Injury to thorax and abdomen-Medicolegal Aspect

injury to thorax and abdomen. tension pneumothorax , cardiac tamponade, rupture of kidney, rupture of liver, intestinal perforation, foreign body in rectum

1. Dr Mohd Kaleem Khan Assistant Professor Department o f Forensic Medicine J.N.M.C., A.M.U., Aligarh INJURY TO THORAX AND ABDOMEN

2. Injury to thorax The relationship of pleural cavities, lungs, heart, mediastinum and diaphragm is depicted. From the forensic aspect, The spleen and most of The liver and Stomach Are thoracic organs as they lie largely beneath the costal margin, Vulnerable to both stabbing and blunt injury to the chest.

3. Penetrating injuries, especially by knife to the lower lateral wall of the thorax, May enter the peritoneal cavity as well as the pleural spaces, perforating The diaphragm en route. The stomach, The heart

4. INJURIES TO THE CHEST WALL The integrity can be compromised either by Severe mechanical failure of the rib cage By penetration of the pleural cavities. Fractures of ribs are common, but do not greatly embarrass respiration unless: They are numerous that they prevent expansion of the thorax Broken ends penetrate the pleura and lungs Pleural and muscular pain limit respiratory effort.

5. Flail Chest Bilateral fractures of ribs on the anterolateral sides of the thorax , Multiple fractures of some ribs and Sometimes with added fracture(s) of the sternum. Expanding the thoracic volume during inspiration are impaired. The loose section is sucked inwards during inspiration, this clinical sign being known as 'paradoxical respiration'. Dyspnoea and cyanosis may develop Death because of progressive hypoxia.

6. The flail chest is caused by frontal violence, In motor vehicle accidents - against the steering wheel or fascia In stamping assaults, foot is violently applied to the supine body . In chest injury, broken rib ends may be displaced inwards , the jagged tips ripping the parietal and visceral pleura . This may cause A pneumothorax or a haemothorax, or both, This is rare in civil practice, though common in battle casualties.

7. Rib fractures most in the anterior or posterior axillary lines. The upper ribs less often fractured. The fracture show bleeding beneath the periosteum . Attempts at resuscitation, external cardiac massage , common cause for extensive rib fractures(up to 40 per cent)

8. Infants In infants, especially victims of child abuse, rib fractures. Infant is squeezed from side to side, as Adult hands are clamped in each axilla or lower on the lateral sides of the chest. The hyper flexion break ribs in their posterior segments, near their necks.

9. The ribs are levered against the transverse processes of the vertebrae by excessive anterior flexion, fracture in the paravertebral gutter. Fresh fractures on radiography and at autopsy. Within about 2 weeks (though this is very variable), callus will form and be Visible both on x-ray And by direct post-mortem inspection. It is extremely difficult to date such callus.

10. Anterior rib fractures are rare in infancy other than from child abuse; check bony injury if resuscitation attempted.(infant ribs pliable). In infants, older fractures due to birth injury may be found. The sternum may be fractured by Stamping Frontal impacts Posterior displacement of fragment, heart or great vessels may be severely damaged.

11. HAEMORRHAGE AND INFECTION IN THE CHEST Breaches blood vessels and the pleural lining can lead to a haemothorax. Intercostal and, less often, mammary arteries. Massive haemorrhage -large vessels in the lung or mediastinum. The lung hilum can be torn or penetrated by stabs wounds . Several litres of blood may accumulate in the chest, Either as liquid or Clot, or Mixture of both. Death may occur from loss of circulating blood volume.

12. A knife that passes obliquely into the chest may puncture A great vessel or Heart chamber, Fatal cardiac tamponade or haemothorax , The valve-like overlap of the tissues after withdrawal of the blade may seal up-the external wound. The same may apply to a gunshot wound, where bleeding can be virtually absent if the wound is uppermost after death

13. Pneumothorax Pneumothorax is caused by entry of air into pleural space leading to sudden increase of intrathoracic pressure as in Blunt chest injury, or Sharp penetrating injury, Fractured rib Or stab with a sharp instrument. There are three types of pneumothorax:

14. Contd.. A simple type where a leakage through the pleura allows air to enter the pleural cavity, But where the communication rapidly closes. The lung partly collapses, but If death does not supervene The air is soon absorbed . If the communication remains open, then a bronchopleural fistula ensues with air in the pleural cavity but, as it is not under pressure, Not bubble out when the autopsy ‘water test’ is attempted. Radiology is for demonstrating the air in the pleural cavity.

