Tangential Wounds Research Articles

Morphological Features of Wound Canals and Intracranial Pathology in Non-Penetrating Gunshot Craniocerebral Injuries

Background. Non-penetrating craniocerebral trauma in modern warfare, according to our data, accounts for up to a fifth of all gunshot wounds of the skull and brain in armed conflicts at the end of the last century and the beginning of the current century. It is a complex problem of military field surgery, first of all from the point of view of solving an important task of the medical services of the warring parties – restoring the maximum number of wounded. The study of pathomorphological wound channels in various types of gunshot non-penetrating craniocerebral injuries gives opportunities for the development of adequate options for access during surgical treatment. 
 Object: to reveal the morphological features of wound canals and internal cranial injuries in gunshot non-penetrating craniocerebral injuries for optimal planning the primary surgical treatment of the wound.
 Material and Methods. Study and analysis of morphological features of wound canals and intracranial pathology in 155 non-penetrating gunshot craniocerebral injuries of the military who underwent surgical treatment in the 2nd and 3rd level healthcare institutions during the war in 2014-2020. The morphology of wound canals and intracranial injuries were studied based on the laws of wound ballistics, clinical data, and computed tomography data.
 Results. The largest proportion of non-penetrating gunshot wounds is perforated and depressed fractures (39.9%); perforated fractures with penetration of a fragment to the inner plate of the bone account for 20% and incomplete (to the bone) make up 5.8%. Among blind non-penetrating wounds, single ones prevail (65.2%). More often, they have a cylindrical blind canal. Subarachnoid hemorrhage, brain congestion, and very rarely epidural hematoma (one case) are found in almost all perforated bone fractures. A more complex pathomorphological structure is present in multiple non-penetrating gunshot wounds. At the same time, only one fragment causes a depressed skull fracture. Large and small wound canals can be distinguished by width. The latter do not damage the bones and do not require surgical treatment. This type of injury is accompanied by a subarachnoid hemorrhage in 78% of cases and by brain congestion near the fracture in 43% of cases. Tangential injuries occur in 21.9% of injuries; they have a grooved elongated shape. The bottom of these wounds are linear and compressed fractures. Rarely, subdural and intracerebral hematomas are formed in the projection of the fracture. All non-penetrating injuries are accompanied by small brain congestion of the I-II degrees and subarachnoid hemorrhage. Epidural and intracerebral hematomas can rarely occur with blind non-penetrating cranial injuries.
 Conclusions. Non-penetrating multiple fragmental injuries are accompanied by the greatest soft tissue damage. In case of blind wound canals, there are incomplete perforated and perforated-depressed skull fractures; linear and depressed fractures occur in tangential canals. Regardless of the type of wound canals in the brain, there are small congestions (hemorrhages) and subarachnoid hemorrhage. In rare cases, epidural and intracerebral hematomas are formed. Subdural hematomas, sometimes combined with intracerebral hematomas, are found in tangential non-penetrating wounds. Projectiles in tangential wounds do not cause molecular shock and do not lead to secondary necrosis, therefore, it is not necessary to cut the edges of the wound during the primary surgical treatment.

Harvesting human skin allografts for burn care in a developing country

The usage of fresh and glycerolized preserved human skin allograft in burn care is a challenge in a developing countries despites it’s benefits in improving morbidity and mortalities in burn patients. We present two case reports to demonstrates it’s usage. In our first case report, the skin harvested allograft was from a consented patient who was undergoing abdominoplasty. It was harvested as a full thickness skin graft from the panniculus. The harvested skin allograft underwent process of glycerolisation and was stored in 85% glycerol in a fridge at 4°C. The skin allografts were used on the donor site of a patient with 51 percent burns undergoing burn wound excision and skin grafting. The skin was secured with sutures and adherence of the skin allograft on the donor site was noted on the wound review on the third day. Evidence of rejection of some parts of the skin allograft (sloughing off of the skin) was noted by the 7th day post-surgery. The second case report, a two-year-old girl who presented with 37% total burn surface area predominantly deep dermal flame burn injury with suspected inhalation injury. She had tangential wound excision and split thickness skin grafting with both autograft and living donor allograft (donor was the mother). The donor was screened for human immunodeficiency virus (HIV) I and II, hepatitis B surface antigen (HBsAg) and hepatitis C virus (HCV). The autografts were meshed 6:1. Allografts were previously harvested from the thigh of the mother on the same day using a power dermatome and meshed 3:1. By the 12th day, there was a 60% loss of the allograft on the left thigh while there was 5% graft loss for the autograft. On the right thigh, there was a 50% graft loss for the allograft while there was a 2% graft loss for the autograft. Human Skin allograft can be used as an option for wound coverage in patients who have sustained burns.

