Head accomodates one of the most vital organs of the body, the brain. Generally speaking, it is well protected within the bony cranial cage. But once the impact of a force crosses the protective threshold, then life is invariably in danger. The external, injury on the head and the face may or may not be representative of the internal injury and the extent of danger of the impact.
External injury on the head and the face –
Head and face may suffer blunt force injury as other parts of the body. But it must be remembered that fatal blunt force injuries inflicted with intention to kill a person will be on the head.
The specific features and peculiarities of blunt force injuries on the head and the face.
Fist blow or a similar blow on the face may cause abrasion, bruise and if with a ring on a finger, may also cause laceration. Laceration with fist blow is common if the impact is on the malar prominence, on the eyebrows, on the forehead and in the inner aspect of the lips due to impact of the lips with the teeth behind. With fist blow, there may be fracture of the nasal bone with bleeding from the nose. Similarly, there may be dislocation of the teeth. If on the eye, then there may be damage to the eyeball, dislocation of lens, displacement of the retinal vessels. Blow over the forehead and the eyebrows may cause black eye due to settling and accumulation of blood in the loose tissue of the eyelids. In addition to these, there may be subconjuctival haemorrhage. A fist blow on the ear may cause rupture or tear of the pinna and bleeding from the ear. A forceful fist blow on the temple may cause cerebral apoplexy and instantaneous death.
Blow with a hard blunt weapon, other than fist, e.g. with a wooden or iron rod will cause more severe and dangerous injuries, including fracture of the bone and internal injury. Externally, if a long rod like weapon is used over the forehead, scalp, eyebrow or over the malar prominence, then an incised looking split laceration will be produced. On the scalp, a bruise is better palpated than seen due to the general bluish colour of the scalp due to hair roots. Split laceration may also occur on the chin.
In case of smothering, there may be bruises, abrasions with occasional nail scratches present around the mouth and the nose with similar injuries on the inner aspects of the lips with occasional dislocation of teeth, fracture of the nasal bone and bleeding from the nose. In these cases, petechial haemorrhages may be present in the conjunctiva, over the temple, the eyelids and the forehead.
Cut injury over the face and the head is common only in homicidal circumstances.
Stab wounds are comparatively uncommon on head and face. Concealed punctured wounds may be caused at the inner canthus of the eyes, over the nape of the neck and over the fontanelle in case of infants, all of which are homicidal in nature.
Suicidal gunshot wounds may be present on the palate inside the mouth cavity, over the temples, on the forehead, on the eyes and below the chin. All these suicidal wounds are likely to be contact wounds.
In case of burn injuries, except the part of the head covered by the hair, there may be any degree burn injuries, elsewhere on the head and the face. The scalp hair show singeing and give the smell of the fuel in suicidal and some homicidal cases.
In case of ingestion of corrosive agents, there may be corrosion and stain on the angles of the mouth, over the lips, with evidence of trickling of the corrosive agents in front of the chin. Inside the mouth cavity, there will be signs of irritation, disquamation, haemorrhagic points, discolouration, depending on the type and concentration of the agent. In case of sulphuric acid, there is, carbonization of the corroded area and white brittle appearance of the teeth. In case of corrosive alkalies, in addition to corrosion, there will be bleached, sodden and translucent appearance of the mucous membrane of the mouth and the tongue. In case of vitriolage, evidence of spilling of the agent will be there on the face. Pouring of acid or alkalies on the eyes may cause total damage of the eyes with loss of the eyesight.
The subcutaneous tissue –
In case of hard blunt impact, the loose tissue of the scalp may show extravasation which may be diffused or may form extensive frank haematoma at times. In case of impact over the forehead or the front of the head, there may not be much accumulation of blood at the site of impact but the extravasated blood may settle down into the tissue of the eye lid causing black eye. Subcutaneous extravasation in the loose tissue of the scalp may be present all around the head or may be localised sporadically at and around the sites of impact.
Injury to the bones of the head –
Fractures of skull –
Fracture of the skull bones may be simple or compound. However, irrespective of whether closed or open, the fractures of the skull bones may be of the following types –
1. Fissured fracture – These are linear or thread like fractures running in a line, straight or curved. A fissured fracture may be continuous over one or two or more bones. Fissured fractures are caused due to impact with hard, tough and flat surface. This type of fracture is often the result of a fall on the ground or after being knocked down on the ground by a vehicle.
