Index

 Age identification
 Sex identification
 Blunt injuries
 Sharp Wounds
 Head injuries
 Firearm Injuries
 Ballistics
 Physical injuries
 Death & Postmortem changes
 Asphyxia
 Child Abuse
 Age Identification

Age identification
Estimation of Age
 Skull (Fontanelles & Sutures)  Union of epiphyses.
 Mandible and teeth  Appearanceof ossific centers

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 Age Identification

Aged more than 3 years due to:

 Frontal suture is closed (closes from 3 to 5 year).
Aged less than 25-30 years due to
 The sagital suture is still opened (closes at 25-30)

 Because the posterior fontanelle is closed (closes at full term)

 but the anterior fontanelle is still opened (closes at 18- 24 months).

Because
 Lambdoid suture is closed (closes at 50
years in females).
 All permanent teeth are erupted

 All the permanent teeth including

wisdom teeth are erupted (18-25
years).
 The angle between the body and the
ramus is nearly right.
 Mental foramina are midway between upper and lower borders of the mandible

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 Age Identification

 Because trochlea and capitalum are not united with each

other (unites at 14years in males).

 Because the head of humerus is united with the shaft

(epiphysis unites at 20 years in males)

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 Age Identification

 A → Because the upper end of ulna is not

united with the shaft (epiphysis unites at 16
years in males).
 B → Because the head of radius is not
united with the shaft

 Because the lower end of ulna is

united with the shaft
(epiphysis unites at 20 years in males).
 Because the lower end of radius is
united with the shaft
(epiphysis unites at 20 years in males)

 (A): Medullary cavity reached surgical neck (30 years in males).

 (B): Medullary cavity reached anatomical neck (33 years in males).

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 Age Identification

 A → Because lesser trochanter is not united

with the shaft (epiphysis unites at 16 years in
males).
 B → Because lower ends of tibia and fibula
arc not united with their shafts epiphyses unite at 18 years in males ).

 Because the lower end ol femur is

united with the shaft (epiphysis
unites at 21 years in males).

 Because the upper end of tibia is united with the

shaft (epiphysis unites at 21 years in males).

 Because → Thc pubic ramus is not united with the ischial ramus
 (unites at 6 years).

 Because the epiphysis of iliac crest is united

 (unites at 23 years in males)

 Because the epiphysis of iliac crest is united

 (unites at 21 years)

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 Age Identification

Aged more than 13years:

 Because illium, ischium and pubic
bones are united in the acetabulum
 (unites at 13 years in females).
Aged less than 19 years:
 Because the epiphysis of ischial tuberosity is not united (unites at 19 years in females).

X-Ray
Comment On X- Rays
 view? AP or L
 Site? Elbow; knee; wrist, etc.
 The age, Why?

Because:
 The epiphysis of head of humerus is united with the shaft
 (unites at 20 years in male).

Because:-
 The epiphysis between trochlea and capitulum is not united
 {unites at 14 years in male).

More than 15 year because:

 The trochlea and capitulum is united with the shaft
 (unites at 15years in males).
Less than 16 sears because
 The epiphysis of lateral epicondyle of humerus
 not united with the shaft (unites at 16 years in males).

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 Age Identification

Because:
 The epiphysis of medial epicondyle of humerus is unite with the shaft
OR
 The epiphysis of head of radius united with the shaft (unites at 17 years in males)

Because:
 The epiphyses of lower ends of radius and ulna are united with
their shafts (unite at 20 years in males).

Because:
 The epiphyses of lower ends of radius and ulna are not united
with their shafts (unite at 20 years in males)

Because
 The epiphyses of metacarpal bones and phalanges are
not united with their shafts
 (unite at 18 years in males).

Because
 The epiphyses of metacarpal bones and phalanges
are united with their shahs
 (unite at 18 years in males)

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 Age Identification

Because
 The epiphyses of ischial and pubic rami arc not united
 (unite at 6 years).

More than 6 years because

 The epiphyses of ischial and pubic rami are
united (unite at 6 years).

Less than 15 years because

 The Y shaped suture of acetabulum (ilium, ischium &pubis) are not united
 (unite al 5 years in males)

Because
 Epiphysis of iliac crest is united (united at 23 year in male)

Because
 The epiphyses of lower end of femur and upper ends of tibia and
fibula arc not united with their shafts (unite at 21years in males).

Because
 The epiphyses of lower end of femur and upper ends of tibia and
fibula are united with their shafts (unite at 21 years in males)

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 Age Identification

Because
 The epiphyses of lower ends of tibia and fibula are not united with
their shahs (unite at I8 years in males).

Because
 The epiphyses of lower ends of tibia and fibula are not united with
their shafts (unite at 18 years in males).

Because
 The epiphyses of metatarsal bones anti phalanges are united with their
shafts
 (unite at 18 years in males)

Because
 The epiphyses of metatarsal bones anil phalanges are not united with
their shafts
 (unite at 18 years in male).

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 Age Identification

Tell the age and why

Because
 The anterior fontancllc is still opened
 (closes at 18- 24 months).

More than 18 years because:

 The head of femur is united with the shaft
 (united at 18 year in male)

Less than 23 years because:

 Epiphysis of iliac crest is not united
 (united at 23 year in male)

Because
 The epiphyses of lower ends of tibia and fibula are
not united with their shafts
 (unite at 18years in males).

Because
 The epiphysis of head of humerus is not united with the shaft
 (unites at 20 years in male).

Because
 Because the lower end of ulna is united with the shaft
 (epiphysis unites at 20 years in males).

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 Age Identification

Because
 The epiphyses of lower ends of radius and ulna are
united with their shafts
 (unite at 20 years in males).

Because:
 The epiphyses of lower end of femur and upper ends of tibia and
fibula are not united with their shafts
 (unite at 21years in males ).

Because:
 The lower end of femur is united with the shaft
 (epiphysis unites at 21 years in males).

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 Sex identification

Sex identification
Sex Identification Steps

Identification Of Sex From Bones

 It is possible to recognize the sex of a skeleton with considerable accuracy only after
puberty.
 The degree of accuracy in sexing adult skeletal remains is as follows:
a) Entire skeleton: 100%.
b) Pelvis and skull:98%
c) Pelvis alone: 95%
d) Skull alone: 90%
e) Long bones alone:80%
Sex differences in the skeleton:

The bones are heavier and The bones are lighter and
General characters of bones
bigger. smaller.
Muscular ridges, depressions,
More prominent Less prominent.
and processes
Shafts of the long bones Are relatively rough. Shafts are smooth.

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 Sex identification

Differences Between Male & Female

Superciliary ridge Prominent Less marked

Fnonto-nasal junction Angular Smooth
Square with thick rounded Rounded with thin sharp
Orbits
margins margins.
Occipital condyles Long & narrow Short &broad
Mastoid process Long Short

Orbit

Fronto nasal junction

A → male / B → Female

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 Sex identification

A female skull Due to

1) The parietal eminences are prominent.
2) The superciliary ridges are less marked.
3) The fronto nasal junction is smoothly arched.
4) The mastoid processes are short and small.
5) The occipital condyles are short and broad.
Aged more than 50 years due to:
 Lambdoid suture is closed (closes at 50 years in females)
 All permanent teeth arc erupted.

male skull due to

1) The superciliary ridges are marked.
2) The fronto-nasal junction is angular.
3) The parietal eminences arc less prominent.
4) The mastoid processes are long and large.
5) The occipital condyles are long and small.

Examples

A- Male skull due to

 The superciliary ridges are marked.
 The fronto-nasal junction is angular.
 The parietal eminences arc less prominent.
 The mastoid processes are long and large.
 The occipital condyles are long and small.
B- Female skull due to
 The parietal eminences are prominent.
 The superciliary ridges are less marked.
 The fronto nasal junction is smoothly arched.
 The mastoid processes are short and small.
 The occipital condyles are short and broad.
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 Sex identification

Differences Between Male & Female Mandible

Shape U shaped V shaped

Chin Square Pointed or rounded
Ramus More broad Less broad
Angle region Everted Inverted

A → male / B → Female

A male mandible due to

 The chin is square.
 The angle region is everted

Aged above 18 years (in the middle life):

 All the permanent teeth including wisdom
teeth are erupted (18-25 years)
 The angle between the body and the ramus is nearly right (in middle life).
 Mental Foramina are midway between upper and lower borders of the mandible

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 Sex identification

A female mandible due to

 The chin is V shaped
 The angle region is not everted

Aged more than 18years (in the middle life) due

to:
 All the permanent teeth including wisdom teeth are
erupted (18-25 years).
 The angle between the body and the ramus is nearly right (in middle life).
 Mental Foramina are midway between u pper, lower borders of mandible

A male mandible aged above 18 years A male mandible aged above 18

(in the middle life). years (in the middle life)

Differences Between Male & Female STERNUM

Size Longer & broader. Shorter & narrower.

Length of > double the length < double the length of
the body of manubrium. manubrium
On the level of On the level of lower
Level of the
lower part of the part of the body of Th
upper notch
body of Th 2 3

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 Sex identification

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 Sex identification

DIFFERENCES BETWEEN MALE PELVIS

1- General characters
 The female pelvis: is shallow and wide.
 The male pelvis: is deep and narrow.
2- Whole pelvis

3- Hip bones

Iliac crest Highly arched Less curved.

