Wounds: what do you need to know about them?

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

Wounds are the most common type of open injury and account for 47-50% of all emergency trauma conditions, and wound management and wound healing takes up 70% of the working time of surgeons and traumatologists.

With regard to injuries to internal organs, most traumatologists tend to differentiate the concepts. The term "wound" refers to damage caused by a cutting or piercing object (lung, heart, liver wound). Damage due to impact with a blunt hard object or as a result of a blow by the organ itself (for example, a lung against the chest wall at the moment of injury) is considered a "rupture". Gross destruction of tissue of internal organs, with extensive hemorrhages, is designated as "crushing".

The types of wounds are multifaceted and include several positions. The classification belongs to the international category and is defined as "working".

1. Depending on the nature of the injury, types of wounds are divided into intentional (surgical) and accidental (traumatic).
2. Depending on the type of wounding instrument, the following types of wounds are distinguished: stab, cut, chopped, bruised, lacerated, bitten, gunshot, crushed, scalped wounds.
3. In relation to body cavities, types of wounds can be non-penetrating (superficial) and penetrating into cavities (pleural, pericardium, abdominal, etc.). Penetrating wounds are divided into two groups: without damage to internal organs and with injury to internal organs.
4. According to infection, wound types are defined as: aseptic, inflicted in an operating room (intentional); primary infected, inflicted by a non-sterile object, during the first 12-24 hours after injury, when the introduced microflora is exposed to local defense factors (enzymes, phagocytes, etc.), which keep it in a latent state or can stop it completely; purulent wounds, when the microflora freely develops in the wound in the form of purulent inflammation.
5. Depending on the presence of complications, wounds are divided into uncomplicated and complicated. Complications include: damage to major vessels, nerves, penetrating wounds, especially with damage to internal organs, injuries to bones, muscles, tendons, shock, blood loss, multiple and combined wounds.

Causes of the wound

Depending on the nature of tissue damage, wounds are classified as cut, chopped, punctured, bruised, torn, bitten, poisoned and gunshot wounds.

• Cut wounds are caused by sharp objects (e.g., razor, knife). The edges of the wounds are even, smooth. The wound is shallow, gaping. The bottom of the wound is slightly damaged, unless it is a large vessel or nerve, for example, on the neck. Cut wounds are the most favorable for healing.
• Chopped wounds are the result of the impact of a sharp but heavy object (axe, saber), and are similar in clinical presentation to cut wounds. A distinctive feature is more significant destruction of the wound bottom. Usually, adjacent tendons, muscles, and even bone are damaged.
• Puncture wounds occur as a result of injury with sharp and thin long objects (knife, sharpening, awl, etc.). These are often extremely dangerous wounds, since a small, sometimes pinpoint wound does not gape, does not bleed, and quickly becomes covered with a crust. At the same time, the wounding object could damage the lung, intestines, liver, and after some time, anemia, pneumothorax, or peritonitis are possible.
• Contused wounds are the result of the impact of a blunt object (stick, bottle). The edges of the wound are crushed, as are the tissues in the wound itself. The latter are soaked in blood, dark in color, do not bleed or bleed slightly. Visible vessels are thrombosed.
• Lacerations occur when a relatively sharp object slides along the skin surface with additional pressure on it. The wound is irregular in shape, with scalp-type flaps, and bleeds. The destruction of underlying tissue depends on the force that pressed on the wounding projectile. Lacerations, like bruised wounds, usually have a protracted healing process due to necrosis of the destroyed tissue and suppuration in the wound.
• Poisoned wounds occur when poisonous substances (snake venom, toxic substances) enter them.
• The difference between gunshot wounds and all other wounds is the specificity of the wounding projectile, the wound channel and the course of the wound process.

Depending on the cause of injury, wounds are divided into surgical and accidental.

Based on microbial contamination, wounds are divided into aseptic and microbially contaminated.

