Morphological features of some bodily injuries (principles of description). Educational and methodological recommendations for students and interns / ed. N.S.Edeleva. - Nizhny Novgorod, 1991.
A forensic medical expert and a clinician must be fluent in describing injuries in order to objectify the diagnosis and resolve questions about the instrument, mechanism and duration of the injury. The foregoing determines the feasibility of issuing these recommendations, which will help the student, intern, novice forensic expert and clinician. They will also be useful to law enforcement officials - the police, the prosecutor's office and the court.
Methodological recommendations “Morphological features of injuries (principles of description)” were compiled by a team - the head of the department, Doctor of Medical Sciences N.S. Edelev, associate professors E.G. Kolpashchikov and S.A. Volodin, assistant candidate of medical sciences L.I. Zaitseva-Ilyinogorskaya, assistants V.N. Barulin, A.D. Kvasnikov, I.P. Kraev, S.V. Pukhov and S.O. Ukhov.
Morphological features of some bodily injuries (principles of description)
bibliographic description:
Morphological features of some bodily injuries (principles of description) / Edelev N.S., Kolpashchikov E.G., Volodin S.A., Zaitseva-Ilyinogorskaya L.I., Barulin V.N., Kvasnikov A.D., Kraev I. L.P., Pukhov S.V., Ukhov S.O. — 1991.
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/ Edelev N.S., Kolpashchikov E.G., Volodin S.A., Zaitseva-Ilyinogorskaya L.I., Barulin V.N., Kvasnikov A.D., Kraev I.P., Pukhov S.V. , Ukhov S.O. — 1991.
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Morphological features of some bodily injuries (principles of description) / Edelev N.S., Kolpashchikov E.G., Volodin S.A., Zaitseva-Ilyinogorskaya L.I., Barulin V.N., Kvasnikov A.D., Kraev I. L.P., Pukhov S.V., Ukhov S.O. — 1991.
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/ Edelev N.S., Kolpashchikov E.G., Volodin S.A., Zaitseva-Ilyinogorskaya L.I., Barulin V.N., Kvasnikov A.D., Kraev I.P., Pukhov S.V. , Ukhov S.O. — 1991.
Preface
The need to publish methodological recommendations “On the morphological features of some bodily injuries” is due to the lack of educational literature in forensic medicine and clinical traumatology, a clear scheme for describing bodily injuries.
At the same time, as practice shows, not all injuries present on the body of a traumatic patient are not only described in detail, but are not always fully recorded in medical documentation. Clinicians, as a rule, explain this circumstance by the urgency of providing medical care to the victim, when, in their opinion, it is inappropriate to make a detailed description of the injuries (sometimes the health and life of the patient does not depend on this), and even more so to detain attention at all to minor “ secondary" damage that does not affect clinical course main injury. Often, clinicians generally refuse to describe the injury (only the diagnosis is given), citing lack of time in general. Meanwhile, the characteristics of all manifestations of injury in the aggregate are of decisive importance in resolving many important issues, including for a forensic expert - about the instrument, mechanism and duration of injury, the sequence of damage, etc. It is well known that teachers of a number of Clinical departments train future doctors to diagnose and treat trauma, but, unfortunately, they do not introduce them to the principles of describing those injuries. That is why attending physicians often replace data on the morphological features of a particular injury with diagnostic concepts. Therefore, the main essence of these recommendations is aimed at resolving this significant shortcoming in the teaching of certain provisions of forensic and clinical traumatology.
As noted above, the main issues of forensic medical examination of bodily injuries are the determination of the weapon, duration and mechanism of injury. The solution to this problem is carried out comprehensively, as a rule, in several stages using special laboratory and instrumental studies carried out in various departments of the forensic medical service. Clinicians (surgeons, gynecologists, traumatologists, radiologists, etc.) also play a certain role in this, who are usually the first to meet with victims who have certain mechanical injuries. In this case, the attending physician must fully and objectively describe morphological features damage, because after some time its original appearance may change significantly after rendering surgical care, further healing, etc. It is not uncommon for a forensic expert, when performing an examination, to deal with injuries that have changed in appearance (for one reason or another), for which it is not possible to make a specific judgment about the instrument, mechanism and age of the injury due to for defects in the description of herbs we. In general, the clinician must remember that the diagnosis of injury should always be objectified by the signs of a particular injury, and not replaced by diagnostic (even correct) concepts. If such a description is not available in the submitted medical documentation, then the forensic expert has no right to take into account the diagnosis, much less determine the instrument and mechanism of the injury, or the period of its infliction. Thus, every clinician needs to know the principles of describing damage and be able to apply this knowledge in appropriate cases, both when examining a patient with damage, and during a forensic medical examination of a corpse or a living person regarding damage, when he is involved as a doctor -expert.
Naturally, a forensic expert must be perfectly able to describe injuries during an examination of a corpse or a living person (victim, accused, etc.) and critically and correctly evaluate the description of injuries, the validity clinical diagnosis injuries recorded in the medical documentation submitted for examination.
1. GENERAL PROVISIONS
Personal injury should be understood as any violation of the anatomical integrity or physiological function organs, tissues and body systems caused by mechanical, thermal, chemical, infectious, mental and other factors.
Damage, as pathological phenomena, is extremely diverse, one way or another always causes harm to the body, disrupting its health and ability to work, often leading to death.
During a forensic medical examination regarding bodily injuries in mandatory should be reflected:
- - nature of the damage (diagnosis) - abrasion, bruise, wound, dislocation, bone fracture, avulsion, rupture, crushing, etc.; their localization and properties;
- - type of weapon or means that could cause damage;
- - mechanism of damage;
- - limitation (period) of causing damage;
- - the severity of bodily injury, indicating the qualifying characteristic.
In cases of death, it is necessary to establish a causal relationship between the death and the injury.
As for mechanical damage, they arise from the action of a tool (weapon) in relation to a person, as well as the movement of the person himself, followed by contact with a stationary object (tool, weapon).
There are three main types of mechanical damage - blunt, sharp, gunshot.
A blunt instrument can cause damage of both a functional and anatomical nature. The latter include abrasions, bruises, bruised and bitten wounds, dislocations, bone fractures, ruptures, crushing and separation of internal organs.
When exposed to a weapon, cut, stabbed, stabbed, and chopped injuries occur.
As a result of the action firearms corresponding specific damage occurs. Regarding each of these injuries, when describing them in medical or forensic documentation, the doctor (clinician or forensic physician) should most fully and objectively note characteristic features and features. These include:
- - View. Medical definition damage (wound, abrasion, bruise, fracture, dislocation, separation, etc.);
- - Localization. In addition to indicating the area of the body in which the injury is located (for example, “on the anterior surface of the left half chest"), the distance from the injury to the nearest known anatomical points using a rectangular coordinate system should be noted (for example, "at a distance of 5.0 cm down from the lower edge of the clavicle and 7.0 cm to the left from the edge of the sternum").
In some cases, in particular with gunshots, stabs and stab wounds, in case of transport accidents, etc., when the question of the mechanism of injury usually arises, it is necessary to determine the height of the location of the injuries from the level of the plantar surface of the corresponding foot; - - Direction. It is necessary to indicate the position of the length of the damage relative to longitudinal axis body (it is advisable to determine the angle of deviation in degrees) - vertical, oblique, horizontal, in two directions, etc. It is advisable to orient some damage along the watch dial (with the center at the midpoint of the light).
- - Form. Applied to geometric shapes(for example, “irregular oval-shaped bruise,” “straight-line scratch,” etc.) or well-known objects (for example, “triradiate-shaped wound,” “crescent-shaped abrasion,” etc.). It should not be noted that the damage (abrasion, bruise) has an irregular shape, such a shape does not exist at all;
- - Color indicating both the main background and shades (for example, “a bruise of red-violet color in the center and yellow-green along the periphery”).
