Civilian maxillo-facial gunshot injuries

Utilization of Ophthalmic Management in Patients with Head-and-Neck Trauma Secondary to Firearms

Introduction

This retrospective cohort study presents the epidemiology of severe firearm-related ophthalmic injury and the level of ophthalmology involvement in the multidisciplinary management of head-and-neck gunshot injuries.

Methods

A retrospective study identified 207 patients with firearm-related injuries involving the head and neck treated at an Academic Tertiary Care Institution from 2010 to 2020.

Results

Ophthalmology consulted on 29% of patients with head-and-neck firearm injuries. At least one of the services managing facial trauma (plastic surgery and otolaryngology) consulted on 71.5% of cases (P < 0.001). Of patients evaluated by ophthalmology, 93.3% survived to discharge; 78.2% of patients who were not evaluated survived to discharge (P = 0.009). Ophthalmology consulted on all patients with open globe injury (10.6%) (P < 0.001), all of which were evaluated by the facial trauma service (P = 0.002), 77.3% by otolaryngology (P = 0.42), 50% by neurosurgery, 36.4% by plastic surgery, 13.6% by orthopedic surgery, and 4.5% by vascular surgery. Ophthalmology consulted on 76.5% of patients with orbital fracture (32.9%) (P < 0.001); 83.8% were evaluated by the facial trauma service (P = 0.006), 69.1% by otolaryngology (P = 0.014), 54.4% by neurosurgery, 27.9% by plastic surgery, 10.3% by orthopedic surgery, and 2.9% by vascular surgery. For patients with orbital fractures, 92.3% survived when ophthalmology was consulted (P = 0.698); 43.8% survived when not consulted (P = 0.001).

Conclusions

Firearm-related injuries of the head and neck frequently involve ocular and orbital structures, often causing serious vision-threatening injuries. Multispecialty management is common and early ophthalmology specialist evaluation and co-management are indicated to best identify ophthalmic injuries.

Efficacy of open reduction and internal fixation in achieving bony union of comminuted mandibular fractures caused by civilian gunshot injuries

INTRODUCTION

Comminuted fractures of the mandible caused by gunshot injuries were traditionally treated with closed reduction using maxillo-mandibular fixation (MMF).^2,3 Open reduction and internal fixation (ORIF) has become a valuable treatment modality in the management of comminuted mandibular fractures due to low rate of complications and predictable healing ^{4, 5}.

OBJECTIVE

To compare the efficacy of ORIF compared with MMF in achieving bony union of comminuted mandibular fractures in gunshot injury patients.

METHOD

ology: Randomized controlled trial conducted at the department of Oral & Maxillofacial Surgery, Abbasi Shaheed Hospital for a period of 3 years; total of 40 patients divided equally into two groups. Group A were treated with ORIF and group B were treated with MMF. Callus formation radiographically was confirmed by 8th week post operatively. Data was collected using proforma, entered on a statistical software SPSS version 20. Frequency percentages were computed for age and gender. Chi square and Fisher's exact tests were applied. P value ≤ 0.05 considered significant.

RESULT

A total of 40 patients of gunshot injuries were included in this study. 37 (92.5%) were males and 3 (7.5%) were Females with mean age of 36.35 ± 12.9 years SD. 19 (47.5%) patients showed callus formation, whereas, 21 (52.5%) did not. Out of 19 patients, 14 (70%) belonged to group A, and 5 (25%) from group B. The final healing considered by 8th week was in 16 (80%) of ORIF group A, and 8 (40%) group B (MMF) after calculating the clinical and radiographic evidences.

CONCLUSION

Comparative clinical trials have proven that ORIF is superior to MMF in the management of comminuted mandibular fractures. Early primary repair and internal fixation provides predictable and cost effective results.

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.

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.

Management of a mandibular fracture accompanying a gunshot wound

Gunshot injuries of the mandible can result in high rates of complications, especially in cases of bone loss. A fractured mandible accompanying a gunshot wound almost always has an external wound; the fracture is always compound and comminuted. Sometimes management of these injuries may require multiple surgical interventions. In this clinical report, treatment of a patient, who had a mandibular fracture due to a gunshot wound, is presented.A 52-year-old man with a mandibular fracture in the right mandibular body accompanying a gunshot wound was operated on. Owing to a nonunion, a second surgery was performed using reconstruction plates after hyperbaric oxygen treatment. Healing was uneventful after the second surgical intervention.