Pubic arch Narrow, forms acute angle. Wide, forms obtuse angle.
Body of pubic bone Small& triangular. Large& square.
Well defined especially in
Preauricular sulcus ill defined or absent.
multipara.
llio-pectineal line Sharp& well-defined. Smooth & ill-defined.
Greater sciatic notch Narrow& deep. Wide& shallow.
Obturator foramen Oval Triangular

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 Sex identification

Male

Female

A Left male hip bone, due to

 A narrow deepgreater sciatic notch which forms an
acute angle.
 Highly arelied itiac crest.
 Body of pubis is triangular in shape.
 A narrow pubicarch which forms acute apglc.
 Ill defined prc-auricularsulcus.
 Sharp and well defined ilio poctincal line.
 Oval obturator foramen.
Aged more than 23 year due to
 The epiphysis of iliac crest is united (unites at 23years in males)

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 Sex identification

A left female hip bone due to

 A wide greater sciatic notch forming
obtuse angle.
 Less arched iliac crest
 Body of pubis is quadrangular in shape.
 A wide pubic arch forming an obtuse
angle.
 Well-defined pre-auricular sulcus.
 Smooth and ill-defined illio pectineal line.
 Triangular obturator foramen.
Aged more than 21 years due to.
 The epiphysis of iliac crest is united (unites At 21 years in females)

A right female hip bone due to

 Less arched iliac crest.
 Body of pubis is quadrangular in shape.
 A wide pubic arch forming an obtuse angle.
 A wide greater sciatic notch forming obtuse angle.
 Smooth and ill defined illio-pectineal line.
 Triangular obturator foramen.
Aged more than 13 years and less than 19 years due to
 Ilium, ischium and pubic bones are united in the acetabulum (unites at 13 years in
females).
 The epiphysis of ischial tuberosity is not united (unites at 19 years in females).

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 Sex identification

A right female hip bone due to

 A wide greater sciatic notch forming obtuse angle.
 Less arched iliac crest.
 Body of pubis is quadrangular in shape.
 A wide pubic arch forming an obtuse angle.
 Well-defined pre-auricular sulcus.
 Smooth and ill-defined illio- pectineal line.
 Triangular obturator foramen.
Aged more than 19 and less 21 years due to:
 The epiphysis of ischial tuberisity isunited (unites at 19 years in females)
 The epiphysis of iliac crest is not united (unitesat 21 years in females)

A: male hip bone, due to

 A narrow deep greater sciatic notch which forms an acute
angle.
 Highly arched iliac crest.
 Body of pubis is triangular in shape.
 A narrow pubic arch which forms acute angle
 III defined pre-auricular sulcus.
 Sharpand well defined ilio pectineal line.
 Oval obturator foramen.

B: female hip hone due to

 A widegreater sciatic notch forming obtuse angle.
 Less arched iliae crest.
 Body of pubis is quadrangular in shape
 A wide [mine arch fanning obtuse angle
 Well-defined pre-auricular sulcus.
 Smooth and ill-defined illio-pectineal line.
 Triangular obturator foramen

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 Sex identification

Differences Between Male & Female Pelvis (Cont)

4- Sacrum

Long& narrow with

Short & wide, curved only in its
Shape homogenous curve and
lower part
projecting sacral promontory.
Articulating surface
Extend to 3rd sacral seg. Extend only to 2nd sacral seg.
with illium
Formed mainly by the body Formed mainly by the alae of the
B ase
of 1st sacral verteb sacrum.

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 Sex identification

male sacrum due to:

 The body is lory? and narrow with homogenous
curve and projecting sacral promontory.
 The articular surface with the i[hum extends to
the third sacral segment.

A female sacrum due to

 The body is short wide and curved only in its
lower part
 The articular surface with the illium extends
only to the second sacral segment

male sacrum due to

 The body is long arid narrow with homogenous curve and
projecting sacral promontory,
 The articular surface with the ilium extends to the third sacral
segment

A female sacrum due to

 The body is short, wide and curved only in its lower part.
 The articular surface with the illium extends only to the second
sacral segment

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 Blunt Injuries

Blunt Injuries
Blunt Instruments

Types of blunt Injuries

1) Abrasions 2) Contusions 3) Contused wound

 Type of lesion: tangential abrasions

 Causative instrument: blunt instrument with rough surface

 Type of lesion: graze

(tangential abrasions)
 Causative instrument
blunt instrument with
rough surface

 Type of lesion: linear abrasion

 Causative instrument: blunt instrument with pointed end

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 Blunt Injuries

Imprint abrasion

 Type of lesion: Imprint (patterned, crush) abrasions

 Causative instrument: blunt instrument with patterned surface

Types of bruises
 According to amount of extravasated blood
1) Hematoma: large bruise.
2) Ecchymosis: small bruise.
3) Petechial hemorrhage: size of pin head < 2mm
 According to site
1) External bruise.
2) Internal bruise.

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 Blunt Injuries

According to amount of extravasated blood

 Type of lesion: black eye (Raccoon eye)

 Differential diagnosis:
1) direct blow to orbit.
2) Fracture anterior cranial fossa
3) Tracking from forehead bruises (migrating) (gravitational)
 Type of lesion: Bruises behind the ear (Battle sign)
 Differential diagnosis: fracture middle cranial fossa. or direct
blow

 Type of lesion: patterned bruises

 Causative instrument: heavy blunt instrument reflecting its shape

Internal bruises

 Type of lesion: liver contusion and laceration

 Causative instrument: heavy blunt instrument

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 Blunt Injuries

Characters
1) shape: any shape.
2) Edge: irregular.
3) Surrounded by abrasions
4) Tissue bridging in the base.
5) Surrounding hair is irregularly cut.
6) Minimal bleeding
7) Greater liability for sepsis except in scalp
8) Delayed healing with thick scar

 Type of lesion: contused wound of the chin (Contused wound

simulating cut wound as it is over bone)
 Causative instrument: heavy blunt instrument
 Possible cause of death: May be shock, hemorrhage or injury
to vital structures.

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 Blunt Injuries

 Type of lesion: Contused wound simulating cut wound as it is

over bone
 Causative instrument: heavy blunt instrument

 Lacerated wound
N.B.
 There are surrounding bruises & edema
 One angle is acute as the skin is stretched over teeth

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 Sharp Wounds

Sharp Wounds
1) Incised (cut) wound 2) Stab wound

‫جرح قطعى‬
 Clean division
 Full thickness
 Causative instrument → Sharp edged weapon

Characters of cut wound (Comment on)

1) Shape 2) Bleeding
3) Edges 4) Healing
5) Angles 6) Sepsis liability
7) Hair 8) Base

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 Sharp Wounds

 What is the diagnosis → cut or incised wound

 What is Causative instrument → Sharp edged instrument
 What is Possible cause of death →Shock, hemorrhage & injury to vital organs

MLI of cut wound

1) Reflect sharp edged instrument, not weapon type.
2) No Trace evidence except
3) Time of infliction by histopathological examination
4) Direction
5) Danger.....(site, depth)
6) Manner: (suicidal, homicidal, accidental)

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 Sharp Wounds

 Depth > dimensions of the wound on

body surface
 Causative instrument:
 Sharp pointed
 Blunt pointed
 Long with blunted end
 Types:
1) Stab 2) Puncture
3) Perforating (transfixing) 4) Penetrating

 Causative instrument: Blunt pointed instrument As needle

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 Sharp Wounds

Mechanism Of Tailing Of Edges

 Stab is a dynamic process.
 Dragging of instrument at different angle resulting in tailing
of edges.
 Victim moves.

 Perforating Wounds: When the weapon, after penetrating the body tissues, comes out
from the other side making an exit wound, the injury is termed as perforating wound
(Transfixing Wound)

 Penetrating wound: when the weapon enters body cavity such as Thorax, abdomen →
the injury is termed as penetrating wound

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 Sharp Wounds

MLI of stab wound

1) There may be little external blood loss but internal blood loss is profuse.
2) Examination of wound reflects → shape, size
3) Manner of injury (homicidal , suicidal )

 Type of wound → Cut or incised wound

 Causative instrument → Sharp edged instrument

 Type of wound → Multiple stab wounds

 Causes of death → Shock, hemorrhage, injury to vital organs.

Specimens
 Specimen: An opened heart & overlying skin
 Lesions: Stab penetrating wound of the right
ventricle of the heart & overlying skin.
 Causative instrument: Sharp pointed instrument
 Possible cause of death → May be shock,
hemorrhage or cardiac tamponade

 Specimen: Opened heart and overlying skin

 Lesions: Stab penetrating wound in the heart &
overlying skin with 2 acute angles
 Causative instrument: Sharp pointed bi-bladed
instrument “elliptical wound’
 Possible cause of death: May be shock,
hemorrhage or cardiac tamponade

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 Sharp Wounds
 Specimen: Heart & overlying chest wall
 Lesions: Stab penetrating wound in the left ventricle
& overlying chest wall, regular edges and acute
angles.
 Causative instrument: Sharp pointed instrument
 Possible cause of death: May be shock, hemorrhage
or cardiac tamponade
 Specimen: Kidney & overlying skin of back
 Lesions: Multiple stub NON-penetrating wounds →
because surface of the kidney is retroperitoneal
 Causative instrument: sharp pointed instrument.
 Possible cause of death: May be shock, hemorrhage
or kidney injury.

 Specimen: A piece of liver & the overlying skin.

