Chapter 17: Regional Injuries

**Regional injuries**

comprise of injuries to various anatomical regions of the body having medicolegal significance and include injuries to the — head, neck, spine and spinal cord, chest, abdomen, limb bones and joints.

**Head injury**

a morbid state, resulting from gross or subtle structural changes in the scalp, skull, and/ or the contents of the skull, produced by mechanical forces

**Scalp**

**______** is the outermost covering of the head and is continuous with the skin of the face and has five layers from outside to inwards.

**Black eye**

This is a condition due to the bleeding in the soft tissue around the eye owing to blunt trauma of the forehead rupturing the blood vessels and the blood tracks along the facial attachments around the lower margin of the orbits.

**Spectacle haematoma**

This is a condition in which the blood is collected in the soft tissue around the eyes, due to the fracture of the base of the skull – anterior cranial fossa fractures.

**Skull**

**____** is a diploic bone having an outer table and inner table.

**Diploe**

the spongy bone in between the tables and gives greater elasticity to the bone.

**Direct violence**

Here the forces acting directly on the bone produce a fracture

**Indirect violence**

Here the force is acting on the skull indirectly, through some other structures, which receive the primary impact.

**Fissured Fracture**

a linear fracture involving only outer or inner table or both tables simultaneously. Also called as crack fracture.

**Coup-fissured fracture**

 a fracture that occurs when head is stationary.

**Contra coup-fissured fracture**

A fracture occurs when the moving head strikes a stationary object.

**Bursting-fissured fracture**

A fracture that  occurs on the vertex and may extend up to the base of the skull or vice versa, when the head is compressed between mechanical force on one side and a hard surface on other side.

**Depressed Fracture**

 fracture wherein the fractured bone fragment is driven inwards for some distance below the rest of the adjacent skull's contour.

**Comminuted Fracture**

a fracture, wherein the bone is broken into several pieces of different sizes, also known as crushed fracture.

**Stellate Fracture**

a comminuted fracture with fissured fractured fragments radiating from it and held intact.

**Mosaic Fracture**

a non-depressed comminuted fracture where fractured site appears in the form of several fissures forming a spider's web or cob web.

**Elevated Fracture**

a fracture, wherein one end of the fractured fragment is elevated above the surface of skull, while the other end may dip down into the cranial cavity and injure the dura mater of the brain directly.

**Diastatic Fracture**

a fracture occurring along skull sutures, and occurs in children and young persons.

**Gutter Fracture**

a fracture wherein the thickness of the skull bone is affected leading to an irregular depressed fracture of the inner table.

**Pond Fracture**

a simple dent in the skull, which results from an obstetric forceps blade, or a blow from blunt object or forcible impact against some protruding object

**Perforating Fracture**

an open fracture caused by a projectile (bullet) passing through the affected bone.

**Cut Fracture**

A heavy cutting weapon can cause straight chops of the skull, involving either the outer table alone, or sometimes affecting both tables.

**Combined Fracture**

a fracture, wherein there is a combination of more than one.

**Fracture of the Anterior Cranial Fossa**

It is due to direct impact or as a result of contracoup injuries, resulting in a black eye or escape of CSF and blood from the nose and damage to the roof of the orbit.

**Fracture of the Middle Cranial Fossa**

It is due to direct impact behind the ears or crush injuries of the head resulting in escape of CSF and blood from the ear when the petrous part of the temporal bone is fractured.

**Fracture of the Posterior Cranial Fossa**

It is due to the impact on the back of the head, resulting in escape of CSF and blood into the tissues of the back of the neck.

**Fracture around Foramen Magnum**

It is a fissured fracture occurring around the foramen magnum, situated 3 to 5 cm outside foramen magnum at the back, the middle ear on either side and the roof of the nose anteriorly.

**Hinge Fracture**

a fracture of the base of the skull where the fracture line runs from side to side across the floor of the middle cranial fossa, passing through the pituitary fossa in the midline following the course of least structural resistance.

**Dura mater**

 the strong and gray/bluish connective tissue membrane and is firmly attached to the skull, penetrated by bridging veins (emissary veins) along the vertex.

**Arachnoid mater**

A thin, vascular meshwork-like membrane beneath dura.

**Pia mater**

a surface network of glial fibers that are inseparable from underlying brain.

**Traumatic Brain Injury**

brain injuries of traumatic origin, which happens to be the major cause of death among the population less than 45 years age.

**Accelerating Injury**

When a moving object hits the head, which is static, the skull picks up the momentum first and hits the brain, which is still at rest, yet to pick up the momentum a fraction of a second later.

**Decelerating Injury**

When a non-moving object suddenly arrests the head in motion, the skull loses its momentum much prior to brain, which hits the inner aspects of the skull before becoming static.

**Shear Strain/Rotational Injury**

This is due to side to side or rotational movement of the head, which makes the brain to get jolted on the sharp edges of the tentorial attachments in the interior of the skull and on the bony buttresses produced by the bones of the base of the skull and get injured.

**Coup Injury**

Here the injury to skull and brain both occurs at the site of impact.