Atypical Keyhole Gunshot Wound to the Head: A Descriptive and Pictorial Case Report

Keyhole gunshot wounds to the cranium are rare and typically indicative of tangential wounds. The authors present an atypical keyhole gunshot wound to the parietal bone that exhibits a groove that gradually widens and deepens, terminating with an embedded bullet fragment (core). This appears to be the first report describing a groove or “impact platform” indicating the entrance portion of a keyhole injury. This case provides information based on a multidisciplinary approach augmented with 3D photogrammetry that may explain the cranial wound pattern and variability associated with keyhole injuries in partial and complete crania.

Laparoscopy in Management of Blunt and Penetrating Abdominal Trauma: Single Center Experience

Introduction: Exploratory laparotomy in either blunt or penetrating abdominal trauma with suspected intra-abdominal injuries is associated with a high negative (non-therapeutic) laparotomy rate and a high procedure-related morbidity. In abdominal trauma, laparoscopy may be used either as a diagnostic or therapeutic tool in hemodynamically stable patients. Laparoscopy can avoid unnecessary (non-therapeutic) laparotomy and may allow laparoscopic repair of these injuries. Diagnostic laparoscopy can reliably rule out a significant intra-abdominal injury in patients with equivocal abdominal examination following trauma. In sharp abdominal trauma laparoscopy has been shown to be very effective in determining violation of the peritoneal cavity by tangential wounds. Patients and methods: 38 patients with abdominal trauma were enrolled for this study. Exclusion criteria for all patients included; hemodynamic instability, clinical or radiological evidence of major abdominal organs or vascular injuries, posterior abdominal wall penetrating injuries, bowel evisceration, evidence of 2 thoracic injuries (as pneumothorax), or head injuries. Pneumo-peritoneum is achieved with low CO flow and maintained at low pressures (10–12 mmHg). We started by exploration of abdominal cavity and suction of the free blood from the peritoneal cavity. In sharp injuries, inspection of the peritoneal membrane was done for evidence of penetration. Small hepatic and splenic hematomas were left undisturbed. Small and accessible tears ware sutured. Deep or inaccessible liver and splenic tears needed conversion to laparotomy. Small intestinal simple tears were sutured laparoscopically while complex tears needed laparotomy conversion. Left colonic tears needed laparotomy conversion and colonic diversion. Results: Patients with blunt trauma (26 patients), in whom laparoscopic management was completed were18 patients (69%). 5 patients (26%) of the later, had negative laparoscopic exploration, for which the operations were terminated, 6 patients (37%) had retroperitoneal hematomas with free hemo-peritoneum, 2 cases (10.5%) showed only right hepatic lobe small sub-capsular hematomas, 3 cases (16%) showed small liver tears, and 2 cases (10.5%) showed small splenic sub-capsular hematomas and small superficial tear. All the previous injuries were left undisturbed with laparoscopic suturing of the 2 cases with liver tears. 12 cases (31.5%) with sharp penetrating anterior abdominal wall trauma were included in this study. The cases with penetrating abdominal trauma that could be completed laparoscopically were 8 cases (67%) and those who needed laparotomy conversion were 4 cases (33%). The mean operative time in the cases that were completed laparoscopically was 85 minutes and in the laparotomy converted group was 67 minutes. Analysis of postoperative pain in all patients was done using the Numeric Rating Scale (NRS) for pain. Pain was subjectively more severe and statistically different in the laparotomy group than laparoscopic group. The range of hospital stay in the laparoscopy group was 2 to 5 days, and in the laparotomy group it was from 6 to 8 days. No cases in the laparoscopy group showed wound infection; while it was 3 cases (25%) in the laparotomy converted group. Long term follow up showed one case (8.3%) in the laparotomy group developed incisional hernia related to the main abdominal wound, while no similar case was detected in the laparoscopy completed group. Conclusion: The evaluation and management of abdominal trauma are multi-factorial. Careful selection of trauma patients, high index of suspicion, and a low threshold for laparotomy will provide them the benefits of laparoscopic management and reduce the rates and morbidity of unnecessary laparotomy.