 Lesions: Multiple stub penetrating wounds in the
anterior surface of the liver & its overlying skin with
regular edges &unite angles
 Causative instrument: Pointed sharp edged
 Possible cause of death: May be shock hemorrhage
or injury to liver
 Specimen: is a piece of skin.
 Lesion: stab wound with regular edges and two acute
angles with tailing of the ends (cither stab wound with
dragging or stab wound by partially opened
scissors),
 Causative instrument: sharp edged instrument.
 Possible causes of death: may be shock, hemorrhage
or injury to a vital organ

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 Head Injuries

Head injuries
Types
1) Scalp injuries 2) Skull fractures
3) Meningeal injuries 4) Cerebral injuries

Comment on skull fracture

 Name of specimen.
 Sex and age if possible.
 Description of the lesion:
 site, type number
 Radiating fissure
 meningeal affection
 surgical intervention
 healing
 Causative instrument. (Type, force, surface area)
 Possible causes of death.

Factors affecting skull fracture

1) Force 2) Surface area
3) Position of the head 4) Elasticity
5) Thickness

Causative Instruments

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 Head Injuries

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 Head Injuries

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 Head Injuries

Causes of death in skull fractures

Concussion
Intracranial sepsis
Compression
Epilepsy
Brain lacerations

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 Head Injuries

Write full comment on specimen

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 Head Injuries

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 Head Injuries

X-Ray

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 Head Injuries

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 Firearm Injuries

Firearm Injuries

Characters of firearm wounds

 More in inlet than in exit

exceptions
1) more than one inlet.
2) more than one exit.
3) only one wound

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 Firearm Injuries

 may be absent. (When?)

 Internally at the inlet

 Externally at the exit.

Differences between inlet & exit

1) Loss of substance?
2) Size?
3) Edges?
4) Powder marks?
5) Soiling ring?
6) Beveling?
7) Microscopic examination?
How to comment on jar or bone?
1) Name of specimen,
2) Description of the lesion.
3) Causative instrument.
4) Possible causes of death.

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 Firearm Injuries

Female due to
 It is short and narrow.
 The length of the body is less than double the length of the
manubrium sterni.
Aged more than 60 years due to
 The manubrium is united with the body (unites at 60 years in
females).
 Lesion → firearm with internal beveling in the center of the body
of the sternum
 Causative Instrument → Rifled weapon
 Possible causes of death → may be Shock, hemorrhage or injury to vital organs

 Specimen: Vault of skull.

 Lesion: Two rounded bony detects one in the right temporal
bone with internal beveling, and the second bone defect is in
the left temporal bone with external beveling with radiating
fissure fractures.
 Causative instrument: Rifled weapon (fires bullets).
 Possible cause of deaths: may be brain laceration.

 Specimen: Piece of the vault of skull.

 Lesion: Firearm inlet with internal beveling and two radiating
fissure fracture in the left parietal bone.
 Causative instrument: Rifled weapon (fires bullets).
 Possible cause of deaths: may be brain laceration.

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 Firearm Injuries

 Specimen: Vault of the skull

 Lesion: Two rounded bony detects one in the left temporal
bone with internal beveling, and the second bone defect is
in the right temporo-parietal bone with external beveling
with radiating fissure fractures.
 Causative Instrument: Rifled weapon (fires bullets).
 Possible cause of death: May be brain laceration.
The second bone defect (exit) (External Beveling)

 Specimen: Vault of skull.

 Lesion → Two bony defects in the left frontal bone
with internal beveling
 There is deposition of lead shots in the substance of
skull in the frontal bone
 There are rounded non-penetrating bone defects in
the frontal bone.
 Causative instrument → Non rifled weapon (Fire shots)
 Possible cause of death: May be brain laceration.

 Specimen: A piece of the skin of the anterior chest

wall
 Lesions:
Two injuries with loss of substance (firearm injury)
 One is circular (Perpendicular firing)
 The other is oval or slit like (oblique firing)
 Causative instrument: Rifled weapon (fire bullets)
 Possible cause of death:
may be shock, hemorrhage or injury to vital organs

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 Firearm Injuries

 Specimen: Heart
 Lesions:
2 injuries with loss of substance (firearm injury)
 1st one in the right ventricle with regular inverted edges
(Inlet)
 the other one is in the left ventricle which is rounded
with irregular everted edges (exit)
 Causative instrument: Rifled weapon (fire bullets)
 Possible cause of death: may be shock or hemorrhage

 Specimen: 4 pieces of skin

 Lesions:
Injuries with loss of substance
 2 injuries are inlets with regular inverted edges
 2 injuries are exits with irregular everted edges
 Causative instrument: Rifled weapon (fire bullets)
 Possible cause of death: may be shock,
hemorrhage or injury to vital organs

 Specimen: Liver & overlying skin

 Lesions:
An inlet firearm wound
 Injury is small circular hole with loss of substance
 Everted edges because it's in a fatty area of anterior
abdominal wall
 Notice the cruciate appearance of the inlet in the liver
 Causative instrument: Rifled weapon (fire bullets)
 Possible cause of death: may be shock, hemorrhage or
injury to vital Organs

47 | P a g e
 Ballistics

Ballistics

Ballistics
1) Cartridge (Rifled and Non-rifled w.)
2) Bullet (Rifled w.)
3) Shots (Non-rifled w.
4) Wads
5) Powder

How to comment on cartilage

1) Cartridge
2) Complete or empty
3) Fired or not.
4) Type of weapon:
 Rifled w. (service rifle, automatic pistol, revolver)
 Non-rifled w. (sporting gun)

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 Ballistics

Mechanism of firing
 On firing, needle strikes the percussion cap → spark → ignition of powder of gases →
huge volume of gases → drive the missile out of the barrel.

Type of weapon

 Long, non-rifled.
 Cartridge of cardboard or plastic.
 Percussion cap.
 Black or smokeless powder.
 Internal wad.
 Shots
 External wad.

49 | P a g e
 Ballistics

50 | P a g e
 Ballistics

How to comment on bullet

1) Bullet
2) Fired or not.
3) Type of weapon:
 Rifled w. (Long rifled, short rifled)

Rifling
 Parallel longitudinal ridges (lands) alternating with
grooves on the inner surface of the barrel, vary in number, direction, depth and width.

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 Ballistics

Irregular black clumps or Different uniform shapes, colors&

Shape & color
powder sizes
Carbon 15% Nitro-cellulose 60%
Composion Sulfur 10% Nitro-glycerin 35%
Potassium nitrate 75% Mineral gel 5%
Volume of gases 1 → 300 1 → 900

Reaction after Alkaline Neutral

ignition Carbonates & bicarbonates Nitrites & nitrates
Sporting gun, and Old Sporting gun, and rifled w, except
Weapons
revolver old revolver
Inlet Blackening Grayish colorI

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 Physical injuries

Physical injuries
Classification of Physical agents:
1. Thermal: heat (dry & wet) and cold (frost bites).
2. Electrocution.
3. Chemicals as corrosives.
4. Radiations.
5. Lightning.

Skin histology

 Destruction of epidermis without loss of dermis.

 Erythema (v.d. capillaries)
 Pain (++ nerve endings)
 Heals without scaring

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 Physical injuries

SUNBURN 1st degree BURN

 Destruction of partial thickness of the skin.

 Erythema blister
 Very painful
 Heals with scaring & disfigurement.

❖ Accidental deep second degree flame burn with vesicles caused by gas cylinder
explosion at home affecting both hands and wrists in a 51 years old rural illiterate
female patient.
54 | P a g e
 Physical injuries

 Destruction of Full thickness & deeper tissues Lesion may be white, red or black.

❖ Female patient with third degree flame burn while cooking caused by gas cylindrical
explosion. The burns were 20% of total body surface area. The lesions were distributed
her face, hands, wrists , forearms and lower third of both legs.

❖ Accidental third degree flame bum in 13 y old rural illiterate male patient at home
caused by gas cylinder explosion, burns were distributed in the face. neck, chest front,
abdomen, front of both thighs and upper limbs and w ere about of total body surface
area.

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 Physical injuries
❖ Burns complicated with wound infection with pseudomonas and generalized edema.

Mention the degree of burn in the photo?

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 Physical injuries
FACTORS AFFECTING BURN GRAVITY ?
1. Degree 2. age
3. Extent 4. Sex
5. Site 6. Health

vital reaction, cellular

+ -
infiIteration & Erythema
Vesicles content ++ ALBUMIN & cl Gases filled
Haemoconcentration + -
Co HB Level High -
Other causes of death - +
Soot + -
Soot depoistion

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 Physical injuries

✓ Fissure ✓ Any type

Type
✓ Not displaced ✓ Displaced
Signs AM burn ✓ + ✓ -
AM wound ✓ - ✓ +
Brain ✓ Shrunken ✓ edematous
✓ Brown & spongy, doesn't
✓ Fills the space between
fill the spare between
brain and skull and
Extradural hematoma brain and skull & not
localized at the site of
localized opposite the
fracture.
charred outer table.
Co Hb ✓ Increase ✓ Decrease
(charring + thermal fractures)

1. What is this sign?

▪ Soot deposition in respiratory passage
2. Mention the cause?
▪ Carbon dioxide deposition in
respiratory tract in case of dry
burn

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 Physical injuries

 Contact with hot metals e.g, spoon burn.

 If applied for a very short time, they may result in redness taking the shape and the size
of instrument with a blister.
 Generally, they are small in size and sharply demarcated.
 They are often deep with uniform depth up to charring if contact
continues for a long time.
 The hair is dry, black & appears shriveled.

Hot irons (applied on the hands buttocks or legs)

Hair dryer burns

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 Physical injuries
Steam Iron Injury

Cigarette burns
Shape ✓ circular or triangular if oblique.
✓ fresh, they are pink or red.
Color ✓ After healing, they tend to be silvery In the center with a
narrow red rim.
D.D ✓ Child abuse vs accidental.
Accidental ✓ shallow, ill-defined, irregular.

