by stick.


Finger pad bruises
are round or oval,
Due to gripping by fingertips in forceful restraint
Found on -
limbs and face
(child abuse),
thighs
(rape),
neck
(throttling (manual strangulation)),
arms
(forceful restraint or post mortem movement of the body).


Due to impact with a hard, patterned object with ridges/grooves.
The resulting accumulation of a small amount of blood, near the epidermis may demonstrate
the obvious pattern of the causal surface

(tyre, shoe tread, car bumper, clothing, gun muzzle)

Kicking (or shod foot assault)

Stomping, jumping may reproduce the pattern of the sole
Glancing kick may cause a scuffed abrasion

Typical target sites:
face, neck, loin, groin, back, chest
. Associated internal injury and fractures is often severe.
Battle sign :
represents ecchymosis around the mastoid process from head trauma that has caused a temporal bone fracture.
Deep bruises may not be visible externally and may be discovered only on
incising
the soft tissue.
migratory bruises


causes :
fist blow to orbit
fractured skull (R.T.A., gunshot, fall)
tracking from forehead bruise.
or flying injury ;
or grinding compression.

Teeth marks may be abrasions, bruises or lacerations, or a combination.

Animal bite

is deeply arched or 'U-shaped'.

Human bite
is near circular or shallow oval ;
Size -indicates whether inflicted by an adult or child

Human bite may present as a series of separate bruises with central linear abrasions or a continuous, curved line of bruising. The mark may represent only part of the dental arcade

Allows comparison with suspect, Early expert dental opinion and photographs required;
When fresh, may provide useful evidence of asssailant's identity

Seen on breasts, neck, thighs, abdomen and vulva in
sexual assault;
Any site in child abuse.

Self-inflicted (fabricated assault, psychiatric). Accessible!
BITE MARKS
Incised looking lacerations !!
No pattern can be distinguish from lacerated wounds ..
hammer , pistol whipping ?!!

a flexible strap will wrap around the convexity producing a longer and often curved tramline bruise.
"six penny"
undermining edge
beveled/abraded edge
bridging
linear abrasion known as the scratch
(fingernail abrasion)
.


gravel rash
or road rash


Other damage may caused following autopsy, even the normal procedure of post-autopsy reconstruction and handling in the mortuary may cause dermal damage.
till 3 days
brownish due to hemosidein
4-5 days
green due to
biliverdin
5-7 days
7-12 days
2 weeks
Patterned injuries (abrasions and intradermal bruising) following pedestrian impact by the radiator grill of a vehicle.
PATTERNED BRUISE – INTRADERMAL BRUISING CAUSED BY STAMPING ON BACK WITH TEXTURED CLOTHING INTERVENING.
; unilateral
"monocle hematoma"
; bilateral
"spectacle hematoma"
Women
seem to bruise more
easily
, While well-conditioned muscular individuals are more resistant to bruising.
Soft, lax, vascular tissue, such as in the
eyelid
,
genitalia
are more susceptible to bruising than areas such as the palms and soles,
where dense Fibrous tissue prevent easy accumulation of blood.
can we see patterned in laceration ?!
A variation of an avulsive laceration is one produced by shearing forces,
where the skin shows no signs of injury but the underlying soft tissue has been avulsed from the underlying fascia or connective tissue, creating

a pocket that may be filled with a large quantity of blood.

This injury is occasionally encountered on the backs of the thighs of pedestrians struck by motor vehicles.
fabricated wounds
Self-inflicted/ self suffered wounds are those inflicted by a person on his own body or by another With his consent.

Fabricated wounds are mostly
incised wounds
, and sometimes contusions, stab wounds and burns.
Incised wounds are usually superficial, multiple and parallel.


Location is easily reachable, the clothes are not cut and if cuts are seen they are not compatible with the nature of the wounds. The history of the assault is incompatible with the injuries.
Fabricated wounds (fictitious, forged or invented wounds)
Sharp force wounds
parallel wound !?
transverse or oblique wounds ?!
what will happen with ?
Points of differentiation between suicidal & homicidal
cut-throat wounds
direction
hesitation cuts
severity
other wounds
defense wounds
weapon at site
clothes
circumstantial ev.
It is not safe to find out the depth of a stab wound by introducing a probe, because it may disturb a loose clot and may lead to fatal hemorrhage, or cause serious damage and may produce multiple false tracks.
its indicated by the track of the wound but evidence of undercutting - if present- will give an idea about the direction.
Therapeutic or Diagnostic Wounds

Incised wounds of the neck mostly
homicidal,
can be

suicidal
or
accidental


Homicidal incised wounds of the neck present two different pictures, depending on whether they are
produced from the back or the front;

Most commonly, a person’s throat is cut from

behind.



The wound occur when the intensity of the applied force
exceeds
the capability of the tissues to
adapt
or
resist
.
it can caused by several mechanisms ;
compression,
traction
friction and shear stresses ..
Subject's related
Object's related
Nature of weapon;
surface making contact

Amount of force

Time over which the force
is delivered


Amount of body surface

Anatomical region

Age

Medical situation "Drugs"
postmortem abrasion
factors affecting the prominence of a Bruise..
Patterned Intradermal bruise
Tramline bruising "railway appearance"
senile ecchymoses !
Medico-legal
Considerations
inflammatory
infiltrate !!
WBCs !
Definition of wound
Classification of wounds ..
Blunt force wounds
abrasion
Bruises
laceration
Sharp force wounds
Incised
stab
chop
Defense wounds
fabricated wounds
Survival period
after wounding !
Medicolegal Considerations
Artifacts
Cause , site , appearance , margins , superimposed abrasions, Microscopically ..
On incision
; blood is extravasated in the surrounding tissues
On pressure
; not blenching
External signs Internal injuries
Patterns
&
identification of weapons
Sites & distributions of the injuries
&
manners
Skin tags
&
directions
Stage of healing
~
approx. period of the injury
Fabricated wound
=
accesability
vital organs involved in trauma ! ex;
" commotio cordis"
Hidden areas !! .. anogenital , oral cavity

" Alveolar vestibules laceration"
Repeated trauma !! ~ clues for abuse
"Battered child syndrome"
vs
doucmentation & photography
(Microscopically there is always a
narrow zone
of injury, but this is minimal compared with the tissue destruction caused by blunt injury).
Sucide or
Homocide ?!
incised wound produced while facing the victim tend to be

short and angled.
Injuries from other sharp objects
Defense wounds are absent if the victim is :

- Unconscious
- Taken by surprise
- Attacked from behind
- Under the influence of alcohol /Drugs.

Other knife wounds can be on the backs of the hands or fingers or forearm from nongrasping movements trying to ward off the weapon.



with attacks from
blunt
instruments or fists,
bruises
are the hallmark of defence attempts.


The most obvious defence, injuries are seen in

knife
attacks
, as the victim often attempts to ward off the thrusts by seizing the weapon.

When the fingers are closed around the blade, its withdrawal cuts across the flexures of the phalanges, slicing through the skin and perhaps tendons.

Defense wounds
SURVIVAL PERIOD AFTER WOUNDING
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