Cardiac War Wounds

Summary The paper presents myocardial contusion and penetrating cardiac war wounds. The authors report their experience with thirteen cases of penetrating wounds, out of which only two were treated in the conditions acceptable for surgery. The other 11 wounds were treated in war hospitals which were mostly improvised, and in mobile surgical teams. The basic, exclusively physical examination methods are described here, with the emphasis that “it is better to open and see than wait and see”. Such procedure gave the results that could be compared with the best ones in the literature (only one death). Three, conditionally speaking, specific cases are presented: one tangential wound with relapsing hemorrhage and two spontaneously sanitized ventricle wounds followed by other kinds of complications.

Safe management of paediatric penetrating head injury without a CT scanner: A strategy for humanitarian surgeons based on experience in southern Afghanistan.

In many parts of the world, access to a CT scanner remains almost non-existent, and patients with a head injury are managed expectantly, often with poor results. Recent military medical experience in southern Afghanistan using a well-equipped surgical facility with a CT scanner has provided new insights into safe surgical practice in resource-poor environments. All cases of children aged under 16 years with penetrating head injury who were treated in a trauma unit in southern Afghanistan by a single neurosurgeon between 2008 and 2010 were reviewed. Based on a previously published retrospective review, a clinical strategy aimed specifically at generalist surgeons is proposed for selecting children who can benefit from surgical intervention in environments with no access to CT scanners. Fourteen patients were reviewed, of whom three had a tangential wound, 10 had a penetrating wound with retained fragments and one had a perforating injury. Two operations for generalist surgeons are described in detail: limited wound excision; and simple decompression of the intra-cranial compartment without brain resection or dural repair. In resource-poor environments, clinically-based criteria may be used as a safe and appropriate strategy for selecting children who may benefit from relatively straightforward surgery after penetrating brain injury.

Non-operative Management in Penetrating Abdominal Trauma: IS it Feasible at a Level II Trauma Center?

BackgroundThe recent mandate for surgical exploration for all penetrating abdominal trauma has been questioned. High-volume centers report good outcomes for non-operative treatment in penetrating trauma for hemodynamically stable patients without peritonitis and with tangential wounds. The applicability of this strategy in smaller hospitals is unknown. Study ObjectivesThe purpose of this study was to evaluate non-operative management of penetrating abdominal trauma at a Level II trauma center. MethodsWe retrospectively reviewed all patients with penetrating abdominal trauma from 2006 through 2008. Demographic information, treatments, and outcomes were analyzed using descriptive statistics. ResultsOur sample consisted of 86 patients with penetrating abdominal trauma; 12 (14%) had documented peritoneal violation and were managed non-operatively. The average age was 30 years (range 21–39 years), with 50% African American, 33% Caucasian, and 17% Hispanic. Male patients accounted for 92%, and the average Injury Severity Score was 5.2 (range 1–13). Overall non-operative treatment failed in 3 patients (25%); one required drainage of a retrogastric abscess on hospital day 4, and another underwent gastric and diaphragm repair on hospital day 1. The third treatment failure did not require an operation but developed a biloma requiring percutaneous drainage. There were no other complications related to non-operative therapy and no mortalities. The average length of stay was 3.9 days; 83% of patients were discharged home. ConclusionsIn hemodynamically stable patients without peritonitis and documented isolated injuries to solid organs, non-operative management of penetrating abdominal trauma seems safe; however, it can delay diagnosis of hollow viscus injuries. Until further data emerge, extreme caution should be used in employing non-operative management for penetrating abdominal injuries at small trauma centers.