Definition:
 Tissue damage from hot liquids usually water or stream.
Degrees of burn:
 First & second degree burn (erythema & blistering) and desquamation.

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 Physical injuries
What are the circumstances of scalds?
1- Immersion
 Common in child abuse.
 Results from dipping into hot liquid
Characters of immersion scalds :
 Site: commonly found on hands, buttocks, upper thighs &
heals.
 Clear demarcation line between
 NO splash marks.
 Cloves & stocks distribution.
 Symmetrical burns.
 Uniform depth.

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 Physical injuries

2- Splashing (trickle patterns)

Splashing of hot water
 May help to determine the posture of the victim when scalded.
 In children who pull a container of hot liquid down on themselves→ scalds on face, neck,
chest & arms, with areas of undamaged skin in the axilla & back.
 the worst injury is found at area of initial contact, it decreases in severity as liquid runs
away and cools.

❖ 2 yean old rural male child presented with scald burn.

❖ Burn injuries were distributed in neck, chest front, both deltoids and both arms.
❖ Burns were about 12% of total bodv surface area

✓ Child placed in hot liquid. ✓ Hot fluid fall onto victim.

✓ Clear line of demarcation. ✓ Irregular margin.
✓ Deep. ✓ Non uniform
✓ Uniform depth. ✓ depth.
✓ Gloves & stocking or buttock. ✓ Site: help in abuse exclusion (back not accidental).

62 | P a g e
 Physical injuries

 follow the same burn classification

 Caused by irritants or corrosives strong acids, alkalis and detergents

Second decree chemical burn by sulphuric acid Full thickntu burn cauwd by ctnunt.

Chemical burn from anhydrous ammonia Burn due to corrosives (thick scars)

Airbag (sodium hydroxide in the aerosol - Sodium Azide (NaN 3)

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 Physical injuries

Agent Dry heat Hot liquid chemical

Extension increase Decrease Decrease
Clubbed
Hair Comma Wetted Eaten up
Absent
Clothes burnt Wetted Eaten up
Soot + + -
CO HB + + -
Scar disfigured not disfigured
Heinoconc. + + -

Scald intact hair

 Body fell into bath of hot fluid. hair not burn
 While in dry Burn comma shaped- Hair

Quiz 1
1. What is this type burn?
▪ Dry contact burn
2. What is the causative agent?
▪ Contact with cigarette
3. What is the most common circumstances?
▪ May be accidental or child abuse

64 | P a g e
 Physical injuries
Quiz 2
1. What is this type burn?
▪ Scald or wet burn
2. What is the causative agent?
▪ Immersion in hot liquid
3. What is the most common circumstances?
▪ child abuse

Quiz 3
1. What is this type burn?
▪ Scald or wet burn
2. What is the causative agent?
▪ Contact with hot liquid
▪ Splashing >trickle pattern
3. What is the most common circumstances?
▪ May be accidental or child abuse

Mechanism of electrical injury:

 The passage of electric current involves flow of energy (electrons) through the body while
the victim is earthed (body in contact with earth) →complete electrical circuit is formed →
biological damage.

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 Physical injuries
Factors involved in electrocution
1. Voltage (V)
2. Current (A)
3. Resistance (R) (A=V/R)
4. Earthling
5. Duration
6. Site of contact

Pathway of the current

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 Physical injuries
Signs of Electrocution
1. Local signs
2. Systemic effects

Local Signs
1. Electric Mark
2. Effect muscle
3. metallization
4. Histological

 At the site of entry.

 Blister which will collapse
 May be absent (bath).
 Look for earthling lesions in contralateral side
Inlet and exit of electric current
 Irregular chalky white lesion (areola), often with raised borders and central cratel

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 Physical injuries
Inlet of low voltage electric current
 Irregular chalky white lesion, often with raised borders and a central crater

High voltage entry

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 Physical injuries
Absent entry mark occurs:
 If the contact area is large.
 If the contact time is only few seconds.
 If the voltage is very low.
 Ex: bathtub.
.

 It is not often seen, but should be looked for

 on the contralateral hand or feet.
 It is similar to entry mark but less severe.
 Exit Wound: Current flows through the body from the entrance point
, until finally exiting where the body is closest tothe g
''und Toto H foot suffered massive internal Iinjuries,
which weren't readily visible, and had to be
amputated a few

Exit of low voltage electric current

 Irregular chalky white lesion, often with raised borders and a central crater

69 | P a g e
 Death & Postmortem Changes

Death & Postmortem Changes

Definition of death
 It is irreversible cessation of brain and brain stem functions.
 Or irreversible cessation of respiration and circulation.

✓ Pallor and loss of elasticity.

Skin

A. Absence of corneal and light

reflexes of the eyes.
B. Dilated pupil
C. Dimness of the cornea with loss of corneal
luster)
D. Reduction in the intra-ocular tension that
drops to zero after 2 hours with depression of coneal centre,
hard, dry, hazy & opaque
E. Sclera: tache noire dc la sclerotique due to
Eye: absent of eyelid blinking.
▪ Red brown discoloration arranged
transversely across the anterior
aspect of the iris and sclera.
▪ Drying change.
▪ Indicates that the eyelids were
partially open.
F. Trucking of blood in retinal vessels

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 Death & Postmortem Changes

Flat
ECG

Immediate signs of death

1. Skin pallor
2. Eye sign
3. Cessation of respiration
4. Cessation of circulation
5. Muscular relaxation

 Algor mortis (cooling)

 Livor mortis hypostasis) - discoloration in dependent regions
 Rigor mortis (stiffening)

Livor mortis ( hypostasis)

 discoloration in dependent regions except areas of contact.
 Begins immediately at death,
not generally apparent for 1-2
hours
 “Fixed” after 6-12 hours
MLI ????

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 Death & Postmortem Changes

❖ He was dead on prone position this is commonly cases of fit, convulsion and alcohol
drinking

Rigor mortis

Right and left arm

defying gravity

Rigor mortis fixes the

body imposition

Rigor mortis affects

erector pillae muscles
(goose skin
appearance)

Rigor mortis versus

cadaveric spasm

72 | P a g e
 Death & Postmortem Changes

 Decomposition
 Adipocere
 Mummification
 Skeletonization

 It occurs due to bacterial activity, it is the major component of decomposition.

 Remains often become discolored and
malodorous Greenish discoloration of
abdomen starts over right iliac fossa after
24-36 hours.
 Marbling -intravascular hydrogen sulfide-
producing bacteria.
 Distension of abdomen & Swelling of
scrotum
 Protrusion of eyes,
swelling of lips & or
Tongue protrusion
 Extrusion of thick,
brownish & foetid odor froth from mouth & nose.
 DD of froth????
 Gas formation and skin blistering and
skin slippage.

73 | P a g e
 Death & Postmortem Changes
Quiz 1
1. What is postmortem change in this photo?
 Putrefaction
 Late postmortem Change

Quiz 2
1. What is this sign?
 Putrefaction Froth
2. Mention differential diagnosis!?
 D. D.
 Putrefaction Froth
 Drowning Froth
 + their characters
Quiz 3
1. What is this sign?
 Arborization or marbling phenomenon
2. lechanism of occurrence?
 Arborization occurs by the intravascular hydrogen sulphide-
producing bacteria.
Quiz 4

1. What is postmortem change in this photo?

 The rigor mortis
2. Enumerate differential diagnosis?
 Cadaveric spasm, heatnstiffness, cold stiffness.
Quiz 5

1. What are eye signs in this photo?

 Tache noire de la sclerotique

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 Asphyxial Deaths

Asphyxial deaths
Definition:
 Failure of tissue to receive or utilize oxygen (lack of tissue oxygenation = hypoxia) Due
to Interference with: mechanism or function of respiration

General signs of asphyxia

1. External signs
2. Internal signs

✓ swollen with prominent eyes

Face

✓ swollen & may be bitten.

Tongue

✓ pin head blood spots seen in:

Petechial
hemorrhage

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 Asphyxial Deaths
✓ seen in lips, ears & fingernails.

Deep cyanosis

✓ from mouth & nostril.

Blood stained
froth

✓ ark blue or black.

✓ Urine, faces & semen
Hypostasis
incontinence

Asphyxia due to neck compression

1. Ligature strangulation
2. Manual strangulation
3. Hanging

76 | P a g e
 Asphyxial Deaths

 General signs of asphyxia plus the following:

✓ stretched
Neck

✓ Tilted to the opposite side of not

Head
✓ Head tilt to opposite of knot in partial hanging

✓ protruded, swollen,
exposed part may be
Tongue dark brown even black
due to dryness.

✓ dripping from mouth corner to

the opposite side of knot (AM
Saliva
suspension sign) .

✓ found in lower limbs, external genitalia, distal forearms & hands.

hypostasis

77 | P a g e
 Asphyxial Deaths

✓ Pressure or imprint abrasion on neck.

✓ Appears as depression
Neck
✓ Reflects the pattern of ligature

✓ Early after death appears pale

✓ Then yellowish brown, hard, dry & parchment like.

Color

✓ upper part of neck above thyroid cartilage.

Position

✓ bliquely upwards along the line of

Direction mandible and reaches the mastoid
process behind ears.
✓ best seen on front & sides of the neck.

Asymmetrical

✓ Complete or incomplete according to knot:

knot

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 Asphyxial Deaths

✓ depends on thebnature of ligature.

Depth & width
✓ Ill-defined if soft material is used .
of the mark

Postmortem
appearance:

✓ The most common cause of death is cerebral anemia

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 Asphyxial Deaths

 General signs of asphyxia plus the following:

✓ Congested

face

✓ swollen, bitten by teeth &

protruded.
Tongue
✓ General signs of resistance.

