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Ffigure 5.

9 Black eye from a direct impact into the orbit from a


punch. This is the third mechanism of production of a periorbital
haematoma, the others being a fracture of the anterior base of the
skull and a frontal scalp wound. FIGURE 5.10
Black eye as a result of gravitational seepage of blood
downwards from a forehead injury. The woman was struck with
a rock on the frontal area and eyebrow, blood then descending
during the few hours of coma before death occurred.

and those from blows from a blunt object. Toecap marks are not all that common, especially
since the more flexible rubber ‘trainer’ shoes have become almost universal footwear. In
stamping, there is the chance that the sole pattern may leave an imprint, but a swing from a
toe may leave a non-specific abrasion, bruise or laceration. It may be that the severity of the
injury, including underlying bone damage, may be a better indication of a kick than the shape
of the injuries, as the force delivered by a swinging foot at the end of a muscular leg is greater
than that from a fist.

Black eyes
The usual periorbital haematoma or ‘black eye’ is usually caused by a direct punch or
kick into the eye-socket, but the pathologist must always consider the several alternative
explanations. A black eye may be the result of:
 direct violence, which may or may not be associated with abrasion or laceration on
the upper cheek, eyebrow, nose or other part of the face.
 gravitational seepage of blood beneath the scalp from a bruise or laceration on or
above the eyebrow. Survival and at least a partially upright posture of the head must
have been maintained for at least some minutes, usually longer, between the time of
injury and death. When the scalp lesion is high up on the frontal region, this time will
probably be measured in hours.
 percolation of blood into the orbit from a fracture of the anterior fossa of the skull.
This is often from a contrecoup injury caused by a fall on to the back of the head,
leading to secondary fracture of the paper-thin bone of the orbital roof. It is invariably
associated with contrecoup contusion of the frontal lobes of the brain, as described
later in this chapter.
A simple fall onto the face on a flat surface does not usually cause a black eye, as the
prominences of the eyebrow, cheekbone and nose prevent damage to the orbit.

Damage to the ear


The external ear often suffers from blows to the head and is an obvious target in child
abuse. Bruising and laceration of the pinna is obvious on examination and – in severe trauma
– the root of the ear may be detached from the head, usually by a tear at the posterior margin
where the ear joins the head. Where gross damage is present, especially with partial avulsion
of the pinna, kicking must be considered.
The ear may be bitten and even partly detached, a fate which occasionally is suffered
by the nose. In such cases the advice of a forensic odontologist may be invaluable, as teeth
marks may form vital evidence.

FALLS
Falls are extremely common, the severity not necessarily being directly related to the
distance that the person falls. Many people die after falling from a standing position, yet
others sometimes survive a fall of many metres.
Falls from a standing position can occur if a person is drunk, from an assault, during
illness (such as a fit or faint) and for many other reasons. Death can follow from a head
injury, especially onto the back of the head. An occipital scalp laceration or a fracture of the
skull is not necessary for cerebral damage (often frontal contrecoup) to occur. There may also
be a subdural or (less often) an extradural haemorrhage, the latter more common from a fall
on to the side of the head.
The vexed question of head injury from falls in children is discussed in Chapter 22,
but here it may be stated that, although fatal head injury from a fall usually requires a drop of
a number of feet, there are well authenticated instances of skull fractures and brain damage
from trivial falls, including some medically witnessed falls from tables and settees. The
experimental work of Weber (see Chapter 22) showed that the skulls of small infants could
be fractured against a variety of floor surfaces from passive falls of only 34 inches. It is thus
invalid for medical witnesses to claim it cannot happen, as even one authenticated case
creates a precedent. In adults, fractures have certainly occurred from falls onto very hard
surfaces from only a foot or so. One such case was a drunk lying on concrete; equally
drunken friends attempted to lift him but allowed his head and shoulders to fall back from
about half-sitting position, causing occipital fracture.
Falls in old people very frequently cause fractures of the post-cranial skeleton –
especially the neck of femur – though ribs, arms and pelvis may also suffer. Osteoporosis is
the major reason for the large number of such injuries from falls. More than 47 000 fractured
femora occur each year in Britain, with a 25 per cent mortality rate, mainly from subsequent
pulmonary embolism or bronchopneumonia.

FIGURE 5.11 Bilateral black eyes caused by leakage of blood into


the orbits through comminuted fractures in the floor of the anterior
fossa. This homicide victim was struck on the head with a shovel
and survived for some days. Brain tissue is escaping from the nostrils
through basal skull fractures.
FIGURE 5.12 The production of a black eye: (1) A
direct blow into the orbit. (2) An injury to the front of the scalp,
draining down over the supraorbital ridge. (3) A fracture of the
base of the skull (direct or contrecoup) allowing meningeal
haemorrhage to escape through the orbital roof.