Abrasion is the superficial denudation of the epithelium due to scraping, impact or pressure. While the management of abrasions is relatively simple, these can be extremely important medico-legally. This activity illustrates the evaluation and management of abrasion and highlights the role of medical personnel in managing patients with abrasion.
Outline the etiology, pathophysiology, and epidemiology of abrasions.
Summarize the patient history, medical management, and medicolegal evaluation of abrasions.
Identify the appropriate needs for screening, further investigation, and documentation on the presentation of abrasion that are medicolegally significant.
Review the importance of improving documentation and management among the interdisciplinary and interprofessional teams to improve outcomes for patients who have sustained abrasions.
Abrasions are superficial injuries of the skin and visceral linings in the body, resulting in a break in the continuity of tissue. These are the simplest of injuries in terms of healing, with most injuries being confined to the epidermis and result in minimal bleeding at most. The majority of the abrasions heal without leaving any scar. However, the abrasions that extend into the dermis may result in scarring of the tissue upon healing. The most common mechanism of formation of abrasion is due to friction against the epidermis, resulting in its denudation. Abrasions appear in all forms of blunt trauma, with friction and impact being the most common mechanisms. Pressure abrasions, while less frequent in occurrence, can have a greater medicolegal significance, especially for the identification of the causative material.
Abrasions are classified into three types:
Linear or scratch abrasions – Linear abrasions are caused by tangential forces resulting in denuding of the epidermis. Linear abrasions are the simplest of injuries and tend to heal by primary intention, without any sequelae. Linear abrasions have significant medicolegal importance, especially when seen over the neck, inner thighs, and genitalia. Linear or semicircular injuries are classically seen as a result of nail scratches, and their presence on the inner aspect of thighs and around female genitalia may indicate resistance in cases of sexual assault. Likewise, nail scratch abrasions on the neck may be suggestive of throttling.
Grazed or brush abrasions – Grazed abrasions are usually multiple in presentation and result from friction against a broad, rough surface. These are most commonly seen in cases of road traffic accidents as well as in sports falls. Grazed abrasions are caused by the dragging of the body against a rough surface, resulting in the scrapping of the epidermis. The depth of grazed injuries varies depending on the irregularity of the surface, as well as the speed tugging the body. Extensive, grazed abrasions are sometimes referred to as "brush burns."
Patterned abrasion – Patterned abrasions are a result of perpendicular force on the epidermis, resulting in an impression of the offending item. Patterned abrasions can be further sub-classified as pressure abrasion and impact abrasion, depending on the duration of contact with the offending object.
Pressure abrasions result from prolonged compression of the epidermis. The force required to produce pressure abrasion is, however, minimal. E.g., the use of rough material for hanging produces a ligature mark that is an imprint of the material used.
Impact abrasions result from a swift blow and require considerable force. Patterned abrasions resulting from blows, collisions, and run-over, etc. are examples of impact abrasions.
Abrasions can occur at any time of life, with no particular propensity for any age or sex. Abrasions are primarily accidental throughout all phases of life. Abrasions caused by intentional injuries are found more frequently in the middle age groups as compared to the extremes of ages. Intentional injuries of a sexual nature that are associated with sexual offenses are found to be more common in females. Unintentional abrasions are frequently associated with falls and sports-related injuries among children and with falls in the elderly.
Abrasions are the most common form of injury in children accounting for 70.7% of all injuries. Head and torso are the most common site, comprising of 50% of all abrasions; the upper limbs account for 15.4% and the lower limbs for 34.6% of all abrasions. However, there exists a possibility of substantial under-reporting of the overall prevalence of abrasions and its predilection for a particular site, especially because people sustaining minor abrasions, scratches, etc. on the non-vital parts of the body do not attend clinics and hospitals for its management.
Abrasions range from a break in the epithelial lining to damage to the deeper structures, including nerves, blood vessels, muscles, tendons, organs, and even bone.
Forensic investigations are necessary to determine the extent of the injury and the antemortem or postmortem nature of the wound. The presence of vital reactions, including hemorrhage, cell infiltration, granulation tissue, etc. are indicative of the antemortem quality of an abrasion.
History and Physical
Relevant history should be documented, including the time of injury, cause, and mechanism of injury, as well as other relevant details pertaining to the causation as well as management of the injury.
Abrasions are commonly associated with physical trauma; this could result from falls and impact against hard and uneven surfaces, as well as the pressure of impending objects. They are commonly seen along with other forms of blunt force trauma, such as contusions and lacerations.
While the physical examination of abrasions is important for treatment, the medicolegal examination of abrasions is considerably more significant. Abrasions could be present over any part of the body, frequently seen over the exposed parts of the body, especially the head and neck, as well as the extremities. When found over the neck or genitalia, they tend to have a particular significance that could be precarious, if wrongly interpreted.
The physical examination should include the type, size, shape, color, location, size, depth, association with other injuries as well as the presence of extraneous material. The scientific collection and evaluation of these extraneous materials can provide valuable information regarding the scene of a crime, and in linking the suspect to the crime.
The systematic management of the injury for medical and medicolegal purposes will ensure not just treatment of the injury but also help in providing justice to the victim. The medicolegal examination is especially important in injuries over the head and neck and around the genitalia. Injuries around the genitalia could be vital in identifying sexual violence, while minor injuries over the head and neck could be an indication of more serious underlying injuries.