✓ Bleeding.
ears & nose

✓ below thyroid
cartilage.
Site

✓ transverse.

Direction

✓ equal all around neck, completely encircling the neck.

Symmetrical

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 Asphyxial Deaths

LIGATURE
STRANGULATI
ON

✓ The most common of death is strangulation asphyxia

✓ semi lunar ot triangular on front & sides of neck around larynx &
above
it.

Bruises (mainly
discoid) & finger
nail abrasions

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 Asphyxial Deaths

 Semilunar or triangular nail abrasions & bruises mainly discoid around mouth & nose.

 Injuries of the inner aspect of the lower lip in a smothering death where pressure was
applied to the mouth and nose.

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 Asphyxial Deaths

 Congestion & deep cyanosis of face, neck , shoulder & may be upper chest.

 Bleeding from mouth & nose

 Numerous petichiae on face, neck, shoulder & may be upper chest.

 Demarcation line.

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 Asphyxial Deaths

Signs of immersion:
1. Goose skin (cutis inseria)
2. Washerwomen skin
3. Peeling of epidermis of hands & feet in the form of gloves
& socks after 2 weeks

4. Dark blue hypostasis in head, neck, shoulder & upper part of chest

Highly suggestive signs of drowning

✓ Fine
✓ Whitish
✓ Odorless
✓ Abundant
✓ Increase by chest compression.
1. Froth
✓ D.D froth of putrefaction & asphyxia..

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 Asphyxial Deaths

2. cadaveric
spasm

What will you do if u suspect drowing ?

 ‫في الحاله دي مش هكتب تقرير وفاه ولكن هطلب العرض علي الطب الشرعي‬

EXAM QUESTION PRACTICE

1. Describe ligature mark?
1. Pressure, crush or imprint abrasion
2. It appears as a depression... + )site( at above the upper
the level part of thyroid neck cartilage
3. Upper edge → hyperemic
4. Lower edge → pale
5. Oblique & asymmetrical
-------------------------------------------------------------------------------------------------------------
1. Identify this sign?
▪ Froth of drowning
2. Describe?
▪ Fine, white, odorless, abundant & increase with compression of the
chest
3. In which cases you can see this sign?
▪ Drowning, asphyxia & putrefacti on + characters
-------------------------------------------------------------------------------------------------------------
1. Describe neck injury.
▪ Semilunar abrasions and bruises at the side of the neck
2. In which conditions you can find this sign?
▪ Throttling

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 Asphyxial Deaths
1. Identify the sign?
▪ Petechial hemorrhage
2. Mention one case in which you can find this sign?
▪ Asphyxia & congestive Heart Failure
-------------------------------------------------------------------------------------------------------------
1. Identify this sign?
▪ Cadaveric spasm
2. In which cases you can see this sign??
▪ Suicide & drowning
-------------------------------------------------------------------------------------------------------------
Diagnosis?
▪ Demarcating line of traumatic asphyxia
Describe these injury

-------------------------------------------------------------------------------------------------------------
Describe neck injury?
▪ I Ligature mark of hanging + full description

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 Child Abuse

Child Abuse
Definition
 It is a form of child maltreatment, usually induced by parents or caregiver
Types of child abuse
 Physical abuse
 Sexial abuse
 Emotional abuse
 Neglect
Physical abuse
 It is usually episodes of violence (It may be a
single event)
 Different types of injuries.
 Different ages of healing
 In multiple sites of the body.
 Most injuries are non-fatal .
D.D: from common murder:
 It is usually the culmination of repeated injury, rather than a single episode of deliberate
killing.
 In child abuse weapons are rarely used and manual violence being offered in most
cases.

1. Bruising:
 The cardinal sign particularly those of
different ages.
 Common bruises highly suggestive of abuse
are:

87 | P a g e
 Child Abuse

 Size: About 1 cm in diameter.

 Site: Around large joints, front or sides of chest in shaking.
 Mechanism: May be evidence of adult gripping.
 Shaking of the child

 On Chest, abdomen and neck :

88 | P a g e
 Child Abuse

On buttocks:

On trunk:

On ear:

Black eye

 Row of 3 or 4 nearly round bruises

 Commonly found on the back especially over the spine (skin covering bones or over facial
bones.

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 Child Abuse

D.D:
 from other children (a bite made by a child has a narrow arch & is smaller than one
made by an adult)
 Domestic pets (parallel rows of bruises that may be associated with puncture wounds d.t
prominent canines).

Animal bite Human bite mark, recent

MLI of Bite Marks :

 must be matched with a suspected assailant by« Swabs may recover saliva which can be
blood grouped if the person was a secretor or tested for DNA printing.
 Photography, measurements or Latex casts.
 Compare wit suspected assailant.

 Butterfly shaped bruise with one wing (caused by thumb) larger than other.

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 Child Abuse

Belt injuries:

✓ ension cord, belt, or some similar object was used to punish him
✓ The color of the bruise is red, which indicates that the few days old.

Loop mark:

Hard stik

Ligature

2. Burns:
D.D from accidental bums:
 Generally, more severe, deeper (due to long contact), uniform depth and larger.
 Burn is either dry (flame or contact) or scald burn.

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 Child Abuse

Accidental scalds

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 Child Abuse
Immersion Scald, Stocking Pattern

Shape ✓ usually circular (perpendicular) or triangular (oblique)

✓ When fresh, they are pink or red. After healing, they tend to be
Color
silvery in the center with a narrow red rim
✓ May be in the face, limbs & not reachable as back highly
Site
suspicious

D.D;From Accidental Cigarette bums

 On the back & buttocks unlikely to be accidental.
 Accidental more shallow, irregular & less well-defined than deliberate burns.

93 | P a g e
 Child Abuse

 (especially of skull and limbs)

 Fractures may be either fresh, or old healing

Spiral fractures
 Spiral fractures of limb bones are of great significance.
Mechanism:
 resulting from limb twisting (twisting at the elbow → spiral fracture of the humerus)

94 | P a g e
 Child Abuse
Evidence of previous damage
 vital in confirming long- term abuse. It includes the following:
1. Callus formation at previous fracture sites.

A classical radiological picture

 multiple callus formation on the ribs, in the paravertebral gutters, giving a string of beads
appearance, indicating healing fractures.
 Mechanism: following squeezing of the chest by adult hands.

Metaphyseal damage

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 Child Abuse
Classic Metaphyseal Lesions
 CML requires shearing forces not produced in accidental trauma
 Consider forceful twisting or traction
 Possibly produced during shaking where limbs flail about
Chipped Epiphyses F near large joints such as elbow and knee.

typical corner fracture very specific for accidental trauma

Sub- periosteal calcification in old haematomata

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 Child Abuse

Head injuries:
 The most frequent cause of death in child abuse.
 may result in severe permanent neurological disability.
 Commonly caused by blows from a punch or heavy slap.
 There may be no external head injury, though a hematoma is often found under the scalp.

Mechanism:
 It may arise from direct impact or from vigorous shaking (Whip lash) (causing shearing
stresses to the cranial contents → rupture of bridging veins in the subdural space)

Shaken baby syndrome

 The act of Violent shaking leads to serious or fatal injuries.
 Triad of subdural hge, retinal he & encephalopathy.

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 Child Abuse

 Commonly caused by throwing the infant against a floor or hard surface (smashed head).
 It is usually a fissure fracture across the temporal or parietal bone.
 Less often in occipital or frontal bones, uncommon at the base.
 Cerebral edema and diffuse axonal damage are often present.

 They include vitreous hemorrhage, dislocated lens and detached retina, (resulting from
violent shaking or impact upon the head).
 Permanent loss of vision is possible in such cases

 The lips are bruised or abraded by blows to the face or lacerated if the child has teeth.
 Torn frenulum inside the upper lips (characteristic lesion).
Mechanism:
 caused by tangential blow across the mouth or
by a feeding bottle being forced between lip
and gum.

Lip Lacerations

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 Child Abuse

They are the second most frequent cause of death.

✓ In infants with thin anterior abdominal wall, blows on the front
can sandwich the duodenum and jejunum between the impact
Intestine:
and the lumbar spine, crushing or even cleanly transecting the
gut, with consequent peritonitis and shock.
Mesentery ✓ be lacerated → intraperitoneal bleeding.

