Injury
to internal organs.
Wounds such as stab wounds may be associated
with damage to internal organs. Treatment of penetrating abdominal or thoracic
wounds has been discussed elsewhere. The possibility of blunt or sharp abdominal
trauma must not be overlooked when treating extensive injuries elsewhere,
particularly in an unconscious patient.
Gunshot injuries are associated with different
severity of tissue damage depending upon whether the injury is of low or high
velocity. Low-velocity injuries, such as from a hand gun, result in an entry and
exit wound, the latter being the larger, and damage along the tract of the
missile. Such injuries are often associated with severe tissue contamination
from clothing, dirt or other foreign materials. High-velocity injuries (from
modern assault rifles) cause explosive pressure and decom
pression effect, such that there is widespread
tissue damage, with injury to major limb vessels and nerves situated some
distance from the tract of the missile. Where a high-velocity missile strikes
bone, the high-energy exchange results in fragmentation of the bone. Gunshot
wounds and war wounds require careful surgical excision and such wounds should
be left open. Following high-velocity injuries, fasciotomy of all of the fascial
compartments of the limb should be undertaken. The damage from a shotgun wound
depends on the scatter of the shot and therefore on the range. A large track of
damage may result in severe bleeding or a pneumothorax, which requires immediate
appropriate emergency management.
Injuries to
bone and joints
Fractures may be closed where the skin is intact or open where there is a wound. Open fractures may have a skin wound
due to penetration from the outside or, more frequently, due to bursting of the
skin from within by bone fragments. The bone displacement is worst at the very
moment of injury and bone fragments partially reduce spontaneously thereafter.
It is important to appreciate that a puncture wound of the skin overlying a
fracture is almost certainly evidence that the skin was penetrated by bone. The
usual principles of wound management apply in that an adequate excision of the
wound is necessary followed by antibiotic treatment and appropriate treatment of
the fracture. Severe open lower limb injuries often have extensive damage to the
skin and muscle in addition to fractures. It is best to treat the fracture and
soft-tissue injuries simultaneously. Extensive removal of damaged soft tissue
may be required and skin cover achieved by a one-stage microvascular tissue
transfer.
Where a wound is associated with much bleeding
there is the possibility that a significantly large vessel has been divided. As
a first aid measure, bleeding will almost always be controlled by direct
pressure, and elevation of the part where practicable. Limb tourniquets should
not be applied as a first aid measure. In the emergency department it is never
desirable to plunge vascular damps or artery forceps into a wound without a
proper view of the bleeding point, as grasping