BLUNT FORCE TRAUMA

Berti Nelwan
berti@indosat.net.id

 Guidelines for Reports by Autopsy Pathologists;

Vernard Irvine Adams, MD; Department of
Pathology and Cell Biology, University of South
Florida, Tampa, Florida, USA. 2008
Textbook of Traumatic Brain Injury; Thomas
Genrelli MD. American Psychiatic. 2005
Clinical ForensicMedicine3rd editionEdited by
W.D.S. McLay. 2009
Blunt Force Trauma; Pathology Forensic Journal.
2010

Forensic Pathology
Forensic Pathology is the branch of medicine
which analyses victims of crime scenes
medically.
They are the last physician for the deceased
and their role is to discover and interpret the
evidence left during the autopsy.

Analysis of Wounds
Not every crime victim is murdered.
Physicians can contribute to proof of the
severity of a crime or that a crime
actually occurred in some cases for a
living victim.
Wounds provide evidence of the crime.

Wound Categories

Bruises (or contusions)

Abrasions (or grazes or scratches)
Lacerations
Incised wounds
Puncture (or stab) wounds
Gunshot wounds

Definition

Injuries resulting from an

impact with a dull, firm surface
or object.

 The deaths resulting from blunt force trauma

occur in a variety of scenarios:
almost all transportation fatalities
jumping or falling from heights,
blast injuries,
Be struck by a firm object, such as a fist, crowbar,
bat, or ball.
Bite wounds and chop injuries may be considered
variants of blunt force trauma, sharp force
trauma, or a class of injuries unto themselves.

 Blunt force trauma is routinely involved

in cases classified as accidents, as well as
in cases of suicide and homicide.
it is important to document evidence of
blunt force trauma in all autopsies
one should not immediately assume that
blunt force trauma is the cause of death

For example,
Individuals may die of infections, thromboemboli, or
organ failure that occurs as a delayed result of previous
blunt force trauma.
For purposes of death certification:
Proximate Cause of Death
the cause of death of an individual who dies of
pneumonia after being hospitalized for several days for
treatment of blunt force injuries following a motor
vehicle collision should be certified as "acute
bronchopneumonia complicating blunt force injuries
due to a motor vehicle accident."
the manner of death should then be certified as
"accident."

 The severity of injuries inflicted as a result of

blunt force trauma is dependent on the
amount of kinetic energy transferred and the
tissue to which the energy is transferred.
The kinetic energy associated with a moving
object is equal to one half the mass of that
object multiplied by the velocity of the object
squared (Ek= 1/2 mv2).

 Important: the characteristics of the

blunt object and the surface that is
impacted.
Impacts involving a large surface will result in a
greater dispersion of energy over a larger area and
less injury to the impacted tissues.
an impact on a small area of a curved surface, such as
the head, will cause greater damage than would be
caused were that same impact to occur on a flat
surface, such as the back, since there will be a more
concentrated point of impact on the head.

 The composition, or plasticity, of the

tissues impacted also affects the
resultant injuries.
For example, a person who is kicked in the
chest may have only minimal injuries to the
elastic skin surface, whereas deeper, more
solid tissues such as ribs and internal organs
may experience fractures and lacerations.

 The another factor affecting the severity

of blunt force injuries is the amount of
time the body and the impacting object
are in contact.
A longer period of contact allows kinetic
energy to be dissipated over a prolonged
period, resulting in less damage to the
tissues than an equally forceful impact with
dispersion of energy over a brief period.

This lecture focuses on the

cutaneous manifestations of blunt
force injury
Note:
The blunt force trauma may cause contusions and lacerations of the internal
organs and soft tissues, as well as fractures and dislocations of bony
structures.

 The major types of cutaneous

blunt force injuries are as follows:

Contusion (bruise)
Abrasion
Laceration
Avulsion
Fracture

Bruises
A bruise is "a hemorrhage into tissues
produced by the escape of blood from blood
vessels".
Bruises may be found in the skin, muscles, and
internal organs.

Bruises
Bruises are typically produced by a blunt force
impact, such as a blow or a fall.
They may also be produced by squeezing or
pinching, where the force is applied gradually
and then maintained.

Contusions (Bruises)

Contusions are
discolorations of the skin caused by bleeding
into the tissues from ruptured blood vessels.

Important: Natural Bruises

Bruises may occur in a variety of natural diseases in
which there is an abnormality of the clotting
mechanism of the blood, e.g. scurvy (vitamin C
deficiency), leukemia, alcoholic liver disease.
This bruising is "spontaneous" because the injury
which produces it is so insignificant as to typically
pass unnoticed.
The presence of such natural disease will exaggerate
the bruising effects of any trauma.

