Stab wounds. The mechanism of their formation, morphology

Tools that have a sharp end and a cutting edge have a complex effect, that is, such tools not only pierce, but also cut tissue when immersed in them.

Piercing and cutting tools combine the properties of piercing and cutting tools. Consequently, damage from them will combine signs of both puncture and incised wounds.

A stab wound has the following elements:

1) entrance hole in the skin;

2) wound channel in tissues or organs;

3) sometimes an exit hole (in case of through damage).

Stab wounds have their own characteristic features that distinguish them from both stab and cut wounds:

1) spindle-shaped and slit-shaped stab wounds are more common. The shape of the wounds can also be arched, angular, etc. In cases where the instrument is rotated around its axis when removed from the wound, in addition to the main one, an additional incision also appears;

2) the edges of stab wounds are usually smooth, without bruising or with slight bruising according to the area of ​​impact of the butt;

3) the shape of the ends of the wound in the case of a double-edged blade - in the form of an acute angle. When sharpening a weapon on one side, one end of the wound is sharp, and the other from the butt is rounded or U-, M-, L-shaped;

4) the wound channel in more or less dense tissues has a slit-like character, its walls are even, smooth, and fatty lobules of subcutaneous tissue may protrude into the lumen of the wound channel. The depth of the wound channel will not always correspond to the length of the weapon blade: the blade may not be completely immersed in the body, then the depth of the wound channel will be less than the length of the weapon blade. When such a pliable part of the body as the stomach is wounded, the blade of the weapon can be completely immersed in the wound and, when pressed, the anterior abdominal wall can move backward. In such cases, after removing the instrument from the wound, it may turn out that the depth of the wound channel will be greater than the length of the wedge of the injury instrument. The depth of the wound channel can also change when the position of the body changes with a change in the relative position of the injured organs.

Most fatal stab wounds are located on the left side of the chest. One explanation for this fact is that most people are right-handed and, when standing face to face with the victim, will strike more likely to the left side of the chest. In addition, if there is an intention to kill, the blow is applied to the left side, because that is where the heart is located.

In most cases, fatal stab wounds to the chest involve the heart or aorta. Death due to lung injury alone is less common.

Most deaths from stab wounds are homicides. In such cases, there are usually many widely scattered wounds on the body. Most of them are often shallow and therefore not life threatening. Death usually occurs quite quickly, due to large loss of blood.

Stabbing for suicide is rare. When a person decides to stab himself, he usually unbuttons or turns away his clothing to expose the part of the body where he intends to stab. In most of these cases, stab wounds are found in the middle and left part of the chest and there are many of them, with most causing minimal damage to the skin. These are the so-called “indecisive” wounds. Stab wounds in suicide vary in size and depth, usually the last one or two are quite deep, penetrating through the wall of the chest cavity into the internal organs. Sometimes the knife plunges into the body without any sign of hesitation.

A specific method of suicide associated with the traditions of the Japanese samurai has been noted, which consists of inflicting a stab wound to the abdomen (harakiri), i.e., when one large wound is inflicted. Sudden evisceration of the internal organs leads to an immediate drop in intra-abdominal pressure and cardiac outflow and, as a result, to sudden collapse. Properly performed hara-kiri involves cutting sharply with a short sword to the left side of the abdomen, passing the blade through the right side of the abdomen and twisting downward to create an L-shaped cut.

According to our data, injuries of the anterior abdominal wall, which do not penetrate, occur in 13.2-15.3% of all abdominal wounds. In some of the patients we observed, wounds from both bladed weapons and firearms were clearly of a demonstrative nature, like a “cry for help,” like a desperate attempt to attract the attention of others. Such wounds are often cut and although they have a dramatic appearance, they do not pose a threat to life, with rare exceptions when the inferior epigastric artery is damaged.

Substantial part lumbar region injuries, without penetrating the abdominal cavity, leads to damage to the organs of the retroperitoneal space. The most commonly observed injuries are the kidneys, ascending and descending colon, somewhat less frequently - the duodenum and pancreas, the aorta and the inferior vena cava.

Injuries of the anterior abdominal wall and lumbar region caused by low-velocity firearms do not pose major problems for surgical treatment. When using high-velocity projectiles, the effect of a combat strike can be so severe that it leads to a life-threatening condition.