Penetrierende Verletzungen - eine wachsende Gefahr in Westeuropa

BACKGROUND: Penetrating injuries (PI) in Germany are rising slowly but steadily. Because of their great variety there is still a need for treatment algorithms adjusted to german infrastructure. METHODS: 199 patients with penetrating injuries, treated from 1986 to 2005, were analysed with the aid of a questionnaire retrospectively. After literature review and evaluation of our results we developed some policies of mandatory therapeutic interventions. RESULTS: In 42 gunshot, 144 stab and 2 combined gunshot and stab wound injuries chest and abdomen were the most often injured regions. Chest x-ray (54.3 %) and ultrasound (49.5 %) were the most frequent diagnostic procedures. 61.7 % of all patients were operated within 24 h. Out of 73 thoracic PI we performed thoracic surgery in 27.4 %, 30.1 % were treated only with a chest tube, the remaining were observed closely. Out of 78 abdominal PI laparoscopy was performed in 35.9 %; in 31 % the latter conversion to laparotomy was necessary. 64.1 % were operated by laparotomy. 22 % of the laparotomies were of explorative character. In only 57.7 % injuries of the abdominal organs could be found. Altogether the complication rate was 28.7 % and the mortality as low as 1.6 %. In 11 impalements the rectum and perineal region was injured most often in 64 %, only 9 % developed septic complications. CONCLUSIONS: Based on appropriate diagnostic procedures we recommend a selective management for stab and gunshot wounds, which also includes minimal invasive procedures as therapy standards. Patients in shock have to be treated immediately surgical. In thoracic injuries chest tube application is of high diagnostic and therapeutic significance. Thoracotomy should performed in blood loss ≥ 1 500 ml. Thoracoscopy is indicated in blood loss ≤ 1 500 ml, clotted hemothorax and persistent pneumothorax. Supposed cardiac injuries require immediate sternotomy. Laparoscopy should be used in abdominal stab wounds to exclude peritoneal penetration and gives also therapeutic options. For supposed intestinal leckage and gunshot wounds laparotomy is the golden standard. In abdominal gunshots only tangential wounds can be managed without laparotomy. Therapy of rectal impalements includes primary closure, presacral drainage, colostomy and wound debridement.

Enzymatic debridement of burn wound with collagenase in children with partial-thickness burns

Seventy-eight pediatric burn patients treated by enzymatic debridement with collagenase clostridiopeptidase A (CCA), were compared to 41 patients those burn wounds were excised surgically. Patients whose burn wounds were initially assessed as partial-thickness at admission were enrolled in the study. Total removal of eschar was achieved in 49 of 78 (62.8%) patients by CCA only (group D). In 29 patients (37.2%), therapy with CCA was ceased because of the development of burn wound infection or a manifest need for grafting of the wound, therefore, these patients underwent tangential wound excision (group DS). The records of 41 patients, treated by early tangential excision, having similar burn wounds by extent and depth with groups D and DS were used as controls (group S). There was no significant difference between the time to achieve a clean wound bed in groups D, DS and S (mean 7.8, 8, and 7 days, respectively, P>0.05). In group D, none of the patients required blood transfusion, except one. Patients in group DS were found to have fewer excisions (mean 1.1) when compared to those in group S (mean 1.5, P<0.05). The shortest hospital stay was found in group D (12.5 days, P<0.01). In conclusion, the use of CCA, provided a short hospital stay, reduced the overall need for surgery and blood transfusions in patients with partial-thickness burns. Thus, CCA should be considered as an initial treatment of choice for removal of eschar in children, having a partial-thickness burn wound without infection.

Cavitary endoscopy in trauma: 2001.

Laparoscopy and thoracoscopy have been used in the evaluation of injured patients for over 30 years. Despite this long history, indications for use of these techniques remains controversial. The widespread availability of videoscopic equipment which followed the introduction of laparoscopic cholecystectomy increased interest and utilization of minimally invasive techniques in evaluation of trauma patients. Laparoscopy has been most beneficial in the evaluation of hemodynamically stable victims of stabbings and gunshots. This technique has primarily been used to detect peritoneal penetration in tangential wounds of the abdominal wall and for evaluation of the diaphragm in patients with thoracoabdominal wounds. Laparoscopic evaluation in blunt trauma patients is of unproven utility, but has been used in the assessment of patients with documented solid organ injury and in the evaluation of patients with suspected hollow viscus injury. Small subsets of patients are candidates for therapeutic laparoscopic interventions, i.e., suture repair of diaphragmatic lacerations. Thoracoscopy or videoassisted thoracic surgery (VATS) is useful for evaluation of the diaphragm, early evacuation of clotted hemothorax, and assessment of ongoing bleeding.

Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy.

