REGIONAL INJURIES (LECTURE III) INJURIES TO SPINE, NECK, CHEST, ABDOMEN AND PELVIS.

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1 REGIONAL INJURIES (LECTURE III) INJURIES TO SPINE, NECK, CHEST, ABDOMEN AND PELVIS. LEARNING OBJECTIVES At the end of this lecture, last in the series of regional injuries, the students will be knowing about; Injuries to spine with special stress on injuries to cervical spine as seen in hanging, strangulation, throttling. Definition and idea about railway spine Characteristic features of suicidal and homicidal cut throat, injuries to neck structures of medicolegal significance. Chest injuries such as fractures of ribs,pneumothorax, haemothorax, traumatic asphyxia, cardiac temponade, stab wounds of heart. Abdominal injuries such as rupture of internal organs in medicolegal cases. Injuries to pelvis with stress on pelvic fractures. INJURIES TO THE UPPER CERVICAL SPINE VERTICAL IMPACT TO THE HEAD WITH STRAIGHTENED NECK MAY LEAD TO COMPRESSION FRACTURE OF ATLAS KNOWN AS JEFFERSON S FRACTURE, ANOTHER COMMON FRACTURE SEEN IS IN SECOND CERVICAL VERTERBA, AXIS IS KNOWN AS HANGMAN S FRACTURE IN WHICH THERE IS ANTERIOR DISLOCATION OF C2 WITH FRACTURE OF ODONTOID PROCESS OR IT S ANTERIOR DISLOCATION CRUSHING THE MEDULLA AND PONS WHERE VITAL CARDIAC AND RESPIRATORY CENTERS ARE SITUATED,THIS IS SPECIALLY SEEN IN JUDICIAL HANGING. INJURIES TO MIDDLE AND LOWER CERVICAL SPINE MOST COMMON INJURIES ARE HYPER FLEXION AND HYPER EXTENSION INJURIES KNOWN AS WHIPLASH INJURIES, WHICH ARE MOST COMMONLY SEEN IN MOTOR CAR ACCIDENTS WHERE DUE TO SUDDEN STOPPAGE OF A VEHICLE IN SPEED CAUSES HYPERFLEXION AND THEN HYPER EXTENSION OF NECK, PULLING THE NERVES AT THE ROOT OF NECK LEADING TO PARALYSIS OF LIMBS. DISLOCATION AT LEVEL OF C4-C6 IS SEEN. THORACIC AND LUMBAR SPINE T1 TO T10 ARE MORE RESISTANT TO INJURIES BECAUSE OF ADDITIONAL STABILITY OF THORACIC RIB CAGE, SO DISLOCATOIN AND ROTATIONAL INJURIES ARE LESS COMMON AS COMPARED TO LOWER THORACIC AND LUMBAR SPINE BECAUSE OF INCREASED FLEXIBILITY. LUMBOSACCRAL SPINE IS MORE PRONE TO FRACTURES AND COMPRESSION INJURIES. INJURIES TO SPINAL CORD SPINAL CORD INJURY MAY RESULT IN QUADRIPLEGIA OR PARAPLEGIA. QUADRIPLEGIA(PARALYSIS OF ALL FOUR LIMBS) IS SEEN WHEN INJURY IS ABOVE THE LEVEL OF EMERGENCE OF ROOTS SERVING THE BRACHIAL PLEXUS(4 TH CERVICAL) AND PARAPLEGIA (PARALYSIS OF LOWER LIMBS)IS SEEN DUE TO INJURY BELOW THE LEVEL OF EMERGENCE OF BRACHIAL PLEXUS(1 ST

