Regional Injuries د / عبد المنعم جودة مدبولى دكتوراة الطب الشرعي و السموم الإكلينيكية, مدرس الطب الشرعي و السموم الإكلينيكية, استشاري علاج التسمم بمستشفى بنها الجامعي عضو لجنة مراجعة البرامج و المقررات بوحدة الجودة بسم الله الرحمن الرحيم

Incised wound in neck “ Cut throat ”: They are seen in suicide & homicide and rarely accidental. Accidental cut throat may be caused by glass injury that can produce an incised wound. It can be identified by the presence of fragments of glass in the wound, by small side cuts in its margin and by the circumstances.

Suicidal cut throat Homicidal cut throat 1- Circum stances Scene of the crime 1-History of troubles. 2- +/- suicide notes Door is looked from inside 2- No disturbance of furniture 3- No physical evidence e.g. bl. Stains, finger prints of another persons 4- Weapon is usually present, the fingerprints & bl-stains on it related to the victim 1-History of threatening. 2- +/- threading notes Door isn’t looked from inside 2- Disturbance of furniture 3- Presence of physical evidence belonging to another persons 4- Weapon is usually not presented. Fingerprints related to the assailant.

3-Exam. of the victim: 1-Sex 2-Position 3-Site of blood 4-Cadaveric spasm 5-Signs of struggle 6-Other injuries 1-Usually male front of a mirror 2-Usually in front of a mirror front of the body 3- Directed in the front of the body 4- On the knife the victim firmly catch weapon on his hand 5- Not present 6- As cut wrist, superficial cuts in left index & thumb fingers 1-Any sex Any where 2-Any where directed in the back 3- Blood is directed in the back 4- On assailant e.g. hair or piece of clothes 5- Defense abrasions or tears in the clothes 6- As multiple stabs in chest & abdomen

4-Exam of wound 1-Site 2-Direction 3-Depth 4-Character 1- High up in the neck. 2- Oblique. 3- Usually starts deep & high up on the lt. side below the angle of the jaw “ Rt. handed “ 4- Slanting : cuts skin at a higher level than S.C. tissues & muscles of the neck “ trachea or larynx “ 1- Low down. 2- Transverse. 3- Deep all through cutting all vital structures. 4-Not slanting “ cuts skin & muscles at same level “

5- Hesitation marks 6-Edge 7-Cut vessels 8-Number superficial, slight, repetitive incised wounds at beginning of wound 5- Present == superficial, slight, repetitive incised wounds at beginning of wound 6- Linear- clean cut which since the skin is under tension when the victim throws back his head to clear a path for the weapon 7- Not divide jugular V. or carotid a. as protected by the extended sternomastoid muscle 8-usually one 5- Not present but have multiple irregular cuts 6- Toothed “ dental “ even e’ sharp weapon because the skin isn’t under tension “ thrown into folds” 7- Divide jugular V. or carotid a. 8-may be multiple

5-Examination of the assailant 6- Examination of the weapon -No assailant Cadaveric spasm 1. Signs of struggle, abrasion & bruises. 2. Clothes : tears or lost buttons. 3. Fingerprints & blood group compared with those found at scene of crime Fingerprints & blood group

Homicidal Cut Throat Suicidal cut throat

Mechanism of death in cut throat : 1-Neurogenic shock: from vagal cardiac inhibition. 2-Hemorrhage: from injured carotid & jugular vessels. 3-Venous air embolism: through the opened big veins in the neck. 4- Mechanical Asphyxia (Chocking): if the trachea is opened,blood may be inhaled & chocking occurs. Or the soft parts of the neck fall in & closure of the airway results in mechanical asphyxia. 6-Delayed causes: due to edema of the glottis or sepsis of the wounds & aspiration pneumonia === 2ry bronchopneumonia.

سؤاااال هاااام When cut simulate lacerated wound? 1- Homicidal cut throat 2- Cut with serrated sharp object 3- Corrugated skin (axilla & scrotum) When lacerated simulate cut wound? Only in scalp laceration سؤاااال هاااام

Traumatic asphyxia:- The thoracic cage is squeezed for a considerable time, with sufficient force to impair respiratory movements. Fractures of the ribs & sternum:- Fr actures of the ribs are dangerous if :- سؤال هام 1.Multiple 1.Multiple; prevent expansion of the chest causing fatal respiratory embarrassment. penetrate pleura &lungs 2.Fractured ends which penetrate pleura &lungs causing he & pneumothorax. 3.Pleural & muscular pain 3.Pleural & muscular pain that limit respiratory effort. Fractures of the ribs are dangerous if :- سؤال هام

Flail Chest >3 consecutive ribs 1.Multiple rib fracture >3 consecutive ribs. frontal violence 2.Commonly occurs in frontal violence e.g. stamping assaults or motor car accidents. 3.Loss of rigidity of the chest cage “paradoxical respiration”. 3.Loss of rigidity of the chest cage, attempts at expanding chest volume during inspiration are impaired & the loose section is sucked inwards during inspiration “paradoxical respiration”. -C/P. : dyspnea, cyanosis,hypoxia in extreme degree of flail chest. -NB. Injury to liver (ribs 7-10), spleen (9-10) & kidney (11- 12) Flail Chest

Paravertebral fractures & child abuse: The ribs of infants and children are very pliable and accidental fractures are uncommon except in gross injury. lateral compression of the infant chest multiple paravertebral fracturesHowever, lateral compression of the infant chest by adult hands in the battered child syndrome can cause multiple paravertebral fractures. مهمممممممم

Stab wounds of chest: Most common homicidal stabbing [heart, lungs, & great vessels; pulmonary a., aorta} Stab w. in the atria, Rt. V., or great vessels are often more rapidly fatal than Lt. V. ? سؤااال Contraction of the thick muscles of the Lt.V. can partially close the stab w. “valve mechanism”. Rt. V. is more often injured ? as it forms a great part of the anterior surface of the heart. سؤااال.... Rupture aorta due to acc /dec →rapid death سؤااال Stab w. in the atria, Rt. V., or great vessels are often more rapidly fatal than Lt. V. ? سؤااال Rt. V. is more often injured ? as it forms a great part of the anterior surface of the heart. سؤااال....

Mechanism of death due to Stab wounds of chest : Internal hemorrhage into the pleural cavity, the mediastinum, or the pericardial sac (cardiac tamponade). 200 ml مهممممم However there may be little external bleeding.

Abdominal Injuries Blunt inj. of the abdomen: Kicking or impact against the steering wheel in MVA. To the ant. Abdominal wall causing compression of the viscera,with lacerations & contusions. Stomach, intestine & mesentery: In adults, can tear the mesentery or intestine, leading to hge & peritonitis. the rigid lumbar spine In infants,compression of the intestine & mesentery against the rigid lumbar spine can tear them. سؤاال D.D. Bet. traumatic & pathological rupture : سؤاال st one shows irregular edges surrounded by bruises with bulging of m.m.to the outside & normal other parts of G.I.T. 2nd one shows regular edges surrounded by fibrosis with evidence of disease as typhoid or peptic ulcer. سؤاال D.D. Bet. traumatic & pathological rupture : سؤاال

Urinary Bladder: More common in males than in females ? سؤاااال Types 1- Extaperitoneal when the bladder is empty or contains only small amount of urine.it is associated with fractures of the pelvis. 2- Intraperitoneal when the bladder is markedly distended with urine. caused by a kick, a blow,or any blunt force to the lower abdominal wall.