- - Dimensions. The length and width of the damage are given in centimeters or millimeters. Determining the size by eye and comparing it with the size of any objects (for example, a coin, a pea, an egg, etc.) is not allowed. With stab, cut and chopped wounds, no tissue defect is formed and therefore the damage has only one size - the length measured when the edges are connected. The second size, mistakenly taken for width, characterizes the degree of gaping of the wound, due to the location of elastic fibers in a given area of the body;
- - Edge condition wounds (smooth, uneven, with small or large flaps, with notches, with bridges; swelling, hemorrhage, sedimentation in the circumference, their location and character);
- - Condition of the ends wounds (acute-angled, rounded, “T”-shaped, with notches and scratches; bruising and hemorrhage in the circumference);
- -Bottom(wet, drying, crusty - above, below or at skin level, color);
- - Specific deposits and contamination(tightly adherent or falling off crusts of pus, blood, interstitial fluid, their location in relation to the surrounding skin; exogenous pollution, soot, unburnt grains of gunpowder, lubricating oils, dyes, soil, sand, rust, etc., their location and character).
One more important circumstance should be noted: it is necessary to indicate the exact number of injuries of one type or another in the victim. Counting such as “many”, “uncountable”, “single”, etc. is unacceptable; it is required to clearly indicate the number of abrasions, bruises, wounds, etc.
It is well known that during a forensic medical examination of a corpse and living persons, a thorough examination and description of clothing is mandatory. Therefore, in case of death from injury in medical institutions Along with the corpse, the clothes that were on the victim’s body at the time of the injury should also be sent to the morgue. The same applies to victims with certain injuries who were admitted to a hospital for treatment, if they also have corresponding damage to their clothing. In this case, the clothing must be described, packed in a wax paper bag and marked with complete data about the patient (corpse) and the medical history number. Clothing must be issued to law enforcement officers against a signature, which is attached to the medical history.
Damage and characteristic contaminants on clothing are taken into account when resolving many issues that arise in expert practice:
- - when the injuries (for example, wounds on the body) are surgically treated and do not contain the information necessary to judge the characteristics of the instrument of injury, or the wounds are in varying degrees of healing, and the description of the original type of injury in the medical history is not complete enough;
- - with gunshot wounds inflicted through clothing, traces of a shot at close range remain on the latter (so-called by-products - flame, gases, soot, unburned grains of gunpowder), while in the area of the entrance hole on the skin they may be absent; in such cases, a judgment about the shooting distance can be made only after examining the clothing;
- - in case of transport accidents, when clothes may show traces of the action of parts Vehicle in the form of damage (ruptures, traces of sliding, friction, etc.), as well as characteristic deposits (lubricating oils, metals, sand, slag, etc.);
- - in case of electrical injury, when traces of electrical conductor metal can be detected on clothing.
Similar to damage to the body, when examining clothing, the nature, location, shape, size and other features of cuts, tears, defects, as well as characteristic dirt and other traces are noted in detail. When determining the location of the damage, measure the distance to it from certain parts of the clothing - seams, edges, sides, etc. (using a rectangular coordinate system). It is advisable to use the same identification points on different items of clothing.
Along with this, the clinician must remember that wound edges excised during primary surgical treatment and any other objects removed from the victim’s body during surgery should be stored, inform the investigator about this, who can send them for appropriate research to the forensic medical department. or crime lab.
2. MORPHOLOGICAL FEATURES OF MECHANICAL DAMAGE
1. Damage from a blunt instrument
A blunt instrument usually compresses tissues and organs. If the impact is not very strong, there may be no traces left. As pressure builds, the blunt instrument begins to crush, tear and displace tissue, especially when located on a hard base (bone). In cases of preservation of integrity skin(the skin is, to a certain extent, relatively resistant to compression and stretching), only rupture of the subcutaneous vessels can be observed, and bruising occurs. If the skin, subcutaneous tissue and underlying tissues are torn, a wound is formed. An increase in load leads to damage to internal organs and bones, including ruptures, crushing and avulsions.
a) Abrasion.
An abrasion is a violation of the integrity of the surface layer of the skin, involving the epidermis and often the adjacent part of the measles to the papillary layer. In this case, the epidermis at the site of damage exfoliates and is often absent. If only the epidermis is damaged, a superficial abrasion occurs, and if both the epidermis and corium are damaged, a deep abrasion is formed, which may even be accompanied by bleeding from the damaged vessels. The latter circumstance often makes it difficult to differentiate between an abrasion and a wound. It must be remembered that after healing of the latter, a scar is always formed, which never appears in the place of a healed abrasion. One more circumstance should be noted: abrasions often occur along the edges of bruised wounds.
The shape of abrasions can be very diverse: crescentic, oval, round, irregularly rectangular, star-shaped, etc.
As already noted, in the besieged area the epidermis is partially or completely absent with an adjacent layer of corium. Therefore, at first, the bottom of the abrasion is always below the level of the surrounding intact skin. Then a crust forms at the site of the abrasion, usually dry and brownish. It should be noted that the crust is a characteristic indicator of the lifetime of the abrasion.
During the course of an abrasion, four stages are noted, knowledge of which allows us to establish the age of its origin:
- - up to approximately 12 hours after the cause of the injury: the bottom of the abrasion is below the level of intact skin, the surface is initially slightly damp, with deep abrasions with a layer of gradually drying blood;
- - from 12 to 24 hours (occasionally up to 48 hours): the dried, brownish with a reddish tint, the bottom of the abrasion begins to grow. Its level is compared with the surrounding skin, then becomes higher. The result is a typical crust, characteristic of a lifetime abrasion;
- -from 3 to 10 days: the crust begins to peel off along the periphery from 3-4 days, and disappears on days 7-12;
- - from 7 to 15 days, occasionally more. The surface at the site of the fallen off crust during a deep abrasion is initially pink and smooth, gradually approaches in appearance to neighboring areas of the skin, and any trace of the former abrasion gradually disappears.
Often abrasions are caused posthumously. At the same time, the surface, devoid of the stratum corneum, dries out, and a somewhat in-depth yellowish-gray or brownish bottom appears, sometimes with a reddish tint from the translucent vessels (“parchment spots”).
b) Bruising.
From a blow or pressure with a blunt object, blood vessels often rupture, the gushing blood penetrates the surrounding tissues and saturates them, forming a bruise. If a cavity filled with blood forms (under exfoliated skin or between muscles, between the membranes of the brain, under the periosteum, etc.), it is called a hematoma.
Bruising can be superficial or deep. The former are usually located in the subcutaneous tissue.
Translucent through the skin, bruises initially give it either a faint or a pronounced purple color. Blue colour A. If the bruise is localized in the corium, then the color of the bruise is purple. Depending on the amount of blood at the staining site, there may be swelling, induration and pain on palpation. Superficial bruises, especially in loose tissue, where blood easily flows, are noticeable after 20-30 minutes, and their intensity and area increase while the blood is flowing.
At first (the first 2-3 days), deep bruises may not be detected. However, the coloring matter in the blood diffuses and later stains the skin, often immediately greenish or yellow.
The shape of a bruise from various weapons is most often oval. This is explained by the fact that the pressure of the spilled blood is the same in all directions, and the resistance of the surrounding tissues is uneven, always less along the main mass of tissue cells and fibers and greater in the transverse direction. Occasionally, a bruise may clearly reproduce the shape of the striking surface (belt buckle, iron chain ring, etc.).