Non-penetrating wounds can be through (tangential), when the wound channel passes from right to left (or vice versa) in the thickness of the back muscles and in the retroperitoneal space, accompanied by the formation of hemorrhages of various sizes, with damage to the vertebrae and spinal cord.

Penetrating wounds of the abdominal wall

Near 20-25% of wounds with melee weapons penetrating into the abdominal cavity are not accompanied by damage to internal organs, even when a sharp object is deeply immersed. Most often this happens when struck with a knife with little force and speed, when the movable loops of the small and large intestines, due to elasticity, manage to slip away from the blade.

It should be noted that the presence postoperative scars and adhesions in the abdominal cavity, limiting the mobility of organs, sharply increases the possibility of their damage during penetrating stab wounds.

Puncture wounds are caused bayonet, a narrow stiletto, sharpened files and screwdrivers, an awl, a dinner fork and other sharp objects. Such wounds are characterized by small sizes, but significant depth of the wound channel.

At extensive incised wounds penetrating into the abdominal cavity, prolapse of the abdominal organs occurs, most often the greater omentum and loops of the small intestine. In the literature, there are observations of prolapse of the spleen, tail of the pancreas, and left lobe of the liver from wounds.

Prolapsed organs are subject to massive infection and can be pinched.

An artistic description of a cut wound to the stomach can be found in Hans Evers (collection of stories “Horror.” Grenada): “... dealt his opponent a terrible blow to the stomach from bottom to top and pulled the blade back from the side. A disgusting mass of intestines literally began to flow from the long wound.” It was the section of the liver that fell into the wound of the abdominal wall that was successfully removed in the 12th century, followed by cauterization of the Hildanus parenchyma with a hot iron, marking the beginning of liver resections.

In car accidents and work-related injuries, injuries caused by secondary projectiles. Such wounds are similar in nature to lacerations and bruises.

Skin wounds in most cases they are localized on the anterior abdominal wall. In second place in frequency are wounds of the lower parts of the chest with the spread of the wound channel through the diaphragm into the abdominal cavity or retroperitoneal space. Blood, bile, liquid intestinal contents, and urine can come from a wound in the abdominal wall. Much less often, wounds are localized in the lumbar, sacral or gluteal regions.

In observations F. Henao et al. with penetrating wounds of the lumbar region, the wound channel penetrated into the abdominal cavity in 60%, into the pleural cavity in 31%, and in 9% the wound was of a thoracoabdominal nature.

In a detailed message J. J. Peck, T.V. Berne emphasized that most often such wounds are located to the left of the spine; in 22% they are punctured in nature with a narrow and long wound channel, the course of which in the muscle mass can be displaced. Information on the frequency of injuries to the abdominal organs and retroperitoneal space is contradictory: the literature often reports from 5.8 to 75%.

Concerning gunshot wounds, then the morphological features of damage to parenchymal organs are due to their homogeneous structure and abundant blood supply. Therefore, usually the wound channel in these organs has a straight direction and is filled with detritus and blood clots. Cracks of varying depths extend from it in different directions.

Morphological features damage to hollow organs due to the fact that these organs differ sharply in the content of liquid and gases. It is due to the displacement of liquid and gases during injuries of hollow organs that a temporary pulsating cavity of large size appears, which leads to extensive ruptures and dissections of the organ walls at a great distance from the wound channel. In this case, hollow organs filled with liquid contents and gas are damaged much more severely than hollow organs without contents. This fact was well known during the First World War, when soldiers were given only sugar before an attack, prohibiting large meals and limiting fluid intake.

Determined that presence of dense stool in the colon reduces the degree of hydraulic lateral shock to some extent and therefore reduces the likelihood of large ruptures. At the same time, the places of natural bends of the intestine and the places of its fixation, making it difficult for the shock wave to pass along the intestinal tube, are typical places of ruptures, which must be paid attention to when revising the abdominal organs.

Depending on the kinetic energy of a wounding projectile, it can pass through both walls of a hollow organ or stop in its lumen. In the latter case, the stopping effect of the wall of a hollow organ may be accompanied by its bruise followed by necrosis. Contusions of hollow organs from the outside lead to the formation of subserous hematomas, which can also subsequently lead to necrosis of the deep layers of the intestine.