2 AND 2 ND THORACIC VERTEBRAE). PENETRATING INJURIES OF THE SPINAL CORD PENETRATING INJURIES ARE USUALLY CAUSED BY MISSILES SUCH AS BULLETS. ANOTHER TYPE OF PENETRATING INJURY IS PITHING IN WHICH A NEEDLE IS PUT IN NAPE OF NECK BETWEEN 2 ND AND 3 RD CERVICAL VERTEBRAE AND ROTATED TO SEPARATE SPINAL CORD FROM MEDULLA, THIS IS ONE OF THE COMMON METHOD OF INFANTICIDE. INJURIES TO THE SPINE CONCUSSION OF SPINE THIS CONDITION CAN OCCUR WITHOUT ANY EVIDENCE OF EXTERNAL INJURY TO THE SPINAL COLUMN, FROM A FORCIBLE BLOW ON THE BACK OR A FALL FROM HEIGHT OR A BULLET INJURY BUT IS COMMONLY SEEN IN RAILWAY ACCIDENTS AND MOTOR CAR COLLISIONS, HENCE ALSO KNOWN AS RAILWAY SPINE. INJURIES TO THE NECK (I)SUICIDAL CUT THROAT (ii)homicidal CUT THROAT CUT THROAT INJURIES TO THE NECK (cont) HYOID BONE The most common injury to Hyoid bone is FRACTURE. In persons above 40 years of age the bone is ossified and is likely to fracture easily. In young persons the bone is elastic and more resistant to fracture, but fracture can occur at any age depending upon the force applied on the neck. The most common cause of fracture of Hyoid bone is THROTTLING, i.e. pressing the neck with human hands. INJURIES TO THE FACE LOSS OF SIGHT LOSS OF HEARING

3 DISLOCATION OF A TOOTH CUTTING OF NOSE CUTTING OF EAR LOBES CUTTING OF LIPS CUTTING OF TONGUE DISFIGURATION OF THE FACE (VITRIOLAGE) FRACTURE OF ZYGOMATIC BONE FRACTURE/ DISLOCATION OF MANDIBLE INJURIES TO THE FACE (cont) A COMMON INJURY TO THE FACE SEEN IN ROAD TRAFFIC ACCIDENTS TO THE DRIVER IS BIRD FEET INJURY WHICH IS DUE TO BREAKING OF WIND SCREEN CAUSING PIECES OF BROKEN GLASS TO CAUSE LACERATED WOUNDS OF THE FACE AND IT APPEAR AS IF SOME BIRD HAS INJURED THE FACE WITH CLAWS.(WIND SCREEN INJURIES) INJURIES TO THE CHEST TRAUMATIC ASPHYXIA Traumatic Asphyxia or crush Asphyxia, is a form of Asphyxia resulting from trauma to the chest, or pressure on the chest and back, which prevents respiratory movements. This may occur accidentally through. The chest being pressed violently in crowds at big fairs. Being trampled in stamped crowds. Chest trauma from run over car accident. Steering wheel injury. Building collapse. AUTOPSY FINDING In addition to signs of asphyxia, there are 4 characteristic features. Deep cyanosis of the face. Numerous Petechial hemorrhages. Demarcating line between discolored upper part and normal colour below the line.

4 Blood shot eyes. Traumatic Asphyxia (cont) The mechanism is as follows. Compression of the chest displaces blood from superior vena cava and subclavian veins in to smaller veins and capillaries of the head and neck which are considerably engorged and pressure in them rises so rapidly as to burst their walls. Therefore the face and neck of the victim are deeply cyanosed, almost black, eyes are bloody red (blood shot), and numerous petichae are found over the scalp, face, neck and shoulders. The level of compression is indicated by a well defined demarcating line between dis coloured upon portion of the body and lower normally colour part. INJURIES TO THE CHEST (cont) Flail chest or Stove in Chest: occurs when there are multiple bilateral fractures of most of the ribs and also of the sternum. The rigidity of the rib cage is lost and attempts at expanding the thoracic volume during inspiration are impaired. The loose section is sucked inwards during inspiration, is called paradoxical respiration. In this condition dyspnoea, cyanosis and progressive hypoxia results that is incompatible with life. The Flail chest is caused by striking of front of chest against steering wheel in vehicular accidents and in stampeding in big crowds. CHEST INJURIES (cont) RIBS. MOST COMMON ARE FRACTURES OF THE RIBS. THE RIBS WHICH ARE MOST COMMONLY FRACTURED ARE 4 TH,5 TH,6 TH, 7 TH AND 8 TH RIBS, AS THEY ARE MOST PROMINENT AND FIXED AT BOTH ENDS.THE MOST COMMON SITE OF FRACTURE IS AT THE MOST CONVEX PARTS OF THE RIBS NEAR THEIR ANGLES.BILATERAL FRACTURES OF RIBS ARE SEEN IN RUN OVER VEHICULAR ACCIDENTS.THE BROKEN ENDS OF RIBS MAY RUTURE THE PLEURA OR LUNGS LEADING TO PNEUMOTHORAX OR HAEMOTHORAX. CHEST INJURIES (cont) STERNUM FRACTURE OF STERNUM IS RARE EXPECT IN CASES OF STEERING WHEEL INJURY TO THE DRIVER OF A CAR WHEN HIS CHEST STRIKES THE STEERING WHEEL IN CAR COLLISION. THE MOST COMMON FRACTURE IS A TRANSVERSE FRACTURE EITHER BETWEEN THE MANIBRIUM AND BODY OF STERNUM OR SLIGHTLY BELOW.BACKWARD DISPLACEMENT OF LOWER SEGMENT OF FRACTURE CAN CAUSE DAMAGE TO VISCERA BEHIND IT. CHEST INJURIES (cont) LUNGS WOUNDS OF THE LUNGS ARE MORE COMMON BECAUSE OF FRACTURE OF THE RIBS CAUSING LACERATIONS OR PENETRATING INJURIES DUE TO SHARP POINTED WEAPONS OR FIRE ARMS.MOVE OVER HIGH EXPLOSIVE BLAST CAN ALSO CAUSE EXTENSIVE INJURIES TO THE LUNGS CAUSING CONGESTION, HAEMORRHAGE AND SUBPLEURAL BULLAE IN THE LUNGS.BECAUSE OF GLIDING IN CAR ACCIDENTS CONTRE COUP INJURIES MAY BE SEEN IN THE LUNGS.THE INJURIES CAN CAUSE PLEURISY, AIR EMBOLISM, PNEUMOTHORAX,

