Wounds: what do you need to know about them?

Wounds are open mechanical damages of soft tissues and internal organs (with penetrating wounds) with violation of their integrity, accompanied by gaping and bleeding.

Wounds are the most common type of open injuries and constitute 47-50% of all emergency traumatological conditions, and the management of wounds and wound process occupies 70% of the working time of surgeons and traumatologists.

With regard to injuries of internal organs, most trauma doctors tend to differentiate concepts. The term "wound" means damage caused by a cutting or stabbing object (wound of the lung, heart, liver). Damage due to the impact of a blunt solid object or as a result of the impact of the body itself (for example, light against the chest wall at the time of injury) is regarded as a "rupture". Rough destruction of the tissues of internal organs, with extensive hemorrhages, is referred to as "crushing".

Types of wounds are multifaceted and includes several positions. Classification refers to the category of international and is defined as "working".

1. By the nature of the application, the types of wounds are divided into intentional (operational) and accidental (traumatic).
2. According to the type of wounding weapon, these types of wounds can be distinguished: chipped, cut, chopped, bruised, torn, bitten, gunshot, smashed, scalped wounds.
3. In relation to the body cavities, the types of wounds can be non-penetrating (superficial) and penetrating into the cavity (pleural, pericardium, abdominal, etc.). Penetrating wounds; are divided into two groups: without damage to internal organs and with injury of internal organs.
4. According to infection, the types of wounds are defined as: aseptic, applied under operating conditions (intentional); Primarily infected with an unsterile subject during the first 12-24 hours after injury, when the introduced microflora is exposed to local defense factors (enzymes, phagocytes, etc.) that hold it or latent state, or can be completely doped; purulent wounds, when the microflora freely develops in the wound in the form of purulent inflammation.
5. By the presence of complications, the types of wounds are divided into uncomplicated and complicated. Complications include: damage to the main vessels, nerves, penetrating wounds, especially with damage to the internal organs, trauma to bones, muscles, tendons, shock, blood loss, multiple and combined wounds.

Causes of a wound

By the nature of tissue damage, cut, chopped, chipped, bruised, ripped, bitten, poisoned and gunshot wounds are distinguished.

• Cut wounds arise from the impact of sharp objects (for example, a razor, a knife). The edges of the wounds are smooth, smooth. The wound is shallow, gaping. The bottom of the wound is not significantly damaged if they are not large vessels and nerves, for example, on the neck. Cut wounds are most beneficial for healing.
• Chopped wounds are the result of the impact of an acute but heavy object (ax, checker), according to the clinical picture, resemble cuts. A distinctive feature is a more significant destruction of the bottom of the wound. Usually damaged tendons, muscles and even bone.
• Stab wounds occur as a result of the defeat of sharp and thin long objects (knife, sharpening, awl, etc.). This is often extremely dangerous injuries, because a small, sometimes point-like wound does not gap, does not bleed and quickly becomes crusted. At the same time, a wounding object could damage the lung, intestines, liver and after some time, anemia, pneumothorax or peritonitis are possible.
• The bruised wounds are the result of the impact of a dull object (stick, bottle). The edges of the wound are mashed, as are the tissues in the wound itself. The latter are impregnated with blood, dark color, do not bleed or bleed slightly. Visible vessels are thrombosed.
• Lacerations occur when a relatively sharp object slides over the surface of the skin with additional pressure on it. The wound is irregular in shape, with scrapes like a scalp, bleeds. The destruction of the underlying tissues depends on the force that presses the wounding projectile. Usually lacerations, as well as bruised, have a protracted healing character due to necrosis of the destroyed tissues and suppuration in the wound.
• Poisoned wounds occur when poisonous substances enter into them (snake venom, poisonous substances).
• The difference between gunshot wounds from all the others is a feature of a wounding projectile, a wound channel and the course of a wound process.

For reasons of injury, wounds are divided into operating and casual.

According to microbial contamination, aseptic and microbial-contaminated wounds are distinguished.

In relation to the closed cavities of the human body (skull, chest, abdomen, joint) distinguish penetrating and non-penetrating wounds. Penetrating called wounds, which resulted in damage to the internal serous membrane lining the cavity (dura mater, parietal pleura, parietal peritoneum, synovial membrane).

[1], [2], [3], [4], [5], [6], [7], [8]

Symptoms of a wound

The symptoms of wounds depend on the nature of the wound, the wounding projectile, the size of the wound, the damage to the cavities and internal organs, the violation of the integrity of the vessels, nerves and bones. It consists of local and general symptoms.

Local symptoms include pain, blistering of the wound, bleeding, dysfunction of the damaged segment. Common symptoms include signs of a complicating injury (eg, anemia, shock, peritonitis, etc.).

