Head injury in forensic medicine: the scalp and an overview
- Topic
Head injury is the commonest cause of death from blunt force; the forensic doctor reads the scalp, the skull and the brain as layers of one event.
What it is
In forensic practice the head is examined in layers: scalp, skull, membranes and brain. Each layer answers a different question. The scalp shows where and how many times the head was struck and what kind of surface struck it. The skull shows the force and direction. The bleeding inside the skull and the brain damage explain how the person died and how long they may have lived. Scalp lacerations over bone can look straight like cuts, and scalp bruises are often only seen once the scalp is reflected at autopsy. Many fatal head injuries leave little outside: the absence of an external wound does not exclude a lethal injury. This page is the overview; skull fractures, intracranial bleeding, brain injury and the neck have their own pages.
Key facts
- Number and site of scalp injuries count the impacts; their shape may reflect the object (see patterned injuries).
- Swelling and bleeding of the scalp may track down to the eyelids and behind the ears, imitating a separate blow.
- Alcohol, anticoagulants and old age change both the injury and the clinical course (falls, subdural bleeding).
- Death may be immediate (brainstem, massive injury) or delayed by swelling, rising pressure, infection or pneumonia: the medical record bridges the gap.
Structure
- Scalp: skin, dense connective tissue, galea aponeurotica, loose areolar tissue and pericranium; bleeding spreads freely in the loose layer.
- Skull: vault and base; the base has thin areas (orbital roofs, temporal bone) that break more easily.
- Membranes: dura (extradural space above it), arachnoid (subdural space between them), pia (subarachnoid space below the arachnoid).
- Brain: cortex (contusions), white matter (axonal injury), brainstem (secondary bleeding after herniation).
Step by step
- Shave or part the hair around each injury and photograph it with a scale.
- Describe each wound: site, size, shape, edges, base, tissue bridges and surrounding bruising.
- At autopsy, reflect the scalp and record bruises seen only from the inner surface.
- Relate each injury to the skull, membranes and brain beneath it.
- Compare the pattern with the history: a single fall or several blows.
Fall or blow? Patterns that guide, not prove
| Feature | Points to a fall | Points to blows |
|---|---|---|
| Number of impact sites | Usually one, sometimes two | Often several |
| Site | Prominent points at the level of the hat brim (occiput, forehead, side) | Top of the head and sites protected from the ground |
| Brain contusions | Often contrecoup (opposite side), especially after a fall onto the back of the head | Mostly coup, under the impact |
| Other findings | Abrasions on other prominent points of the same side | Defence injuries on hands and forearms |
Next step: what to do and document
- In a living patient, document every scalp wound before suturing: site, length, shape, edges and tissue bridges, with a photograph and scale if possible.
- Write the Glasgow score, the pupils and the time of each assessment; record any period of lost consciousness and any later deterioration.
- Keep the first CT images and the report: they are evidence of the injury as it was at admission.
- If the injury may have been caused by another person, follow the reporting route and keep the clothing with chain of custody.
- In a death after head injury, do not sign the death certificate as natural: the case goes to the medico-legal autopsy.
Legal framework in Colombia
- In Colombia, a living person with a head injury from violence is examined for lesiones personales and incapacidad médico-legal (see those pages).
- A death from head injury is a violent death and needs a medico-legal autopsy; the doctor who treated the patient provides the medical record and the reports.
Test yourself
Think of the answer, then tap the question to see it.
Why can a scalp laceration be mistaken for an incised wound?
Because over bone the skin splits in a straight line. Tissue bridges in the depth, crushed hairs and bruised edges show it is a laceration.
Where are scalp bruises often seen only at autopsy?
On the inner surface of the scalp after it is reflected, especially under thick hair or dark skin.
Does the absence of an external head wound exclude a fatal head injury?
No. Skull fractures, intracranial bleeding and brain injury can occur with little or no visible external wound.
What site of impact suggests a blow rather than a fall?
Injuries on the top of the head or above the hat-brim level, especially several of them, point to blows; a fall usually injures one prominent point.
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Educational content on forensic and legal medicine; not legal advice and no substitute for the technical guides of Colombia's National Institute of Legal Medicine and Forensic Sciences. Laws change: each page links the official text and says when it was last checked. For a real case, follow the guide in force and ask the competent authority.
Sources: Traumatic Brain Injury (StatPearls Publishing (NCBI Bookshelf), 2025); Scalp Laceration (StatPearls Publishing (NCBI Bookshelf), 2023); Blunt Force Trauma (StatPearls Publishing (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.