Jenis Luka (Vulnus)

01Foundational Concepts: How Wounds Are Classified

Before diving into each type, understand that the exam tests you on three overlapping classification systems simultaneously. You must be able to navigate between them.

The first system is classification by causative mechanism, which is the most commonly tested. Every wound type has a Latin name and is defined by what kind of force produced it. The mechanism directly determines the wound's morphology: edge characteristics, depth pattern, tissue bridging, and bleeding behavior. A test question will describe wound morphology and expect you to work backward to the mechanism.

The second system is classification by wound depth. This separates wounds into superficial (involving only epidermis), partial-thickness (involving dermis), and full-thickness (penetrating through skin into subcutaneous tissue, fascia, muscle, or deeper). Depth determines management: superficial wounds can often heal without closure, while full-thickness wounds need formal surgical repair.

The third system, which is uniquely important for the Indonesian exam, is classification by medicolegal severity (derajat luka). This system does not care about wound morphology. Instead, it asks: what was the functional impact on the victim? This classification is anchored to the Indonesian Criminal Code (KUHP) and directly affects the criminal charge brought against the perpetrator. A wound that looks gruesome may still be classified as mild if it does not impair function, while a "clean" wound that severs a tendon and causes permanent disability is classified as severe.

02Classification by Mechanism (Types of Vulnus)

This is the most heavily tested section. The table below is your primary reference, followed by detailed explanations.

03Detailed Characteristics of Each Wound Type

Vulnus Excoriatum (Abrasion). This is the most superficial form of open wound. The mechanism involves tangential friction that shears off the epidermis and exposes the papillary dermis. The exposed dermis appears moist and reddish with pinpoint bleeding or serous oozing. On exam, the critical concept is directionality: the pattern of abraded skin tags (rolled-up epidermal flaps) points toward the direction of the applied force. In forensic medicine, abrasions are classified into scratch abrasions (caused by a pointed object like a fingernail), graze abrasions (caused by broad friction like dragging on pavement), pressure abrasions (caused by sustained pressure, e.g., ligature marks on the neck in strangulation), and impact abrasions (caused by perpendicular impact of a rough surface). The patterned abrasion is forensically valuable because it may reproduce the surface pattern of the causative object (e.g., tire tread marks, rope marks).

Vulnus Contusio (Bruise/Contusion). This is a closed wound in which blunt force ruptures small blood vessels in the subcutaneous tissue and dermis without breaking the skin surface. The extravasated blood produces discoloration. The testable concept here is color evolution over time, which helps forensic physicians estimate wound age: fresh bruises appear red-blue (0-2 days), then turn blue-purple (2-5 days), then green (5-7 days), then yellow (7-10 days), and finally brown before fading (10-14+ days). However, modern forensic consensus acknowledges that this timeline is approximate and can be unreliable, especially in older individuals or those on anticoagulants. On the exam, remember that the location of a bruise does not always correspond to the site of impact because blood can track along tissue planes (e.g., periorbital ecchymosis from a basilar skull fracture, "raccoon eyes"). Deep organ contusions (brain, liver, spleen) can occur with intact overlying skin.

Vulnus Laceratum (Laceration). This is the wound type that students most often confuse with incised wounds, and this confusion is a classic exam trap. Lacerations are caused by blunt force that stretches and tears the skin beyond its elastic limit. The key identifying features are: irregular, ragged wound edges; intact tissue bridges (blood vessels, nerves, and connective tissue strands stretching across the wound gap, because blunt force tears tissue unevenly); bruised or crushed wound margins; and variable depth. Tissue bridging is the single most important differentiator between a laceration and an incised wound. In an incised wound, all structures are cleanly divided; in a laceration, stronger structures survive while weaker tissues tear. Lacerations bleed less than incised wounds of comparable size because the vessel walls are crushed and torn irregularly, promoting clot formation. Lacerations heal by secondary intention and carry a higher infection risk due to the crushed, devitalized tissue margins.