The initial color of the skin from the translucency of the shed blood is purple-blue; Over time, the color changes: the bruise, as they say, “blooms.”
The most typical transition is the transition of the initial blue-purple color of the bruise to green, green to yellow, and yellow, gradually weakening, disappears. However, bruises (hemorrhages) on the mucous membrane of the eyelids, in the white membrane of the eyes, on the mucous membrane of the lips do not change color, their purplish-reddish color fades and disappears.
Usually there are no traces left at the site of the bruise, but sometimes brownish pigmentation remains for some time.
The “blooming” of a bruise depends on changes in blood pigment. The spilled blood quickly coagulates, and the separated serum is absorbed. Depending on the breakdown of hemoglobin, the blue-purple color of the bruise may turn green if the formation of biliverdin dominates, and yellow if bilirubin is formed.
The blue-purple color of the bruise turns green, usually 4-8 days after the incident, and then after another 5-7 days it turns yellow, after which it gradually disappears.
c) Wounds.
A wound is damage to the skin and visible mucous membranes, penetrating into the subcutaneous fat (or submucosal) tissue and deeper. Unlike abrasions, as already noted, wounds heal with the formation of a scar.
Wounds (bruised, lacerated, lacerated-bruised) have very characteristic edges, ends and wound surface.
Thus, the epidermis along the edges for a greater or lesser extent is partially or completely absent, the line of such deposition is uneven. The edges of the wound, that is, the skin with subcutaneous tissue, and sometimes the muscles, are uneven, crushed, soaked in blood, and sometimes detached from the underlying bones or fascia. The ends of the wounds can be extremely varied in nature, often they are of an indeterminate appearance, sometimes they can be sharp-angled. The bottom of the wound is uneven. There is usually significant bruising around the wound circumference. Between the edges, especially in the area of the ends, as a rule, thin, thread-like bridges are found, formed by the most stable elements of the underlying tissues, most often by bundles of connective tissue fibers.
d) Bone damage.
Damage to bones as a result of the action of a blunt instrument is presented in the form of incomplete (cracks) and complete, closed and open, simple and complicated, multi-comminuted fractures. When the skull bones are damaged, the following features should be noted: if the blow is applied perpendicularly, a fracture is formed in the form of cracks, evenly diverging along the radii. If the blow is applied at an angle in a certain direction, then it dominates among the radiating cracks.
With a significant impact force of a blunt object with a small surface (9-16 cm2), the corresponding area is knocked out or pressed into the bones of the skull, reproducing general shape and dimensions of the impacting surface. Skull fractures distant from the site of injury occur when there is a large force and a wide impact surface due to changes in the configuration of the skull.
When a blunt-edged tool is improperly deepened, terrace-like fractures occur, while the depression in the bones of the skull forms a slope, sometimes consisting of two or three steps rising one above the other, forming a “staircase”. Stepped indentations indicate the action of a blunt object at an angle.
2. Damage caused by a sharp instrument.
As you know, sharp objects include: cutting (razor, knife, glass shard, axe, etc.), piercing (awl, fork, pitchfork, nail, knitting needle, etc.), chopping (axe, hoe, checker , saber, shovel, etc.). piercing-cutting (knife, dagger, glass shard, etc.) weapons.
A sharp weapon is an object with a sharp blade or sharp end; tools that have a sharp blade and a point are possible. When exposed to such objects, cut, chopped, stabbed and stabbed injuries occur.
a) Incised wound.
An incised wound is characterized by a straight or arcuate shape. As a rule, the damage gapes and has a spindle-shaped shape. Only when the edges come together does the wound acquire its true (original) shape and size. The edges of the cut wounds are smooth. A smooth surface is also characteristic of the side walls of wounds. It is clearly visible throughout the muscles, blood vessels and cartilage when they enter the cut. The length of incised wounds, as a rule, exceeds the width and depth, and cross section has the shape of a wedge (if the wound is gaping) or a straight slit (if the edges are close together). The ends of the injury are sharp-angled, sometimes from the end of the wound, more often where the incision ends, a thin incision comes off.
The depth of the wound is not the same throughout: it decreases according to the direction in which the blade is removed from the tissue.
b) Chopped wound.
Incised wounds usually involve not only soft fabrics, but also the underlying bones. These injuries, like cut wounds, straight or arcuate, gape due to the divergence of the edges, the latter are usually even and smooth, the shape of the ends depends on the active part of the chopping tool (axe, cleaver, poleaxe, etc.), and can be acute-angled, “Th>, “M”-shaped. The blade of a chopping weapon, penetrating the bone, acts like a wedge. If the blade penetrates deeply, and its cross-section melts significantly as it deepens, then cracks appear at the ends of the cut, breaks appear along the edges, and with repeated blows, splintered fractures appear, reminiscent of damage from a blunt instrument.
c) Puncture wound.
Puncture injuries have a puncture wound and a wound channel going deep; occasionally there is an exit hole. The nature of puncture wounds on the skin is determined by the part of the damaging object that immediately follows the sharp end. When exposed to a cylindrical-conical object, due to the elastic properties of the skin, a slit-like wound with ends similar to acute-angled ones is formed; sometimes the damage can be besieged at the edges. In flat bones, a sharp-conical tool causes the appearance of a hole, the shape and dimensions of which reproduce the cross-section of the traumatic object.
The type of skin wound from a sharp-conical tool with edges is determined by the latter, since tissue cuts with sharp edges are added to the splitting action of the cone (cylinder), resulting in the formation of star-shaped wounds, often three- and four-rayed in shape.
d) Stab wound.
Penetrating into the tissue, a piercing-cutting instrument (knives and daggers) pierces and cuts them, thereby forming a stab-cut lesion that has a wound at the injection site and a channel going deep. The wound has smooth edges and sharp-angled ends (under the action of a dagger) “M”, “Th>-shaped, rounded and acute-angled (under the action of a knife) ends. As a rule, the wound is a broken line in the form of an obtuse angle formed by the main (as a result of immersion of the injection) and additional (when removing the blade) incisions. The length of the main cut is used to judge the maximum width of the tool blade along the immersed part to the immersion level. In a stab skin wound - one size (length), determined when the edges are closed. When a knife is used, the part of the skin wound adjacent to the butt end is the main size. When exposed to a dagger, it is possible to determine the localization of the main cut only by using special research methods (see methodological recommendations “Laboratory research methods for forensic medical examination of mechanical damage” - Gorky, 1990). In this case, you only need to indicate the dimensions (length of the main and additional incisions, depth of the wound channel).
3. Gunshot damage.
The gunshot entrance hole is usually round or oval, characterized by a tissue defect (“minus” tissue). This sign is easily determined due to the formation of skin folds that occur when trying to close the edges of the wound. The edges of the hole are smooth or finely scalloped with bands of rubbing and settling (in fact, they merge with each other and form a grayish ring with a width of 0.1 to 0.3 cm). With a so-called “close” shot, by-products of the shot can be determined in the area of the entrance gunshot hole - the action of flame (singing the ends of hair), gases (as a rule, mechanical, thermal and chemical effects of gases occur during so-called shots at partial point-blank range), soot and unburnt grains of gunpowder. In this case, it is necessary to measure the area and indicate the shape of the distribution of soot and grains of gunpowder. This is advisable for later deciding the issue of shot distance. In case of a shot wound, it is necessary to state the number of entrance holes, the distance between them and the dispersion area in order to formulate conclusions about the distance of the shot. A shot at a geometric (full) stop is accompanied by the formation of a “stun mark” in the form of an abrasion, bruise or superficial bruised wound around the hole. The wound channel in the body can be through and end with an exit hole, essentially representing a laceration. They represent a certain feature of bone tissue damage. In flat bones, a rounded entrance hole is formed, the diameter of which is equal to a bullet. The hole widens towards the exit; on the opposite plate it is always larger. In general, the bullet hole of the flat bone has the characteristic shape of a truncated cone with the apex facing the entrance.
