REGIONAL INJURIES

DR.S. PERANANTHAM, MD.,

Assistant Professor,
CMC
 Fracture of Skull
 Fractures may be caused by
 (A) Direct violence :-

 Compression of head under a wheel.

 An object in motion striking the head.

 Ex:- Bullet, Bricks, Machinery etc.,

 Head in motion striking an object, as

in falls and traffic injuries.
 (B) Indirect Violence:-

 Injury to the skull occurs from a fall

on the feet or buttock.
 Mechanism of Fracture
 (A) Fracture due to Local Deformation:-
 When the skull receives a focal
impact,
 The contents of skull are virtually
incompressible,
 The area under the point of impact
bends in wards and compensatory
bulging occurs at other areas.
 If the distortion of the bone exceeds
the limit of elasticity.
 Both these intruded and extruded
areas can be the site of fracturing,
(B) Fracture Due to General Deformation:-

 1.Between two external objects,

such as the ground and wheel of a
vehicle.
 2.Between an external object and
spinal column.
 The vertical and longitudinal
diameters are increased causing
distortion and bulging of the part
distant to the point of impact,
 Which may fracture by bending.
 Types of Fracture Skull
 1. Fissured Fracture:-
 Are produced by general deformation
of the skull.
 They are likely to be caused by
forcible contact with a broad hard
surface or
 Blows with an agent having a
relatively broad striking surface.
 The outer table is capable of
rebounding to its normal shape, while
the more brittle inner table fractures.
LINEAR
FRACTURE
 2. Depressed Fracture
 Produced by local deformation of skull.
 Fractured part is driven inward into the
skull cavity.
 They are also called “Fracture Ala
Signature”
as their pattern often resembles the
weapon or agent which caused it.
 Localized depressed fractures are
caused by blows from heavy weapons
with a small striking surface.
 Ex:- Hammer, stone, chopper.
DEPRESSED
FRACTURE
DEPRESSED
FRACTURE
 3. Comminuted Fracture :
(Comminution – Fragmentation)
 It is often a complication of
fissured or depressed fracture.
 In a communicated fracture
there are two or more
intersecting lines of fracture,
 Which divide the bone into three
or more fragments.
 When there is no displacement of
fragments, it resembles a
spider’s web or mosaic.
COMMINUTION

COMMINUTED
FRCTURE
 4. Pond or Indented Fracture
 This is a descriptive term for a
shallow depressed fracture forming a
concave “Pond”.
 It is more common in the more
pliable bones of infants.
 Can be caused by obstetric forceps ,
a blow from blunt object or impact
against some protruding object.
 No fracture of inner table but

fissured fracture may occur in the

outer table around the periphery of
‘Dent’.
 5. Gutter Fracture: (Thickness)
 When a part of bone is removed,
so as to form a gutter.
 Ex:- In oblique (Glancing) bullet
wound.
 Usually associated with irregular
depressed fracture of inner table
of skull.
 6. Ring or Foramen Fracture
 It is a fissured fracture
 It encircles the skull in such a manner
that the anterior third is separated at
its junction with middle and posterior
third.
 It is a fracture which runs at about 3-
5cm out side the foramen of magnum
at the back and sides of skull.
 Due to which the skull is separated
from the spine.
Causes:-

 Fallfrom a height on the feet or

buttock .
 A severe blow to the vertex.

 A forceful blow on the chin in RTA.

 May be caused by sudden violent

turn of the head on spine.
 7. Perforating Fractures

 Caused by fire arms and

pointed sharp weapons like
daggers, knives and axe.
 The weapon passes through
both the tables of the skull.
 The size and shape of it
corresponds to the cross
section of the weapon used.
Cut Fracture
 8. Diastatic or Sutural Fracture.

 Separation of the sutures, seen only

in young persons, due to non fusion
of sutures.
 It may be associated with other
fracture.
 Fractures of the skull occurring
opposite to the site of force is known
as ‘Contre Coup Fracture’.
 Occurs when the head is not
supported.
 Fracture Base of Skull
 May be produced by
 1. Force applied directly at the
level of base.
 2. Due to general deformation of
skull.
 3. Extension of force from the
vault.
 4. Force applied to the base
through the spinal column or face.
Fracture of the base of skull may be
 1. Longitudinal :-
 Front to back or back to front
compression
 Ex:- Run over,

 2. Transverse:-

 Side to Side compression.

 3. Ring fracture:-
 Fracture of anterior cranial fossa can
be indicated with loss of blood from
mouth and nose.
 Fracture of the middle cranial fossa
diagnosed by loss of blood from
mouth.
 Fracture of petrous temporal bone,
which allows blood and CSF escape
from ear.
 Fracture of the posterior cranial fossa
extravasations of blood is seen
behind the mastoid process, or
 A large haematoma in the soft tissues
of the back of neck.
 Coup and Contre Coup Injuries
 Coup
 Means the injury is located beneath the
area of impact and results directly from
the impacting force.
 Contre-Coup injury of brain

 It is one in which damage of the brain is

noticed exactly opposite the site of impact
of blow of coup injury.
 A line drawn between the centers of coup
and contre coup indicates the directions of
impact
 Impact Area Contre Coup
Lesion
 Occipital area - Bruising and
laceration of undersurface of frontal
lobes and tips of temporal lobes.

