Characteristics of ballistic and blast injuries

Non-Medical Urethral Sounding: A review of literature and rare case of sounding with a live firearm round

Management of urethral sounding related injuries continues to be a challenge due to the wide breath of objects implicated, the rarity of cases, and chance of significant complication. We present a particularly challenging and novel case where a patient inserted a round of live ammunition into his urethra. Non-surgical removal was limited over concern for accidental discharge of the round, and the patient was taken to the operating room where open removal was performed. Psychiatric evaluation should be considered for cases where sounding injury requires surgical intervention, and a patient-centered, prevention-focused approach is best for building physician-patient rapport and adherence.

Delayed reconstruction of the combat-related mandibular defects with non-vascularized iliac crest grafts: Defining the optimal conditions for a positive outcome in the retrospective study

BACKGROUND

Reconstruction of mandibular defects caused by combat injuries is challenging for clinicians due to soft tissue defects and high complication risk. This study evaluated the outcomes of mandibular continuous defects reconstruction with non-vascularized iliac crest graft (NVICG) in patients with combat injuries.

MATERIAL AND METHODS

Patients with continuous mandibular defects acquired by high-velocity agents, who received NVICG reconstruction with or without microvascular-free soft tissue or regional flaps, were included in the study. The outcome variable was graft loss due to postoperative complications or full (more than 90 %) resorption. The primary predictor variable was soft tissue defect in the recipient area. The secondary predictor variable was the length of the defect. Variables related to patients, defect site, surgery, and other complications were also evaluated. Statistical analysis was performed with the usage of independent sample t-test, Pearson's chi-squared and Fisher's exact tests with a significance level of P < 0.05 RESULTS: The study included 24 patients with 27 mandibular defects. Overall, the general success rate of reconstructions was 59.3 %. Soft tissue defects were significantly associated with graft failure and other complications (p < 0.05), which were mostly related to soft tissue defects. The graft success rate was only 14.3 % even in minor soft tissue defects. In turn, in reconstructions with sufficient soft tissue coverage, the graft survived in 75.0 % of the cases. In addition, patients with more delayed reconstruction had significantly fewer graft failures than those with earlier surgery (p < 0.05). No associations were found between defect size and complications.

CONCLUSION

The sufficient soft tissue coverage is essential in the reconstruction of mandibular defects caused by combat injuries. Also, minor soft tissue defects should be covered with soft tissue flaps to avoid complications and graft loss in these specific injuries. Even large defects can be reconstructed with NIVICG if the soft tissue coverage is sufficient.

Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted?

Study Design

This was a retrospective cohort study of the 2014 Nationwide Emergency Department Sample (NEDS).

Objective

Intraoral and submental projectile entry points may be less fatal than other facial entry points due to the indirect access to the intracranial structures and the protection offered by the intervening maxillofacial complex. Because intraoral and submental trajectories are almost always present in the setting of attempted suicide, this study sought to determine if intent (self-harm versus other-harm) influenced mortality in facial gunshot wound (GSW) patients.

Methods

All patients with a diagnosis of a facial fracture secondary to firearm injury were included in the study sample. The primary predictor was self-harm. Secondary predictors were derived from patient, injury, and hospitalization characteristics. The study outcome was death. Univariate time to event analyses were conducted for all study predictors. A multivariate regression model for mortality was created using all relevant predictors.

Results

The final sample included 668 facial GSW injuries, of which 19.3% were attributed to self-harm. Self-inflicted GSWs were more likely to involve the mandible (58.9 vs 46.0%, P < 0.01), ZMC/maxilla (47.3 vs 32.5%, P < 0.01), and intracranial cavity (48.1 vs 22.6%, P < 0.01). The overall mortality rate was 7.3%, and the mean time to death was 2.2 days. After controlling for pertinent covariates, the risk of mortality was independently decreased with mandibular injury (HR = 0.36, P = 0.03). However, mortality was increased by self-harm intent (HR = 3.94, P < 0.01) and intracranial involvement (HR = 11.24, P < 0.01).

Conclusions

Consistent with a pattern of intraoral and submental entry points, self-inflicted facial GSWs demonstrated higher rates of mandibular injury. Despite this finding, self-harm injuries still carried a higher incidence of intracranial injury and a greater independent risk of mortality. Our results refute any notion that the mechanism and trajectory of self-inflicted GSWs is less fatal.