Application 1.
DAMAGE DESCRIPTION DIAGRAM
A. General characteristics
- TYPE - wound, abrasion, bruise, fracture, dislocation, separation, etc.
- LOCALIZATION - distance along a rectangular coordinate system from anatomical points, as well as from the sole of the foot.
- DIRECTION - vertical, oblique (relative to the longitudinal axis of the body), horizontal, in two directions, etc., orientation along the watch dial.
- SIZE - for bruises, abrasions, wounds with a tissue defect (for example, gunshot wounds) - two sizes, for linear wounds (cuts, bruises, chopped, stabs, stabs) - one size; for round wounds (damage) - diameter.
- SHAPE - correspondingly geometric: round, square, oval, triangular, rectangular, three-rayed, striped, irregularly rounded, irregularly triangular.
- REACTIVE CHANGES - redness, swelling, purulent discharge, emphysema (intensity, extent).
- SPECIFIC CONTAMINATIONS - blood, soot, grains of gunpowder, lubricating oils, etc. (intensity, color, area, shape, direction).
B. Detailed characteristics.
- WOUND - edges: smooth, uneven (finely jagged, wavy, scalloped, etc.), upset, crushed, etc.; ends: acute-angled, rounded, “M”- and “T”-shaped with subsidence, tears, cuts, etc.; bottom: tissue bridges, broken bones, crushed tissue, foreign inclusions.
- ABRASION - bottom: wet, drying, covered with a crust (above, below, at the level of the surrounding skin), color.
- BLEEDING - color in the center and on the periphery, clarity, blurred outline, swelling along the length and in the circumference, etc.
- FRACTURE - shape, direction of the edge (bevel, overhang), displacement, fragments (shape, position, etc.), damage to surrounding tissues.
Appendix 2.
SAMPLES DESCRIPTION OF DAMAGE.
1. Bruised wound.
On the skin of the right parietal region, 1.5 cm above the auricle, there is an irregularly triangular-shaped injury in the form of three rays extending from an imaginary center. The first ray is directed upward and posteriorly towards the back of the head, its length is 2.5 cm; the second goes anteriorly in the direction of the forehead, its length is 2.0 cm; the third is directed downwards towards auricle, its length is 2.2 cm. The upper edges of the first and second rays, the left one of the third are beveled, and the opposite ones are undermined. The edges of the wound are not smooth, with small tears, the underlying soft tissue is crushed, fringed with many pinpoint bluish-black inclusions. In the depths of the wound, closer to the ends, there are transverse tissue bridges (jumpers). The wound gapes slightly, exposing the underlying intact bone.
2. Bumper fracture.
In the middle third of the left femur, at a distance of 82 cm from the plantar surface of the corresponding foot, there is a comminuted fracture. The line runs from back to front somewhat obliquely from top to bottom and in the middle of the bone it divides into two, the first extends upward at an angle of about 45° to its length, the second at an angle of about 30° downwards. The fracture lines form a bone fragment of an irregular triangular shape measuring 4.0×0.5 cm. The edges of the bone fragment are coarsely toothed. 1.5 cm short of the point of bifurcation of the fracture line, a thread-like convoluted crack 2.5 cm long extends upward at an angle of about 40°.
3. Stab wound.
On the skin of the chest on the left, 7.0 cm below the middle of the clavicle, 8.0 cm to the left from the midline of the sternum and 147.0 cm from the plantar surface of the corresponding foot, there is a linear wound in the form of a blunt angle 120°), open upward and to the right ; the upper side of the wound is 3.0 cm long, the lower side is 1.5 cm. Its edges are smooth, the upper end is acute-angled, the lower end is “L”-shaped. The width of the wound at the lower end is 0.1 cm. No specific contaminants or inclusions were found at the edges and ends of the wound. The wound gapes moderately and penetrates through all layers of the anterior chest wall into the pleural cavity.
4. Entry gunshot damage (shot at geometric stop).
On the skin of the chest on the left, 10.0 cm below the middle of the clavicle, 7.0 cm to the left from the midline of the sternum and 152.0 cm from the plantar surface of the corresponding foot, there is a round-shaped wound with a diameter of 0.9 cm, with a smooth edge and a ring-shaped strip wide from 0.1 cm at the lower pole to 0.2 cm at the upper pole in the form of an area of missing superficial layer of skin (belt of ablation). Around the wound there is a rounded area of depression with a diameter of 2.7 cm and a depth of up to 0.2 cm. The surface of the depression is covered with gray-brown contamination in the form of a motley pattern.
5. Gunshot wound to the skull.
On the frontal hand on the right, 6.0 cm above the middle of the brow ridge and 176.0 cm from the plantar surface of the corresponding foot, there is a round-shaped through lesion with a diameter of 0.9 cm with a smooth edge. On the side of the internal bone plate around this hole there is chipping of bone substance with a diameter of up to 1.5 cm, the edge of the damage is wavy. Thus, the wound channel in the bone has the shape of a truncated cone, expanding towards the inner bone plate.
6. Damage due to technical electricity (“Electrical mark”).
On the skin of the outer-lateral surface of the lower third of the right forearm, 2 cm above the wrist joint, in the vertical direction there is a damage in the form of an oval-extended abrasion measuring 5x1.7 cm. Its edges are uneven, with wavy lines along the mud. The bottom is grayish-white, deep, dense, the surface layer of skin is absent in places, raised in places and peeled off towards the periphery. There are no signs of redness or hemorrhage in the damaged area or surrounding skin.
7. Strangulation groove.
On the neck of a corpse there is a single, obliquely ascending anterior to posterior, open strangulation groove, interrupted on the posterior surface. On the anterior surface of the neck it runs horizontally in the projection of the upper edge of the thyroid cartilage. Then its branches pass to the lateral surfaces of the neck in an upward and posterior direction under the angles of the lower jaw. On the left, the groove is located 1 cm below the angle of the jaw and 3 cm below the earlobe, on the right, 0.5 cm and 2.5 cm, respectively. Next, its branches move to the back surface and are directed upward into scalp heads and lose track. When mentally continuing the branches of the sulcus, they connect at an obtuse angle of about 100° in the region of the occipital protuberance. The bottom of the furrow is brownish-gray, deep, dense, smooth, with a confused surface layer of skin in places in the form of small whitish scales. The width of the groove ranges from 0.7 to 0.5 cm. Its greatest depth, up to 0.4 cm, is expressed in the anterolateral sections of the neck. There is an overhang of the marginal skin ridges, especially the upper one, and small pinpoint dark red scattered hemorrhages in them and along the bottom of the groove.
15.2. SOFT TISSUE DAMAGE
Non-gunshot injuries to soft tissues of the maxillofacial area and neck are often the result of mechanical trauma. According to our data (Ukrainian Center for Maxillofacial Surgery), isolated soft tissue injuries are observed in 16% of patients who sought emergency care at a trauma center. The victims are most often men aged 18 to 37 years. Domestic trauma predominates among the causes.
A.P. Agroskina (1986), according to the nature and degree of damage, divides all injuries of soft tissues of the face into two main groups:
1) isolated injuries of soft tissues of the face(without violating the integrity of the skin or oral mucosa - bruises: with violation of the integrity of the skin or mucous membrane of the oral cavity - abrasions, wounds);
2) combined injuries of soft tissues of the face and bones of the facial skull(without violating the integrity of the skin or mucous membrane of the oral cavity, with violating the integrity of the skin or mucous membrane of the oral cavity).