A prospective study was performed to determine the usefulness of triple-contrast helical CT in predicting peritoneal violation and the need for laparotomy in the treatment of penetrating torso trauma. Triple-contrast helical CT scans were obtained in 104 hemodynamically stable patients with penetrating injuries to the torso (thoracoabdominal region including tangential wounds to the anterior abdomen, flank, back, and pelvis) over a 17-month period. The study group included 54 patients with gunshot wounds and 50 with stab wounds. No patient had a radiographic or clinical indication for immediate laparotomy. A positive finding on CT was defined as evidence of peritoneal violation or injury to the retroperitoneal colon, major vessel, or urinary tract. Patients with a positive CT, except patients with isolated liver injury or free fluid, underwent laparotomy. Patients with a negative finding on CT were initially observed. CT studies were positive in 35 (34%) of 104 patients and negative in 69 (66%) of 104 of patients. Laparotomy was performed in 21 (60%) of 35 patients with positive CT; 19 (86%) of 22 were therapeutic, two (9%) were nontherapeutic, and one (5%) was negative (no injury was found). Nine patients with isolated hepatic injuries were successfully treated without laparotomy. Among patients with a negative CT, 67 (97%) of 69 were treated nonoperatively with success. CT had 100% (19/19) sensitivity, 96% (69/72) specificity, 100% (69/69) negative predictive value, and 97% (101/104) accuracy in predicting the need for laparotomy. Triple-contrast helical CT can accurately predict the need for laparotomy and exclude peritoneal violation in penetrating torso trauma including tangential abdominal wounds.

Principles for managing penetrating craniocerebral injuries caused by firearm missiles

Penetrating craniocerebral firearm injuries remain one of the most lethal causes of all trauma and are common both in war or peace time. Data were reviewed for 4140 severely head-injured patients (Glasgow Coma Scale (GCS) scores 3–8) treated at Xi-Jing Hospital between 1973 and 1993; 51 of these patients had acute penetrating craniocerebral injuries caused by firearm missiles. These patients consisted of 46 males (90.2%) and 5 females (9.8%) ranging in age from 3 months to 48 years (median 22.4 years). The lesion types included 2 tangential wounds, 37 tubular wounds and 12 through-and-through wounds. All cases were urgent with the patients in severe and unstable states. After emergency treatment and operation, 5 cases died (9.8%). Follow up studies at three months showed that 23 cases (45.1%) had made a good recovery. Moderate disability, severe disability and vegetative states in this series were 29.4%, 13.7% and 2.0% respectively. Long term follow up studies indicated that 32 were able to resume their occupation. The principles for managing penetrating craniocerebral firearm injuries and suggestions for operation are discussed.

Porometric measurements indicate wound severity and tuber maturity affect the early stages of wound-healing

We demonstrated that porometrically derived wound-healing profiles of whole tubers were greatly affected by the depth or severity of the wound. A rapid decrease in water vapor conductance was detected during the first 24 h of healing after mature, whole tubers were wounded by tangentially cutting into the cortex. The rapid decline in vapor conductance, indicating deposition of soluble waxes, was not concurrent with detectable deposition of polymeric phenolic or polymeric aliphatic components of the suberin polyester; instead these polymerized components were detected after vapor conductance decreased by approximately 80% and was nearly stable. The rate of decline of vapor conductance of wound-healing tubers was hormonally hastened with abscisic acid treatments. Although deeper tangential wounds (3.0 mm) had slower initial rates of wound-healing than did shallow wounds (0.75 mm) through tuber growth and maturation, the ability to wound-heal more rapidly increased as the tubers matured in the field. The vapor conductance of wound healing tubers declined in a log-linear fashion during the first 1 to 3 days after wounding depending upon tuber maturity and genotype.

Cranial tangential gunshot wounds

The effects of high velocity missiles are described. A series of cases of craniocerebral tangential gunshot wounds over a 6 year period is presented with unsuspected cerebral contusion shown by CT. Tangential wounds are defined and classified into four groups. The associated brain damage, often unsuspected prior to CT, and in some cases without radiographic changes, of the four groups is compared. The short- and long-term sequelae and the extent of cerebral damage belie the innocent appearance of the scalp wound. This influences the management of this unusual type of head injury.

Tangential wounds of the head.