Low-velocity, civilian firearm extremity injuries-review and update for radiologists

Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.

CT of Penetrating Abdominopelvic Trauma

Penetrating abdominopelvic trauma usually results from abdominal cavity violation from a firearm injury or a stab wound and is a leading cause of morbidity and mortality from traumatic injuries. Penetrating trauma can have subtle or complex imaging findings, posing a diagnostic challenge for radiologists. Contrast-enhanced CT is the modality of choice for evaluating penetrating injuries, with good sensitivity and specificity for solid-organ and hollow viscus injuries. Familiarity with the projectile kinetics of penetrating injuries is an important skill set for radiologists and aids in the diagnosis of both overt and subtle injuries. CT trajectography is a useful tool in CT interpretation that allows the identification of subtle injuries from the transfer of kinetic injury from the projectile to surrounding tissue. In CT trajectography, after the entry and exit wounds are delineated, the two points can be connected by placing cross-cursors and swiveling the cut planes obliquely in orthogonal planes to obtain a double-oblique orientation to visualize the wound track in profile. The path of the projectile and its ensuing damage is not always straight, and the imaging characteristics of free fluid of different attenuation in the abdomen (including hemoperitoneum) can support the diagnosis of visceral and vascular injuries. In addition, CT is increasingly used for evaluation of patients after damage control surgery and helps guide the management of injuries that were overlooked at surgery. An invited commentary by Paes and Munera is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Current opinion in the assessment and management of ballistic trauma to the craniomaxillofacial region

PURPOSE OF REVIEW

Ballistic trauma represents a small proportion of injuries to the craniomaxillofacial (CMF) region, even in societies where the availability of firearms is more prevalent. The aim of this article is to review current opinion in the assessment and management of ballistic injuries sequentially from primary survey to definitive reconstruction.

RECENT FINDINGS

For mandibular fractures because of ballistic trauma, load-bearing fixation remains the mainstay in the treatment. The use of load sharing fixation is rarely advised, even if the fracture pattern radiologically appears to fulfil the traditional indications for its use. Clinicians must be aware of specific situations in early internal fixation is contraindicated, particularly in those unstable patients requiring short damage control surgical procedures, avulsive soft and hard tissue defects and those injuries at increased risk of infection.

SUMMARY

Staged surgery for complex injuries is increasingly becoming accepted, by which injuries are temporarily stabilized by means of maxillary--mandibular fixation (MMF) or an external fixation. Patients are subsequently repeat CT-scanned, and definitive internal fixation performed a few days later. Increased access to virtual surgical planning (VSP) and three-dimensional plates has revolutionized fracture reconstruction.

[Ballistic trauma of the face: A new scourge in Tunisia]

INTRODUCTION

Ballistic trauma of the face has aroused growing interest since the proliferation of conflicts in the world and particularly in the fight against terrorism. Their polymorphous and disfiguring character, their particular evolution and prognosis due to the ballistic aetiology, differentiate them from classic maxillofacial trauma. Tunisia did not escape this scourge after the revolution of 2011, and must therefore face the challenge of ballistic trauma in general and of the face in particular.

MATERIALS AND METHODS

We conducted a descriptive retrospective study on 30 patients who were victims of ballistic trauma of the face in the otolaryngology and maxillofacial surgery and ophthalmology departments of the Main Military Hospital of Tunis during the period from January 2011 to April 2018. Our objective was to assess the prevalence of these traumas in Tunisia after the revolution, and to assess their clinical and therapeutic aspects.

RESULTS

Our results showed a clear upward trend in these traumas, mainly caused by the opposition of our armed forces to the terrorist threat. The discussion of our results was therefore descriptive, comparing them to the literature.

CONCLUSION

Currently, it is imperative to develop a strategy for precise and effective management of ballistic trauma of the face due to the increase of armed conflicts, attacks and terrorist acts. Likewise, technological advances to develop soldier protection systems must be implemented.