Bruises(contusio) - closed mechanical damage to soft tissues without visible violation of their anatomical integrity. They occur when soft tissue is exposed to a blunt object with little force. This is accompanied by severe damage to the underlying tissues (subcutaneous tissue, muscle) while maintaining the integrity of the skin. In the underlying tissues, damage to small vessels, hemorrhage, and impregnation (imbibition) of tissues with blood are observed. Are formed bruises- hemorrhages into the thickness of the skin or mucous membrane or hematomas- limited accumulation of blood in tissues with the formation of a cavity containing liquid or coagulated blood. The presence of loose fiber contributes to the rapid development and widespread spread of edema, bruising and hematomas.
A fresh bruise turns the skin blue - purple or blue (that's why it's called a bruise). The blood in the tissues coagulates, hemolysis (decay) of formed elements (erythrocytes) is observed and reduced (brown) hemoglobin (deoxyhemoglobin is a form of hemoglobin in which it is capable of attaching oxygen or other compounds, for example, water, carbon monoxide) turns into methemoglobin, and then gradually transforms into green verdohemoglobin (verdohemochromogen). The latter breaks down and turns into hemosiderin (yellow pigment).
Bruising is an indicator of intravital tissue damage. The “blooming” of the bruise allows us to judge how long ago the injury was. The purple-bluish color of the bruise persists for 2-4 days, a green color appears on the 5-6th day after the injury, and a yellow color of the skin appears on the 7-8-10th day. After 10-14 days (depending on the size of the hemorrhage), the bruises disappear.
The size of a hematoma in the maxillofacial area can vary - from small (several centimeters in diameter) to extensive (covering half of the face, spreading to the neck and upper third of the chest).
The hematoma will fill until the pressure in the vessel is balanced with the pressure in the surrounding tissues. The size of the hematoma depends on the following factors: the type and size (diameter) of the damaged vessel (artery or vein), the magnitude of intravascular pressure, the size of the damage, the state of the blood coagulation system, the consistency of the surrounding tissues (fiber, muscles, etc.).
Poured out V the blood cavity undergoes the following changes: fibrin falls out of it, the formed elements disintegrate and hemoglobin leaves the red blood cells and gradually turns into hemosiderin. In the central part of the hematoma, hematoidin, a yellowish-brown pigment, accumulates, which is an iron-free breakdown product of hemoglobin.
Hematomas are classified into depending on the fabric where they are located(subcutaneous, submucosal, subperiosteal, intermuscular, subfascial), localization(buccal, infraorbital, periorbital and other areas), states of bleeding(non-festering hematoma, infected or festering hematoma, organized or encapsulated hematoma), relationship to the lumen of a blood vessel(non-pulsating, pulsating and bursting).
Soft tissue bruises can often be combined with damage to the bones of the facial skeleton. An increase in edema and unexpressed functional impairment can create a false impression that damage to soft tissues is isolated only. To clarify the diagnosis, an x-ray examination is necessary.
Treatment soft tissue bruises in the first two days after injury consists of applying cold (ice pack every hour with a break of 15-20 minutes) on this area. From the third day after injury, thermal procedures can be prescribed (UV irradiation in an erythemal dose, SOLLUX, UHF therapy, ultrasound, phonophoresis with iodine or lidase, electrophoresis of anesthetics, paraffin therapy, warm compresses, etc.). Troxevasin (gel 2%), heparoid, heparin ointment, dollit cream (cream containing ibuprofen) and other ointments can be prescribed to the area of bruises.
For fresh soft tissue hematomas (in the first two days) cold is indicated, from 3-4 days - thermal procedures. Hematomas are opened when they suppurate and encapsulate(organized hematoma).
Physical therapy is prescribed from 2-3 days after injury. I.N. Mishina (1986) indicates that special attention should be paid to patients with hemarthrosis of the temporomandibular joint, for whom special exercises for the masticatory muscles are indicated to prevent limitation of function.
In most cases, with isolated soft tissue bruises, victims are treated on an outpatient basis, and in case of combined injuries (with the bones of the facial skeleton) they are hospitalized in the maxillofacial departments.
♦ Abrasions
Abrasion- this is injury (mechanical damage) to the surface layers of the skin (epidermis) or oral mucosa. Most often they occur on the protruding parts of the face - the nose, chin, forehead, eyebrows and cheekbones. Abrasions often accompany soft tissue bruises, and less commonly, wounds to the face and neck. They occupy about 8% of all soft tissue injuries (according to our clinic). The following periods are distinguished in the healing of an abrasion:from the formation of an abrasion to the appearance of a crust(up to 10-12 hours); healing of the bottom of the abrasion to the level of intact skin, and then higher(12-24 hours, A sometimes up to 48 hours); epithelialization(up to 4-5 days); crust falling off(on days 6-8-10); disappearance of abrasion marks(for 7-14 days). Healing times vary depending on the size of the abrasion. Healing occurs without scar formation.
Treatment abrasions is to treat it 1% -2% alcohol solution brilliant green or 3%-5% alcohol solution of iodine.
♦ Wounds
Wound(vulnus) - violation of the integrity of the skin or mucous membrane throughout its entire thickness (often and deeper underlying tissues), caused by mechanical stress.
Wounds are divided into superficial And deep, non-penetrating And penetrating(in the oral and nasal cavity, maxillary sinus, orbit, etc.).
Depending on the type and shape of the wounding object, wounds are distinguished: bruised(v. contusum); torn(v. laceratum); sliced(v. incisum); stabbed(v. punctum); chopped(v. caesum); bitten(v. morsum); crushed(v. conquassatum); scalped.
Bruised wounds - arise from a blow with a blunt object with simultaneous bruising of surrounding tissues; characterized by extensive areas of primary and, especially, secondary traumatic necrosis. Observed as a result of the action of blunt objects with a small impact surface with a significant impact force in places close to the bone (superciliary and zygomatic areas, lower orbital edge, chin and nose area).
The wound has uneven edges, the skin around it is hyperemic and covered with pinpoint hemorrhages, there are bruises, and there is also a possible area of marginal necrosis. There is heavy bleeding. It often becomes contaminated. Moderate gaping of the wound due to stretching of the edges facial muscles. When struck in the area of the cheek, upper and lower lip, as a result of damage to the teeth, wounds may form on the mucous membrane. Thus, the wounds become infected with the microflora of the oral cavity. Saliva flowing through the wound irritates the skin.
With bruised wounds, the severity and duration of pain is much sharper than, for example, with cut wounds. Bruised wounds of the face are often accompanied by fractures of the bones of the facial skeleton (a blow from a blunt object or a horse’s hoof, from a fall, etc.).
Rice. 15.2.1. Appearance of a patient with a lacerated wound of the soft tissues of the floor of the mouth, caused by a boron during dental treatment.
Laceration - a wound caused by tissue overstretching; characterized by irregularly shaped edges, detachment or tearing of tissue, and a significant area of damage.
Wounds are formed: when struck by uneven objects, during a fall, industrial or sports injuries, and other cases. More common are bruised and lacerated wounds, which are characterized by: uneven edges; irregular shape; small scraps of fabric are visible at the edges; the presence of hemorrhages around the wounds and along their edges; tissue ruptures can penetrate to a great depth, which is uneven throughout the wound. Often these wounds are through (penetrating) and painful. During their healing process, marginal tissue necrosis is observed. Lacerated wounds in dental practice are observed when injured by a bur, tooth extraction forceps and other small instruments (Fig. 15.2.1).