Early management of gunshot injuries to the face in civilian practice

BACKGROUND

Gunshot injuries to the face in civilian practice are rarely reported. Potential complications in the Emergency Department can have catastrophic consequences, and inappropriate operative management of the facial soft and skeletal tissues are related to outcome.

METHODS

A structured diagnostic and management approach is used in our Trauma Unit to deal with gunshot wounds to the face. A retrospective study of 55 patients who sustained gunshot injury to the face was conducted over a 6(1/2)-year period. Demographic details, mechanism of injury, and mode of presentation and management were recorded. Mortality and morbidity data were collated.

RESULTS

There were 51 male and 4 female patients. All injuries were caused by low-velocity gunshots, except for one that was a shotgun injury. Overall, 28 of the 55 patients (50%) underwent orotracheal intubation on scene or in the resuscitation room, and 2 had cricothyroidotomy. In addition to the maxillofacial trauma, associated injuries were common. Forty patients underwent operation for maxillofacial trauma, 34 on the day of admission and the remaining 6 within 5 days of injury. Multiple operations over a 2-week period were necessary for 18 of the 40 patients. Complications directly related to the gunshot injury to the face were very limited. Mortality was related to associated injuries.

CONCLUSIONS

Gunshot injury to the face in civilian violence is a "benign" condition as long as the Patient's airway is kept patent and hemorrhage is controlled. Early operative intervention for repair of the soft and skeletal facial structures leads to satisfactory results. Mortality directly related to the facial trauma is uncommon.

Surgical treatment of gunshot injuries to the mandible

OBJECTIVES

Our goal was to review and identify risk factors for complications from treatment of mandible fractures due to gunshot wounds. Study design and setting We conducted a retrospective review of treatment outcomes in 90 patients with gunshot wounds to the mandible treated over a 10-year period at 2 tertiary care centers.

RESULTS

Our series of 90 patients with mandibular injuries due to gunshot wounds included 68 patients who underwent surgical procedures on the mandible. There were 14 complications in this group. Complications were more common in patients whose mandibles were rigidly fixated; however, these patients' injuries were more severe. Complications were significantly increased in patients who lost a segment of mandible in the injury.

CONCLUSIONS

Complications were related to severity of injury and independent of treatment modality.

SIGNIFICANCE

The complication rate for patients with gunshot injuries can be very high, particularly if bone is missing. Stabilization of remaining mandibular segments with potentially multiple subsequent reconstructive procedures is often required to restore mandibular continuity in these patients.

Treatment considerations for comminuted mandibular fractures

PURPOSE

We sought to assess the methods of treatment used and outcomes for a large sample of patients with comminuted fractures of the mandible.

PATIENTS AND METHODS

The records of all patients who were identified as having comminuted fractures of the mandible over a 10-year period with sufficient follow-up were collected and analyzed for demographic information, treatment rendered, and outcomes. Standard descriptive statistics and nonparametric statistics were used to analyze the data.

RESULTS

A total of 196 patients (167 males and 29 females) with 198 comminuted fractures met the inclusion criteria. The mandibular body was the most commonly affected region. Approximately half were sustained in altercations. Gunshot wounds created fractures that were more comminuted than other causes. The comminuted regions were treated by closed reduction and maxillomandibular fixation (MMF) in 35 fractures, open reduction with stable internal fixation in 146 fractures, and 17 were treated with external pin fixation. For those patients treated with open reduction, a single reconstruction bone plate was used in the majority of cases (114). For those patients treated open, 98 were treated using an intraoral approach and 52 were treated using an extraoral approach. The mean follow-up was 140.6 days. Complications occurred in 26 fractures (13%). The complications were malocclusion in 8 fractures and nonocclusal (ie, infection, nonunion, etc) in 18 fractures. There was a statistically significant relationship between the development of complications and the degree of fragmentation (P <.05). There was also a significant relationship between treatment and the development of complications (P <.05). Patients treated with external pin fixation had a 35.2% complication rate compared with a 17.1% complication rate for patients undergoing closed treatment with MMF, or patients treated with open reduction and stable internal fixation (10.3%). However, patients treated with external pin fixation had more severe injuries.