The course of the wound process

In a clean wound with good contact between the edges, their gluing takes place. Dead cell elements and bacteria dissolve, there is an increased multiplication of connective tissue cells, which eventually turn into a scar. He firmly connects the walls of the former wound - this is how the wound is healed by the primary tension.

If between the walls of the wound there is diastasis or a purulent infection develops, the wound heals slowly, with a gradual filling of the granulation from its bottom. This healing is secondary tension.

During the wound process during the healing of purulent wounds, it is expedient to distinguish the following stages: inflammation, the formation and maturation of granulation tissue, epithelization.

The selection of stages, despite their definite sequence, is conditional, since it is impossible to draw a strict line between the end of one stage and the beginning of another. Usually, after 48 hours, a granulation tissue appears. After the abatement of the inflammatory reaction begins the process of transformation, proliferation of fibroblasts, the formation of a new tissue - the process of reparative regeneration. Throughout the course of the inflammatory reaction, starting from the moment of tissue damage, proliferative or productive phenomena (multiplication of cellular elements) are observed. These phenomena are especially pronounced in the later stages of inflammation. As the granulation tissue grows, the formation and maturation of connective tissue is marked by the abatement of inflammatory phenomena, epithelization occurs from the edges of the wound to its bottom.

Clinical characteristics and diagnosis of wounds

Depending on the nature of the wounding instrument, and its identification is mandatory for the conduct of the investigation, each kind of wound has specific features that you need not only to know for differential diagnosis, but also to be able to describe correctly.

[9], [10], [11], [12], [13], [14], [15], [16], [17], [18]

Stab wounds

Are applied by any sharp object of the narrow form and the big length (a knife, a fin, an awl, a screwdriver, scissors, etc.). Their characteristic feature is the excess of depth above the outer dimensions. Stitched wounds, in most cases, penetrating into the cavity with damage to the internal organs or deep formations of soft tissues (the neurovascular bundle of the tendon, muscles), have a narrow wound channel. Most often they become infected, as optimal conditions are created for the development of microflora. Depending on the severity and shape of the wounding object, the edges of the wound can be smooth and sharp, linear (knife, fin), rounded (awl, armature), scalloped or star-shaped (screwdriver, scissors), etc. Depending on the severity of the object, the edge The wounds can be without hemorrhages or have minor hemorrhages and sedation. The same features have wound walls. But the bottom of the wound can be anything and it is not visible. Therefore, when the victim is treated with a chopped wound, the audit should be carried out especially carefully.

Cut wounds

They are applied by a sharp object (a knife of a fin, a razor, etc.) parallel to the surface of the body by linear motion. Therefore, such wounds have a linear shape, the outer dimensions are greater than the depth, the bottom is clearly visible. The edges and walls of the wound are even, clear, without hemorrhages and crushing, the bottom is even and clear. These injuries are among the most favorable for treatment and healing.

[19], [20], [21], [22], [23]

Chopped wounds

They are applied with a sharp object of great kinetic mass, with a single chopping blow (ax, shovel, shovel, checker, etc.). They are very deep, often with amputation of the limb segment (eg, fingers). Edges and walls have a linear shape, even, but the clarity depends on the severity of the object, which is wound. If the object is sharply sharpened - the edges and walls of the wound are even and clear. If, the subject is obtuse - the edges of the wound will be sagged, with areas of hemorrhage, their area is usually not broad, depending on the severity of the object. At the bottom, which is easy to see, there are jumpers that correspond to jags on the wounding object, should be clearly measured and described for subsequent forensic examination and identification of the gun.

[24], [25], [26], [27], [28]

Lacerations

They are applied by a pointed object hooked or serrated in parallel to the surface of the body. In this case, a rupture of the skin and subcutaneous tissue is formed. They are superficial, linear. The edges are uneven (scalloped), indistinct due to precipitation. The walls are uneven, with areas of hemorrhage. The bottom of the wound with hemorrhages, uneven.

Injured wounds

They are applied by a blunt solid object, which has a great kinetic energy (stick, brick, stone, bottle). In themselves, they are superficial, but because of the high kinetic energy of the agent, they often cause damage to the internal organs: with wounds on the head, damage to the brain, chest, lungs and heart.

The kind of wounds can be very different, it all depends on the shape of the gun, its mass, the force with which it is struck, the direction of the strike. A distinctive feature is extensive hemorrhage, sedimentation and crushing of the edges, walls and bottom of the wound. If the wound is applied by one direct impact perpendicular to the body surface, its appearance repeats the contours of the wounding instrument. At the same time there is a crushing of soft tissues, uniform to the full depth. The edges can be of a very different shape: square, stellate, linear; it all depends on the shape of the object, which is wound.