Incised wound - a wound caused by a sharp object; characterized by a linear or fusiform shape, smooth parallel edges and an almost complete absence of primary traumatic necrosis. In incised wounds, length may prevail over depth. Immediately after injury, wounds usually bleed heavily. The influence of microbial contamination is negligible. Incised wounds, even if they do not pass through the deep layers of soft tissue of the maxillofacial area, gape quite strongly. This occurs due to injury to the facial muscles, which contract strongly and expand the wound. A false impression is created about the presence of a tissue defect. On the skin of the face there is a large number of small muscle fibers, which with their endings are woven into the thickness of the skin and when they contract (when wounded), some tuck of the edges of the wound inward occurs. For a more precise fit, it is necessary to separate the edges of the wound (Fig. 15.2.2).
R 
is. 15.2.2(a, b). Appearance of a patient with an incised wound of the nose, infraorbital, frontal, supra-brow and zygomatic areas, as well as the base of the external ear (after suturing).
In dental practice, incised wounds are encountered when the tongue, lips, or cheeks are injured by a separation disc; microbial contamination of these injuries is large.
Puncture wound - a wound caused by a sharp object with small transverse dimensions; characterized by a narrow and long wound channel. There is always an entrance hole and a wound channel. If the wound is penetrating, then the wound also has an exit hole. The divergence of the edges of the wound is insignificant; the formation of hematomas and pockets that do not correspond to the size of the external wound is possible. As a result of damage to large vessels (external carotid artery or its branches), significant bleeding may develop. And if a puncture wound penetrates the oropharynx or trachea, aspiration asphyxia may occur. Puncture wounds resemble cut wounds, but unlike the latter, they have small transverse dimensions and penetrate to a great depth. Observed when struck by household piercing objects (knife, awl, screwdriver, etc.), in dental practice - by an elevator. When soft tissues are injured by a dental elevator, microbial contamination of the wound is significantly pronounced. We often observed puncture wounds of the palate in children under the age of 4 years (when injured with a pencil or other sharp objects). With puncture wounds, the introduction of a foreign body is possible (Fig. 15.2.3), which is also observed with gunshot wounds (Fig. 15.2.4).
Chopped wound - wound from a blow with a heavy sharp object. They have a slit-like shape and are characterized by great depth. Unlike incised wounds, they have more extensive damage to soft tissue and wound edges. Most often, these injuries are accompanied by fractures of the bones of the facial skeleton and can penetrate into cavities (mouth, nose, orbit, skull, maxillary sinus). Bone fractures are usually comminuted. Microbial contamination is usually pronounced. It is often accompanied by suppuration of wounds, the development of post-traumatic sinusitis and other inflammatory complications. Therefore, when performing primary surgical treatment of a wound, all bone fragments should be removed and a thorough antiseptic treatment should be carried out. Post-traumatic complications come to the fore, so treatment of patients must be aimed at combating them (Fig. 15.2.5).
Rice. 15.2.3 (a, b). Radiographs of the patient’s skull with a foreign body (sewing needle)
soft tissues of the superciliary region.
A 
)
Rice. 15.2.4. Plain (a) and lateral (b) radiographs of the lower jaw in a patient with a gunshot wound. There is a foreign body (a homemade bullet) in the soft tissues of the parotid region, and a fracture of the lower jaw in the area of the corner. Around a foreign body - bone loss
rounded fabrics.
Rice. 15.2.5(a B C). Appearance of a patient with a chopped wound in the maxillofacial area (2 months after an industrial injury).
Bite wound - a wound caused by the teeth of an animal or person; characterized by infection, uneven and crushed edges.
Most often observed in the area of the nose, ear, lips, cheeks, eyebrows. The peculiarity of damage (from human bites) is infection due to the microflora of the oral cavity, as well as the addition of a secondary infection or contamination of the wound. When teeth are clenched, traumatic amputation of tissue is possible. If a person is bitten by an animal, the wound is always contaminated with pathogenic microflora. It is possible to become infected with rabies, especially when bitten by wild animals, so these victims need a course of rabies vaccinations. Wounds from animal bites are characterized by extensive damage and, often, traumatic amputation of tissue. The edges of the wound are crushed, subsequently often become necrotic, healing is slow due to infection of the injury (Fig. 15.2.6).
Rice. 15.2.6. Appearance of a patient (a, b) with a bite wound to the nose and traumatic amputation of tissue. View of the patient (c) after plastic surgery (before removal of sutures).
Crushed wound - a wound in which crushing and tissue rupture (explosions) occurred. It is characterized by a wide area of primary traumatic necrosis, frequent damage to the bones of the facial skeleton, wounds usually penetrating (into the oral or nasal cavity, orbit, maxillary sinus). Often deep-lying tissues and organs are damaged (salivary glands, eyeball, larynx, trachea, tongue, teeth) and large vessels, nerves. Heavy bleeding occurs and asphyxia is possible.
scalped wound - a wound with complete or almost complete separation of a large flap of skin. It occurs mainly on protruding areas of the facial skeleton (nose, forehead, cheekbone, chin, etc.). It is characterized by microbial infection and the introduction of foreign particles (sand, coal, etc.) into the tissue. Healing occurs under the blood crust that forms on the wound surface.
♦ Features of the clinical picture of soft tissue wounds depending on their location
If damaged oral mucosa What immediately attracts attention is that there is a discrepancy in the size of the wound on the skin ( large sizes) and mucous membrane (smaller in size). This occurs due to the fact that the mucous membrane is very mobile and elastic, so it stretches and its edges come closer together, and the size of the wound quickly decreases.
In case of tissue damage perioral area the mucous membrane is injured by sharp edges of teeth or broken plastic dentures. This is most often observed in the lips and cheeks. The wounds bleed profusely and are always infected. In case of defects in the mucous membrane of the inner and outer surface of the alveolar process of the jaw body, as well as the hard palate, it is not possible to bring it together, because it is tightly fused to the periosteum. Wound mucous membrane in retromolar area or pharynx, as well as the floor of the mouth causes heavy bleeding and rapid development of edema with corresponding clinical symptoms (pain when swallowing, opening the mouth, moving the tongue). It is possible to develop an infectious complication - phlegmon (aerobic and anaerobic).
In adults (falling on a ski pole) and in children (injury from a pencil, etc.) it is possible injury to the soft palate. Due to the mobility of soft tissues, these wounds can be stitched quite easily.
Rice. 15.2.7. Appearance of patients with post-traumatic cicatricial ectropion of the lower eyelid:
a) front view; b) side view; c) front view.
The dentist may cause a deep wound in the area soft tissues of the floor of the mouth, tongue and cheek both with a bur (during dental treatment) and with a separation disc (when preparing teeth for prosthetics). If the tissue of the sublingual area is injured by the separation disc, the lingual artery or vein can be damaged, which will be accompanied by heavy bleeding. If it is not possible to stop the bleeding by ligating the damaged vessel (in or around the wound), then we resort to ligation of the vessel along its length (lingual artery in Pirogov’s triangle or external carotid artery). Wounds are always infected. Therefore, when the tongue is injured, swelling quickly develops, which can lead to asphyxia. Possible injury excretory duct submandibular gland, sublingual gland parenchyma, lingual nerve.
Tongue injury can be observed when a person falls (biting the tongue with teeth) or during epileptic seizures, during injuries with a fishing hook, etc. These wounds have a gaping or torn appearance, sharply painful (both when moving the tongue - talking, eating, and at rest). After 10-12 hours, the wounds become covered with a fibrin coating (greasy, whitish). An unpleasant odor appears from the mouth (due to poor cleansing of the oral mucosa).