In addition, the feature gunshot wounds to the abdomen is the so-called transformation of the external contours of the abdominal cavity [Alexandrov L.N. et al.], which consists in the fact that the transverse dimensions of the abdomen at the time of injury change sharply towards increasing and decreasing. These vibrations are repeated several times and, in the case of penetrating wounds, are accompanied by an intermittent release of the contents of the damaged hollow organs from the outlet, often ending with the loss of intestinal loops or strands of the greater omentum from this hole.

– this is tissue damage in which the depth of the wound channel exceeds the width of the entrance hole. It has smooth edges and is applied with a thin sharp object (an awl, a sharpener). Massive external bleeding from puncture wounds is usually absent; the condition in the initial stages often remains satisfactory, which can lead to an underestimation of the severity of the injury. The diagnosis is made on the basis of anamnesis and external examination data. If damage to internal organs is suspected, additional studies are required: chest x-ray, laparoscopy, etc. Surgical treatment: PSO, suturing, dressings.

ICD-10

S41 S51 S71 S81

General information

A puncture wound is a wound with smooth edges, a small entrance hole and a deep wound channel. Puncture wounds in their pure form are rare. In traumatological practice, combined injuries are more often observed - stab wounds inflicted with a knife or dagger. The wound can penetrate into the natural cavities of the body (abdominal, thoracic, joint cavity), accompanied by damage to nerves, blood vessels and internal organs. Sometimes combined with TBI, bone fractures, closed chest injury, blunt abdominal trauma and injuries to the genitourinary system.

Causes

Possible causes of a puncture wound can be a criminal incident (strike with a sharpener), an accident (falling on a pin), a traffic accident, an industrial or natural disaster.

Pathogenesis

The characteristics of the damage depend on the location of the puncture wound. It should be noted that such injuries must be treated with particular vigilance, not excluding severe injuries based on the small size of the entrance hole and the satisfactory condition of the patient. For wounds caused by sharpening, the depth of the wound channel can be 15-20 cm with the size of the entrance hole only 1-2 cm. Wounds caused by an awl reach 8-10 cm in depth, and the length of the channel left by a metal pin is completely impossible to predict without carrying out PHO.

Injuries in the area of ​​the neurovascular bundles may be accompanied by damage to blood vessels and nerves. At the same time, the absence of massive external bleeding does not exclude damage to blood vessels, since after removing a sharp object, the tissues are sometimes displaced, blocking the narrow wound channel, and the blood does not pour out, but into the natural cavities or surrounding tissues.

The likelihood of damage to internal organs depends on the location. With a wound in the chest area, damage to the lungs and heart is possible, in the abdomen - damage to the liver, spleen, intestines, in the neck - damage to the trachea, larynx and esophagus, in the lumbar region - damage to the kidney, etc. It should be taken into account that the possibility injury to one or another internal organ depends not only on the anatomical zone, but also on the direction and depth of the wound channel. Thus, with a puncture wound to the abdomen, inflicted from the bottom up, damage may occur not only to the liver, spleen or stomach, but also to the chest organs. And with a similar location of the inlet, but the wound channel directed from front to back, damage to the kidney is possible.

Another distinctive feature of such wounds is the increased likelihood of developing wound infection. This feature is due to the fact that bacteria and contaminants that have penetrated into the wound cavity are poorly washed out by the blood and remain in the tissues. In addition, blood flowing not outward, but into the surrounding tissues, creates a favorable environment for the proliferation of microbes.

Classification

Taking into account the depth of penetration in traumatology and orthopedics, all wounds are divided into through and blind. Taking into account the features that have a significant impact on the prognosis and treatment tactics, wounds without damage and those with damage to internal organs are distinguished. Taking into account the presence of local complications, wounds complicated by massive bleeding or partial prolapse of internal organs are distinguished.

Symptoms of a puncture wound

With fresh wounds on the skin, a small round wound opening with smooth edges is revealed. If a traumatic object (for example, a pin) remains in the wound, its edges are bent inward. Bleeding is usually minor. With stab wounds, the opening is slit-shaped or angular, the edges are smooth, one or both ends of the wound are sharp. Bleeding is usually not intense, but more blood is shed than with puncture wounds.