 Leftparietal area - External

surface of frontal and temporal lobe
of opposite side.
 Concussion of Brain or
Commotio Cerebri
 State of temporary unconsciousness,
due to head injury seen immediately
after injury, and is always followed
by amnesia and tends to recovery is
spontaneous
 Concussion most often occurs with
acceleration or deceleration injuries,
when the head is moving or is freely
movable.
 This is a term popularly know as
‘Stunning’.
 When the shock due to
concussion is severe the patient
may die without regaining
consciousness.
 P.M Findings:-

 May not be revealing but in

some cases, may show Petechial
hemorrhages over cerebral
cortex at the junction of gray
and white matter.
 Diffuse neuronal injury on
microscopic examination.
Intra Cranial Haemorrhages
 If a bleeding is small and thin
layered it is called as
haemorrhage,
 If it is large ad space occupying,
it is called as haematoma.
 According to their situation in
relation to the membranes,
intracranial haemorrhages are
classified as
 Extra Dural
 Subdural
 Sub Arachnoid
 Intra Cerebral which may be of

 Cerebellar

o Cortical, Thalamic, Pontine, or

Medullary
Extra Dural / Epidural Haemorrhage
 Bleeding occurs between inner table
of the skull and the dura
 Mostly Traumatic in origin.

 It occurs usually on the side of blow.

 Causes:-

 Blow over the lateral convexity of the

head may result in rupture of Middle
Meningeal Artery/one of its branches
 It is due to fissured fracture of
squamus part of temporal bone or
parietal bone.
 DURA SKULL
EXTRA DURAL
HAEMORRHAGE
EXTRADURAL
HAEMORRHAGE
 Features of EDH
 Oval or semicircular in shape.
 May be 10-20cm in diameter, 2-6
cm in thick and weighs between
30-300gm.
 The clot will press the brain
inwards,
 Produces a localized concavity or
flattening of external surface of
brain.
 Clinical Features
 Following injury patient looses
consciousness due to concussion.
 After some time he regains the
consciousness and does some
involuntary acts during this lucid
Interval.
 Lateron due to continued bleeding or
recurrence of fresh bleeding causes
cerebral compression when patient
merges into coma.
 Sub Dural Haemorrhage
 Occurs in the sub dural space in
between the dura matter and
arachnoid mater often referred as
sub dural haematoma.
 Sub dural space is very narrow and
contains a small amount of fluid
 Which permit the thin and tough
arachnoid to move relatively to the
dura.
 This is commoner than extra dural
haemorrhage.
 It is invariably traumatic in origin
following a blow or fall.
 It may occur even without any
fracture of skull or injury to the
scalp,
 May follow insignificant trauma to
head with out loss of consciousness.
 Sub dural hamorrhage is essentially
venous or capillary bleeding and not
arterial bleeding.
 Causes of SDH
 1. Rupture of the bridging veins
or communicating veins when the
brain moves across the face of the
dura.
 2. Rupture of inferior cerebral
veins, entering the sinuses at the
base of the skull.
 3. Rupture of dural venous
sinuses following a blow.
 4. Injury to the cortical veins.
 Sub Arachnoid Haemorrhage
 The space between the arachnoid
and the pia is called sub
arachnoid space.
 It is filled with CSF produced by
the choroid plexuses of the
lateral and fourth ventricles.
 This is the most common form of
intra cranial haemorrhages.
 In all cases of significant brain
injury some degree of SAH is
found.
SUB ARACHNOID HAEMORRHAGE
SUB ARACHNOID HAEMORRHAGE
 Causes of Sub Arachnoid
Haemorrhage
 A. Non Traumatic :-
 1. Common in young adults due
to rupture of minute
developmental aneurysms of
vessels of circle of Willis.
 2. In elderly subjects
spontaneous rupture of anterior
and posterior cerebral arteries.
 3. In case of asphyxia, In some
blood disorders and leukemia.
 (B). Traumatic Causes:-
 1. Commonly associated with
traumatic head injuries.
 2. Blow over jaw or side of upper
part of neck may cause rupture of
vertebral artery with basal SAH.
 3. Traumatic Asphyxia.

 4. Minor injury directed to the

base of skull of a chronic alcoholic
may cause rupture of basilar
artery.
 Intra Cerebral Haemorrhage
 This may be found on the surface or
in the substance of the brain.
 It occurs most frequently and
spontaneously in the elderly and
middle aged hypertensives
 Due to rupture of lenticulostriate
artery in the basal ganglia, pons etc.
 Large haemorrhage occurs at the
junction of gray and white matter of
frontal and temporal lobes.
Causes of ICH other than Trauma

 a) Arterial thrombosis, fat

embolism, cerebral aneurysm.
 b) Under treatment of
anticoagulants – Warfarin.
 c) Angioma, Malignant brain
tumor or secondary metastasis.
 “Punch Drunk”

 “Punch Drunk” is a state that

occurs in old boxers due to the
tiny haemorrhages in the brain.
 The patient suffers from post
traumatic psychosis, loss of
memory, tremor, dysarthria.
 THANK U