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 Child Abuse
✓ Liver can be ruptured by frontal blows,
even by deep prodding by adult
fingers.
Liver & spleen:
✓ The spleen is rarely damaged due to its
sheltered position from frontal trauma

 Examination should be performed by a specialist in clinical forensic medicine in

cooperation with a gynaecologist and/or a paediatrician

 Child abuse is frequently-unrecognized, however, increased awareness of its incidence has

led to its diagnosis….
16000 ‫خط نجده االطفال التابع للمجلس القومي لألمومة والطفولة‬

With my best wishes

See you soon in

 Endocrinology  Hematology  Patient safety

100 | P a g e
 ‫‪DEATH CERTIFICATE‬‬

‫"شهادة الوفاة"‬
‫تكتب باللغة العربية كاملة ‪.‬‬
‫من يكتب شهادة الوفاة ؟‬

‫في الحاالت التي بها شبهه جنائية‪ :‬الطبيب الشرعي‪.‬‬

‫في الحاالت التي ليس بها شبهه جنائية‪ .1 :‬طبيب الوحدة الصحية‪ .2 .‬مفتش الصحة‪.‬‬

‫حالة الوفاة‪:‬‬
‫يتم فحص الجثة من لبل طبيب الوحدة الصحية او مفتش الصحه ‪:‬‬

‫‪ ‬إذا كان بها شبهه جنائية >> ال يكتب اخطار الوفاة ويتم تبليغ الشرطة النيابية وتحويلها الي الطب الشرعي‪.‬‬
‫‪ ‬إذا لم يكن بها شبهه جنائية >> يكتب اخطار الوفاة ويصدر تصريح الدفن‪.‬‬

‫أجزاء شهادة الوفاة‪:‬‬

‫بيانات المتوفي‬ ‫‪-1‬‬
‫بيانات المبلغ‬ ‫‪-2‬‬
‫اسباب الوفاة ( شهادة الوفاة الطبية )‬ ‫‪-3‬‬
‫جزء خاص بوفيات االناث (‪ 44-15‬عام )‬ ‫‪-4‬‬

‫‪ 1‬ــ بيانات المتوفي‬

‫تاريخ الوفاة‬ ‫محل الميد بالسجل المدني‬ ‫العنوان‬ ‫الجنسية‬ ‫االسم الكامل‬
‫جهه الوفاة‬ ‫البطالة‬ ‫السن‬ ‫النوع‬
‫مكان الوفاة‬ ‫تاريخ ومحل االلامة‬ ‫الحالة العائلية‬ ‫الديانة‬
‫‪ 2‬ــ بيانات المبلغ‬
‫عنوان محل االلامة‬ ‫عاللته بالمتوفي‬ ‫البطالة‬ ‫االسم‬
‫‪ 3‬ــ أسباب الوفاة (شهادة الوفاة الطبية )‬
‫المدة بين السبب والوفاة‬ ‫شهادة الوفاة الطبية‬

‫ــ‬ ‫أ‪.‬‬ ‫السبب المباشر للوفاة‬

‫ــ‬ ‫ب‪.‬‬ ‫أحوال مرضية نشأ عنها السبب المباشر (ان وجدت)‬ ‫‪1‬‬

‫ــ‬ ‫ج‪.‬‬

‫ــ‬ ‫أحوال مرضية اخري ساعدت علي الوفاة وال صلة‬ ‫‪2‬‬
‫لها بالمرض االصلي (ان وجدت)‬

‫التاريخ‪/‬‬ ‫اسم الطبيب‪/‬‬ ‫التوليع‪/‬‬

‫‪10‬‬
 ‫لواعد مهمه لكتابة شهادة الوفاة‬
‫‪ . 1‬تكتب باللغة العربية كاملة ‪.‬‬

‫‪ . 2‬ال تكتب ‪:‬‬

‫طريمة الوفاة ( انتحار ‪ ,‬لتل ‪ ,‬حادث )‬ ‫‪‬‬

‫عالمات االنتحار او الوفاة مثل ( تولف التنفس ‪ ,‬تولف الملب ‪ ,‬هبوط حاد في الدورة الدموية ‪ ,‬هبوط حاد في‬ ‫‪‬‬
‫الدورة التنفسية)‬
‫االعراض المرضية مثل ( الم ‪ ,‬ارتفاع درجة الحرارة )‬ ‫‪‬‬

‫أ‬ ‫ب‬ ‫‪ . 3‬االلتزام بعاللة السببية والترتيب الزمني بين ( أ& ب & ج ) ج‬

‫‪ . 4‬من الممكن في بعض الحاالت اال نحتاج لكتابة كل االسطر في اسباب الوفاة ولكن البد ان يوجد السبب المباشر للوفاة‬
‫علي االلل (أ)‬

‫‪ . 5‬السطور الغير مستخدمة نكتب فيها ( ال يوجد )‬

‫‪1 . An elderly pedestrian was hit from the back by a car , she sustained bruises of Rt. Leg.‬‬
‫‪She confined to bed and after 10 days she complained of severe chest pain, dyspnea and‬‬
‫‪cyanosis, then she died.‬‬

‫‪ . 1‬أـ انحذاف رئوي‪.‬‬

‫ب ـ جلطة بأوردة الساق ‪.‬‬

‫ج ـ رلاد طويل بالفراش‪.‬‬

‫‪ . 2‬ال يوجد‬

‫‪2 . A diabetic man who had been on a therapy form ischemic heart disease and‬‬
‫& ‪atherosclerosis suddenly suffered from chest pain radiating to the left arm, dyspnea‬‬
‫‪sweating. He was diagnosed coronary artery occlusion and myocardial infarction but he‬‬
‫‪died.‬‬

‫‪ . 1‬أ ــ احتشاء بعضلة الملب ‪.‬‬

‫ب ــ انسداد في الشرايين التاجية‪.‬‬

‫ج ــ نمص التروية الدموية لعضله الملب نتيجه تصلب الشرايين‪.‬‬

‫‪ . 2‬مرض البول السكري‪.‬‬

‫‪11‬‬
3 . 55 years old man complaint progressive severe headache for one year. One week age,
vomiting started. On examination, papilledema was detected. A localized swelling in the brain
was diagnosed by CT scanning. After one day, he passed into coma and died.

.‫جـ ــ ال يوجد‬ .‫ب ــ ورم في المخ‬ . ‫ أ ــ انضغاط خاليا المخ‬. 1

‫ ال يوجـد‬. 2

4 . An alcoholic patient fell down on uncovered active electric wire. He died at once.

‫ج ــ ال يوجد‬ ‫ب ــ ال يوجد‬ ‫) أ ــ صعك كهربي‬I

.‫) تعاطي الكحول‬II

5 . An old man fell down stairs. He suffered from comminuted fracture of the femur. Plaster
splint was done in less than 24 hours. Then he developed severe chest pain, dyspnea, cyanosis
and shock with blood pressure 80/50 mmHg and was diagnosed as fat embolism. On his way to
the hospital he died.

.‫ج ــ السموط علي درج‬ .‫ب ــ كسر بعظمة الفخذ‬ .‫) أ ــ انحذاف (سدة) رئوي دهني‬I

.‫) ال يوجد‬II

6 . A patient was admitted to fever hospital where you are working suffering from viral
hepatitis. He gave past history of passing renal stones and bronchial asthma. By the afternoon
he passed into coma and died on next morning.

.‫ج ــ ال يوجد‬ .‫ب ــ ال يوجد‬ .‫) أ ــ التهاب كبدي فيروسي‬I

. ‫) ربو شعبي ــ حصوات بالكلية‬II

.‫ج ــ ال يوجد‬ .‫ب ــ التهاب كبدي فيروسي‬ .‫) أ ــ فشل كبدى‬I

.‫) ربو شعبي ــ حصوات بالكلية‬II

7. One year old child suffered from acute gastroenteritis with sunken eyes and cold skin
(dehydration was diagnosed). He received fluids but died few hours later.

‫ج ــ ال يوجد‬ ‫ب ــ نزلة معوية حادة‬ ‫) أ ــ جفاف‬I

.‫) ال يوجد‬II

12
8 . A child 7 years old suffering from a rheumatic heart, developed subacute bacterial
endocarditis. On the 3rd day, he developed hemiparesis followed in the afternoon by coma.
The diagnosis was cerebral artery embolism then he died.

.‫ج ــ حمي روماتزمية بالملب‬ ‫ب ــ التهاب بكتيري بعضلة الملب‬ .‫) أ ــ انحذاف (سدة) في شرايين المخ‬I

.‫) ال يوجد‬II

9 . 55 year old bilharzial man developed viral hepatitis. Few days later, his condition
deteriorated. His investigations revealed high level of ammonia with deteriorated liver
functions then he died.

.‫ج ــ ال يوجد‬ .‫ب ــ التهاب كبدي فيروسي‬ .‫) أ ــ فشل كبدي‬I

.‫) بلهارسيا‬II

10 . An anemic pregnant female came to the hospital with severe vaginal bleeding. On
examination, the cervix was dilated and was diagnosed as inevitable abortion. She died later on.

.‫ج ــ ال يوجد‬ .‫ب ــ اجهاض حتمي‬ .‫) أ ــ نزيف مهبلي حاد‬I

.)‫) انيميا ( فمر الدم‬II

11 . Chlorine gas cylinder exploded in a factory. Ten workers got chlorine toxicity. One of them
was severely cyanosed. She died from laryngeal edema.

.‫ج ــ ال يوجد‬ .‫ب ــ تسمم بغاز الكلور‬ .‫) أ ــ اوذيما بالحنجرة‬I

‫) ال يوجد‬II

12 . An alcohol addict man was found dead in a smoke filled room. He had sustained 1st degree
burns on his right hand. On examination, skin was red in color, alcohol level was 100 mg%, and
carboxyhemoglobin level was 80%.

.‫ج ــ ال يوجد‬ .‫ب ــ ال يوجد‬ .‫) أ ــ تسمم بغاز اول اكسيد الكربون‬I

.‫) تعاطي الكحول‬II

13
13 . During playing of one baby by a coin, he aspirated it on his trachea, he become cyanosed,
unconscious. He received treatment in emergency room but he died. During autopsy, we found
deep blue hypothesis, the right side of the heart, great vessels were congested, and also, the
lung was congested.

‫ج ــ ال يوجد‬ .‫ب ــ انزالق جسم غريب (عملة معدنية) الي المصبة الهوائية‬ .)‫ ) أ ــ اسفكسيا الشرق (الغصص‬I

.‫) ال يوجد‬II

14 . A hemophilic child was playing with fellows when he was struck on the lt, temple by a stick,
he staggered and fell momentarily concussed, but got to his feet. Next morning, he was found
unconscious with signs of liberalization. On his way to hospital he died.