Other clinical manifestations depend on the location of the wounds, the presence or absence of damage to internal organs, nerves and blood vessels. A rapid increase in the volume of the damaged anatomical area in combination with weakness, dizziness and fainting indicates bleeding into the surrounding tissues; increasing shortness of breath with injury in the chest area indicates lung damage, pneumothorax or hemothorax; weakness, shock and percussion dullness of sound with injuries to the abdominal area – about possible damage to parenchymal organs (liver, spleen).

The edges of the infected wound are hyperemic, local hyperthermia is detected. Serous or purulent discharge is visible in the wound canal. Due to the development of deep-seated infection and poor drainage of contents, significant swelling of the surrounding soft tissue is often observed. Patients complain of intense tugging or throbbing pain. Symptoms of general intoxication are observed: fever, chills, weakness, weakness, headaches.

Diagnostics

The diagnosis of a puncture wound is made based on the medical history and the results of an external examination. The scope of additional research depends on the patient’s condition and complaints, the location of the wound, the intended direction and depth of the wound canal. To evaluate blood loss, a general blood test is done. If lung damage is suspected, a chest x-ray and consultation with a thoracic surgeon are indicated; if damage to the abdominal organs is suspected, a consultation with an abdominal surgeon and laparoscopy (if there are sufficient grounds). Suspicion of damage to a large vessel is grounds for consultation with a vascular surgeon; suspicion of nerve damage is grounds for consultation with a neurosurgeon.

Treatment of a puncture wound

At the prehospital stage, in case of mild bleeding, the skin around the wound should be washed and disinfected, and then a sterile bandage should be applied. In case of massive bleeding, it is necessary to use one of the methods to temporarily stop the bleeding (apply a tourniquet or a pressure bandage, perform wound tamponade). If a sharp object (pin, sharpening) remains in the wound, it should not be removed, as this may lead to increased bleeding and the development of shock. All patients with puncture wounds must be immediately evacuated to a specialized medical facility.

Orthopedic traumatologists treat fresh puncture wounds without damaging internal organs. Patients with suspected damage to internal organs, nerves and blood vessels are referred to the appropriate specialists: thoracic surgeons, abdominal surgeons, cardiac surgeons, urologists, vascular surgeons, neurosurgeons, etc. Treatment of infected puncture wounds is carried out by surgeons.

In the presence of a fresh, uncomplicated puncture wound, PSO is indicated, which is usually performed under local anesthesia. The doctor rinses with solutions of peroxide and furatsilin, examines the wound canal with a finger or probe,, if possible, excises contaminated areas and sutures the tissue layer-by-layer. To improve outflow, puncture wounds must be drained with half-tubes or rubber outlets. Drains are removed 1-3 days after surgery, sutures are removed on days 8-10.

Patients with deep wounds, muscle damage and significant blood loss should be hospitalized in the trauma department. For minor soft tissue injuries, outpatient treatment at the emergency room is possible. In the postoperative period, UHF and antibiotic therapy are prescribed.

Damage to an internal organ is an indication for appropriate abdominal surgery. If the lung is injured, a thoracotomy is performed, if the abdominal organs are damaged, a laparotomy is performed, etc. The doctor carries out an inspection, suturing the damaged organ and performs other therapeutic measures (the list of measures and tactics of surgical treatment depends on the characteristics of the wound). All patients with internal organ damage are hospitalized.

Infected wounds are opened, washed and drained. Local treatment is carried out against the background of antibiotic therapy. First, broad-spectrum antibiotics are used, then the drug is prescribed taking into account the sensitivity of the detected microorganisms. Depending on the patient’s condition, treatment can be either inpatient or outpatient.

Prognosis and prevention

The prognosis for uncomplicated stab and stab wounds is more favorable than for lacerated and lacerated wounds. Relatively clean and smooth edges provide better conditions for healing. At the same time, the risk of developing infection with such wounds is higher than with shallow incised wounds. The outcome of complicated wounds depends on the characteristics of the injury (the severity of damage to certain organs, the amount of blood loss, the presence or absence of shock). Prevention includes measures to prevent injuries.