If the impact is applied at an angle, a tangential action is formed. Soft tissues are actually bursting under the influence of force. The shape of the edges depends on the angle; the application of force. When applying the wound at an angle of more than 30 degrees to the surface of the body (impact on the flight of kinetic energy), the edges of the wound have a triangular formula with a base at the point where the force is applied. When the force is applied at an angle less than 30 degrees to the surface of the body or parallel to it (for example, when striking with a stick, whip, scourge, as the people say: "with extension"), the edges of the wound are scalloped, have a linear shape, but its depth is uneven, central part of the wound is always deeper.

Bitten Wounds

Apply by animal or human. In appearance they resemble torn, but the distinctive feature is the presence of dental prints. There may be tissue defects up to a slipping or amputation, for example, a finger; when a patch of skin and soft tissue breaks out.

[29], [30], [31], [32], [33], [34], [35], [36]

Razmozhennye wounds

In practice, they are rare, but this is one of the most severe types of damage, since they are formed when the limb is squashed.

Gunshot wounds

Gunshot wounds due to their specificity, severity of injuries, complications, characteristics of care and management, adverse outcomes - are separated into a separate group. By the type of weapons are distinguished: bullet, shot, fragmentation. By the nature of the wound channel: through, blind, tangential. Gunshot wounds belong to the category of the most difficult to diagnose, treat and describe, as they are often accompanied by internal injuries, fractures of bones, damages of neuromuscular bundles, the presence of foreign bodies giving suppuration, have massive destruction of soft tissues.

With bullet wounds, the inlet has a rounded shape with uneven and fuzzy edges due to sediments and hemorrhages. Of great importance is the distance from which the shot is fired. At a distance of up to a meter or shot at the stop, there is a burn zone and powder inclusions around the wound, their vastness determines the distance and the caliber of the weapon, they must be accurately measured and clearly described. At large distances, these changes are not noted.

At shrapnel wounds, the entrance aperture resembles a lacerated one, but with an extensive zone of hemorrhages and crushing of tissues, it also differs by the presence of a wound channel.

Bullet wounds and shrapnel wounds have 3 layers: the wound canal itself, filled with tissue detritus, foreign bodies and the remains of a wounding object (bullet or fragment); the zone of crushing of tissues is 2-5 times greater than the wound channel; the zone of molecular shock is 5-10 times greater than the wound channel. These tissues are gradually necrotic and torn away, creating the threat of severe suppuration.

For shotgun wounds, a lot of small-sized inlet openings, often with scalloped edges, small zones of hemorrhages and crushing around them, are characteristic. Shot wounds are also accompanied by fractures and injuries to internal organs.

Wound description rules

Diagnosis of the wound is not a problem, but it must be described in a qualified manner for subsequent forensic medical examination, since the doctor who provides assistance to the victim sees it in a "natural" form for the first and last time. The following requirements apply to the description of wounds.

• Indicate the localization of the anatomical segment of the body: head, face, neck, chest, trunk, etc.
• A clarification of the position with an indication of anatomical landmarks is given (for example, in the chest, right, fourth intercostal space, mid-clavicular line, in the left hip, inner surface, above the knee joint by 6 cm, etc.).
• Specify the dimensions of its gap - 2 by 5 cm, etc. If the bottom of the wound is visible, the third measurement is marked - depth (depth up to 2 cm).
• The form and type of wounds are described: linear, round, stellate, oval, crescent, triangular, etc.
• The direction along the longitudinal axis of the body is indicated: oblique, longitudinal, transverse.
• The edges are described: even, uneven (scalloped), clear or indistinct, the presence of deposits and crushing, hemorrhages, their size, shape and color for bruising.
• The description of the walls is similar to the edges: even, uneven, the presence of crushing and hemorrhages.
• The bottom of the wound: a thorough examination and description is necessary. In some cases, if it is not visible, it is necessary to cut the wound to the bottom for inspection and revision. With wounds penetrating into the cavity, it is necessary to perform cavitary operations or endoscopic studies to describe: the course of the wound channel, the condition of the bottom and injuries to internal organs, as well as the simultaneous surgical aid aimed at hemostasis and the removal of lesions.

The bottom can be even, uneven, have bridges, crushing, hemorrhages, foreign bodies, damage to serous leaves, which indicates penetration of it into the cavity. It is necessarily indicated that the bottom of the wound is: soft tissues, bones, internal organs. Describe the state of the bottom of the wound.

• The direction of the wound channel (if it has the form of a narrow stroke, for example, when the wound is stabbed or knifed): from front to back, from right to left, or vice versa. Contents of the wound canal: tissue detritus, bone fragments, earth, foreign bodies, etc.
• The presence of complications: damage to internal organs, neurovascular bundles, tendons, muscles, etc.