Vulnus Incisivum / Scissum (Incised Wound). A sharp-edged object drawn across the skin produces this wound. The hallmark is clean, well-defined, regular wound edges with no tissue bridging, no bruising of the margins, and sharp-angled wound tails. The wound is typically longer on the surface than it is deep. Bleeding tends to be profuse because the blood vessels are cleanly transected and cannot retract or clot as easily as crushed vessels. When evaluating a vignette, look for these phrases: "smooth edges," "clean-cut margins," "no irregularity," and "gaping wound." A defense wound on the palm or fingers of the victim's hand is a classic exam scenario. Incised wounds are associated with sharp force violence (kekerasan tajam) in medicolegal documentation.

Vulnus Punctum / Ictum (Stab/Puncture Wound). This wound is caused by a sharp, pointed object thrust perpendicular or obliquely into the tissue. The critical distinguishing feature is that depth exceeds surface length. The entry wound on the skin surface may appear deceptively small while the wound track extends deep into body cavities or organs. This is what makes stab wounds dangerous and why the exam calls them "iceberg wounds." Evaluate the wound shape to determine the weapon: a single-edged blade produces a wound with one sharp angle and one blunt (fish-tail) angle, while a double-edged blade produces a wound with two sharp angles. The wound may show a clean edge on one side and a slightly irregular edge on the other if the blade was single-edged. Always consider internal organ injury disproportionate to the skin wound.

Vulnus Caesum (Chop Wound). This is produced by a heavy object with a sharp edge (machete, cleaver, axe) that is swung with force. It combines features of both sharp and blunt force injury. The wound edges may be relatively clean near the entry point (sharp force component), but there will be underlying bone fractures or fragmentation (blunt force component) with significant crush injury to deeper tissues. Chop wounds are commonly tested in the context of distinguishing from pure incised wounds: the presence of bone damage and the weight-driven mechanism are the discriminators.

Vulnus Sclopetarium (Gunshot Wound). Firearm injuries are classified by range (contact, near-contact, intermediate, distant) and by wound type (entry, exit). The entry wound typically has an abrasion collar (marginal abrasion ring), is smaller and more regular, and may show soot, powder stippling (tattooing), or muzzle imprint depending on range. The exit wound is typically larger, more irregular (stellate), and has no abrasion collar, no soot, and no powder burns. The distinction between entry and exit is one of the most testable concepts in forensic wound assessment. At contact range, the entry wound may be stellate (star-shaped) due to expanding gases tearing the skin from beneath, and soot is deposited inside the wound track. At intermediate range, there is powder stippling (punctate abrasions from unburned gunpowder particles) around the entry wound but no soot.

Vulnus Morsum (Bite Wound). Bite wounds are produced by teeth and may come from human or animal sources. They appear as a paired, semicircular (arch-shaped) pattern of contusions or lacerations reflecting the dental arch. Human bite wounds carry a very high infection risk, particularly for Eikenella corrodens and mixed anaerobic flora. Animal bites, especially from dogs and cats, raise concerns for rabies and Pasteurella multocida infection. Cat bites tend to be deeper (puncture-type) with a higher rate of infection compared to dog bites. On the exam, if you see a bite wound question, think: tetanus prophylaxis, rabies prophylaxis (for animal bites), antibiotics, and wound irrigation.

Vulnus Combustio (Burn Wound). Burns are classified by depth and by body surface area (BSA). First-degree burns involve only the epidermis (pain, erythema, no blisters). Second-degree burns extend into the dermis and are subdivided into superficial partial-thickness (painful, blisters, moist base) and deep partial-thickness (less painful, white/mottled base). Third-degree burns destroy the full thickness of the skin (painless due to nerve destruction, leathery eschar, waxy white/charred). Fourth-degree burns extend into underlying fascia, muscle, or bone. The Rule of Nines is used to estimate BSA involvement in adults (head 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%). In children, the Lund-Browder chart is preferred due to different body proportions. For burn wound management, the Parkland formula ($4mL\times kg\times \mathrm{\%}BSA4\backslash \; mL\; \backslash times\; kg\; \backslash times\; \backslash \%BSA$) calculates crystalloid fluid resuscitation in the first 24 hours, with half given in the first 8 hours and the remainder over the next 16 hours.