A wound on the abdomen is a serious lesion of the skin, soft tissues, and sometimes internal organs. In such cases, it is important to provide first aid in a timely manner. The further prognosis of the victim’s life depends on this.

Symptoms and types of injuries

If you are wounded in the stomach, you need to stop the bleeding with clean rollers

Injuries are usually classified into two groups. You should definitely pay attention to this when providing assistance, since not all actions are acceptable. Abdominal wound occurs:

• Knife. Received as a result of a direct or oblique blow to the peritoneum with a knife blade.
• Firearms. Occurs as a result of a shot from a pistol, shotgun, or shotgun. May be cross-cutting. Sometimes several wounds form from one shot.

Knife wounds of the abdominal cavity according to the ICD (10) have individual codes depending on the stage. Injuries may be:

• Open (according to ICD S31). The blade penetrated deep into the abdominal cavity. Intestinal loops and internal organs may be visible from the wound. Visible areas of the mucous membranes and the skin around the injured area become pale and sometimes turn blue. The victim has difficulty breathing and attacks of vomiting develop.
• Closed (according to ICD S36). Formed when struck by a blunt blade through outer clothing. With such a wound, internal organs are not damaged. Only soft tissue bruises and skin cuts are possible. A non-penetrating wound is characterized by minor capillary bleeding and the formation of hematomas around the injury.
  
• Infected wounds of the anterior abdominal wall. They have unclear boundaries. Dirt ingress is noticeable, suppuration appears, and peritonitis develops.
• Uninfected injuries have clear boundaries. Internal organs are not affected.

A closed wound on the abdomen may be accompanied by internal bleeding, as evidenced by profuse cyanosis and swelling of the tissue at the site of impact.

First aid



Providing first aid for injury

Regardless of the complexity of the injury, the victim needs first aid. It must be performed in any situation. It is important to follow the rules for carrying out certain manipulations so as not to harm the wounded.

1. First of all, call an ambulance, and then begin providing first aid.
2. If the person is unconscious, tilt their head back and turn them on their side. This will allow oxygen to freely penetrate into the lungs. Vomit will be easily removed from the mouth.
3. Treat open wounds with alcohol, hydrogen peroxide, and Miramistin only on the outside. Do not pour antiseptics inside under any circumstances.

   

   For any injury in the abdominal area, do not feed or water the victim.

4. If possible, place the prolapsed internal organs next to each other with wet hands wearing sterile gloves. Then place them in a clean bag or cloth. If that fails, apply a bandage. To do this, form rolls from a clean cloth or gauze and place them around the wound; place the cloth on top of them.
5. To prevent internal organs from drying out, they need to be regularly moistened by spraying water on the cloth for 10-15 minutes.
6. If there is an object sticking out of the wound, secure it. To do this, glue long strips of bandages on both sides of the impact site, then wrap them around the foreign object and secure the strips again with adhesive tape. If you don't have a bandage at hand, use any long fabric.
7. Under no circumstances remove the weapon from the wound. This can cause bleeding and death of the victim.
   
8. Do not give the wounded person antipyretics or painkillers. Such actions will hide the etiology of the injury.
9. After providing first aid, place the victim in a sitting position, leaning his back against a wall or tree. Bend your legs at the knees.
10. If the internal organs are not visible, be sure to clean the wound of dirt and treat it with an antiseptic. If you don't have one at hand, use any alcoholic drink.
11. After providing assistance, fold a piece of bandage or gauze into 10 layers, moisten it with water or peroxide and apply it to the wound. Attach with adhesive tape or tape to undamaged areas of the skin.

After providing first aid, you must remain next to the wounded person until the ambulance team arrives. Doctors need to tell what actions were performed.

Regardless of whether the victim is conscious or unconscious, first aid must be provided.

What is prohibited to do

A penetrating abdominal wound causes severe thirst in the victim. At this moment he is forbidden to give anything to drink. To relieve the condition, dampen a cloth with water and wipe your lips, temples and forehead. You can simply rinse your mouth. Any food is contraindicated.

The wounded person must not be moved or tried to be transported to another place. This can cause pinching of internal organs, deeper penetration, and bleeding.

Is it possible to determine the pattern of abdominal wounds?