Abrasions are usually simple in nature and frequently small in size. These abrasions usually heal by the first intention and do not leave any scarring. However, the involvement of large surface area can lead to healing by second intentions, resulting in scar formation. This is particularly seen in individuals susceptible to keloid hyperplasia and should be started on steroid therapy to prevent keloid formation.
The medicolegal investigation may require a biopsy of the abrasion for histological examination. The histological examination investigates the stage of wound healing to provide an estimate of time of injury. Wound healing involves a series of coordinated cellular changes that include bleeding and coagulation, inflammatory response, regeneration, and remodeling. The regeneration process further involves migration and proliferation, while remodeling involves extracellular matrix protein and collagen synthesis, as well as the formation of new parenchymal and connective tissue. These processes are four time-dependent phases: (i) bleeding and coagulation, begins immediately (ii) inflammation, also begins without delay; (iii) regeneration, begins in days and lasts for the primary part of the acute healing phase; and (iv) remodeling, begins weeks after the injury and can last for longer than a year.
The information may be further augmented by histochemical analysis of inflammatory cells and cell mediators. This may assist in informing the law enforcement about the time of occurrence of injury. A skin biopsy is relatively painless and can even be performed in the living if required. Histopathology of an injury can provide vital information for the investigation.
Infection of the injury is another concern and should be managed judiciously. At the same time, the emergence of antibiotic resistance in many organisms should ensure strict follow-up to evaluate compliance and adherence to the full protocol. Injuries should also be swabbed and sent for culture and sensitivity.
Treatment / Management
Abrasions are usually simple, minor injuries that do not require much medical intervention. A sponsored study showed that wet healing, using polyurethane and hydrocolloid plasters, are found to be more efficient and effective in wound healing.
Due to the loss of the epidermis, the outermost layer of protection of the body, abrasions are particularly susceptible to Clostridium tetani and Staphylococcus aureus, particularly in sports injuries. Tetanus toxoid status should always be checked. Abrasions should be cleansed and dressed, protecting the area from reinjury. Debridement may be required, especially if dirt or other contaminants are found embedded. Prevention of infection is the primary objective of any medical intervention. Antibiotic ointments may be applied; after confirming the allergy history, a dressing may be necessary, depending on the area and depth of the injury. Systemic antibiotics may be indicated and should be judiciously prescribed.
Facial abrasions and considered more serious as these have a higher risk of cicatrization and should be cleaned, debrided, and dressed daily. Dressings may require skin adhesives like the combination of gum mastic, styrax, alcohol, and methyl salicylate or tincture of benzoin.
The presence of foreign material may indicate the causation and nature of the injury. Abrasion over the eyes, including the conjunctiva, could be mistaken for a variety of ocular conditions, including conjunctivitis, corneal ulcer, and endophthalmitis.
Abrasions are frequently associated with poor hygiene, napkin rashes, and pruritis, etc.
In medico-legal examinations, the nature of abrasion is more important than the gravity of the injury. The location of abrasion may present significant findings and could be a vital piece of evidence. Injuries present over the neck may indicate a case of (attempted) homicide. Similarly, injuries present over the thighs and genitalia could indicate a case of sexual assault.
Abrasions are generally minor injuries and tend to heal within two weeks, without any resultant scarring. Extensive and deep abrasions, as well as infection, may result in scarring, which can be prevented by daily cleaning and dressing. Debridement should be performed to avoid extensive cicatrization.
Wound infection is a common complication. Cleaning the wound is essential. Local antibiotic ointments may be applied to superficial, contaminated wounds. Systemic antibiotics may need to be prescribed in large and deep abrasions. It is important to weigh the need to prevent infection against the increase in antibiotic resistance. The tetanus immunization status of the patient should be assessed.
Wide and deep abrasions may result in the development of soft scars that may persist for months or years. Individuals with a tendency for keloid formation may develop extensive scarring, especially over the chest and shoulders.
The nature and association of abrasions are perhaps the most important and should require adequate attention from clinical physicians to prevent negligence claims. The documentation, including photography of the injuries, should be preserved for a specified period.
Deterrence and Patient Education
Abrasions occur due to a variety of causes, some innocuous and other extremely grievous. Patients and relatives need to be educated on the medicolegal importance of these seemingly inconsequential injuries. Clinicians also need to be advocated on the importance of documentation. Abrasions in sports can be reduced by using protective measures, paddings, and appropriate clothing, etc.
Simple abrasions resulting from falls can be treated with first aid, and the patient and their relatives should receive education on first aid procedures, including cleaning the wound, removal of foreign material, and dressing with a non-adhesive material.
Enhancing Healthcare Team Outcomes
Abrasions are one of the most common physical injuries. While a lot of them are simple and treated at home, healthcare workers will inevitably encounter patients with abrasions. They are usually associated with other injuries. However, the presence of abrasions should be appropriately investigated and managed clinically and medicolegally. The initial assessment may be by emergency medical technicians, trauma nurses, and physicians. Emergency room and ambulatory care nurses provide direct care and educate patients. Pharmacists are often called upon to counsel on over the counter and prescription medications. They, too, inform patients about the use of these treatments. [Level 5]
(Click Image to Enlarge)
Parallel, linear abrasions of the ventral right wrist.
Contributed by Andrea L. Wiens, DO
(Click Image to Enlarge)
Abrasion caused by sliding fall on concrete
Contributed by Wikimedia Commons (Public Domain)
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