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

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Wound symptoms

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

Local symptoms include pain, gaping wound, bleeding, and dysfunction of the damaged segment. General symptoms include signs of a complication of the injury (e.g., anemia, shock, peritonitis, etc.).

The course of the wound healing process

In a clean wound with good contact between the edges, they are glued together. Dead cellular elements and bacteria are absorbed, there is an increased proliferation of connective tissue cells, which over time turn into a scar. It firmly connects the walls of the former wound - this is how the wound heals by primary intention.

If there was a diastasis between the wound walls or a purulent infection developed, the wound heals slowly, gradually filling with granulations from its bottom. This is healing by secondary intention.

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

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

Clinical characteristics and diagnostics of wounds

Depending on the nature of the wounding weapon, and its identification is mandatory for the investigation, each type of wound has specific features that must not only be known for differential diagnosis, but also correctly described.

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Puncture wounds

They are inflicted by any sharp object of narrow shape and long length (knife, Finnish knife, awl, screwdriver, scissors, etc.). Their characteristic feature is that their depth exceeds their external dimensions. Puncture wounds, in most cases, penetrating into cavities with damage to internal organs or deep formations of soft tissues (neurovascular bundle, tendon, muscle), have a narrow wound channel. Most often they become infected, since optimal conditions are created for the development of microflora. Depending on the sharpness and shape of the wounding object, the edges of the wound can be smooth and clear, linear (knife, Finnish knife), rounded (awl, reinforcement), scalloped or star-shaped (screwdriver, scissors), etc. Depending on the sharpness of the object, the edges of the wound can be without hemorrhage or have minor hemorrhage and abrasion. The walls of the wound have the same feature. But the bottom of the wound can be anything and it is not visible. Therefore, when a victim with a stab wound comes to the doctor, its revision should be carried out especially carefully.

Cut wounds

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

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Chopped wounds

They are inflicted by a sharp object of large kinetic mass, with one chopping blow (an axe, a cleaver, a shovel, a saber, etc.). They are characterized by great depth, often with amputation of a segment of the limb (for example, fingers). The edges and walls have a linear shape, are smooth, but the clarity depends on the sharpness of the object that inflicted the wound. If the object is sharpened, the edges and walls of the wound are smooth and clear. If the object is blunt, the edges of the wound will be abraded, with areas of hemorrhage, their zone is usually not extensive, which depends on the sharpness of the object. On the bottom, which is easily visible, there are bridges that correspond to the serrations on the wounding object, they must be clearly measured and described for subsequent forensic examination and identification of the weapon.

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Lacerated wounds

They are applied with a pointed hooked or jagged object parallel to the body surface. This causes a rupture of the skin and subcutaneous tissue. They are superficial, linear in shape. The edges are uneven (scalloped), unclear due to abrasions. The walls are uneven, with areas of hemorrhage. The bottom of the wound is hemorrhagic, uneven.

Contused wounds

They are applied with a blunt hard object that has high kinetic energy (a stick, a brick, a stone, a bottle). They are superficial in themselves, but due to the high kinetic energy of the agent, they often cause damage to internal organs: in case of wounds on the head - damage to the brain, chest - lungs and heart.

The type of wound can be very different, it all depends on the shape of the weapon, its weight, the force with which the blow was delivered, the direction of the blow. The distinctive feature is extensive hemorrhaging, abrasion and crushing of the edges, walls and bottom of the wound. If the wound is inflicted by one direct blow, perpendicular to the surface of the body, its appearance follows the contours of the wounding weapon. In this case, there is crushing of soft tissues, uniformly over the entire depth. The edges can be of various shapes: square, star-shaped, linear; it all depends on the shape of the object that inflicted the wound.

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

Bite wounds

They are inflicted by an animal or a person. They look like torn ones, but a distinctive feature is the presence of teeth marks. There may be tissue defects up to scalping or amputation, for example, of a finger; when a section of skin and soft tissue is torn out.

