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 of 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.

5.  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

6. 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.

7. 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.

10.  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.

11.  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)

12. 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.

13.  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.

15.  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.

16. 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.

17.  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

18. 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:

19. Contd..
1. 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.

20. 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.

21. 3. 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.

22.  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.

24. 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

25.  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

26. 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.

27.  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.

28. 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.

30.  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.

31. Blunt Injuries of the 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,

32.  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.

33. 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.

34. 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

37. 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.

39.  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.

40.  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

41. 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.

44. 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.

45. The Intestine and its 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.
.

46.  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

48. Rupture of the 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.

50. 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

52.  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.

53. Kidneys
 Traffic impacts, mainly in pedestrians,
 Kicking
 Peri renal haemorrhage is much more
common
 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

54. Foreign Bodies in the 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)

55.  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.

56. Injuries to the 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.

57.  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.

58. thank