.‫ج ــ اصابة بالراس‬ .‫ب ــ نزيف خارج االم الجافية‬ .‫) أ ــ انضغاط بالمخ‬I

. ‫) هيموفيليا‬II

Xiphoid process ‫الزائدة الخنجرية‬ Index finger ‫السبابة‬ Duodenal ulcer ‫لرحه باالثني عشر‬
Symphysis pubis ‫اإلرتفاق العاني‬ Middle finger ‫الوسطي‬ Haematuria ‫بول دموي‬
Hyoid bone ‫العظم السالمي‬ Ring finger ‫البنصر‬ Polycystic kidney ‫كلي متعددة الحصوات‬
Medial side ‫الجهه اإلنسية‬ Little finger ‫الخنصر‬ Hydronephrosis ‫استسماء كلوي‬
Lateral side ‫الجهه الوحشية‬ Wounds ‫الجروح‬ Renal failure ‫لصور كلوي‬
Ventral ‫بطني‬ Abrasions )‫سحج (سحجات‬ Gangrene )‫موت عضو(غرغرينا‬
Dorsal ‫ظهري‬ Contusions ‫كدمات‬ Subdural hg ‫نزيف تحت االم الجافية‬
Anterior ‫امامي‬ Ecchymosis ‫ايكيموز‬ Extradural hg ‫نزيف خارج االم الجافية‬
Posterior ‫خلفي‬ Contused wound ‫جرح رضي‬ Pia mater ‫االم الحنون‬
Proximal ‫ لريب‬-‫أدني‬ Lacerated wound ‫جرح رضي متهتط‬ Pontine hg ‫نزيف بجسر المخ‬
Distal ‫الصي –بعيد‬ Crush wound ‫جرح هرسي‬ Hemiplegia ‫شلل نصفي‬
Mid-axillary line ‫خط منتصف االبط‬ Tear laceration ‫جرح مزعي‬ Coma ‫غيبوبة‬
Mid-clavicular line ‫خط منتصف الترلوة‬ Cut laceration ‫جرح لطعي رضي‬ Ascites ‫استسماء‬

14
 Incised wound (cut wound) ‫جرح لطعي‬ Uraemia ‫ارتفاع نسبة البولينيا بالدم‬
Stab puncture wound ‫جرح طعني وخزي‬ Needle ‫ابرة ضرب النار‬
Puncture wound ‫جرح وخزي‬ Striker ‫طارق‬
Penetrating wound ‫جرح نافذ‬ To ignite ‫يشعل‬
Fabricated wound ‫جرح مفتعل‬ Ignitor ‫مشعل‬
Depressed fracture ‫كسر منخسف‬ Automatic ‫ألي‬
Depressed comminuted ‫كسر مهشم‬ Staghorn stone kidney ‫حصاة مرجانية بالكلية‬
fracture
Fissured fractures ‫كسرشرخي‬ Carbuncle ‫جمرة او دمل متعدد الفتحات‬
Burr hole (trephine) ‫تربنة‬ Diabetes mellitus ‫امراض البول السكري‬
Burns ‫حروق‬ Extractor hook ‫ظفر مجر الفشنن‬
Corrosion ‫كي‬ Revolver ‫رفولف‬
Scald ‫سلك‬ Subarachnoid hg ‫نزيف تحت العنكبوتية‬
Pneumothorax ‫تجمع بلوري في تجويف البلورا (استرياح‬ Revolving magazine ‫خزنة دوارة‬
)‫الصدر‬
Haemothorax ‫تجمع دموي في تجويف البلورة‬ Magazine ‫خزنة‬
Haemoptysis ‫سعال دموي‬ Pistol ‫مسدس‬
Haematemesis ‫لئ دموي‬ Handle ‫ممبض او يد‬
Fibrosis ‫تليف‬ Sliding cover ‫غطاء الترباس المنزلك‬
Necrosis ‫تخسر‬ Shots )‫رش (ممذوف‬
Lymphadenopathy ‫مرض الغدد الليمفاوية‬ Flame of light ‫لهيب ضوئي‬
Hodgkin’s disease ‫مرض هيدجوكين‬ Firearm injury ‫جرح ناري‬
Liver cirrhosis )‫تليف بالكبد (كساد مزمن او كيسيه الكبد‬ Inlet of firearm ‫فتحه دخول طلك ناري‬
Bilharzial hepatic fibrosis ‫تليف كبدي بلهارسي‬ Exit of firearm ‫فتحه خروج طلك ناري‬
Strangulated inguinal hernia ‫فتك اربي مختنك‬ Bevelling ‫انتشار‬
Bullet ‫رصاصة او ممذوف‬ Dispersion ‫كشط – شطف‬
Projectile, missile ‫ممذوف‬ Base of the car-tridge ‫لاعدة الخرطوشة‬
Supraclavicular ‫فوق الترلوة‬ Arm ‫منطمة العضد‬
Midline ‫الخط المنصف االمامي‬ Forearm ‫الساعد‬
Scalp ‫فروة الرأس‬ Elbow ‫المرفك‬
Nipple ‫الحلمه‬ Wrist ‫الرسغ‬
Umbillicus ‫السرة‬ Thigh ‫الفخد‬
Intercostal )‫وربي(بين االضالع‬ Leg ‫الساق‬
Rt & Lt iliac region ‫المنطمة الحرلفية من البطن‬ Foot ‫المدم‬
Rt & Lt femoral region ‫المنطمة االربية‬ Ankle ‫رسغ المدم‬
Rt & Lt hypochondrial region ‫المنطمة المرالية‬ Thumb ‫اصبع االبهام‬
Rt & Lt lumber ‫المنطمة المطنية‬ Loss of substance ‫فمد في النسيج‬
Umbilical region ‫منطمة السرة‬ Wad ‫حشار‬
Epigastric region )‫المسم الشرسوفي(الجزء االوسط العلوي‬ Muzzle ‫فوهة البندلية او المدفع‬
Supra-pubic region ‫فوق العانة‬ Rifled ‫مششحن‬
Palm ‫راحت اليد‬ Rifling ‫ششخنه‬
Sole ‫اخمص المدم‬ Cap ‫كبسولة او طابة‬
Bore ‫المطر الداخلي للماسورة‬ Percussion cap ‫كبسولة طرلة‬
Calibre ‫عيار‬ Trigger ‫زناد‬
Cartridge, case ‫خرطوشة‬ Barrel ‫ماسورة‬
Bifle ‫بندلية‬

15
 ‫‪MEDICO-LEGAL REPORT‬‬

‫‪ )1‬نوع االصابة‪:‬‬
‫‪ )2‬وصف االصابة‪:‬‬
‫‪ )3‬عدد االصابات‪:‬‬
‫‪ )4‬أبعاد االصابة‪:‬‬
‫‪ )5‬موضعها من الجسم‪:‬‬
‫‪ )6‬اآللة المستخدمة في احداث االصابة‪:‬‬
‫‪ )7‬االصابات المشتبه في مصاحبتها لالصابة االصلية‬
‫‪ )8‬العالج الذي اجري‪:‬‬
‫‪ )9‬الولت الالزم للشفاء‬
‫‪ )10‬االمضاء‪:‬‬

‫نوع اإلصابة ووصفها‬

‫هاللية ‪Finger Nails‬‬ ‫‪/‬‬ ‫كشطية ‪ / Tangential‬خطية ‪Scratch‬‬ ‫سحجات‬

‫المنطمة المحيطة بها سحجات او ال‬ ‫‪/‬‬ ‫لونها‬ ‫كدمات‬

‫حواف الجرح >> غير منظمة‬ ‫جرح رضي‬

‫لاعدته >> تهتن باالنسجة في لاعدة الجرح‬

‫المنطمة المحيطة >> بها كدمات وسحجات‬

‫حواف الجرح >> منتظمة‪.‬‬ ‫جرح لطعي‬

‫زواياه >> حادة‪.‬‬

‫لاعدته >> لطع باالنسجة في لاعدة الجرح‪.‬‬

‫المنطمة المحيطة >> ال يوجد بها كدمات او سحجات‪.‬‬

‫حواف الجرح >> منتظمة‬ ‫جرح طعني‬

‫زواياه >> حادة‬
‫لاعدته >> لطع باالنسجة في لاعدة الجرح‬
‫المنطمة المحيطة >> ال يوجد بها كدمات او سحجات‬
‫اوصفه علي حسب الشكل الي هيجيلن‬ ‫جرح لطعي متهتن‬
‫فمد في ‪.....‬‬ ‫بتر‬
‫فمد في جوهر النسيج مصاحب بسناج او نمش بارودي في المنطمة المحيطة‬ ‫الطلك الناري (فتحة دخول)‬
‫فمد في جوهر النسيج‬ ‫الطلك الناري ( فتحة خروج)‬
‫فمد في جوهر النسيج‬ ‫انتشار رش‬

‫‪16‬‬
 ‫عدداالصابات‬
‫واحدة‬ ‫‪‬‬
‫إثنان‬ ‫‪‬‬
‫متعددة‬ ‫‪‬‬

‫أبعاد االصابة‬
‫ماعدا في السحجه الطولية يكون ( الطول فمط)‬ ‫طول ‪ x‬عرض (سم)‬ ‫‪‬‬
‫هنكتب مكان كل اصابة وطولها وعرضها‬ ‫‪‬‬
‫لو اصابات متعددة ( لو كذا اصابة) هتكتب اكبرهم في االبعاد واصغرهم في االبعاد‪.‬‬ ‫‪‬‬

