Description
Situated on the parietal bones overlying the sagittal suture on the vertex of the skull is an approximately circular depressed comminuted fracture involving both tables measuring 3.5 cm in diameter centred 3 cm posterior to the bregma. Extending forward, to the left and downward from the centre are three fissured fractures measuring approximately 4, 5 and 3 cm respectively. The maximum depression is at the centre surrounded by a uniform circular depression measuring 2.5 cm in diameter. Anterior, left and right margins of the fracture is delineated by a semicircular (3/4 of a circle) fissured fracture connecting the radiating fractures. The edges are sharp with no signs of infection or healing.
[Note: The type of fracture, site, (both approximate and exact), size, shape, disposition (since this is circular fracture disposition does not matter), number of tables involved, associated fractures, site of maximum depression, description of the edges etc should be included.]
Complications
Possible complications of this fracture are:-
a). Extradural haemorrhage from ruptured middle meningeal vessels by fissured fractures or from ruptured sagittal sinus by the depressed fracture
b). Brain Contusions (They are 'coup' contusions.)
c). Subdural haemorrhage (is unlikely as the impact may not have produced a 'rotational' movement)
d). Subarachnoid haemorrhage (It is usually present around brain contusions and lacerations.)
e). Uncal and tonsillar herniation contusions (Rarely heavy blows on the top of the head can push the parahippocampal gyri through the tentorial opening bruising the uncus and tonsils through the foramen magnum bruising them.)
Causative Weapon
Blunt, heavy instrument with a round striking surface e.g. fall head-on on a round projection from height or assault with a blunt weapon with round striking surface e.g. base ball bat, rice pounder, falling coconut etc.
(Note: This is how the questions are asked in the forensic medicine OSPEs.)
Sir could you please explain what points should be included in an answer for a question that says,
ReplyDeleteWhat are the medico-legal issues of Extradural Haemorrhage?
Saw the question on a past paper. :) Thank you very much.
Tania,
DeleteThanks for asking this question. I suspect the question should more correctly be asked 'what is the medico-legal importance of EDH?'.
The answer should include
a. EDH as a cause of death in blunt force trauma to head, which include falls, assault with blunt objects and rarely road traffic accidents,
b. the 'lucid interval' it is classically associated with. It is possible that a man regained fully consciousness after being concussed before deterioration of consciousness sets in. During the lucid interval he is capable of communicating with another person of the circumstances leading to his injury,
c. It could give rise to an allegation of medical negligence. A doctor thinking that the person is our of danger during lucid interval might send him home without getting him admitted for observation,
d. Category of hurt. A large EDH is considered to be 'fatal in the ordinary course of nature' as it will be fatal if not evacuated surgically. However, small EDH which has not be surgically evacuated can be considered as 'endangering life' as chance of it becoming large and hence becoming fatal is 'existing',
e. It can be confused with 'heat haematoma', which is a spurious EDH occurs in death due to burns.
f. EDH should always be considered as traumatic but in rare instances there can be spontaneous EDH such as infection, dural vascular malformations, bleeding disorders etc.
I hope this would be enough for an answer.
By the way, I wish you a very happy new year!
Priyanjith
Under C. it should read as 'out of danger' and under d. which has not been surgically... Sorry for the spelling mistake.
DeleteThank you sir. I was thinking the category of hurt of EDH is "fatal in ordinary cause of nature" regardless of its size. Your explanatations were really helpful. I wish you too a very happy new year!
ReplyDeleteSir, please can you brief me on the patterns of head injuries which help you differentiate a fall from an assault? Thank you.
ReplyDeleteBrain Contusions
DeleteA fall on the back of the head causes contusions on the brain surface diametrically opposite to the site of impact (fall). They are usually seen on the temporal and frontal poles and called 'contre coup' injuries. An assault with a blunt object such as a hammer only causes brain contusion directly underneath the site of impact. Hence they are called 'coup' injuries. The presence of contre coup injuries may help the pathologists to differentiate a fall from an assault.
Other injuries on the scalp and the skull
It is traditionally accepted that the injuries due to assaultes are found on the top of the head and the injuries which are on the sides of the head are from falls.(in the west the brim of a hat is taken as an 'anology'. The injuries above the level of the brim of a hat should have been caused by assault and the others, which are present below the brim of the hat should have been a result of a fall.)
Skull Fractures
Depressed fractures (comminuted or non-comminuted) are generally caused by assaults as most of the weapons used have small strking surfaces. They cause skull fractures by local deformation e.g. blow with a hammer.
On the other hand falls generally causes linear fractures as the striking surface, which is the floor, is having a broader striking surface. The mechanism is 'general deformation'. (Of course if the victim falls on a projeted surface suh as a small stone coming out from a concrete floor the result may be a depressed fracture.)
Those are the three different injuries, which can be used to differentiate a fall from an assault.
Sir, I hope you don't mind me asking endless questions?
ReplyDeleteCan a grazed abrasion on the back,legs and arms taken as a "grievous injury"?
By the way,I'm so grateful that you spend your invaluable time on illustrating answers.
Not at all. The sole purpose of my blog is to help our students. Therefore, please ask more and more questions and encourage the others to do the same.
ReplyDeleteWhy would the grazed abrasions on the back, legs and arms be 'grievous'? Under which limb would they come? I do not undersand the reason for you to think them as grievous. Grievous injuries are defined in the Section 311. They are the only grievous injuries. Nothing else will become grievous.
Okay. Well I was thinking maybe it's possible that it could fall under limb (i), the sufferer being in severe bodily pain or unable to follow ordinary pursuits for a period of 20 days. Which now I realize is kind of lame. :D
ReplyDelete