The general picture of stab injuries of the abdominal cavity is determined by three states of the body: shock, organ perforation, and the presence of bleeding. Also, the condition of the internal parts of the body can be assessed by the fluid flowing from the wound: bile, urea and others.

Accurate diagnosis in the absence of these signs is impossible. Only doctors can determine the condition of the victim. Diagnosis may be difficult due to the influence of weather conditions (heat, frost, precipitation).

Diagnosis and treatment



Painkiller

A knife wound requires mandatory hospitalization. In most cases, the victim is prescribed surgical intervention. Initially, a thorough diagnosis of the patient’s condition is performed. The algorithm of actions is as follows.




Heavy physical activity is prohibited for two to three months after surgery. Otherwise, there is a risk of scar divergence at the wound site.

Consequences of a knife wound

With timely detection of abdominal injuries, the chances of a favorable prognosis for the victim’s recovery increase. However, a penetrating or blunt wound can cause some complications. These include:

• Failure of internal organs;
• Inflammation of the peritoneum and soft tissues;
• Sepsis (blood poisoning);
• Pathologies of the small intestine;
• Internal bleeding.

After knife wounds involving internal organs, the body takes a long time to recover and requires lifelong maintenance therapy. Therefore, assistance to the victim must be provided promptly. In such cases, there is a possibility that the person will not remain disabled.

They combine the properties of piercing and cutting. Naturally, the damage from them will combine signs of both puncture and incised wounds.

A stab wound has the following elements: an entrance hole in the skin, a wound channel extending from it in tissues or organs, and, sometimes, if the wound is through, then an exit wound hole. Stab wounds have their own characteristic features that make it possible to distinguish these wounds from both cut and stab wounds.

1. The shape of stab wounds can be slit-shaped, spindle-shaped, arched, angular. The most common are spindle-shaped and slit-shaped wounds. If a weapon was used with a one-sided sharpening of the blade, then the greatest divergence of the edges will be at the edge where the butt of the weapon was used. Wounds from U-shaped weapons with a more or less thick back (more than 2 mm) (for example, from Finnish knives) can have a wedge-shaped triangular shape. In cases where the tool is rotated around its axis when removing it from the wound, in addition to the main one, an additional incision occurs and one of the ends of the wound takes on the shape of a “dovetail.”
2. The edges of stab wounds are usually smooth, without bruising or with slight bruising, depending on the area of ​​impact of the abrasive. If the knife blade was covered with rust or dirty, then a wiping band remains on the skin edges of the wound. When examining the edges of such a wound using the color print method, traces of the metal from which the blade of the weapon is made can be detected.
3. The shape of the ends of the wounds in cases where the weapon (dagger) had a double-sided sharpening in the form of an acute angle. When sharpening a weapon on one side, one end of the wound is sharp, and the other from the butt is rounded or U-shaped, sometimes with small tears or notches from the action of the butt ribs.
4. The wound canal in more or less dense tissues has a slit-like shape, its walls are even and smooth, and fatty lobules of subcutaneous tissue can protrude into the lumen of the wound canal. The length of the wound channel will not necessarily correspond to the length of the weapon blade: the blade may not be completely immersed in the body, then the depth of the wound channel will be less than the length of the weapon blade. When such a pliable part of the body as the stomach is wounded, the blade of the weapon can be completely immersed in the wound and, when pressed, the anterior abdominal wall can move backward. In such cases, after removing the instrument from the wound, it may turn out that the depth of the wound channel will be greater than the length of the blade of the injury instrument.

The length of the skin wound also does not provide grounds for judging the width of the blade of the instrument of injury, since the blade can be immersed in the body and removed from it not in the same position, but move through the tissue along the length of the wound and its length will be in these cases greater than the width of the instrument of injury.

In dense tissues such as cartilage, on the walls of the wound canal, traces of sliding of the tool blade may form in the form of parallel ridges and grooves from the unevenness of the blade. These traces are strictly individual and can be used to identify a specific instance of the instrument of injury. When a strong blow with the end (edge) of a piercing-cutting weapon hits a flat bone at an angle of 90° or close to it, the bone can be damaged - a perforated fracture occurs, the shape and dimensions of which (from the side of the outer plate) practically correspond to the shapes and dimensions of the cross-section of the blade of the wounding weapon at the level of its immersion into the bone.