2. Comminuted fracture – When a part of the skull bone cracks into pieces, it is termed comminuted fracture. This occurs often in radiating fashion, with the centre being at the site of the impact and fissures radiating from that point in more than one direction, along the direction of radiation of the force of impact.
3. Depressed comminuted fracture – This occurs due to foreceful localised impact causing multiple linear fractures radiating from the site of impact with depression of the site of impact where the bone breaks into pieces. Depressed comminuted fractures are called ‘Fracture Ala Signaturea’, because, like the signature of a person the weapon which has caused the fracture may leave its impression on the fracture from which the shape and size of the striking part of the weapon can be known. Thus the depression may be circular, if the striking surface is circular; it will be elongated if the object of impact is an elongated one. This type of fracture may occur in case of primary impact by a vehicle. In such a case, from the size and shape of the fracture, part of the vehicle striking the head can be known. In homicidal cases, if a hammer has been used, then that also can be guessed from the shape and size of the depressed fracture.
4. Pond fracture – This type of fracture is seen in case of infant skull, where the bones are not yet fully calcified and hence are soft and yield on application of force. Thus, at the site of impact of the force there is a depression but there is no cracking anywhere or there will be very small or minor cracking.
5. Gutter fracture – Tangential impact by the sharp edge of a sword or a high velocity bullet over some part of the skull bone may cause the superficial layer of the bone at the site of impact to be slashed out due to the glancing impact. Usually the outer table of the skull is affected and there is no effect on the inner table. Also, there is no cracking of the bone.
6. Ring fracture – This occurs due to indirect impact on the base of the skull, when a person falls from a height on his feet or buttock. The force travels along the vertebral column and strikes the atlas and thence the part of the occipital bone around the foramen magnum. This may cause separation of the base of the skull from the rest. The separation starts about 2 to 4 cm. away from the foramen magnum and then travels by the side of the ear bones and base of the eye bones. Sometimes the separated part of the base is pushed inside the cranial cavity. Ring fracture may be caused due to a shearing force resulting from an impact on the frontal or occipital bones.
7. Cut fracture – Sharp cutting heavy or moderately heavy weapon causes straight linear cut when except the line of contact with the edge of weapon there may not be any lack of continuity of the bony substance anywhere. If the edge is not very sharp and if the weapon is quite heavy then there may be any of the conventional types of the fractures present along the direction of passage of the force.
8. Suture fracture or sutural separation – When the impact is over an wider area of the head, there may be separation of the bones at the sutures. In case of elderly subjects where partial calcification of the sutures have occurred there may be fracture in the line of the sutural obliteration, if similar impact is applied on the head over an wider area.
9. Bullet fracture – In case of punctured wound of the head due to bullet, there will be punched in hole on the bone at the site of entrance of the bullet with bevelling at the inner table of the bone, and at the site of the exit of the bullet, there will be a punched out hole with bevelling at the outer table of the bone.
10. Crush fracture – In case of crushing of the head by heavy substance the skull bones are crushed into numerous small pieces with total distortion of the structure of the head and the face. Such crush fracture of the skull bone is seen when the head is run over by the wheel of a heavy vehicle.
11. Heat fracture.
12. Contre-coup fracture – When the impact is over the occipital region, then the force will be directed anteriorly. In course of its path the force causes vibration. Where-ever the force passes through a thin and weak bone in its path, it may cause fracture of that bone. Thus, in a case of reasonably heavy impact on the occipital bone, there may not be any fracture at the site of impact due to toughness of the occipital bone, but the force, when passes anteriorly causes fracture of the thin orbital plates of the frontal bone. Mechanism of contre-coup injury to brain is totally different.
Fracture on the anterior fossa –
At the base of the skull –
Fracture at the anterior fossa of the base of the skull occurs mostly due to an impact in front of the head. Fissured fracture of the orbital plates of the frontal bone may occur due to impact over the occipital bone posteriorly. If the anterior fossa fracture extends upto the sinuses, then there is a chance that this will lead to infection inside the cranial cavity. In some cases, fracture of the anterior fossa may be the extension of fracture of the middle fossa.
