Facial gunshot wounds: a 4-year experience

The Different Surgical Approaches to Maxillofacial Reconstruction after Ballistic Trauma

Background

Ballistic trauma to the face is a challenge, combining complex bone injury with severe soft tissue loss. The various surgical methods available are influenced by the extent of injuries. This study compares different operative modalities and their outcomes with different variables, aiming to define the ideal therapeutic approach.

Methods

We retrospectively compared reconstructive modalities used to treat facial ballistic trauma cases at Hôtel-Dieu de France Hospital, Beirut, Lebanon, for a 12-year span. Statistical analysis was used to determine correlation between several factors and satisfactory results.

Results

Eighteen patients were included, with varying degrees of bone and soft tissue loss. After conservative debridement, fractures were treated by different modalities: open reduction and internal fixation, maxillomandibular fixation, and osteosynthesis with a reconstruction plate. Although primary closure was sufficient in 10 cases, severe loss of tissues was reconstructed with a fibular free flap in five cases, radial free forearm flap in two cases, and free parascapular flap in one case. Two others received an iliac bone graft as secondary reconstruction. The average follow-up was 2.45 years. Most cases achieved good aesthetic and functional results after several secondary operations, with few late complications. Early reconstruction and younger patients were associated with better outcomes.

Conclusions

We favor early debridement and reconstruction. Free flaps were ideal for extensive tissue loss. Bone grafting was needed secondarily. A single surgical procedure seldom led to satisfactory functional and aesthetic outcomes, and secondary operations were inevitable.

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.

The Role of Plastic Surgeons in Addressing Firearm Morbidity and Mortality

Firearm injuries are now the leading cause of pediatric mortality in the United States. With the number of firearm injuries increasing at an alarming rate, the American Medical Association (AMA) declared firearm violence a public health crisis. In response to this emerging public health issue, the American College of Surgeons (ACS) developed the STOP THE BLEED training to educate laypersons on how to mitigate acute hemorrhage following gunshot wounds (GSWs) and other ballistic injuries. Stabilization of patients following GSWs is often handled by a multidisciplinary team of trauma and reconstructive surgeons. Here, we describe the history and ongoing role of reconstructive surgeons in preventing and addressing firearm morbidity and mortality. Hand surgeons are uniquely positioned to counsel patients on firearm safety, e.g., educating patients on proper firearm storage away from minors in the home, in an effort to mitigate accidental firearm injury to the upper extremity. As the evolving climate of firearm violence continues to rise, plastic and reconstructive surgeons will continue to play a critical role in restoring form and function among patients afflicted with GSWs.

Is Maxillofacial Gunshot Wound Location Associated With Operative Intervention?

PURPOSE

Gunshot wound (GSW) injuries are an important public health concern in the United States. The study purpose was to measure the association between GSW location and need for operative treatment.

METHODS

This was a retrospective cohort study. Sample consisted of all patients treated for maxillofacial gunshot wound injuries at Cook County Health from 2008 to 2018. The sample data were collected through a retrospective charts review and review of computed tomography imaging. The predictor variable was the region of the face involved with the GSW and it was divided into 3 levels, upper face (UF), middle face (MF), and lower face (LF). The outcome variable was whether operative intervention was rendered or not (operative vs no intervention). Other variables of interest collected included patient demographics, the type of surgical intervention, disposition (home vs rehab/morgue), rate of intracranial injury, and need for blood transfusion. Data analysis was performed using Chi-square for proportions and relative risk (RR) with 95% confidence interval (CI).

RESULTS

A total of 180 patients were identified to have sustained GSW injuries to the face during abovementioned time frame. Of those, 120 patients had isolated GSW injuries with no other organs involvement. The median age was 25 years. Majority of the patients were males (94%). The involved facial region appeared to influence the need for operative management and this reached statistical significance (Chi-square 22.703, P < .001). GSW injuries to LF were 2.94 times more likely to require operative intervention than injuries to the MF (RR = 2.94, 95% CI = 1.625-5.327). Injuries of the UF were 2 times more likely to require operative intervention than injuries of the MF (RR = 2.03, 95% CI 1.023-4.008). Injuries to the UF were more likely to be associated with intracranial injuries (Chi-square = 20.522, P < .001).