At damage to the upper and lower lips gaping of the wound edges is noted. Lack of hermetic closure of the lips as a result of damage to the orbicularis muscle. When the peripheral branches of the facial nerve are damaged, lip movement is impaired. More often, wounds are penetrating and become contaminated with the contents of the oral cavity (saliva, food).
Wound soft tissues of the submandibular region may be accompanied by heavy bleeding, because Large vessels are located here (facial artery and vein). Damage to the submandibular gland, as well as the marginal branch of the facial nerve, is possible. When the soft tissues of the neck are injured, the carotid artery (common, external), and in some cases the larynx and trachea may be damaged. If the auriculotemporal nerve (parotid-masticatory region) is damaged, auriculotemporal syndrome may occur (see chapter “Disease of the salivary glands”).
Bruised wounds periorbital region can disrupt the movement of the eyelids, and injuries to the eyelids often lead to cicatricial eversion or the formation of epicanthus - a vertical skin fold covering the medial canthus (Fig. 15.2.7).
In case of traumatic injuries to the parotid-masticatory area, injury to the buccal branches of the facial nerve is possible, and in case of deep wounds, injury to the parenchyma of the parotid gland or its duct. Characteristic clinical symptom indicating injury salivary gland- saliva is released from the wound or the bandage is abundantly wet with saliva, the amount of which increases when ingesting salivary food. Wound healing often ends with the formation of salivary fistulas, the elimination of which requires conservative or surgical treatment (see section “Complications during operations on the salivary glands”).
For soft tissue injuries zygomatic region, especially deep ones, the so-called “zygomatic syndrome” may occur - decreased sensitivity of the skin on the corresponding cheek in the area of innervation of the zygomaticofacial and zygomaticotemporal branches of the second branch of the trigeminal nerve, paralysis of the ocular and individual facial muscles.
♦ Pathogenesis wound process
It is customary to distinguish two phases (stages) of the wound process: vascular And cellular.
An obligatory component of the wound process is the infiltration of tissues with neutrophilic leukocytes, monocytes and lymphocytes, which is ensured by the emigration of cells through the vascular wall. Factors that contribute to increased permeability of the vascular wall are inflammatory mediators.
Play an important role throughout the wound process macrophages- these are phagocytic cells that, in addition to microbes, also remove most of the necrotic cells. Macrophages are capable of secreting factors that enhance fibroblast proliferation and collagen synthesis.
Fibroblasts move to the wound surface along with the growth of blood vessels. Without going beyond the healthy tissue, the leukocyte shaft is demarcated. Thin cytoplasmic strands are formed between fibroblasts, which connect one cell to another. A fibroblastic syncytium is formed. Newly formed vessels grow into fibroblastic layers simultaneously with their formation. This is how granulation tissue (young connective tissue) is formed, which gradually fills the wound defect.
Alteration (damage) → Mediator and microcircular reaction → Exudation and emigration of cells through vessels → Clearance of decay products → Proliferation of fibroblasts and vascular growth → Maturation and fibrous transformation of granulation tissue → Reorganization and involution of the scar.
These are links of a single cause and effect mechanism, where each previous stage prepares and launches the next one.
A head wound is damage to the integrity of soft tissues with their divergence (open wound) or with the formation of a hematoma (closed wound), which occurs due to a bruise, blow or fall from a height. Wounds, depending on the type, can be life-threatening with the development of large-scale bleeding. First aid and comprehensive treatment will help reduce the risks of complications.
Considering the nature of the damage, there are several types of wounds:
- 1. Puncture wound of the head - occurs as a result of penetration of a sharp thin object (nail, awl, needle) into the head, which is extremely life-threatening. The deeper the object enters the head, the higher the risk of death.
- 2. Chopped wound of the head - develops due to mechanical impact on the head area of a sharp heavy object: a saber, an ax, parts of a machine in production.
- 3. Incised head wound - formed as a result of penetration of a sharp flat object: a knife, a sharpener, a scalpel. Accompanied by large blood losses.
- 4. Bruised head wound - occurs when exposed to a blunt object: a stone, a bottle, a stick. Accompanied by the appearance of a hematoma.
- 5. Lacerated head wound – the wound has no clear boundaries; its formation is provoked by the impact of a blunt object that damages the outer skin, muscle layer and nerves.
- 6. Gunshot wound to the head - characterized by penetration of a firearm bullet into the head, which can fly out (through wound), or can get stuck in the meninges.
- 7. Bite head wound – develops from animal bites. Requires complex treatment with the prescription of antimicrobial therapy and the administration of anti-rabies serum.
Based on the depth of damage to the head area, wounds are classified into:
- soft tissue damage;
- damage to nerve fibers;
- damage to large blood vessels;
- damage to bone tissue;
- damage to parts of the brain.
Each wound has its own causes and characteristics. In the event of accidents or disasters, injuries can be complex and include several types of wounds with their own characteristics.
Open
An open head wound is accompanied by a dissection of the skin with the characteristic development of bleeding. The amount of blood discharge depends on the location of the wound, its depth and the cause of its occurrence. The danger of this group of wounds is that there are large vessels on the head, the violation of the integrity of which entails the development of full-scale bleeding. Absence qualified assistance can cost a person his life.
Open wounds are accompanied by loss of consciousness, nausea, numbness of the extremities, which indicates a concussion and bruise of the meninges. Along with stopping the bleeding, the victim is resuscitated, restoring all vital processes in the body.
Closed
Most often, a closed wound is the result of impact on the head area with a blunt heavy object, or a fall from a height. A hematoma and bruise are formed, while the skin does not diverge and does not provoke the development of bleeding.
Clinical manifestations are similar to open wounds, except for the absence of bleeding. Since we are talking about the head, in addition to eliminating the hematoma, it is necessary to make sure that there is no damage to the meninges and the brain itself, which may develop somewhat later.
Characteristic signs and clinical manifestations of all types of wounds
Differentiating wounds is not difficult. To do this, you should pay attention to clinical manifestations and the patient's condition.
Gunshot wounds to the head are fatal in 99% of cases. They are characterized by deep penetration of a bullet or shrapnel into the deep layers of the brain with damage to large blood vessels, bone tissue and nerve endings. Only if there is a tangential gunshot wound can a person be conscious. A blind and through wound in almost all cases provokes instant death.
Bite wounds have such distinctive features as:
- laceration with the absence of straight ends of connective tissue;
- bleeding;
- attachment of the inflammatory process.
On the teeth of animals or humans is great amount microbes that, when bitten, enter the victim’s bloodstream. Therapy involves antibacterial therapy and vaccinations against rabies and tetanus.
The following manifestations are typical for a laceration:
- irregular shape of the wound, many edges not touching each other;
- intense bleeding and severe pain;
- impaired sensitivity of organs located on the head.
Numerous and deep lacerations can provoke the development of painful shock, which is characterized by complete loss of sensitivity, loss of consciousness and coma.
A bruised closed wound has a relatively smooth outline in the form of a circle, crumpled inside. Often the appearance of the wound resembles the imprint of the object that provoked its appearance. Small capillaries cause bleeding, which causes the development of a rich purple and purplish-red hematoma. Bleeding is absent completely or partially. Predominantly superficial capillary bleeding develops, caused by a violation of the integrity of the outer layer of skin. Swelling and swelling appears at the site of the injury. Soon a lump forms, which gradually disappears.
Chopped wounds are characterized by a large depth and area of damage to the head. From a strong blow, the victim often loses consciousness. There is proliferation of soft tissues and bones, after which there may be death. Wounds are accompanied by a high probability of infection, since the item has previously been used for its intended purpose, which leads to penetration pathogenic microflora into the deep layers of the cranium.
