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BLUNT FORCE TRAUMABerti Nelwan
berti@indosat.net.id
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Guidelines for Reports by Autopsy Pathologists;
Vernard Irvine Adams, MD; Department of
Pathology and Cell Biology, University of South
Florida, Tampa, Florida, USA. 2008
Textbook of Traumatic Brain Injury; ThomasGenrelli MD. American Psychiatic. 2005
Clinical ForensicMedicine3rd editionEdited by
W.D.S. McLay. 2009 Blunt Force Trauma; Pathology Forensic Journal.
2010
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Forensic Pathology
Forensic Pathology is the branch of medicine
which analysesvictims of crime scenes
medically.
They are the last physicianfor the deceased
and their role is to discover and interpret the
evidence left during the autopsy.
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Analysis of Wounds
Not every crime victim is murdered.
Physicianscan contribute to proof of the
severity of a crime or that a crimeactually occurred in some cases for a
living victim.
Wounds provide evidence of the crime.
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Wound Categories
Bruises (or contusions)
Abrasions (or grazes or scratches)
Lacerations Incised wounds
Puncture (or stab) wounds
Gunshot wounds
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Definition
Injuries resulting from an
impact with a dull, firm surface
or object.
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The deaths resulting from blunt force trauma
occur in a variety of scenarios:
almost all transportation fatalities
jumping or falling from heights,
blast injuries,
Be struck by a firm object, such as a fist, crowbar,
bat, or ball.
Bite wounds and chop injuries may be considered
variants of blunt force trauma, sharp forcetrauma, or a class of injuries unto themselves.
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Blunt force trauma is routinely involved
in cases classified as accidents, as well asin cases of suicideand homicide.
it is importantto document evidence ofblunt force trauma in all autopsies
one should not immediately assume that
blunt force trauma is the cause of death
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For example,
Individuals may die of infections, thromboemboli, ororgan failure that occurs as a delayed result of previousblunt force trauma.
For purposes of death certification:
Proximate Cause of Death
the cause of death of an individual who dies ofpneumonia after being hospitalized for several days fortreatment of blunt force injuries following a motor
vehicle collision should be certified as "acutebronchopneumonia complicating blunt force injuriesdue to a motor vehicle accident."
the manner of death should then be certified as"accident."
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The severity of injuries inflicted as a result of
blunt force trauma is dependent on theamount of kinetic energy transferred and the
tissue to which the energy is transferred.
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 (Ek= 1/2 mv2).
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Important: the characteristics of the
blunt objectand the surface that is
impacted.
Impacts involving a large surface will result in a
greater dispersion of energy over a larger area and
less injury to the impacted tissues.
an impact on a small area of a curved surface, such as
the head, will cause greater damage than would becaused were that same impact to occur on a flat
surface, such as the back, since there will be a more
concentrated point of impact on the head.
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The composition, or plasticity, of the
tissues impacted also affects theresultant injuries.
For example, a person who is kicked in the
chest may have only minimal injuries to the
elastic skin surface, whereas deeper, more
solid tissues such as ribs and internal organs
may experience fractures and lacerations.
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The another factor affecting the severity
of blunt force injuries is the amount oftime the bodyand the impacting object
are in contact.
A longer period of contact allows kinetic
energy to be dissipated over a prolonged
period, resulting in less damage to thetissues than an equally forceful impact with
dispersion of energy over a brief period.
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This lecture focuses on thecutaneous manifestations of blunt
force injury
Note:
The blunt force trauma may cause contusions and lacerations of the internal
organs and soft tissues, as well as fractures and dislocations of bonystructures.
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The major types of cutaneous
blunt force injuries are as follows: Contusion (bruise)
Abrasion Laceration
Avulsion
Fracture
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Bruises
A bruise is "a hemorrhage into tissues
produced by the escape of blood from blood
vessels".
Bruises may be found in the skin, muscles, and
internal organs.
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Bruises
Bruises are typically produced by a blunt force
impact, such as a blow or a fall.
They may also be produced by squeezing or
pinching, where the force is applied gradually
and then maintained.
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Contusions are
discolorations of the skin caused by bleedinginto the tissues from ruptured blood vessels.
Contusions (Bruises)
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Important: Natural Bruises
Bruises may occur in a variety of natural diseases inwhich there is an abnormality of the clottingmechanism of the blood, e.g. scurvy (vitamin Cdeficiency), leukemia, alcoholic liver disease.
This bruising is "spontaneous" because the injurywhich produces it is so insignificant as to typicallypass unnoticed.
The presence of such natural disease will exaggeratethe bruising effects of any trauma.