15. Contd.. 2. When the leak in the pleura (or rarely the chest wall) Has a valve-like action, Air is sucked into the pleural cavity at each inspiration, But cannot escape on expiration. This pumping action leads to a 'tension pneumothorax ', which causes complete collapse of the lung onto its hilum and a shift of the mediastinum to the opposite side. Pneumothorax that may be demonstrated at autopsy by penetrating an Intercostal space under water, Though radiology is a much better method of detection of all types of pneumothorax.

16. When an injury of the chest wall communicates with the pleural cavity, a 'sucking wound' may form with direct passage of air from the exterior. Often seen in military Complicated by haemorrhage and Infection.

17. Stab wound of the chest that allows Direct communication with the exterior, Layered skin and intercostal muscles closes the track when the weapon is withdrawn. The knife often enters the lung, Air can enter the pleural cavity from the bronchi. Natural disease can also cause a pneumothorax, which can lead to sudden death. Common causes are A ruptured emphysematous bulla, A tuberculous lesion at the lung periphery, or A tear at the site of a fibrous pleural adhesion.

18. INJURIES OF THE LUNGS . Any substantial impact on the chest can contuse the lung surface or deeper parts. This may be beneath the area of impact or ' contrecoup ' damage on the opposite surface. Deceleration injuries are seen in falls and traffic accidents, mostly Along the posterior lateral surfaces where a vertical line of sub pleural bruising occurs, Often in the paravertebral gutter. The outline of ribs may be imprinted in the contusion on the pleural surface of the lungs. Bruising may cause sub pleural blood blisters, which may rupture to release blood or air into the pleural cavities.

19. Laceration of the lung can occur in blunt injuries and even lobes or parts of a lobe may be detached . Vessels in the hilum (especially pulmonary veins) or may be ripped, causing severe intrapleural or mediastinal haemorrhage. Osborn describes ‘Pincer Contusions’ of the lung, where the expanded lower margins of the lungs become trapped in the narrow costophrenic angles. In children, lung injuries can occur without fracturing of the ribs , The wounds may be 'through-and through‘ injuries that emerge to cause further damage to the heart or great vessels

20. INJURIES OF THE HEART A common form of homicide is a stab wound. The entry point maybe Anywhere over the pericardium Adjacent areas. Sternum is penetrated Most stab wounds enter Intercostal spaces, Through a rib or Costal cartilage .

21. A stab wound causes injury to The right ventricle The anterior interventricular septum The left ventricle. A shallow stab wound may enter the myocardium and not reach the lumen of the ventricle.

22. Stab Wound Injury to Ventricles Right ventricle( thin walled) The knife passes into heart cavity. Copious bleeding into the pericardial sac. In the left ventricle, Layered thick wall may partly or wholly seal the wound, Bleeding can be slight . If the drainage from the pericardial wound is less than the leakage from the ventricle , eventually TAMPONADE will develop.

23. Many stab wounds of the heart are transfixing or 'through-and-through ' injuries, If the left ventricle carries both wounds, the rapidity of bleeding may still not be torrential. Some of these wounds pass downwards and transfix the heart, then exit through the lower wall of the right ventricle and pass on via the diaphragm to end in the liver.

24. Blunt Injuries of t he Heart Seen in mainly in Traffic accidents, Falls from a height and In stamping assaults, though Any heavy impact (including a punch) can cause fatal damage. There can be heart damage in an intact chest cage, especially in a child with a pliable thorax. Fatal blunt damage of the heart may occur, without mark on skin The cardiac injuries are usually on the front of the organ,

25. Posterior bruising and laceration can occur if The heart is compressed against the thoracic spine, Stamping assaults and Steering wheel impacts. All degrees of damage can occur, from mere epicardial bruising to lacerations that open the ventricular lumen widely. The interventricular septum may be ruptured Aircraft crashes, the whole heart may be avulsed from its root, to be found lying loose in the thorax.

26. Haemopericardium and Cardiac Tamponade Most causes of haemopericardium are From natural disease, Ruptured myocardial infarct or a Ruptured dissecting aneurysm of the aorta Sequel to injury to the chest. When the damage has been caused by a stab perforating pericardial sac, bleeding can escape into the Pleural cavities, Mediastinum Even abdomen if the diaphragm is penetrated .

27. Cardiac Tamponade Blood accumulates in the pericardial sac faster than it can escape, Either because the bleeding rate exceeds the drainage or The exit hole in the pericardium becomes blocked by blood clot. In bleeding from a contusion or laceration of the heart, No Escape Route From The Sac. The Pressure In The Pericardial Sac Increases, Prevent The Passive Filling Of The Atria During Diastole. The cardiac output falls Death will follow,

28. INJURIES TO GREAT VESSELS Aorta commonly Suffers injury in deceleration trauma from both Road accidents Air accidents, Falls from a height. When the thorax is suddenly decelerated, the heart – Being relatively mobile in the chest – Attempts to continue in the original direction. This causes severe traction on the root of the heart, Complete or Partial rupture of the aorta in the descending part.