CONCLUSIONS

The results of this study show that, when possible, the use of open reduction and stable internal fixation is associated with a low complication rate. However, not all comminuted fractures are amenable to this treatment, and in those, alternatives such as closed reduction with MMF or the application of external pin fixation may be necessary.

Estudo da emergência odontológica e traumatologia buco-maxilo-facial nas unidades de internação e de emergência dos hospitais do Município de São Paulo

INTRODUÇÃO: A odontologia atende, através de seus serviços de emergência odontológica e traumatologia buco-maxilo-facial, diversos casos dentro desse contexto e prescinde de conhecer melhor essa morbidade, uma vez que não existem estudos com abrangência populacional nessa área. Devido ao fato de a odontologia hospitalar atender casos com origem nas causas externas e também casos originados da falta de tratamento odontológico ambulatorial, a casuística encontrada é complexa. OBJETIVO: Estudar a morbidade observada através das consultas realizadas em unidades de internação e emergência, segundo sexo, idade, diagnóstico e causa externa da lesão. MÉTODO: Triaram-se as instituições que atendiam a emergência odontológica geral e a traumatologia buco-maxilo-facial, a partir das fontes de dados governamentais (SIH-SUS e SIA-SUS), tomando-se como base os meses ímpares dos anos de 1996 e 1997. Por meio de questionários, configurou-se a rede governamental para esses serviços. Para os vinte e um hospitais que atendiam esses casos elaborou-se uma amostra por conglomerado único, abrangendo 5% dos atendimentos de cada uma das instituições. RESULTADOS: Mais da metade (57%) dos atendimentos está ligada à emergência odontológica comum e 34% à traumatologia buco-maxilo-facial, área na qual aparece prioritariamente o adulto jovem do sexo masculino, configurando perfil semelhante ao encontrado na mortalidade por causas externas. CONCLUSÃO: Esta análise mostra que a sociedade observada ainda apresenta problemas odontológicos básicos, como a cárie e a doença periodontal, mas já indica o impacto das lesões com origem nas causas externas. No grupo Lesões, envenenamento e algumas outras conseqüências de causas externas evidencia-se a superioridade numérica dos casos para o sexo masculino e jovens. Verifica-se concentração maior de casos para diagnósticos mais graves, como as fraturas e ferimentos, do que para os traumatismos superficiais. Os ferimentos da cabeça e os traumatismos superficiais mostram uma distribuição, segundo sexo, mais eqüitativa do que no grupo de fraturas da face, que tendem a acometer mais o sexo masculino. A distribuição proporcional segundo as causas é semelhante em ambos os sexos, mas a mulher se expõe menos às lesões por causas externas.

Transcatheter arterial embolization for intractable epistaxis secondary to gunshot wounds

PURPOSE

To evaluate the efficacy of transcatheter arterial embolization for intractable epistaxis secondary to gunshot wounds.

MATERIALS AND METHODS

Seven patients with intractable epistaxis secondary to penetrating trauma (gunshot wounds) were studied with angiography and subsequently underwent embolization with particles (polyvinyl alcohol, gelatin sponge) and/or microcoils. Clinical follow-up included standard hemodynamic monitoring, serial hematocrit determinations, and clinical observation for recurrent bleeding.

RESULTS

Diagnostic angiography demonstrated evidence of acute arterial injury in all patients. All patients subsequently underwent embolization to complete angiographic stasis. Two patients had persistent bleeding following embolization. One of these patients required maintenance of his nasal packing for 7 days after embolization; no blood products were required during this time. The second patient's bleeding resolved following correction of his coagulopathy. No complications occurred in any of the patients.

CONCLUSIONS

Transcatheter arterial embolization for epistaxis secondary to gunshot wounds is efficacious in the acute setting when conservative management fails.

