Description of wounds
It is important to describe wounds in detail. If possible, photos of wounds should be included, but then a colour chart should also be added so that colour changes can be judged objectively; sketches are also important.
The following must be indicated:
· The number of wounds.
· The time when the wound was inflicted. Except if the contrary is indicated, it is usually assumed that the wounds occurred ante mortem. However, if it is possible that a wound may have occurred in the post-mortem period, it must be mentioned. This type of situation often occurs with drowning victims, where injuries due to propellers of boats as well as rocks may develop in the post-mortem period.
· The precise location of every wound, measured from fixed reference points (eg from the middle of the body in the horizontal level and specific vertical points - like the height above the heel, level of the nipples, level of the eyes, etc). It is also important to remember that the wounds are described with the body in the anatomical position, that is in an upright position with the palms of the hands facing forward. The wound tract of a stab wound therefore does not necessarily represent the position of the body at the time of the stabbing. (The same principle applies when the body is hit by a bullet.)
· The shape of every wound. For instance, is the abrasion an oval shape with accumulation of skin on the one side? Are both corners of the stab wound sharp (pointed), as those made by a knife with a double-edged blade?
· The size of the wound. Abrasions and contusions have two dimensions. Lacerated wounds and incised wounds have only one dimension, namely length, even if the wound is gaping. Stab wounds also have a depth measurement.
· Any additional wounds, for instance abrasions or contusions surrounding a laceration wound.
· The estimated age of the wound. It is important to decide whether the wound is still fresh or whether it shows signs of healing.
· Any signs of complications, for instance inflammation or abscess formation.
· Any signs of medical treatment, for example sutures
In the case of a stab wound, the direction of the wound tract, the depth as well as any important structures involved, must be mentioned. Any other additional factors of importance, including the impression sometimes seen in contusions and abrasions, or the presence of foreign material in the wound, must be mentioned. It is important to examine the entire body, also concealed areas. Some pathologists will even indicate on the sketch with a tick mark that they have examined the part in question and found no wounds.
The distribution of wounds can be of assistance to reconstruct the scenario. Contusions and abrasions over the posterior aspects of the forearms are often seen when the victim tries to protect his head by folding the arms over the head (self-defence wounds). Sometimes incised wounds of the hands can be seen if the victim tried to grab the knife from the assailant. Tentative wounds in cases of suicide have already been mentioned.