The impact of delayed surgical intervention following high velocity maxillofacial injuries

Our study compares the number of postoperative complications of Syrian patients admitted to the Galilee Medical Center (GMC) over a 5-year period (May 2013-May 2018) for treatment after initial high-velocity maxillofacial injuries sustained during the Syrian civil war. Specifically, we evaluated complication rates of patients arriving "early," within 24 h, to the GMC versus those who arrived "late," or 14-28 days following high-velocity maxillofacial injuries. Both groups of patients received definitive surgical treatment within 48 h of admission to our hospital with a total of 60 patients included in this study. The mean age was 26 ± 8 years (range: 9-50) and all except one were male. Postoperative complications in the early group were found to be significantly higher compared to the delayed arrival group (p = 0.006). We found that unintentionally delayed treatment may have contributed to a critical revascularization period resulting in improved healing and decreased postoperative morbidity and complications. We discuss potential mechanisms for complication rate variations, including critical vascularization periods. Our study may add to a growing body of work demonstrating the potential benefit of delayed surgical treatment for high-velocity maxillofacial injuries.

The Impact of Blast Implosions and Bullet Injury on Maxillary Air Sinus

BACKGROUND

Successive waves and generations of terrorists attacked the Iraqis in the years following the fall of the regime in Iraq in 2003, after the US invasion of the country under the pretext of weapons of mass destruction. Hence, the Iraqi people enrolled in ongoing war with these armed groups which led to massive casualties due to blasts and missile injuries.Mechanism of blasts injury can be classified into primary, secondary, tertiary, and quaternary. While bullet injuries can be classified into low and high-energy injuries, the type and severity of the injury will influence the type of management, together with facilities available in the authors' hospitals.In this study the authors aim to compare between the effects of blast implosions and penetrating missiles on the maxillofacial air containing cavities, specifically the maxillary sinuses.

PATIENTS AND METHODS

Twenty-eight patients (26 male patients [92.85%] and 2 [7.14%] female patients) with maxillary sinus wall fractures were admitted to the authors' maxillofacial surgery Department in the Hospital of specialized surgeries/Baghdad Medical city from July 2014 to November 2016.

RESULTS

Seventy-six percent of the total bullet injuries affect the left side of the face, while shell injuries tend to affect the right side of the face by 60% than the left side.Direct maxillary sinus injuries constitute 76.9% of the injuries caused by bullets, while it constitutes only 40% of shell injuries.

CONCLUSION

Bullet injuries are associated with more severe comminuted fractures in addition to involvement of multiple neighboring bones and this may lead to extensive bone loss, while postoperative complications and infection are more common with improvised explosive devices injuries.

Cranial Vault Defects and Deformities Resulting from Combat-Related Gunshot, Blast and Splinter Injuries: How Best to Deal with Them

Combat-related gunshot and blast injuries of the craniomaxillofacial region present a unique and challenging situation for the maxillofacial and reconstructive surgeon. The devastating cosmetic deformities and severe functional debility ensuing as a result of extensive hard and soft tissue disruption caused by these highly complex injuries, can have disastrous consequences, unless managed in a swift and efficient manner, by a multidisciplinary team approach. Large calvarial defects and deformities are frequent sequelae of these injuries and could result from shattering of the cranial vault by the force of an exploding shell, mine or improvised explosive device, or due to penetration of the skull by the projectile, such as a bullet, flying splinters or shrapnel. It could also result from the decompressive craniectomy carried out in these patients as a neurosurgical procedure to deal with the traumatic brain injury sustained. Management of such injuries is significantly different from that of other craniomaxillofacial injuries, owing to the quantum and severity of hard and soft tissue destruction encountered in the former and also the need to deal with aspects such as splinters from the projectile deeply embedded within vital structures such as the delicate brain tissue and meninges. Further, restoration of the lost structural and functional integrity of the cranial vault using the most suitable cranioplasty material, is imperative to provide protection to the vulnerable and vital cranial contents. Correction of the cranial deformity is also essential from an esthetic and psychosocial standpoint, to restore the morale of the patient. The present study elaborates the immediate/primary management as well as the secondary/definitive management of blast and ballistic head injury patients. Comprehensive treatment and rehabilitation of these patients, including reconstruction of extensive calvarial defects and deformities, resulting either directly or indirectly from combat injuries, have been described in detail. This study also aims to analyze, review and reassess the currently accepted management perspectives and treatment protocols of combat-related cranial injuries and proposes a useful algorithm to best manage them.