5 HAEMOTHORAX, EMPHYSEMA. CHEST INJURIES (cont) SIGNS OF LUNG INJURIES. DURING LIFE INJURY TO THE LUNG CAN BE DIAGNOSED BY SEEING SPUTUM WHICH CONTAIN TRACES OF BLOOD AND IN MORE SERIOUS CASES FRANK HAEMOPTYSIS. TRAUMATIC EMPHYSEMA DYSPNOEA CHEST INJURIES(cont) HEART. THE INJURIES TO THE HEART CAN BE, NON PENETRATING PENETRATING NON PENETRATING INJURIES ARE DUE TO BLUNT TRAUMA CAUSING BRUISING OF THE HEART WITH SUDDEN DEATH DUE TO VENTRCULAR FIBRILLATION OR VALVULAR RUPTURE. ANOTHER COMMON CONDITION IS CARDIAC TEMPONADE IN WHICH A DISEASED HEART MAY RUPTURE DUE TO TRAUMA CAUSING ACCUMULATION OF BLOOD IN THE PERICARDIAL SAC WHICH CAN INTERFERE WITH NORMAL CONTRACTION AND RELAXATION OF THE HEART( ML), LEADING TO CARDIAC ASYSTOLE AND DEATH. HEART INJURIES (cont) PENETRATING INJURIES ARE MOST COMMONLY DUE TO, SHARP EDGED POINTED WEAPONS. BULLETS. STAB WOUNDS OF AURICLES ARE MORE DANGEROUS BECAUSE OF THEIR THIN WALLS THEY BLEED MORE PROFUSELY,AS COMPARED TO VENTRICLES WERE WALLS ARE THICK, IN THE SAME WAY STAB IN RIGHT VENTRICLE IS MORE DANGEROUS THAN STAB OF LEFT VENTRICLE WHERE THE WALL IS MORE THICK AS COMPARED TO THE RIGHT SIDE SOME TIMES HEART MAY BE INVOLVED WHEN INJURY IS OVER TRIGGER AREAS SUCH AS CAROTID SINUS,SOLAR PLEXUS OR TESTES WHERE AS A RESULT OF TRAUMA VAGUS NERVE IS STIMULATED WHICH ARRESTS THE HEART(VASOVAGAL SHOCK) CAUSES OF DEATH IN HEART INJURIES