Fracture of the middle fossa –
A linear fracture may extend across the middle fossa including the pituitary fossa. Such fracture commonly occurs due to heavy side by side compression. Middle fossa fracture may extend to the anterior fossa.
Posterior fossa fracture –
Posterior fossa fracture may occur due to the direct impact over the posterior part of the skull.
Fracture of the mandible –
Fracture of the mandible occurs due to direct impact. Vertical fractures by the sides of premolars are the most common ones.
Fracture of the maxilla –
It occurs due to direct impact, when the face of a person directly gets an impact with some hard structure like a wall or a tree, as usually happens in motor-cyclists, colliding against a wall or a tree when he is forcefully thrown forward.
CEREBRAL CONCUSSION (Old term ‘Commotio Cerebri’)
This being a sequelae of trauma is a more complicated condition of brain structure and function than the term suggests. Literally, cerebral concussion means a ‘jar’ or ‘shock’ to the brain. Though that is what actually happens in cerebral concussion, there are something more to consider.
Its pathological and legal status have been questioned in many occasions. Some claim that, it is a condition which essentially is a sort of shock neurosis without any real pathology or damage to the brain and the ’cause’ of the condition is the individual himself and himself alone, which should not be linked with any circumstance of assault or accident. It cannot be denied that the condition may be a feigned one after an accident or assault to claim compensation. But that should not give an impression that the condition does not exist or that it is always negligible or trivial. In occasions, death occurred in circumstances which appeared as post accidental concussion. During post-mortem examination of these cases, no gross or microscopic pathology could be detected in many of these cases.
The most constant post-concussional features are headache, dizziness and nervousness, though there may be other features depending on the extent of internal pathology. During necropsy, in many cases, cerebral contusion, oedema or minute haemorrhagic spots may be noticed macro-scopically and degeneration of the tigroid cells and changes in the nuclei of the nerve cells may be observed by microscopic examination.
Cerebral concussion is more commonly complained of in impacts received on the brain due to sudden deceleration of the moving head than in an impact received by a static head.
In cerebral concussion, there may or may not be any morphological pathology of the brain. Though the condition may have some functional element in it, the individual should not be made responsible outright, inspite of the accepted fact that the condition may be feigned for extracting certain benefit from a circumstance of accident or assault.
Haemorrhages inside the skull cavity may occur at different levels and at different sites. Intracranial haemorrhages may be traumatic, or atraumatic (pathological). When traumatic in origin, there may be accompanying fracture of the skull bone. But in many cases, intracranial haemorrhages may be without fracture of the skull bone, though traumatic in origin.
According to the levels, intra-cranial haemorrhages may be of the following types –
1. Extradural or epidural
In most circumstances, haemorrhage at this level is traumatic in nature. The vessels involved in the trauma are middle meningeal artery (most common due to the peculiar site of involvement) and dural venous sinuses. The accumulation of blood occurs most commonly in the temporal region, with fracture of petrous part of the temporal bone. The fracture may be so small that there is a chance that it may not be detected during postmortem examination or by X’ray examination. The blood which accumulates causes compression of the brain substance and exerts pressure effects. The blood is not encapsulated and may not be absorbed for over a long period. Thus chronic cases of extradural haemorrhage are seen. Chronic extradural haemorrhage is more common on the posterior fossa.
Extradural haemorrhage may occasionally occur due to blood dyscrasias in children.
Fatality is due to compression effect and timely evacuation of the blood may save the life of the patient.
Subdural haemorrhage is almost always traumatic in nature. Traumatic subdural haemorrhage occurs due to laceration or rupture of the superior cerebral veins or when due to an indirect shearing force, there is rupture of the superior longitudinal sinus near the debouchment with the superior cerebral vein of the side of impact. This causes PRIMARY SUBDURAL HAEMORRHAGE when the accumulation of the blood usually occurs at the dorsolateral aspects of the upper surface of either or both hemispheres. SECONDARY SUBDURAL HAEMORRHAGE occurs due to injury (laceration) of the brain substance when the primary site of the haemorrhage is in the brain substance and the extravasated blood accumulates in the subdural space.