CONCLUSIONS

In patients with facial GSW injuries, there is an association between injury location and the need for operative intervention. Injuries to the LF were most likely to require surgical intervention followed by the UF and MF, respectively.

Predictors of Infection and Benefit of Antibiotics in Gunshot Wounds to the Face

BACKGROUND

Gunshot wounds (GSWs) to the face are at high risk for infection due the extent of tissue injury and often-observed violation of oral and sinus cavities. Given the ambiguous data on antibiotic benefit in GSW to the face, the purpose of this study is to characterize antibiotic usage, infection details, and risk factors associated with higher infection rates in GSW to face.

METHODS

We conducted a retrospective review of patients presenting with GSW to the face from 2009 to 2017. The primary outcome was to identify risk factors associated with infections in patients with facial GSWs. A stepwise multivariate linear regression analysis was performed to determine the impact of specific injury details.

RESULTS

Two hundred sixty-nine patients qualified for the study. Demographic information and details of hospital stay are presented in tables. Most patients (88.8%) received admission antibiotics. Facial infections were observed in 36 patients (13.4%). The infected cohort required more antibiotic days (P < 0.001), higher percentage of invasive airway procedures (P = 0.01), longer length of stay (P < 0.001), greater number of surgeries (P < 0.022), and higher readmission rates (P < 0.001). Factors associated with head or neck infections included oral cavity (odds ratio, 1.23; P = 0.04) and sinus involvement (odds ratio, 1.10; P = 0.045).

CONCLUSIONS

Bullet trajectories that violated the oral or maxillary sinus cavities were associated with higher head and neck infection rates. Patients without oral cavity or sinus involvement had a lower chance (4.1%) of developing an infection and therefore may have marginal benefit from antibiotics.

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review

Study Design

Retrospective case series; systematic review.

Objective

It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion.

Methods

A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis.

Results

Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline.

Conclusions

Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Comprehensive Treatment and Reconstructive Algorithm for Functional Restoration after Ballistic Facial Injury

Background:

Ballistic facial injuries are rare, with most trauma centers reporting 1–20 cases annually. These patients present significant management challenges to reconstructive surgeons, not only due to their rarity but also due to the complex decision-making process that is involved. The aim of this study was to review our experience with the application of craniofacial microsurgery in management of facial gunshot wounds.

Methods:

A retrospective review of a single-surgeon experience at a level I trauma center from 2011 to 2020 for patients sustaining self-inflicted gunshot wounds to the face requiring microsurgical reconstruction was performed. Outcomes included reconstructive techniques, free flap type and indication, airway evolution, feeding modality, respective timing of interventions, and complications.

Results:

Between 2012 and 2021, 13 patients presented for microsurgical reconstruction at our institution for gunshot wounds to the face. The majority (90%) of patients were men, and the average age at time of injury was 26. The median from the time of injury to first free flap was 93 days. Thirteen patients represented 23 free flaps. On average, patients underwent a total of two free flaps. The most common microsurgical flap was the fibula flap (14) followed by the radial forearm flap (6).

Conclusions:

Based on our findings, we describe a novel algorithm for function restoration and aesthetic revisions based on injury location. Underlying principles include avoiding early use of reconstruction plates, establishing occlusion early, and aligning bony segments using external fixation. An algorithmic approach to these injuries can improve outcomes.

Dental Management of Maxillofacial Ballistic Trauma

Maxillofacial ballistic trauma represents a devastating functional and aesthetic trauma. The extensive damage to soft and hard tissue is unpredictable, and because of the diversity and the complexity of these traumas, a systematic algorithm is essential. This study attempts to define the best management of maxillofacial ballistic injuries and to describe a standardized, surgical and prosthetic rehabilitation protocol from the first emergency stage up until the complete aesthetic and functional rehabilitation. In low-velocity ballistic injuries (bullet speed <600 m/s), the wound is usually less severe and not-fatal, and the management should be based on early and definitive surgery associated with reconstruction, followed by oral rehabilitation. High-velocity ballistic injuries (bullet speed >600 m/s) are associated with an extensive hard and soft tissue disruption, and the management should be based on a three-stage reconstructive algorithm: debridement and fixation, reconstruction, and final revision. Rehabilitating a patient with ballistic trauma is a multi-step challenging treatment procedure that requires a long time and a multidisciplinary team to ensure successful results. The prosthodontic treatment outcome is one of the most important parameters by which a patient measures the restoration of aesthetic, functional, and psychological deficits. This study is a retrospective review: twenty-two patients diagnosed with outcomes of ballistic traumas were identified from the department database, and eleven patients met the inclusion criteria and were enrolled.

