Emergency treatment strategy and the biodynamic effects of massive, “chopped off”, mandibular tissue and a prolapsed tongue

Evidence-Based Medicine for Ballistic Maxillofacial Trauma

Ballistic trauma is a serious health issue with significant costs to physical, psychosocial, economic, and societal well-being. It may be caused from firearms, explosive devices, or any other projectile forces, and is characterized by severe tissue loss and evolving tissue devitalization. This review covers mechanism, diagnosis, and management of ballistic maxillofacial trauma, specifically. Initial evaluation includes stabilization of airway, bleeding, and circulation, followed by assessment of other injuries. The overall degree of tissue damage is determined by intrinsic patient factors and extrinsic projectile factors. Management of ballistic injuries has shifted toward advocation for early operative repair with the advent of antibiotics and advanced techniques in maxillofacial reconstruction. Appropriate timing and method of reconstruction should be carefully selected on a case-by-case basis. While ballistic trauma research is limited to studies biased by institutional practices, areas for further study identified from current literature include guidelines directing timing of reconstructive surgery; thresholds for free tissue transfer; handling of retained projectiles; incidence of surgical complications; and clinical outcomes for computer-aided surgical repair of these highly destructive injuries.

Use of Kirschner wire for immediate interim reconstruction of continuity defect of mandible in resource poor setting: Our experience

Background

Reconstruction of continuity defect of mandible is challenging, and there has been a lot of advancement in this field with variety of options for restoration. However, choice often becomes restricted in resource limited settings due to lack of trained manpower, time, infrastructure, supply of graft materials, etc. In this context, we aim to test the reliability of Kirschner wire (K-wire) with adaptation of looped-end for immediate interim reconstruction of continuity defect of mandible.

Methods

Retrospectively, medical records of 10 years data were reviewed to include 22 patients who underwent immediate interim reconstruction of mandible with K-wire with looped-end adaptation for continuity defect of mandible. Data regarding patient demographic, type and length of mandibular defect, diameter of the wire and complications were recorded.

Result

Among 22 patients within a follow-up period of 1-60 months (median 7.5), complications developed in 7 (31.8%) patients. Three patients (13.6%) had major complications which required interventions, and 5 patients (22.3%) with minor complications were managed conservatively. Total wire removal in our study is only 9%, which is lowest among the reported literature, migration or extrusion through bone was nil, and overall aesthetic and functional result was good in majority except few where either wire had to be removed or got deformed.

Conclusion

Kirschner wire (K-wire) should be considered in resource limited setting as an immediate interim reconstructive method of mandible for being cheap and widely available. Our technique of looped-end adaptation results in better stabilisation leading to less removal rate, migration or extrusion.

Emergency Management of High-Energy Shell Fragment Midface Complex Injuries

Distinctive mechanisms of heavy artillery and improvised explosive device detonation result in a blast and "spray" of high-energy fragments of diverse shapes, sizes, and characteristics. Associated midface complex injuries differ in both severity and complexity of the anatomical structures involved. Management challenges begin with lifesaving, which is complicated by airway compromise, severe hemorrhage, and unique injuries of the maxillae, nose, and naso-orbitoethmoid.The patients presented fragment impact on the face lateral side directed to other side leads to tissues blown away at the point of high-energy exits, while no survival seen of enface shrapnel hit directed antroposterior toward "cervical spine, intracranial, internal and external carotid arteries and internal jugular vein."Twenty-two patients were selected from unquantified patients who had sustained massive midface shell fragment injuries. To preserve midface architecture, healing, and function, iodoform paste on ribbon gauze packs were utilized successfully. An iodoform paste on ribbon gauze pack serves the dual purpose of preserving the shape and scaffolding of the crushed maxillary sinus wall and buttresses fragments in position for healing. It also acts as a wet pack dressing for denuded bone fragments, stopping bleeding and having antimicrobial properties for severely lacerated wounds. For total or partial nasal tissue loss, a successful procedure consists of definitive early scaffolding stabilization using an intranasal, modified portex tracheostomy tube stent to preserve the internal shape of the nasal pyramid.

Transverse Fracture of the Mandible: Report of a Rare Case of Domestic Violence and its Management

Domestic violence, a grave violation of basic human rights, remains one of the most challenging problems of our society. Though commonly involving the facial region, these injuries are difficult to characterize and treat due to varied and unique presentations. Cases of violent weapon injuries can often be a challenge for the treating surgeon due to nonbiomechanical pattern of the presentation. The purpose of this report is to discuss the presentation and management of a brutal case of domestic violence with a rare “chop” injury pattern caused by an “axe.” Only two previous reports of sharp weapon injury resulting in horizontal fracture of mandible have been found in literature, of which only one was caused by an axe. The important social issue of significance of health care personnel, who are in a unique position and can contribute toward raising the awareness to the plight of silent sufferers of domestic violence for whom home is often the most dangerous place, is also raised.

Interrami intraoral fixation technique for severe mandibular rifle fragmented bullet injury management

Interrami intraoral Kirschner wire fixation technique is presented for the reduction, stabilization, and immobilization of a pulverized and avulsed lower jaw caused by rifle fragmented bullet injuries. This indirect mandibular war injury fixation technique was tolerated by the patients and tissue more than any indirect external fixation. In addition, it is easier than open reduction using large bone plates for disrupted ballistics mandibular injury defects. An interrami intraoral fixation is appropriate for severely disrupted mandibular hard and soft tissues, and has been adapted in cases of mass casualties and limited resources. Benefits of use include limited hospital beds and fewer follow-up visits. Rifle fragmented bullet injuries need more attention for several reasons: not only because of the higher mortality and devastating nature of the injuries, but also because these injuries are responsible for an unreported type of bullet biomechanism wounding in the craniofacial region. In turn, this necessitates specialized victim management. The survival rates depend on immediate proper execution of airway, breathing, and circulation, which become more complicated as it relates to airway compromise and oropharyngeal hemorrhage resuscitation. Survival is predicated on the implementation of feasible, sensible, life-saving techniques that are applied at the appropriate time.