In the primary type, the blood over the dorsolateral aspects of the upper surface of the hemisphere may spread both anteriorly and posteriorly. The accumulated blood exerts pressure, as a result of which there is widening of the sulci on the same side and flattening of the gyrus, of the opposite side. Pressure for a long duration may cause softening of the brain surface, particularly over the frontal area. Evacuation of the primary subdural haemorrhage gives good prognosis.
Secondary subdural haemorrhage may cause accumulation of blood on the medial aspects of the occipital lobes or in the midbrain or above the pons. Secondary subdural haemorrhage may get encapsulated to form a cyst, (pachymeningitis haemorrhagica interna). Prognosis of exploration of the secondary subdural haemorrhage is generally grave.
In the general conception, subdural haemorrhage is more common a phenomenon in young adults. The experience of the present author is that, when due to trauma, it involves victims of almost all ages and in many cases almost the whole of the surface of the brain. Even the base may have accumulation of the blood.
Subarachnoid haemorrhage –
May be traumatic or natural. When traumatic, it may be primary or secondary. In primary subarachnoid haemorrhage the vessels of the circle of Willis, anterior cerebral artery and less commonly the posterior cerebral artery are involved. Young and elderly adults are the usual victims and it is assumed that even in traumatic subarachnoid haemorrhage trauma may actually be a minor factor in causing the haemorrhage. More important is the condition of the vessels. Secondary subarachnoid haemorrhage occurs due to contusion and laceration of the cerebrum, the blood defusing to the undersurface of the arachnoid mater.
Natural subarachnoid haemorrhage is primarily due to degenerative changes of, the vessels in elderly persons or due to rupture of congenital aneurysm in the young, which usually occurs in small amount, mostly near the base of the brain.
Intracerebral haemorrhage –
Intracerebral haemorrhage may be pathological or traumatic in nature. It may be primary or secondary. There is one school of thought that, primary intra-cerebral haemorrhage is not actually of traumatic origin but are due to pathological causes like degenerative changes in the vessels and hypertension. But Curville and others were certain in their observation that primary intracerebral haemorrhage may be due to direct injury to the cerebral vessels. Traumatic primary intra-cerebral haemorrhages occur at the centrum of frontal and the temporal lobes. In the frontal lobe, they are slit like, vertical and passes slightly lateralward. When in the temporal lobe they pass backward into the occipital lobe. During postmortem examination, there is no difficulty in diagnosis of the traumatic nature of the bleeding. But clinically, there may be some problem in the diagnosis and location of the haemorrhage. Even, some of the natural intracerebral haemorrhages of pathological origin, occurring after a month or two of a traumatic incident, has also been linked in some cases with the old incident of trauma with the contention that,‘delayed traumatic apoplexy’ may occur even after 1 or 2 months of sustaining the trauma. Accepting that, ‘delayed traumatic apoplexy’ occurs, with an interval of some period between the incident of trauma and the onset of fatal or dangerous signs and symptoms, it can be safely said that, in case of delayed traumatic apoplexy, the interval for the starting of the signs and symptoms should always be within one week and not more than this, in which case it should be thought to be due to some pathological reason.
Secondary intra-cerebral haemorrhages are due to gross contusions in the brain substance. Outcome of secondary intra-cerebral haemorrhages are always grave.
Intraventricular haemorrhages –
Intraventricular haemorrhage is always secondary, mostly to intra-cerebral haemorrhage or sometimes to subarachnoid haemorrhage. Intra-ventricular haemorrhage is always fatal.
Other injuries of the brain –
In case of blunt force impact, there may be fracture of the bone which, if is a depressed one, will in addition to the haemorrhages cause contusion or laceration of the meninges of the affected part. There may even be depression of the area injured. When a static head is struck, then, there is usually similar lesion over the part of the brain of the area. But when the head being in motion, strikes a static or relatively static object, then, there will be coup lesion at the site of the impact and a contre-coup lesion at a site diagonally opposite to the site of the impact or the coup injury. However a lesion is not common over the occipital lobe in the coup-contre-coup phenomenon. Because, when there will be a coup lesion on the frontal lobe surface, then instead of contre-coup lesion on the diagonally opposite area of the occipital lobe, contre-coup lesion will be over the temporal lobe, possibly due to the uneven bony base at the middle and the posterior fossa. When the force does not strike the head perpendicularly over the midpart of the forehead or the occiput, there may be slight rotational movement of the skull cage and the contre-coup lesion may be due to the shearing effect causing lesions on the upper, middle or the lower surface of the temporal lobe. The contre-coup lesions may be on the vessels causing haemorrhages or may be on the surface of the brain causing contusion.