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Problems with Skin Bruises
Delayed appearance
Ageing (relative)
Site of Trauma Shape of object
Degree of force
Post-mortem bruises Post-mortem lividity
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Classic Causes of Bruises
Finger pad bruises: battered babies, manual
strangulation
Different ages: repeated assaults
Shoulders and arms: forceful restraint
Wrists and ankles: dragging
Inner thighs: forceful intercourse Chest: resuscitation
Bruising is uncommon in Suicides
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Bruises
The extent of bruising is inversely proportional to the
sharpness of the impacting object.
Bruises may be associated with other blunt force
injuries such as abrasions and lacerations. As a general rule bruising is not associated with
incised wounds or stab wounds where there is a free
flow of blood from the cut blood vessels rather than
leaking into the tissues.
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Site of Trauma
In contrast with abrasions, the location of a
bruise does not necessarily reflect the precise
point of injury.
Leaking blood will follow the path of least
resistance and gravity.
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Delayed Appearance
Deep bruises may have delayed appearance at theskin surface. Deep bruises may require as long as 12or 24 hours to become apparent, and some maynever do so
The more superficial the source of bleeding, thesooner the discoloration will be seen on the skinsurface.
In a living victim, a second examination in one or two
days may show bruising. In the dead, a further examination one or two days
after the original autopsy may show bruises whichwere not previously seen and reveal previously faintbruises.
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Autopsy and Bruising
Bruising in Deep Tissue
1. Possibly life-threatening
2. Sometimes no external injury
3. Revealed in autopsy
Documenting Bruising
1.Photography
2. Notes
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Degree of Force
The size of a bruise is an unreliable indicator
of the degree of force causing it.
However, a heavy impact is likely to produce a
large bruise and a light impact to produce a
small bruise.
If bruising is slight, it is reasonable to assume
that the degree of violence was slight.
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Determining Degree of Force in Bruise
Patterns
Location:
Some areas of the body bruise more easily than
others. The face bruises more readily than the
hands.
Bruising occurs more readily in loose tissues and
where there is a large amount of subcutaneous fat
Bruising is less apparent where the skin is stronglysupported by fibrous tissue or if the muscle tone is
good.
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Determining Degree of Force in Bruise
Patterns
Age Infants and the elderly tend to bruise more easily than
young and middle aged adults.
Infants have loose and delicate skin, and the abundant
subcutaneous fat. Elderly have degenerative changes in the tissues which
support the small blood vessels of the skin andsubcutaneous tissues.
Gender:
Women bruise more easily than men because they havemore subcutaneous fat and this is particularly true ofobese women.
Natural Disease
Skin color
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Causitive Object
The shape of the bruise is most likely to reflect
the shape of the causative object when the
object is small and hard and death occurs
soon after injury
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Causitive Object
A doughnut bruise is produced by an object
with a rounded contour (e.g. baseball).
Two parallel linear bruises result from a blow
with a rod or stick
Bruises can follow rounded contours if they
are caused by a flexible object like a lash
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Causitive Object
Bruises produced by fingerpads as a result of
gripping are usually larger than the fingerpads
themselves.
The pattern and location suggests the
mechanism of causation:
On the neck in throttling
On the upper arms in restraint.
Such bruises are referred to as patterned.
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Aging of Bruises
Color changes a bruise goes
through can give a rough estimate
of time of injury
Colors result from breakdown of
hemoglobin from tissuesDark blue/purple (1-18 hours)
Blue/brown (~1 to 2days)
Green (~ 2 to 3 days)Yellow (~3 to 7 days)
This rate assumes person is
healthy, however.
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red immediate
dusky purple / black soon after
green days 4 -5
Yellow days 7 - 10
resolution days 14 - 15
Camps:
violet immediate
blue day 3
green days 5 - 7
yellow days 8 - 10
resolution days 13 - 18
Glaister:
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red dark / red black < 24 h
greenish tinge around day 7
yellow around day 14
resolution up to 30 days
red immediate
purple black soon after
green days 4 -5
yellow days 7 - 10
resolution days 14 - 15
Polson and Gee:
Smith and Fiddes:
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Aging Bruises
While accurate estimation of the age of a singlebruise is not possible, a fresh bruise can bedistinguished easily from one which is several daysold.
Establishing that bruises are of different ages may beof medical importance where there is an allegationof repeated assaults: Child abuse
Wife beating
Where pre-existing injuries need to be distinguished fromthose produced by a recent assault like a chronic alcoholicwho was assaulted.
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Post MortemBruises
It requires considerable violence to produce a bruise
post mortemor after death.
These bruises are smaller relative to the degree of
force used. Post mortembruises are most readily produced in
areas of hypostasis (post mortem lividity, livor
mortis) or where tissues can be forcibly compressed
against bone.
A bruise can develop on the head after the body is
left lying on the back.
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Post Mortem Lividity
(hypostasis, livor mortis)
The settling, after death, of blood within the blood
vessels under the influence of gravity.