29. The lower thoracic aorta is Closely bound to the anterior longitudinal ligament The weak point and transection occurs at this level, Cleanly that it looks like a surgical incision. The tear is annular and at right angles to the axis. May be multiple parallel intimal tears -called 'ladder-rung tears'. In deceleration trauma, incomplete tears of aorta Only the intima and inner media, Found without major transection; Death is delayed, False aneurysms Dissections may be diagnosed on aortograms.

30. The pulmonary artery and vein branches may damaged The great vessels are often involved, stab wounds. Stabs can pass directly into the arch of the aorta, Even a shallow injury may reach the aorta can cause death Other stab wounds may injure The heart valves or May enter large primary branches of the pulmonary artery or veins, Causing gross bleeding

31. Trauma of the Abdomen Open or penetrating wounds The liver and spleen, may bleed - haemoperitoneum . In intestine and mesentery wounds often being multiple, because of the overlapping. The stomach, protected by the ribs is less often penetrated. The kidneys are rarely stabbed except from a thrust in the back.

32. Blunt Trauma Bruising of the abdominal wall, both of the skin and the underlying muscles, Blood may track down the inguinal canal and appear in The scrotum Vulva In Child Abuse Fingertip or knuckle bruises may be seen, Bruises may be seen on the sides of the abdomen In the axillary line of the chest.

33. The Intestine and i ts Mesentery Bruising of the gut and its vascular mesentery crushed against the prominent lumbar spine The duodenum and jejunum transection from Being compressed against the spine, In children, blow in the central or upper. Laceration of the bruising and tearing of the central parts of the mesentery, Multiple fenestrations of mesentery. .

34. Injury to the mesentery may damage local arteries Causing severe bleeding, Thrombosis of arteries. With infarction of the bowel as a consequence Perforation may be delayed for a day or two

35. Rupture of t he Spleen Malaria, glandular fever enlarge the spleen - rupture . The 'stiletto' dagger was specifically designed in medieval Italy for puncturing the enlarged malarious spleen. The spleen damaged either from impact on its surface or from traction on its pedicle . The rupture may be immediate or delayed if a large sub capsular haematoma. The rupture may be immediate or may be delayed if a large subcapsular haematoma and underlying tear are held intact for a time by the capsule. This delay can last for a number of days or even weeks.

36. Rupture of the Liver Rupture of the liver following serious abdominal trauma, Fall from A height or A crush injury between two wagons. Drivers impact on the rim or centre of the steering- wheel. Unrestrained passenger being thrown against the fascia. A pedestrian as a primary impact from a vehicle or as Secondary damage from being thrown to the ground.

37. Linear cracks in liver , most often on the convex upper surface, Superficial sub capsular tears to Complete transection of the organ. The surface lacerations may extend deeply into the liver and may even appear on the opposite surface. There may be internal tears that do not communicate with the surface. Infants suffer liver damage from trauma and it is a well-known component of the child abuse. Liver tears can occur during the process of birth, particularly in breech presentation.

38. Kidneys Traffic impacts, mainly in pedestrians, Kicking Peri renal haemorrhage is much more com mon When a victim is lying on the ground, a swinging boot can conveniently enter the slightly raised arch between the rib margin and hip , where the kidney is situated. All grades of damage from comminuted pulping through transection to shallow surface lacerations.

39. Foreign Bodies in t he Gut Material are found in the alimentary system both clinically and at autopsy. Disorders of the mental state may lead Extraordinary numbers of objects being swallowed Insertion of foreign objects into the Rectum, Urethra, Bladder Vagina ( potatoes, banana, bulb, carrot, cups, a beer can, bottles)

40. In recent years, the smuggling of narcotics through ports and airports has commonly been accomplished by 'body-packing', The drugs being concealed in condoms, Swallowed or, Inserted into the rectum or vagina Deaths have occurred by rupture of a package within the gut, so that a massive dose of heroin or cocaine is released.

41. Injuries to t he Pelvis and Pelvic Organs The bony pelvis suffers a variety of fractures and dislocations in severe trauma: Running over by a vehicle wheel – The pelvis may be splayed open, the symphysis parting and one or both sacroiliac joints becoming dislocated. Impact from the side May shatter the superior pubic ramus The inferior pubic ramus , Dislocate the sacroiliac joint on that side.

42. A fall from a height onto the feet Dislocate the hips or Even to drive one or both femoral heads through the acetabulum . The pelvic girdle may crack The sacroiliac joints may be sheared apart. A kick or heavy fall onto the base of the spine may fracture the coccyx or sacrum. Scrotal and vulval injuries can occur from falling astride an object or in traffic accidents.

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