04Medicolegal Wound Classification (Derajat Luka) Under Indonesian Law

This section is tested under forensic medicine and is critical for the Indonesian licensing exam. The wound degree classification is based on the Indonesian Criminal Code (KUHP, Kitab Undang-Undang Hukum Pidana) and determines the criminal charge and sentencing.

Criteria for Severe Injury (Luka Berat) under KUHP Pasal 90:

A wound is classified as severe if it results in any one of the following:

1. Illness or injury with no hope of complete recovery, or that poses a danger of death (bahaya maut)

2. Permanent inability to carry out one's job, position, or livelihood

3. Loss of one of the five senses (pancaindra)

4. Severe/permanent disability (cacat berat / verminking)

5. Paralysis (sakit lumpuh)

6. Disturbance of cognitive function (daya pikir) for more than four weeks

7. Miscarriage or death of the fetus (gugur/matinya kandungan)

Note: The new KUHP (UU No. 1/2023, Pasal 155) adds an eighth criterion: damage to reproductive function (rusaknya fungsi reproduksi).

The physician's role is to describe the wound objectively in the Visum et Repertum (VeR) and state the functional impact using phrasing that maps to these legal categories. The physician does not state "this is a mild/moderate/severe wound" directly. Instead, the conclusion of the VeR uses formulaic language, for example: "this injury does not cause illness or inability to perform occupation" (for mild) or "this injury causes an illness that results in temporary inability to perform occupation" (for moderate).

05Wound Healing and Closure

Understanding wound closure intention is tested both in surgery and in forensic medicine (because healing patterns help estimate wound age).

Phases of wound healing follow the same sequence regardless of intention: hemostasis (immediate, platelet plug and fibrin clot), inflammation (0-5 days, neutrophils and macrophages clear debris), proliferation (5 days to 3 weeks, fibroblasts deposit collagen, angiogenesis, granulation tissue formation, wound contraction by myofibroblasts), and remodeling (3 weeks to 1-2 years, type III collagen replaced by type I collagen, scar maturation). The maximum tensile strength a healed wound reaches is approximately 80% of the original skin strength. This is a commonly tested number.

06Differential Diagnosis and Distractors: Laceration vs. Incised Wound

This single distinction accounts for a disproportionate number of wrong answers. The table below is your safety net.

Other high-yield differentials:

07Traps and High-Yield Pearls

The number one trap with vulnus questions is the laceration vs. incised wound confusion. Students see "cut" or "gaping wound" in the vignette and jump to "incised wound," but the question will describe ragged edges with intact vessels crossing the wound gap. Any mention of tissue bridges immediately rules out sharp force and confirms blunt force laceration. This is the single highest-yield concept in wound classification.

The second trap involves medicolegal wound grading. Students often grade wounds based on how they look rather than on functional impact. A large, ugly abrasion covering half the forearm is still a mild wound (luka ringan) under KUHP Pasal 352 if it does not cause illness or occupational impairment. Meanwhile, a small stab wound to the hand that severs the median nerve and permanently disables fine motor function is a severe wound (luka berat) under Pasal 90.

The third trap is gunshot wound directionality. Students mix up entry and exit features. Remember: the abrasion collar (marginal abrasion) is present at the entry wound only; the exit wound is larger and irregular with everted edges. Soot and powder stippling are found only around the entry wound and their presence or absence determines the range of fire.

Fourth, for burn wounds, students confuse the pain pattern. Third-degree burns are painless because nerve endings are destroyed. A vignette describing a painless, leathery, insensate wound is a full-thickness burn, not a less severe injury. Paradoxically, the "less painful" burn is the more severe one.

Finally, for the VeR conclusion, remember that the physician's job is to describe, not to adjudicate. The physician does not write "this is a severe wound" (the court decides the legal category). The physician writes the medical description using standardized phrasing that allows the investigator and judge to map it to the correct KUHP article. This is a procedural detail that is tested repeatedly.

The core competency being tested across all vulnus questions is: can you reverse-engineer the mechanism from the wound morphology, classify the wound correctly, describe it in medicolegal terms, and determine the appropriate clinical management?