This results in a purplish discoloration of parts of the
body that are lower while sparing areas of pressurecontact - contact pallor.
The pattern and distribution of lividity distinguishes
it from bruising.
A body found on its back has livor mortison the
dorsal (back) side with pale areas where the bone
contacted the floor.
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Postmortem changes on the chest caused by insect activity.
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Patterns of Injury
Bruises to the knuckles of the hands, togetherwith bruises of the eyelids, bridge of the nose,cheeks and lips, suggest a fist fight.
Bruising around the eyes (spectacle bruises)may be produced by direct blows, but alsocommonly result from a fracture of the baseof the skull, e.g. in vehicle collisions orgunshot wounds to the head
They may also follow blunt impact to theforehead producing jolting of the eyeballs intheir sockets with tearing of small orbital
blood vessels.
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Patterns of Injury
Injuries in motor vehicle collisions almost
invariably include abrasions and lacerations as
well as bruises.
Patterns of injury may allow reconstruction of
incidents involving pedestrians or allow
distinction between driver and front seat
passenger.
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Patterned abrasion on the head due to impact by a motor vehicle.
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Two contusions on the skin of the chest
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A contusion
on the arm.
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BLUNT HEAD TRAUMA Blunt trauma to the scalp and face can produce contusions,
lacerations, and abrasions. Battles sign a bluish discoloration of the skin behind the
ear that occurs from blood leaking under the scalp after askull fracture.
Spectacle hemorrhage (raccoons eyes) a discoloration of
the tissues around the eyes usually due to a fracture of theskull.
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There are three major types of hemorrhages whichoccur in the skull.
The type of hemorrhage helps the examinerunderstand what may have caused death.
1) Epidural hemorrhage bleeding directly under
the skull on top of the dura mater. It is associated
with a skull fracture and a torn artery. This type
of hemorrhage accumulates rapidly and death
may occur quickly.
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2) Subdural hemorrhage bleeding under
duramater on top of the brain. It may or may
not be associated with trauma and is caused
by torn veins which forces the blood toaccumulate more slowly than the epidural
bleed.
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3) Subarachnoid hemorrhage caused by blunt
trauma or ruptured blood vessels. It is located
directly on the surface of the brain.
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Pathologists also look for the presence of coup andcontrecoup injuries to the brain to help differentiate
between a fall and a blow to the head by a second party.
Coup injury caused when a moving object (such as ahammer) strikes a stationary head. The injuries to thebrain will be directly beneath the point where the weaponstrikes the head.
Contrecoup injury caused when a moving head (as in afall) strikes a stationary object like the floor. The injuries to
the brain will be opposite the point ofimpact.
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Abrasions
A scraping injury to the superficial
layers of the skin (epidermis and
dermis) that results from frictionagainst a rough surface
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An abrasion is denuded skin caused byfriction. A wound may be either deep orsuperficial depending on the force and thecoarseness of the surface which caused theabrasion.
Abrasions (Scrapes)
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Abrasions
Side impact produces a moving abrasion:
Indicates direction.
Trace material (e.g. grit).
Direct impact produces an imprint abrasion: Pattern of causative object.
All abrasions reflect site of impact (in contrast with
bruises).
Assessment of age of abrasions is difficult.
Post-mortem abrasions - Brown, leathery
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Abrasion on the elbow. Abrasion on the knee.
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BRUSH-BURN ABRASION
One common type of blunt force injury is the so-
called brush-burn abrasion. Brush-burn abrasions
are broad, dried abrasions that often have a
yellow-orange or orange-red coloration. These abrasions are caused by dragging or
scraping the surface of the skin against a rugged
surface; they are most often encountered when a
body slides on pavement. These abrasions are
sometimes called "road rash."
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Brush-burn type abrasion on the left flank.
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Laceration:
A bursting of the skin or other tissues
resulting from compression or stretching
associated with impact by a blunt object
or surface
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Lacerations (Tears, Splits)
Splitting of the skin by the direct crushing
of blunt trauma.
Typically over bone, e.g. scalp, eyebrow,cheekbone.
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Lacerations
Distinguished from incised wounds by:
Adjacent abrasion/bruise
Ragged edge
Tissue bridges in depth
Forensic Importance
Not related to object shape
Trace evidence
Relatively little blood loss (except scalp)
Rarely suicidal
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Two abraded lacerations on the forehead. A laceration near the vertex of the scalp.
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Several chop injuries inflicted by a boat propeller.
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Avulsion:
A more severe form of laceration in
which the soft tissues, musculature,
and/or bone are torn away from thenormal points of attachment
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Avulsion of the right leg.
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Fracture:
A break, rupture,or separation of
tissue (most
often bone)resulting from an
impact
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Thank You
berti@indosat.net.id
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