High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction

A 17-year experience from 1977 to 1993 with gunshot, shotgun, and high-energy avulsive facial injuries emphasizes the superiority and safety of "ballistic wound" surgical management: (1) immediate stabilization in anatomic position of existing bone, (2) primary closure of existing soft tissue, (3) periodic "second look" serial debridement procedures, and (4) definitive early reconstruction of soft-tissue and bony defects. The series contains 250 gunshot wounds, 53 close-range shotgun wounds, and 15 high-energy avulsive facial injuries. Four general patterns of involvement are noted for both gunshot and shotgun wounds and three for avulsive facial injuries. The treatment algorithm begins with identifying zones of injury and loss for both soft and hard tissue. Gunshot wounds are best classified by the location of the exit wound; shotgun and avulsive facial wounds are classified according to the zone of soft-tissue and bone loss. Treatment, prognosis, and complications vary according to four patterns of gunshot wounds and four patterns of shotgun wounds. Avulsive wounds have not been recommended previously for ballistic wound surgical management. The appropriate management of high-energy avulsive and ballistic facial injuries is best approached by an aggressive treatment program emphasizing initial primary repair of existing tissue, serial conservative debridement, and early definitive reconstruction.

Management of missile wounds of the maxillofacial region during the 20th century

Rapid evacuation from the scene of injury, the Advanced Trauma Life Support (ATLS) protocol and advancements in medical and surgical practice afford high standards of care for maxillofacial gunshot wounds (GSWs). This series of nine case reports illustrates both the changes that have occurred and the similarities that remain in the management of these wounds since the First World War. It serves as a reminder of the problems that may be faced managing maxillofacial injuries both in a future conventional war and also increasingly in the civilian population.

Rigid fixation of comminuted mandibular fractures

Treatment of comminuted mandibular fractures has traditionally involved closed reduction with external fixation in an effort to avoid stripping periosteum from the bony segments. The purpose of this study was to evaluate retrospectively the success rate of rigid fixation used to treat 16 consecutive comminuted fractures of the mandible in 15 patients. The comminuted fractures were as follows: symphysis and body, 10; angle, 3; and ramus, 3. In 13 cases, AO stainless steel reconstruction plates were applied, with a minimum of three 2.7-mm tapped bone screws in each of the two stable segments. In most cases additional screws were placed into the comminuted fragments to stabilize them. In two patients, the mandibular ramus was comminuted (one case bilaterally), which made it impossible to place a large plate. These fractures were stabilized with multiple titanium miniplates (2.0 mm, tapped). All patients' fractures healed to a bony union without bone grafting. The mean maximum incisal opening at longest follow-up was 40 mm (range, 20 to 50 mm). All patients had a satisfactory facial form and none required further surgery for facial recontouring or malocclusion. Complications were observed in three patients. Two patients (13%) developed infections. Both infections were caused by loose hardware and responded to removal of the hardware and did not require any other treatment. One mandible refractured during manipulation after coronoidectomy to treat mandibular hypomobility, a sequellae of a gunshot wound that traversed both mandibular rami. This fracture healed after plate removal and a course of maxillomandibular fixation without bone grafting. This study suggests that rigid fixation of comminuted mandibular fractures is a viable treatment that satisfies the necessity for reestablishment of form and function with minimal morbidity.

Retrospective analysis of low-velocity gunshot wounds to the mandible

A retrospective study was conducted of 32 patients with mandibular fractures resulting from low-velocity gunshot injuries. Airway management was required in 25% of the patients, and 9% sustained major vessel injury. Patients were divided into two groups, depending on site of mandibular fracture: condyle, ramus, and coronoid (n = 10), and angle, body, and symphysis (n = 22). All patients in the condyle, ramus, coronoid group achieved clinical union without infection. Average postinjury maximal mandibular opening was restricted (28 mm), but the average follow-up period was relatively short (2 months). In the angle, body, symphysis group the infection rate was 27%, and in 18% of patients a continuity defect of the mandible developed. The average length of follow-up in this group was 5.4 months with a mean maximal mandibular opening of 36 mm.