6 HAEMORRHAGE SHOCK CARDIAC TEMPONADE CORONARY ARTERY LESION CAUSING ISCHAEMIA OF THE HEART. BIG VESSELS- AORTA & PULMONARY VESSELS. THESE ARE USUALLY INJURED BY PENETRATING WEAPONS OR BULLETS,RUPTURE OF AORTA MAY OCCUR FROM TRAUMA OR DISEASE, SUCH AS RUPTURE OF AORTIC ANEURYSM. FIRE ARM INJURIES WITH BULLETS WHICH IMPART VIBRATION WAVES DUE TO SPINNING MOVEMENT CAN CAUSE RUPTURE OF HEART, LUNGS AND BIG BLOOD VESSELS. ABDOMINAL INJURIES DEATH MAY OCCUR WITH A BLOW WITHOUT DAMAGE TO ABDOMINAL VISCERA DUE TO REFLEX INHIBITION OF THE HEART THROUGH VAGAL NERVE STIMULATION. COMMON INJURIES ARE STABS, GUN SHOT INJURIES AND BLOWS. ABDOMINAL INJURIES (cont) LIVER. OWING TO IT S SIZE, IT S FIXED POSITION AND FRIABLE CONSISTENCY, IT IS COMMONLY INVOLVED IN STABS IN ABDOMEN,KICKS, BLOWS,ROAD TRAFFIC ACCIDENTS AND SOME TIMES BY FRACTURED RIBS AFTER PIERCING THE DIAPHRAGM. COMPLICATIONS OF INJURY TO LIVER ARE, SHOCK MASSIVE INTERNAL HAEMORRHAGE INFECTION, SUCH AS PERITONITIS RUPTURED LIVER ABDOMINAL INJURIES(cont) SPLEEN. IT IS ONE OF THE COMMONEST ORGAN TO RUPTURE DUE TO INJURIES IF ENLARGED IN DISEASES SUCH AS MALARIA. DEATH MAY OCCUR DUE TO, SHOCK

7 EXCESSIVE INTERNAL HAEMORRHAGE ABDOMINAL INJURIES (cont) STOMACH AND INTESTINES. MAY BE RUPTURED IN BLAST INJURIES OR WHEN ALREADY DISEASED SUCH AS PEPTIC ULCER OR ULCERS IN INTESTINES IN TYPHOID AND AMOEBIASIS. OTHER COMMON CAUSES ARE STAB AND GUN SHOT INJURIES. KIDNEYS- BECAUSE OF THEIR ANATOMICAL LOCATION ARE USUALLY NOT RUPTURED, EXCEPT IN STABS AND GUN SHOT INJURIES INJURIES TO THE GENITAL TRACT IN FEMALES, GRAVID UTERUS IS COMMONLY RUPTURED WHEN INSTRUMENTATION IS DONE TO PROCURE CRIMINAL ABORTION. RUPTURE OF FOLLAPIAN TUBES IS COMMON IN ECTOPIC GESTATION. BRUISING AND LACERATION IS COMMON IN FEMALE GENITAL TRACT IN SEXUAL ASSAULT. IN MALES, INJURY TO TESTES BY A KICK CAN CAUSE DEATH DUE TO SHOCK,SOME TIMES CONTUSIONS, LACERATIONS AND EVEN INFARCTION IS SEEN. SOME TIMES THERE MAY BE RUPTURE OF URETHRA DUE TO FALL IN MANHOLE(GUTTER) WITH FRACTURE OF FEMUR OR PELVIS. AMPUTATION OF PENIS MAY ALSO BE SEEN. PELVIC INJURIES In severe trauma, the pelvis undergoes various fractures as well as dislocations such as : (i) When there is application of great pressure to the front of the abdomen or pubic area such as in run over by the wheel, the pelvis is splayed open, symphysis pubis separates and one or both sacroiliac joints also dislocate (ii) When an impact occurs from the side, superior and inferior pubic ramus are fractured with dislocation of sacroiliac joint on the side of impact (iii) In circumstances of fall from height on to the feet, due to transmission of force up the legs, both the sacroiliac joints may dislocate and even one or both femoral head may also be driven into acetabulum. When the hip joints remain intact, the pelvic girdle may fracture and

8 sacroiliac joints may dislocate (iv) Due to a kick or heavy fall on to the base of spine, fracture of sacrum or coccyx may result (v) Empty bladder is rarely injured in trauma but a full bladder gets injured from blows, kicks and other blunt trauma. Other pelvic organs are quite protected from blunt injuries (vi) Male urethra may be injured as a result of direct trauma such as falling astride a solid object like a gate or being kicked in the crutch, due to being compressed against the undersurface of the pubis (vii) External genitalia may suffer injuries especially scrotum is quite vulnerable to severe bruising resulting from kicks. Scrotum and vulva may suffer injuries from falling astride on objects and in vehicular accidents. Thanks