In case of use of a sharp cutting, heavy weapon, there will be incised wound on the brain matter with corresponding cut of the covering meninges. In these cases there will be haemorrhages outside and in the layers of the meninges but only a little bleeding will be there in the substance of the brain.
In case of a stab wound in the brain with a sharp cutting pointed weapon, there will be a narrow stab in the brain substance. When a bullet enters the cranial cavity, there will be gross laceration of the meninges and the brain matter at the wound of entrance and exit, with a straight lacerated blind track. If the bullet strikes the bone on the opposite side of the entry then it may take another course (backward) inside the brain or may pass out by making an exit wound.
In case of gross burn injury there may be production of heat haematoma, along with heat fracture of the skull bone.
Complications of the intracranial injuries –
1. Meningitis is more likely, if there is a communication between the inside of the cranium and the frontal air sinuses.
2. Subdural abscess.
3. Cerebral abscess.
4. Delayed meningitis.
5. Cerebral softening due to occlusion of the injured vessel.
6. Dissecting aneurysm, due to injury to the vessel, particularly to the carotid artery and its branches.
7. Arteriovenous communication between the terminal portion of the carotid artery and the cavernous vein due to fracture of the base of the brain.
8. Post traumatic amnesia and neurosis.
9. Post traumatic epilepsy.
10. Post traumatic encephalopathy in boxer.
11. Post traumatic tumours like meningioma, malignant glioma and acoustic neurofibroma.
12. Disability – (a) Physical – paralysis, sensory disturbance, visual defects, headache, ataxia, epilepsy, (b) Psychic – Lack of self-confidence, (c) Circumstantial disability – when the person is not considered fit to continue in his job though he may actually be fit.
Age of the intracranial injuries –
Reasonably accurate relationship may be established between the infliction of the injuries and the time lapsed. This time interval in case of a subdural haemorrhage is related with presence of the clotted state of the blood (3 weeks) or its liquid state (3 months). At the beginning part there is presence of intact leucocyte (24 hrs). Fibroblastic infiltration occurs within the 2nd day and formation of cellular layer around the dot, within 4 days, which gradually thickens. Phagocytic activity starts by 5th day and break of the clot by the midpart of the 2nd week. Further thickening of the wall of the capsule occurs by the end of the 2nd week. Further breakdown of the cells and completion of the healing may take some months or even a year or two.
Interval between brain injury and death –
C. W. Rand and C. B. Courville undertook extensive work on time interval between brain trauma and death. Interested readers may refer to those works published between 1932 – 1936 in “Archs. Neurological Psychiatry”, Chicago.
Post traumatic encephalopathy in boxers –
It is the disability which develops in a boxer after a long period. There is deficient memory, judgement and emotional balance, with lack of intelligence. There is loss of cortical cells and the cells of corpus striatum and there is secondary overgrowth of neuroglia. Parkinsonism like state may develop.
PUNCH DRUNK – It is a condition in a boxer, who during the events of boxing might have sustained minute haemorrhages in the brain. He may behave like a drunk person with cloudy consciousness, unsteady gait and blunting of faculties.
Head injury and legal responsibility –
This is a pertinant question raised, occasionally for the victims of the head injury. In fact, post traumatic psychosis, mental defect, personality disorder, all may be considered to affect adversely the power of understanding of the sufferer. Obviously questions arise, how much civil responsibilities can these persons shoulder and how much should they be responsible criminally for their acts. Without bringing much controversy in the discussion, it can be safely said that, in some circumstances the person may be wholly absolved from any responsibility, in some other circumstances the doctrine of diminished responsibility may be rightly considered and in the rest he may be held fully responsible. It all depends on the nature of brain damage, extent of incapability and the circumstance in question.
Lucid interval in head injury cases – A person who, due to sustaining intracranial injury, is unconscious and non-responsive to stimuli, may regain consciousness and behave normally for some time only to be unconscious again after some period. This period when he behaves normally is termed lucid interval in head injury patients.