Wounds

Classification by origin

According to the mechanism of occurrence and initial cleanliness, all injuries are divided into three basic groups:

• Surgical. Created purposefully during surgical interventions. Due to adherence to asepsis rules, they are initially sterile.
• Accidental. Any domestic, occupational, or criminal injuries. In surgery, the rule is established: every accidental wound is a priori regarded as infected.
• Combat. Stand out as a separate category due to severity, specific tissue destruction, and special treatment approaches.

Types of wounds by the nature of the injuring agent

The morphology of the injury depends on the tool used to inflict it:

1. Incised. The weapon is a knife, blade, or glass. The edges are always even, and the damage is limited to soft tissues. Often accompanied by transection of tendons, large vessels, and nerves.
2. Puncture. Inflicted with an awl or bayonet. The entrance opening is tiny, and the surrounding tissues are barely affected. However, they pose a colossal threat: they can penetrate deep into the abdomen or chest, and on the limbs, they can transect major vessels with the formation of hidden hemorrhages into the muscles.
3. Chopped. A trace from an axe or saber. The edges are even, but with characteristic abrasion. Bleeding is heavy, the trauma is deep, often with bone destruction.
4. Contused. Occur when struck by a blunt object. They are characterized by irregular shape and bruised edges. Due to local hematomas, the viability of the edges is sharply reduced, leading to their necrosis.
5. Lacerated. Characteristic of injuries from moving mechanisms or saws. They feature a huge tissue defect with jagged edges. The wound is usually filled with blood clots, while external bleeding is moderate. Fragment wounds present a similar picture.

Features of gunshot wounds

The bullet wound tract has a complex anatomical structure comprising three zones:

• Zone of the wound tract. The central cavity containing blood clots, tissue fragments, pieces of clothing, and other foreign bodies.
• Zone of primary traumatic necrosis (contusion). Tissues directly adjacent to the tract. They are irreversibly destroyed and die at the moment the projectile passes.
• Zone of molecular concussion (commotion). The peripheral area. The tissues here are alive, but experience severe disorders of capillary blood flow (vascular ruptures, stasis), leading to petechial hemorrhages.

Note: Modern high-velocity bullets are unstable in flight. Upon entering the body, they deflect, causing the wound tract to lose its straightness and the volume of destroyed tissues to increase manifold.

Rules for primary examination

The gapping of wound edges depends not only on its size, but also on Langer's lines, the direction of elastic fibers in the skin. An incision across these lines results in maximum edge separation and heavy bleeding.

The patient's examination must be comprehensive, with mandatory consideration of the circumstances of the injury. When assessing local status (status localis), the type of injury, its size, degree of contamination, and presence of hematomas are determined. An increase in limb volume and sharp induration are always suspicious of major vessel trauma.

It is strictly prohibited during the initial examination to probe deep into the wound with probes or instruments, as this is a direct path to secondary infection and structural damage.

Class and exam questions

What else to study on this topic

• Pathohistological and biochemical stages of the wound healing process
• Specifics of diagnosing penetrating chest and abdominal wounds
• Clinical presentation and consequences of major nerve trunk injuries
• Pathogenesis of tissue necrosis in contused wounds
• Influence of Langer's lines on scar formation

Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.