Management of Maxillofacial Gunshot Injuries With Emphasis on Damage Control Surgery During the Yemen Civil War. Review of 173 Victims From a Level 1 Trauma Hospital in Najran, Kingdom of Saudi Arabia

Study Design

Studies on the concept of Damage Control Surgery (DCS) in the management of firearm injuries to the oral and maxillofacial region are still scarce, hence the basis for the current study.

Objectives

The objectives of the current study is to share our experience in the management of maxillofacial gunshot injuries with emphasis on DCS and early definitive surgery.

Methods

This was a retrospective study of combatant Yemeni patients with maxillofacial injuries who were transferred across the border from Yemen to Najran, Kingdom of Saudi Arabia. Demographics and etiology of injuries were stored. Paths of entry and exit of the projectiles were also noted. Also recorded were types of gunshot injury and treatment protocols adopted. Data was stored and analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp).

Results

A total of 408 victims, all males, were seen during the study period with 173 (42.4%) males sustaining gunshot injuries to the maxillofacial region. Their ages ranged from 21 to 56 years with mean ± SD (27.5 ± 7.6) years. One hundred and twenty-one (70.0%) victims had extraoral bullet entry, while 53 (30.0%) victims had intraoral entry route. Ocular injuries, consisting of 25 (14.5%) cases of ruptured globe and 6 (3.5%) cases of corneal injuries, were the most commonly associated injuries. A total of 78 (45.1%) hemodynamically unstable victims had DCS as the adopted treatment protocol while early definitive surgery was carried out in 47(27.2%) hemodynamically stable victims. ORIF was the treatment modality used for the fractures in 132 (76.3%) of the victims.

Conclusions

We observed that 42.4% of the war victims sustained gunshot injuries. DCS with ORIF was the main treatment protocol adopted in the management of the hemodynamically unstable patients.

Anatomic Subunit Approach to Composite Reconstruction of Facial Gunshot Wounds

ABSTRACT

With a rise in gun violence in the United States, surgeons are tasked with effectively managing penetrating facial trauma. The purpose of this study is to assess methods used for successful composite reconstruction of each anatomical facial subunit following penetrating trauma. A retrospective chart review was performed in subjects undergoing craniofacial reconstruction following penetrating trauma. Reconstructive methods were analyzed through operative reports. Subjects were categorized by anatomical subunit reconstructed (mandible, maxilla (malar complex and roof/palate), orbit, and cranium) and method of reconstruction (open reduction internal fixation only, bone graft, free flap, implant, and tissue expansion). Thirty-six subjects underwent reconstruction for penetrating facial trauma. Involved subunits include 24 mandible, 11 malar complex, 13 palate, 18 orbit, and 11 cranium. Predominate reconstruction method was open reduction internal fixation only for mandible (45.8%), bone grafting for malar complex (81.8%), implant for orbit (66.7%) and cranium (63.6%), and local tissue rearrangement for palate (84.6%). The predominate bone graft donor site was iliac for mandible (42.9%), rib for malar complex (36.3%) and orbit (40.0%), and frontal bone for cranium (42.8%). The predominate free flap was osteocutaneous for all mandible, orbit, and cranium and 7 of 10 (70.0%) palate reconstructions. Tissue expansion was used in all subunits except cranium. In conclusion, bone grafting, implants, free tissue transfer, and tissue expansion are all viable reconstruction options for penetrating trauma. There is no single approach to use, and decisions regarding definitive reconstruction method should be based upon anatomical subunit involved and the size/area of defects.

Endoscopic management gunshot wound at the face: Fact or fiction?