**Contrecoup Injury**

Here the injury to skull and brain occurs on the opposite side of the site of impact.

**Reversible Cerebral Concussion**

Here clinically the patient will present with loss of consciousness and flaccidity of muscles, followed by recovery of the consciousness, leading to a second loss of consciousness later.

**Lucid interval**

the period of recovered consciousness between two bouts of unconsciousness.

**Irreversible Concussion**

severe trauma can bring about brainstem (vital centre) damage resulting in fatality.

**Retrograde amnesia**

Victim is unable to recollect the exact manner in which the injury occurred and even the events occurring before and after the accident.

**Punch-drunk syndrome**

a syndrome of confusion in a setting of impaired physical function resembling Parkinson's disease. Usually caused by repeated blows to the head. It also resembles the condition found in chronic alcoholics.

**Diffuse axonal injury**

a clinical condition, which is one of the most common and devastating types of brain injuries occurring in almost half of all cases of severe head trauma.

**Cerebral contusion**

 it is the bruising of the cerebral tissue. There may not be any apparent injury of the scalp or skull outside.

**Cerebral irritation**

It includes a peculiar set of symptoms that may follow cerebral concussion, victim lies curled up in the bed, with face hidden beneath the clothes, resents all forms of interference and exposure to light.

**Cerebral Compression**

a clinical condition due to increased intracranial pressure, which disturbs the function of the brain.

**Intra-axial Hemorrhage**

Bleeding within the brain itself.

Intraparenchymal hemorrhage

Bleeding within the brain tissue.

Intraventricular hemorrhage

Bleeding within the brain's ventricles.

**Extra-axial Hemorrhage**

bleeding that occurs within the skull but outside of the brain tissue

**Extradural hemorrhage**

It is caused by trauma, and results from laceration of an artery, most commonly the middle meningeal artery.

**Subdural hemorrhage**

It results from tearing of the bridging veins in the subdural space between the dura and arachnoid mater.

**Subarachnoid hemorrhage**

It result either from trauma or from rupture of aneurysms or arteriovenous malformations.

**Fracture of the temporal bone**

especially the squamous portion can result in rupture of the middle meningeal artery or vein, leading to heavy bleeding into the temporal fossa.

**Fracture of the frontal bone**

It can result in rupture of anterior meningeal artery or vein, leading to anterior cranial fossa hemorrhage, which in turn can press upon the frontal lobe.

**Fracture of the occipital bone**

It can result in rupture of posterior meningeal artery or vein, leading to posterior cranial fossa hemorrhage, which can develop a large hematoma, which in turn can press upon the cerebellum and the occipital lobes.

**Fracture of the vault**

It can result in rupture of superior sagittal sinus or diploic veins and lead to hematoma formation.

**Pontine hemorrhage**

a type of intracranial hemorrhage wherein bleeding occurs in the pons or brain stem.

**Cerebral edema**

occurs due to a localised or diffuse abnormal accumulation of water and sodium, which increases the volume of the brain

**Railway spine**

A condition wherein the victim develops transient paralysis without loss of sexual power.

**Shaken Baby Syndrome**

A trauma suffered by small children as the result of deliberate abuse.

**Pithing**

It is killing by pushing a fine needle into nape of neck between base of skull and first cervical vertebra and is a concealed punctured wound

**Complete fracture**

A fracture in which bone fragments separate completely.

**Incomplete fracture**

A fracture in which the bone fragments are still partially joined.

**Linear fracture**

A fracture that is parallel to the bone's long axis.

**Transverse fracture**

A fracture that is at a right angle to the bone's long axis.

**Oblique fracture**

A fracture that is diagonal to a bone's long axis.

**Compression fracture**

A fracture that usually occurs in the vertebrae.

**Spiral fracture**

A fracture where at least one part of the bone has been twisted.

**Comminuted fracture**

 A fracture causing many fragments.

**Compacted fracture**

A fracture caused when bone fragments are driven into each other

**Open fracture**

 A fracture when the bone reaches the skin.

**Bug fracture**

A fracture when the bone is in place, but the fracture has the appearance of a crushed insect.

**Greenstick fracture**

Occurs because the bone is not as brittle as it would be in an adult, and thus does not completely fracture, but rather exhibits bowing without complete disruption of the bone's cortex.

**Salter-Harris fractures**

growth plate injuries that require careful treatment and accurate reduction to make sure that the bone continues to grow normally.

Fracture of the temporal bone

Occurs especially the squamous portion can result in rupture of the middle meningeal artery or vein, leading to heavy bleeding into the temporal fossa.

Fracture of the frontal bone

It can result in rupture of the anterior meningeal artery or vein, leading to anterior cranial fossa hemorrhage, which in turn can press upon the frontal lobe.

Fracture of the occipital bone

It can result in rupture of the posterior meningeal artery or vein, leading to posterior cranial fossa hemorrhage, which can develop a large hematoma, which in turn can press upon the cerebellum and the occipital lobes.

Fracture of the vault

It can result in rupture of superior sagittal sinus or diploic veins and lead to hematoma formation.