Problems with Skin Bruises

Delayed appearance
Ageing (relative)
Site of Trauma
Shape of object
Degree of force
Post-mortem bruises
Post-mortem lividity

Classic Causes of Bruises

Finger pad bruises: battered babies, manual
strangulation
Different ages: repeated assaults
Shoulders and arms: forceful restraint
Wrists and ankles: dragging
Inner thighs: forceful intercourse
Chest: resuscitation
Bruising is uncommon in Suicides

Bruises
The extent of bruising is inversely proportional to the
sharpness of the impacting object.
Bruises may be associated with other blunt force
injuries such as abrasions and lacerations.
As a general rule bruising is not associated with
incised wounds or stab wounds where there is a free
flow of blood from the cut blood vessels rather than
leaking into the tissues.

Site of Trauma
In contrast with abrasions, the location of a
bruise does not necessarily reflect the precise
point of injury.
Leaking blood will follow the path of least
resistance and gravity.

Delayed Appearance
Deep bruises may have delayed appearance at the
skin surface. Deep bruises may require as long as 12
or 24 hours to become apparent, and some may
never do so
The more superficial the source of bleeding, the
sooner the discoloration will be seen on the skin
surface.
In a living victim, a second examination in one or two
days may show bruising.
In the dead, a further examination one or two days
after the original autopsy may show bruises which
were not previously seen and reveal previously faint
bruises.

Autopsy and Bruising

Bruising in Deep Tissue
1. Possibly life-threatening
2. Sometimes no external injury
3. Revealed in autopsy

Documenting Bruising
1. Photography
2. Notes

Degree of Force
The size of a bruise is an unreliable indicator
of the degree of force causing it.
However, a heavy impact is likely to produce a
large bruise and a light impact to produce a
small bruise.
If bruising is slight, it is reasonable to assume
that the degree of violence was slight.

Determining Degree of Force in Bruise

Patterns
Location:
Some areas of the body bruise more easily than
others. The face bruises more readily than the
hands.
Bruising occurs more readily in loose tissues and
where there is a large amount of subcutaneous fat
Bruising is less apparent where the skin is strongly
supported by fibrous tissue or if the muscle tone is
good.

Determining Degree of Force in Bruise

Patterns
Age
Infants and the elderly tend to bruise more easily than
young and middle aged adults.
Infants have loose and delicate skin, and the abundant
subcutaneous fat.
Elderly have degenerative changes in the tissues which
support the small blood vessels of the skin and
subcutaneous tissues.

Gender:
Women bruise more easily than men because they have
more subcutaneous fat and this is particularly true of
obese women.

Natural Disease
Skin color

Causitive Object
The shape of the bruise is most likely to reflect
the shape of the causative object when the
object is small and hard and death occurs
soon after injury

Causitive Object
A doughnut bruise is produced by an object
with a rounded contour (e.g. baseball).
Two parallel linear bruises result from a blow
with a rod or stick
Bruises can follow rounded contours if they
are caused by a flexible object like a lash

Causitive Object
Bruises produced by fingerpads as a result of
gripping are usually larger than the fingerpads
themselves.
The pattern and location suggests the
mechanism of causation:
On the neck in throttling
On the upper arms in restraint.

Such bruises are referred to as patterned.

Aging of Bruises
Color changes a bruise goes
through can give a rough estimate
of time of injury
Colors result from breakdown of
hemoglobin from tissues
Dark blue/purple (1-18 hours)
Blue/brown (~1 to 2days)
Green (~ 2 to 3 days)

Yellow (~3 to 7 days)

This rate assumes person is

healthy, however.

Camps:
red

immediate

dusky purple / black

soon after

green

days 4 -5

Yellow

days 7 - 10

resolution

days 14 - 15

violet

immediate

blue

day 3

green

days 5 - 7

yellow

days 8 - 10

resolution

days 13 - 18

Glaister:

Polson and Gee:

red dark / red black

< 24 h

greenish tinge

around day 7

yellow

around day 14

resolution

up to 30 days

Smith and Fiddes:

red

immediate

purple black

soon after

green

days 4 -5

yellow

days 7 - 10

resolution

days 14 - 15

Aging Bruises
While accurate estimation of the age of a single
bruise is not possible, a fresh bruise can be
distinguished easily from one which is several days
old.
Establishing that bruises are of different ages may be
of medical importance where there is an allegation
of repeated assaults:
Child abuse
Wife beating
Where pre-existing injuries need to be distinguished from
those produced by a recent assault like a chronic alcoholic
who was assaulted.

Post Mortem Bruises

It requires considerable violence to produce a bruise
post mortem or after death.
These bruises are smaller relative to the degree of
force used.
Post mortem bruises are most readily produced in
areas of hypostasis (post mortem lividity, livor
mortis) or where tissues can be forcibly compressed
against bone.
A bruise can develop on the head after the body is
left lying on the back.