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Crushed wounds

They are rare in practice, but this is one of the most severe types of injuries, as they are formed when a limb is crushed.

Gunshot wounds

Gunshot wounds are classified as a separate group due to their specificity, severity of injuries, complications, features of rendering assistance and management, unfavorable outcomes. By the type of weapon, they are divided into: bullet, shot, shrapnel. By the nature of the wound channel: through, blind, tangential. Gunshot wounds are classified as the most difficult to diagnose, treat and describe, as they are often accompanied by damage to internal organs, bone fractures, damage to neurovascular bundles, the presence of foreign bodies that cause suppuration, and have massive destruction of soft tissues.

In bullet wounds, the entrance hole has a round shape with uneven and unclear edges due to abrasions and hemorrhages. The distance from which the shot was fired is of great importance. At a distance of up to a meter or a point-blank shot, there is a zone of burns and gunpowder inclusions around the wound, their extent is determined by the distance and caliber of the weapon, they must be accurately measured and clearly described. At greater distances, these changes are not noted.

In shrapnel wounds, the entrance hole resembles a torn one, but with an extensive area of hemorrhage and tissue crushing, and is also distinguished by the presence of a wound channel.

Bullet and shrapnel wounds have 3 layers: the wound channel itself, filled with tissue detritus, foreign bodies and remnants of the wounding object (bullet or shrapnel); the tissue crush zone is 2-5 times larger than the wound channel; the molecular concussion zone is 5-10 times larger than the wound channel. These tissues gradually become necrotic and are rejected, creating a threat of severe suppuration.

Shotgun wounds are characterized by multiple pinpoint entry holes, often with scalloped edges, small areas of hemorrhage and crushing around them. Shotgun wounds are also accompanied by fractures and damage to internal organs.

Rules for describing wounds

Diagnosing a wound is not a problem, but it must be described professionally for subsequent forensic examination, since the doctor providing assistance to the victim sees it in its "natural" form for the first and last time. The following requirements are imposed when describing wounds.

• The localization is indicated by the anatomical segment of the body: head, face, neck, chest, torso, etc.
• The position is specified with anatomical landmarks (for example, in the chest area, on the right, in the fourth intercostal space, along the midclavicular line; in the left thigh area, along the inner surface, 6 cm above the knee joint, etc.).
• The dimensions of its gaping are indicated - 2 by 5 cm, etc. If the bottom of the wound is visible, the third dimension is noted - depth (up to 2 cm deep).
• The shape and type of wounds are described: linear, round, star-shaped, oval, crescent-shaped, triangular, etc.
• The direction along the longitudinal axis of the body is indicated: oblique, longitudinal, transverse.
• The edges are described: smooth, uneven (scalloped), clear or unclear, the presence of abrasions and crushing, hemorrhages, their sizes, features of shape and color for bruises.
• The walls are described in the same way as the edges: smooth, uneven, presence of crushing and hemorrhages.
• Wound bottom: a thorough examination and description is necessary. In some cases, if it is not visible, it is necessary to dissect the wound to the bottom for examination and revision. In case of wounds penetrating into cavities, it is necessary to perform cavity operations or endoscopic examinations in order to describe: the course of the wound channel, the condition of the bottom and damage to internal organs, as well as simultaneous surgical intervention aimed at hemostasis and elimination of damage.

The bottom can be smooth, uneven, have bridges, crushing, hemorrhages, foreign bodies, damage to serous layers, which indicates its penetration into the cavities. It is necessary to indicate what is the bottom of the wound: soft tissues, bones, internal organs. Describe the condition of the bottom of the wound.

• The direction of the wound channel (if it has the appearance of a narrow passage, for example, when inflicting a wound with a knife or Finnish knife): from front to back, from right to left - or vice versa. The contents of the wound channel: tissue detritus, bone fragments, soil, foreign bodies, etc.
• Presence of complications: damage to internal organs, neurovascular bundles, tendons, muscles, etc.