They are accompanied by heavy bleeding, as well as the presence of a lumen of varying depth. and nerve fibers. The brain is not injured. Appears sharp pain, causing the development of painful shock. When pathogenic microflora enters the general bloodstream, a clinical picture of intoxication with fever, chills and fever appears.
For puncture wounds distinctive features are:
- relatively smooth edges of the inlet;
- slight swelling and hyperemia of the skin around the puncture;
- no heavy bleeding.
When a punctured object is in the wound, its edges are directed inward. The injury is accompanied by severe pain, dizziness and nausea.
First aid algorithm
First aid kit for wounds First aid, regardless of the type of wound, is carried out according to the following scheme:
- 1. Stop bleeding - apply a clean bandage, cloth or gauze to the wound site and press firmly to the wound site. Apply cold, which will constrict the blood vessels and reduce bleeding.
- 2. Disinfect the area around the wound, but not the wound itself - the surface of the skin is treated with brilliant green, iodine or any disinfectant.
- 3. Monitor the general condition of the victim - control breathing and heartbeat, and in their absence, indirect cardiac massage and artificial respiration are performed.
- 4. Take the patient to the hospital, fixing the head in a motionless position.
Absolutely forbidden:
- press into the wound and set bone fragments on your own;
- rinse deep wounds water;
- independently remove foreign objects from the head;
- Give the victim medication.
A bruised wound to the scalp is almost always accompanied by a concussion and vomiting. Therefore, the patient is placed on his side, with a cushion placed under his head.
In case of a laceration, it is necessary to transport the patient to the hospital as quickly as possible, as stitches will be required.
You can treat a head wound with brilliant green or iodine if it is minor.
Treatment methods depending on the nature of the damage
Providing first aid for head wounds Hematomas and closed wounds are treated with absorbable heparin-based creams. The wound does not require additional treatment. Special attention pay attention to symptomatic treatment, selecting it taking into account the individual characteristics of the body.
Open wounds, especially the lacerated type, require sutures. After this, the scar is treated with brilliant green or iodine solution. A colloidal scar may form at the wound site, to reduce the appearance of which Contractubex ointment is used.
As part of complex therapy, the following groups of drugs are prescribed:
- 1. Analgesics: Analgin, Copacil, Sedalgin.
- 2. Non-steroidal anti-inflammatory drugs: Nurofen, Ibuprofen, Ibuklin.
- 3. Hemostatic drugs: Vikasol.
- 4. Antibiotics: Ceftriaxone, Cefazolin, Cefix, Amoxiclav.
- 5. Nootropic drugs, improving cerebral circulation.
The scalp may have different kinds and shape, as well as the degree of damage. Gunshots are considered the most dangerous, since the survival rate after them is minimal. Treatment of a head wound helps prevent pathogenic microflora from entering the general bloodstream. Correctly provided assistance will save a person’s life.
They are often multiple, localized on the chest, abdominal walls, limbs, head and are a consequence of the impact of so-called secondary projectiles and metal structures, mechanical parts, metal fences, during road traffic accidents, falls from heights, earthquakes, explosions and building collapses.
When falling from heights the victim’s body is mounted on metal structures, like a skewer, and patients are taken to the operating room with the fittings cut off on both sides. The separation of part of the reinforcement fixed in the victim’s body from the rest of the metal structure is carried out by a team of rescuers from the Ministry of Emergency Situations.
Patient N., 34 years old, able alcohol intoxication fell at a construction site from a height of the 4th floor. Approximately at the height of the 3rd floor, he came across a vertically located metal structure (corner) and hung on it. The Emergencies Ministry team cut off the metal structure and the patient was taken to the operating room 3 hours after the injury.
At admission the condition is serious. Consciousness - 11 points on the Glasgow Coma Scale. NPV 28 per minute. On auscultation on the left, breathing is good, but not on the right. Heart sounds are dull, rhythmic, no murmurs. Heart rate per minute, blood pressure 110/70 mm Hg. Art. On the right side of the chest wall there is an entrance laceration of an irregularly oval shape, 25 x 15 cm, located between the posterior and anterior axillary lines at the level of the VII-IX ribs with a metal corner and clothing embedded in it. The exit wound is irregularly oval in shape, 15 x 15 cm, also located on the right side of the chest wall between the parasternal and anterior axillary lines at the level from the clavicle to the third rib. A metal corner and clothing come out through the wound.
Through 20 minutes from the moment of arrival under combined endotrachal anesthesia, with the patient in the supine position with a bolster under the right half of the chest, a right anterolateral thoracotomy was performed in the fifth intercostal space. The metal corner is mostly located intrapleurally, scraps of clothing are soaked in blood. There is a displaced fracture of the clavicle in the middle third and ruptures of the V-IX intercostal vessels.
Various metal objects recovered from the victims' bodies:1 - fragment of a sword; 2 - bicycle handlebar; 3 - metal profile; 4 - corner; 5 - tip of the fence; 6 - rod; 7,8 - parts of door handles; 9-11 - unknown items
Because scraps clothes played the role of tampons, after their removal it began heavy bleeding, which did not exist before. Pericosteal sutures were placed with vicryl on an atraumatic needle. The bleeding has stopped. After removing non-viable fragments of the lung, his wound was sutured layer-by-layer with vicryl using an atraumatic needle. Pleural cavity washed with antiseptic solutions and drained in the second and eighth intercostal spaces. The thoracotomy wound is sutured in layers. Traumatologists performed osteosynthesis of the right clavicle with knitting needles and wire.
Completed primary surgical treatment entrance and exit wounds of the chest wall leaving drainage. Flow postoperative period without serious complications.
In the past often wounds appeared, caused by "fishing hooks and hooks for hanging meat." Some of these objects extracted from the tissues of the victims are shown in the figure. These are scraps of construction reinforcement, a tip from a metal fence, parts of machine tools, parts of door handles, and even a bicycle handlebar that penetrated into the abdominal cavity when a cyclist fell unsuccessfully.
Typically this is heavily contaminated wounds with necrosis of the edges, with multiple pockets in which blood clots and scraps of dead tissue accumulate. The overwhelming majority of them are non-penetrating in nature, and the severity of the victims’ condition is determined mainly by severe closed damage of a combined nature, which determine the relevance of emergency diagnostic and therapeutic measures.
Availability in such neck wounds, chest or abdominal wall contaminated foreign bodies increases the risk of tetanus.
In most cases, bruises are caused by a blunt object. To overcome the resistance of relatively strong and elastic skin, a blunt object must damage less strong but fragile deep formations (muscles, bones). In the circumference of the wound, a wide zone of tissue damage occurs with its impregnation with blood and impaired viability (necrosis). With bruised wounds, pain is pronounced (large area of damage), and external bleeding is small (the walls of blood vessels are damaged over a large area and quickly thrombose), but hemorrhages may occur.
Due to the presence of a large area of damage and a large amount of necrotic tissue, bruised wounds are prone to healing by secondary intention.
- lacerated wound (Vulnus laceratum)
- CRUSHED WOUND (VULNUS CONQVASSATUM)
With bruised, lacerated and crushed wounds, anatomical disruption of large vessels and nerves is observed much less frequently than with stab and cut wounds. They are less likely to be penetrating. However, since a large area of tissue damage forms around these wounds, they heal worse and are more often complicated by the development of infection.
- CHOPED WOUND (VULNUS CAESUM)
- BITE WOUND (VULNUS M0RSUM)
In addition, bite wounds can be infected with the rabies virus, which requires preventive measures.
- MIXED WOUND (VULNUS MIXTUM)