Post Mortem Lividity

(hypostasis, livor mortis)
The settling, after death, of blood within the blood
vessels under the influence of gravity.
This results in a purplish discoloration of parts of the
body that are lower while sparing areas of pressure
contact - contact pallor.
The pattern and distribution of lividity distinguishes
it from bruising.
A body found on its back has livor mortis on the
dorsal (back) side with pale areas where the bone
contacted the floor.

Postmortem changes on the chest caused by insect activity.

Patterns of Injury
Bruises to the knuckles of the hands, together
with bruises of the eyelids, bridge of the nose,
cheeks and lips, suggest a fist fight.
Bruising around the eyes (spectacle bruises)
may be produced by direct blows, but also
commonly result from a fracture of the base
of the skull, e.g. in vehicle collisions or
gunshot wounds to the head
They may also follow blunt impact to the
forehead producing jolting of the eyeballs in
their sockets with tearing of small orbital
blood vessels.

Patterns of Injury
Injuries in motor vehicle collisions almost
invariably include abrasions and lacerations as
well as bruises.
Patterns of injury may allow reconstruction of
incidents involving pedestrians or allow
distinction between driver and front seat
passenger.

Patterned abrasion on the head due to impact by a motor vehicle.

Two contusions on the skin of the chest

 A contusion
on the arm.

BLUNT HEAD TRAUMA

Blunt trauma to the scalp and face can produce contusions,
lacerations, and abrasions.
Battles sign a bluish discoloration of the skin behind the
ear that occurs from blood leaking under the scalp after a
skull fracture.
Spectacle hemorrhage (raccoons eyes) a discoloration of
the tissues around the eyes usually due to a fracture of the
skull.

There are three major types of hemorrhages which

occur in the skull.
The type of hemorrhage helps the examiner
understand what may have caused death.

1) Epidural hemorrhage bleeding directly under

the skull on top of the dura mater. It is associated
with a skull fracture and a torn artery. This type
of hemorrhage accumulates rapidly and death
may occur quickly.

2) Subdural hemorrhage bleeding under

duramater on top of the brain. It may or may
not be associated with trauma and is caused
by torn veins which forces the blood to
accumulate more slowly than the epidural
bleed.

3) Subarachnoid hemorrhage caused by blunt

trauma or ruptured blood vessels. It is located
directly on the surface of the brain.

Pathologists also look for the presence of coup and

contrecoup injuries to the brain to help differentiate
between a fall and a blow to the head by a second party.
Coup injury caused when a moving object (such as a
hammer) strikes a stationary head. The injuries to the
brain will be directly beneath the point where the weapon
strikes the head.
Contrecoup injury caused when a moving head (as in a
fall) strikes a stationary object like the floor. The injuries to
the brain will be opposite the point of
impact.

Abrasions
A scraping injury to the superficial
layers of the skin (epidermis and
dermis) that results from friction
against a rough surface

Abrasions (Scrapes)

An abrasion is denuded skin caused by

friction. A wound may be either deep or
superficial depending on the force and the
coarseness of the surface which caused the
abrasion.

Abrasions
Side impact produces a moving abrasion:
Indicates direction.
Trace material (e.g. grit).

Direct impact produces an imprint abrasion:

Pattern of causative object.

All abrasions reflect site of impact (in contrast with

bruises).
Assessment of age of abrasions is difficult.
Post-mortem abrasions - Brown, leathery

Abrasion on the elbow.

Abrasion on the knee.

BRUSH-BURN ABRASION
One common type of blunt force injury is the socalled brush-burn abrasion. Brush-burn abrasions
are broad, dried abrasions that often have a
yellow-orange or orange-red coloration.
These abrasions are caused by dragging or
scraping the surface of the skin against a rugged
surface; they are most often encountered when a
body slides on pavement. These abrasions are
sometimes called "road rash."

Brush-burn type abrasion on the left flank.

Laceration:
A bursting of the skin or other tissues
resulting from compression or stretching
associated with impact by a blunt object
or surface

Lacerations (Tears, Splits)

Splitting of the skin by the direct crushing
of blunt trauma.
Typically over bone, e.g. scalp, eyebrow,
cheekbone.

Lacerations
Distinguished from incised wounds by:
Adjacent abrasion/bruise
Ragged edge
Tissue bridges in depth

Forensic Importance

Not related to object shape

Trace evidence
Relatively little blood loss (except scalp)
Rarely suicidal

Two abraded lacerations on the forehead.

A laceration near the vertex of the scalp.

Several chop injuries inflicted by a boat propeller.

Avulsion:
A more severe form of laceration in
which the soft tissues, musculature,
and/or bone are torn away from the
normal points of attachment

Avulsion of the right leg.

Fracture:
A break, rupture,
or separation of
tissue (most
often bone)
resulting from an
impact

Thank You

berti@indosat.net.id