Defining animal welfare standards in hunting: body mass determines thresholds for incapacitation time and flight distance

Shooting is an important tool for managing terrestrial wildlife populations worldwide. To date, however, there has been few quantitative methods available enabling assessment of the animal welfare outcomes of rifle hunting. We apply a variety of factors to model flight distance (distance travelled by an animal after bullet impact) and incapacitation from the moment of bullet impact. These factors include body mass, allometric and isometric scaling, comparative physiology, wound ballistics and linear kinematics. This approach provides for the first time a method for quantifying and grading the quality of shooting processes by examining only body mass and flight distance. Our model is a universally applicable tool for measuring animal welfare outcomes of shooting regimes both within and among species. For management agencies the model should be a practical tool for monitoring and evaluating animal welfare outcomes regarding shooting of mammalian populations.

Current concepts in penetrating and blast injury to the central nervous system

Aim

To review the current management, prognostic factors and outcomes of penetrating and blast injuries to the central nervous system and highlight the differences between gunshot wound, blast injury and stabbing.

Methods

A review of the current literature was performed.

Results

Of patients with craniocerebral GSW, 66–90 % die before reaching hospital. Of those who are admitted to hospital, up to 51 % survive. The patient age, GCS, pupil size and reaction, ballistics and CT features are important factors in the decision to operate and in prognostication. Blast injury to the brain is a component of multisystem polytrauma and has become a common injury encountered in war zones and following urban terrorist events. GSW to the spine account for 13–17 % of all gunshot injuries.

Conclusions

Urgent resuscitation, correction of coagulopathy and early surgery with wide cranial decompression may improve the outcome in selected patients with severe craniocerebral GSW. More limited surgery is undertaken for focal brain injury due to GSW. A non-operative approach may be taken if the clinical status is very poor (GCS 3, fixed dilated pupils) or GCS 4–5 with adverse CT findings or where there is a high likelihood of death or poor outcome. Civilian spinal GSWs are usually stable neurologically and biomechanically and do not require exploration. The indications for exploration are as follows: (1) compressive lesions with partial spinal cord or cauda equina injury, (2) mechanical instability and (3) complications. The principles of management of blast injury to the head and spine are the same as for GSW. Multidisciplinary specialist management is required for these complex injuries.

Late treatment of a mandibular gunshot wound

Mandibular gunshot injuries are esthetically and functionally devastating, causing comminuted fractures and adjacent tissue destruction depending on the weapon gauge, projectile shape, impact kinetic energy, and density of the injured structures. If the mandibular fracture is not adequate or promptly treated, the broken fragments will fail to heal. In case of a treatment delay, progressive bone loss and fracture contracture will require a customized approach, which includes open reduction, removal of fibrous tissue between the bony stumps, and fixation of the fracture with a reconstruction plate and autogenous graft. The authors report the case of a 34-year-old man wounded on the mandible 15 years ago. With the aid of computed tomography and a prototype, a surgical plan was designed including open reduction and internal fixation of the segmental mandibular defect with a reconstruction plate and bone graft harvested from the iliac crest. The postoperative follow-up was uneventful and the 12-month follow up showed a positive aesthetic and functional result.

Firearms, bullets, and wound ballistics: an imaging primer

Based on its intrinsic mass and velocity, a bullet has an upper limit of wounding potential. Actual wound severity is a function of the bullet construction and trajectory, as well as the properties of the tissues traversed. Interpreting physicians must evaluate the bullet trajectory and describe patterns of injury resulting from the effect of energy transfer from the projectile into living tissue. A basic understanding of firearms, projectiles, and wound ballistics can help the interpreting physicians in conceptualizing these injuries and interpreting these cases.

Wound ballistics of firearm-related injuries--part 1: missile characteristics and mechanisms of soft tissue wounding

Firearm-related injuries are caused by a wide variety of weapons and projectiles. The kinetic energy of the penetrating projectile defines its ability to disrupt and displace tissue, whereas the actual tissue damage is determined by the mode of energy release during the projectile-tissue interaction and the particular characteristics of the tissues and organs involved. Certain projectile factors, namely shape, construction, and stability, greatly influence the rate of energy transfer to the tissues along the wound track. Two zones of tissue damage can be identified, the permanent cavity created by the passage of the bullet and a potential area of contused tissue surrounding it, produced mainly by temporary cavitation which is a manifestation of effective high-energy transfer to tissue. Due to the complex nature of these injuries, wound assessment and the type and extent of treatment required should be based on an understanding of the various mechanisms contributing to tissue damage.