‫موضع االصابة في الجسم‬

‫‪ ‬هنوصف موضعها من الجسم بالضبط ( في اي منطمة ) ‪ ( //‬امامي او خلفي ) ‪( //‬في الجهه االنسية او الوحشية)‬
‫>> لو في سالميات تعدها من تحت لفوق ( ‪) From proximal to distal‬‬
‫‪ ‬طب لو مش عارفين موضعها بالجسم بالضبط او مش واضح لدامن فالصورة ؟!‬

‫>> هتكتب (( يتم تحديد الموضع اثناء الكشف الظاهري بألرب عالمة تشريحية مميزة ))‬

‫راس‬
‫الكتف‬

‫العضد‬

‫مفصل المرفك‬

‫الساعد‬ ‫راحه اليد‬

‫مفصل الرسغ‬ ‫السالميات‬
‫الساق‬
‫الفخذ‬
‫المنطمة اإليليه‬
‫مفصل الركبة‬
‫المنطمة اإلربية‬
‫مفصل الكاحل‬

‫‪17‬‬
 ‫اآللة المستخدمة‬
‫ذات طرف مدبب ( سحجات هاللية او خطية )‬ ‫آلة راضة‬
‫ذات سطح خشن ( سحجات لشطية )‬
‫ثميلة ( جرح رضي ‪ /‬كدمات ‪ /‬بتر غير منتظم )‬
‫جرح لطعي‬ ‫آلة حادة‬
‫جرح طعني‬
‫بتر منتظم‬
‫مششخن ( منتظمة)‬ ‫سالح ناري‬
‫غير مششخن (غير منتظمة)‬

‫االصابات المشتبه في مصاحبتها لالصابة االصلية‬

‫يتولف علي‪:‬‬

‫ال يوجد سحجات‬ ‫‪‬‬ ‫نوع االصابة‬

‫تهتن ( جرح رضي )‬ ‫‪‬‬
‫لطع في االنسجه ( جرح لطعي او طعني )‬ ‫‪‬‬
‫اصابة في االحشاء ( سالح ناري )‬ ‫‪‬‬
‫في العين او الجبهة‬ ‫‪‬‬ ‫مكان االصابة‬
‫منطمة الرأس‬ ‫‪‬‬
‫كسر في عظام الجمجمة‬ ‫‪‬‬
‫ارتجاج في المخ‬ ‫‪‬‬
‫نزيف فاالغشية الداخلية فالمخ‪.‬‬ ‫‪‬‬

‫نوع العالج الذي أجري‬

‫كدمة‬ ‫جرح رضي‬ ‫جرح لطعي‬ ‫سحجات‬

‫كمادات‪-‬مضاد حيوي ‪-‬‬ ‫غرز‪-‬غيار‪-‬مضاد حيوي‪-‬‬ ‫غرز‪-‬غيار‪-‬مضاد حيوي‪-‬‬ ‫غيار‪-‬مضاد حيوي‪-‬‬

‫عرض واشعة‬ ‫مصل ضد التيتانوس‬ ‫مصل ضد التيتانوس‬ ‫مصل ضد التيتانوس‬

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 ‫جرح رضي في الرأس ‪:‬‬
‫جرح طعني في البطن ‪:‬‬ ‫جرح طعني في الصدر أو الرلية او طلك ناري‪:‬‬
‫‪ -‬غرز‪-‬غيار‪-‬مضاد حيوي‪-‬مصل ضد التيتانوس‬
‫‪-‬سونار علي البطن وعرض علي الجراحه العامة‬ ‫‪-‬اشعة عادية علي الصدر وعرض علي جراحه الملب‬
‫والصدر‪.‬‬ ‫‪ -‬دخول مشتفشي ويوضع تحت المالحظة لمدة ‪ 48‬ساعة‬
‫‪-‬دخول مستشفي الجراء عملية استكشاف‪.‬‬
‫‪ -‬دخول مستشفي الجراء عملية استكشاف‬ ‫‪-‬أشعة عادية علي الراس وعرض علي نائب جراحه المخ‬
‫واالعصاب‬

‫الولت الالزم للشفاء‬

‫في الجرح الرضي والمطعي والسحجات والكدمات ( بس مش فالرأس )‪.‬‬ ‫ألل من ‪ 22‬يوم مالم تحدث مضاعفات‪.‬‬
‫في البتر‪.‬‬ ‫ألل من ‪ 22‬يوم مع ترن عاهة مستديمة‪.‬‬
‫في اصابات الراس‪.‬‬ ‫دخول مستشفي والتمرير النهائي عند الخروج‪.‬‬
‫السالح الناري والجرح الطعني‪.‬‬ ‫دخول مستشفي والتمرير النهائي عند الخروج ومناظرة الطب الشرعي‪.‬‬

‫نوع االصابة ‪ :‬سحجات‪.‬‬

‫وصفها ‪ :‬خطية‬
‫عددها‪ :‬متعددة‬
‫ابعادها‪ :‬يتراوح طول اكبرها من ‪ 8‬ل‪ 11‬سم وطول اصغرها من ‪ 3‬ل‪ 4‬سم‬
‫موضعها‪ :‬في الناحية االنسية من ممدمة الساعد االيمن‬
‫االلة المستخدمة‪ :‬الة راضه ذات سن مدبب‬
‫االصابات المشتبه في مصاحبتها لالصابة االصلية‪ :‬اليوجد‬
‫العالج الذي اجري‪ :‬غيار ‪ /‬مضاد حيوي ‪ /‬مصل ضد التيتانوس‬
‫الولت الالزم للشفاء‪ :‬الل من ‪ 21‬يوم مالم يحدث مضاعفات‬

‫‪19‬‬
 ‫نوع االصابة ‪ :‬كدمة‪.‬‬ ‫‪‬‬
‫وصفها ‪ :‬المنطمة المحيطة ليس بها سحجات‪.‬‬ ‫‪‬‬
‫عددها‪ :‬واحدة‬ ‫‪‬‬
‫ابعادها‪ 3 x 2 :‬سم‬ ‫‪‬‬
‫موضعها‪ :‬في الجهة الوحشية من الساعد االيمن‪.‬‬ ‫‪‬‬
‫االلة المستخدمة‪ :‬الة راضه‬ ‫‪‬‬
‫االصابات المشتبه في مصاحبتها لالصابة االصلية‪:‬‬ ‫‪‬‬
‫تهتن في االوعية الدموية واالعصاب ‪//‬تهتن في االنسجة والعضالت‪//‬كسور في العظام‪.‬‬
‫العالج الذي اجري‪ :‬كمادات ‪ /‬مضاد حيوي ‪ /‬أشعة‬ ‫‪‬‬
‫الولت الالزم للشفاء‪ :‬الل من ‪ 21‬يوم مالم يحدث مضاعفات‬ ‫‪‬‬

‫نوع االصابة ‪ :‬جرح رضي‪.‬‬ ‫‪‬‬

‫عددها‪ :‬واحدة‬ ‫‪‬‬
‫ابعادها‪ 4 :‬سم ‪ 1 x‬سم‪.‬‬ ‫‪‬‬
‫موضعها‪ :‬اعلي اليسار من ممدم فروة الراس‬ ‫‪‬‬
‫االلة المستخدمة‪ :‬الة راضه‪.‬‬ ‫‪‬‬
‫االصابات المشتبه في مصاحبتها لالصابة االصلية‪ :‬تهتن في انسجة الجلد واالنسجة الرخوة‬ ‫‪‬‬
‫تهتن في االوعية الدموية واالعصاب ‪ /‬اشتباه بوجود كسر بعظام الجمجمه‬
‫تهتن في انسجة المخ ونزيف داخلي‪.‬‬
‫العالج الذي اجري‪ :‬غرز ‪ /‬غيار ‪ /‬مضاد حيوي ‪ /‬مصل ضد التيتانوس‬ ‫‪‬‬
‫دخول المستشفي ويوضع المريض تحت المالحظة لمدة ‪ 48‬ساعة‬
‫اشعة عادية علي الراس وعرض علينائب المخ واالعصاب‪.‬‬
‫الولت الالزم للشفاء‪ :‬دخول المستشفي والتمرير النهائي بعد الخروج‪.‬‬ ‫‪‬‬

‫نوع االصابة ‪ :‬جرح لطعي‪.‬‬ ‫‪‬‬

‫وصفها ‪ :‬حواف الجرح منتظمة ‪ /‬زواياه حادة ‪ /‬لاعدته بها لطع باالنسجه‬ ‫‪‬‬
‫المنطمة المحيطه ال يوجد بها كدمات او سحجات‬
‫عددها‪ :‬واحد‬ ‫‪‬‬
‫ابعادها‪ 2 :‬سم ‪ 1 x‬سم‬ ‫‪‬‬
‫موضعها‪ :‬أسفل ممدم رسغ الساعد االيسر‪.‬‬ ‫‪‬‬
‫االلة المستخدمة‪ :‬الة حادة‪.‬‬ ‫‪‬‬
‫االصابات المشتبه في مصاحبتها لالصابة االصلية‪ :‬لطع في االوتار ‪ /‬اليد‬ ‫‪‬‬
‫لطع في االنسجة ‪ /‬لطع في االعصاب‪.‬‬
‫العالج الذي اجري‪ :‬غرز ‪ /‬غيار ‪ /‬مضاد حيوي‬ ‫‪‬‬
‫الولت الالزم للشفاء‪ :‬الل من ‪ 21‬يوم مالم يحدث مضاعفات‪.‬‬ ‫‪‬‬

‫اإلمضاء‬

‫‪20‬‬
 Some examples

‫جرب كدا‬

21