TANGENTIAL head wound is that specific type of injury caused by a missile grazing the head. It is unique in that forces generated at the point of impact cause more damage than the course of the missile per se. Forms of tangential head wounds have been described by Cushing, 4-6 Ascroft, 1,~ Dodge, 9,1~ Lewin and Gibson, ~3 Descuns, et al., s Davidoff and Feiring, 7 Purvis, ~4 and Jacobs. 12 This paper describes the authors' experience with 18 such cases. All patients received their definitive treatment at the United States Army Neurosurgical Treatment Center of the Third Field Hospital, Saigon, Republic of Viet Nam, from November, 1965, through June, 1966.

High velocity bullet wounds of the thorax

High velocity bullets inflict large wounds consisting of permanent and temporary wound tracks. The temporary cavity, which is present for only a few thousanths of a second, may inflict great damage at a distance from the permanent wound track. This feature sets such wounds apart from other penetrating and perforating wounds. Surgeons should attempt to determine the ballistics characteristics of the missile which inflicted the wound since the probable extent of injury may be predicted and appropriate treatment applied. Low specific gravity, low water content, and high elastic fiber content act to limit lung wounds to a greater degree than that of any other tissue. Large arteries and veins are remarkably resistant to rupture, but capillaries are vulnerable. The latter susceptibility explains the widespread parenchymal changes adjacent to the permanent wound track. Myocardium and coronary arteries may be seriously injured by the explosive effect of the temporary cavity. It must be assumed that visceral injuries underlie tangential wounds and appropriate roentgenograms should be obtained. Muscle and rib wounds should be treated by debridement and delayed closure because of the hazard of virulent infection.

Processo di Riparazione di Ferite Tangenziali nel Fusto di Pero

Abstract Healing process in tangential wounds of pear trees. — The healing process of a small narrow wound, in one year old stems of pear trees cultivar «Butirra precoce Morettini» grafted on quince, has been anatomically observed. From the earliest stage of the process (artificial production of the wound) to the last one (complete healing) it has been shown that a real « restitutio ad integrum » can be reached, not through the formation of a characteristic callus, but through a well organized phellogenic and expecially cambial activity. The cambium, producing abundant secondary wood with more or less anomalous characters, stimulates the formation of a circular wound ridge. This originates from the margins of the wound and covers the wounded surface of the old wood, closing it up as a diaphragm. In the wounded wood, meanwhile, gums and tyloses are produced as a reaction to the wound. When the margins of the wounded ridge reach one another, the vascular cambium and the phellogen realise again their continu...

Repair of Glisson's capsule after tangential wounds of the liver

Repair of Glisson's capsule after tangential wounds of the liver

Intracranial hematomas associated with penetrating wounds of the brain.

HIS presentation is a study of a consecutive series of 316 penetrating wounds of the brain with particular reference to the occurrence of intracranial hematomas. The data were made available through the concerted effort of the Medical Officers who were for varying lengths of time associated with an Army Mobile Neurosurgical Unit in Korea3 This unit was attached to a Mobile Army Surgical Hospital, the most forward medical institution offering major surgical facilities. The period represented is from October 13, 1951 through October 31,195~. The report is composed entirely of cases in which operation was performed. By way of definition, any compound wound with entry into the cranial vault and laceration of the meninges, regardless of the severity or extent of cerebral destruction, is considered as a penetrating wound of the brain. This is intended as a broad classification, embracing the through-and-thro ugh wounds and other such descriptive terms as tangential wounds of the brain. The conventional and generally accepted terms are used in the classification of the hematomas. The subcortical or intracerebral hematomas in this series refer, in general, to hematomas of the missile canal resulting from laceration of vascular radicles in the path of the missile. When a hematoma was found to occupy the ventricular cavity, out of particular interest, this was classified as an intraventricular hematoma. Direct visualization of the hematoma was the criterion for this diagnosis and in all instances the penetration traversed the ventricular system. It should be stated that an effort was made to differentiate between a hematoma and a few small clots. It is admittedly difficult to conceive that a missile could penetrate the cerebral substance without provoking some small amount of hemorrhage. Of assistance was the impression gained at operation as to the actual degree of space occupancy. As a rule following sufficient exposure, the hematoma forcefully extruded from its confines. On the contrary, with avulsive wounds of the head and brain occasionally large hematomas were found; however, they were not confined and therefore were not considered as intracranial hematomas in this series. A confined hematoma in excess of ~0 cc. was felt to be of clinical significance and was used as a criterion for the diagnosis of hematoma.

Tangential wounds of scalp and skull.

Tangential wounds of scalp and skull.