Shrapnel or gunshot injuries in Maxillofacial Region are highly considered to be challenging which leads to death in most cases, and even in the case of no mortality, they will cause morbidity and appearance impairment due to complex injuries to bone and soft tissue. Herein, in a particular case, the patient was a person injured by a gunshot of a Kalashnikovs҆ bullet in his face; the bullet was located at the end of the medial wall of the maxillary sinus and was removed through the functional endoscopy of the nose and sinuses. The bullet was removed without causing any additional incisions on the face and further damage through endoscopic ligation of severe bleeding from the sphenopalatine artery. The clinical approach to patients with penetrating trauma from a bullet to head and face demands prompt action. Functional endoscopic nasal and sinus surgery can maintain the patient's face cosmetic appearance.

[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.

Mechanisms of Soft Tissue Injury and Repair from Ballistics

Projectile injuries to the face deserve particular attention to evaluate for involvement of critical structures and functional elements and treat the devastating effects on facial aesthetics. Ballistic trauma to the maxillofacial region often has significant soft tissue and bony defects, creating a greater challenge to the reconstructive surgeon. The main goals of treatment of projectile injuries to the face are decreasing the amount of contaminants and nonviable tissue at the site, ensuring functionality, and restoring aesthetic appearance. There exists a lack of robust research on the subject. Soft tissue injuries from high-velocity projectiles have changed the perspective on treating acute injuries to the face and neck. Injuries encountered during both Operation Iraqi Freedom and Operation Enduring Freedom give the author pause to reflect upon a different wounding pattern than that encountered in stateside trauma centers. Given the dissemination of high-velocity weaponry by enemy combatants such as the improvised explosive device, mortar round, and high-velocity rifles, a higher incidence of facial wounds has been reported. The mechanism of injury and a stepwise approach for surgical repair are discussed incorporating advanced trauma life support principles and a reconstructive ladder of repair.

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.

Maxillofacial gunshot injures and their therapeutic challenges: Case series

Maxillofacial gunshot injuries require proficiency to determine a suitable treatment plan and surgical intervention. In this paper, present 4 gunshot cases. Treatment in these patients is very challenging. Moreover, post-treatment infections are a serious problem in such cases. Thus, step-by-step surgery is essential to obtain a better result in these patients.

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.

The marks of gunshot wounds to the face

Introduction

This article deals with the occurrence of health problems due to gunshot wounds to the face among military police officers, in the metropolitan region of Rio de Janeiro, who were submitted to surgery at the Oral and Maxillofacial Surgery and Traumatology Clinic of Hospital Central da Polícia Militar.

Objective

To identify the profile of patients submitted to surgery as a result of gunshot wounds, the anatomical distribution of maxillofacial fractures, the identified sequelae and complications, the health specialties involved in the rehabilitation of these patients, and to discuss the social, emotional and work performance-related effects of work among these subjects.

Methods

A retrospective epidemiological study was carried out based on secondary data from military police officers who were submitted to surgery at Hospital Central da Polícia Militar due to gunshot wounds from June 2003 to December 2017.

Results

During the study period, 778 surgeries were performed in the operating room by the Oral and Maxillofacial Surgery and Traumatology service at Hospital Central da Polícia Militar, 186 of which were due to gunshot wounds (23.9%). All patients were males and the mean age 34.7 years. Bone segment loss was the most common sequela. Facial esthetic impairment and reports of insomnia were the most often identified late consequences of impact on health and social life. Regarding the occupational impacts of the sustained injury, the mean time away from work due to medical leave for the treatment of maxillofacial injuries was 11.7 months.

Conclusion

The treatment of gunshot wounds patients with facial injuries requires multiple surgical interventions and their rehabilitation requires the involvement of different health specialties. Further studies are needed to qualitatively analyze the impact of this type of facial trauma on the patients' lives and their social consequences.

Periorbital Trauma: A New Classification

Overlooked injured structures in periorbital trauma could lead to aesthetic and functional deficits. As trauma may affect superficial, middle, and deep components, meticulous survey guided by a structured periorbital trauma classification is needed for proper management. Thus, a new classification for periorbital trauma is proposed to serve this purpose. Periorbital region was defined anatomically by anthropometric landmarks. The periorbital injuries were categorized according to anatomical and clinical basis. The new classification was used to study periorbital trauma cases received at Ain Shams University Hospitals between July 2013 and July 2016 retrospectively. The study included 260 patients: 196 (75.38%) males and 64 (24.62%) females. The type and severity of injury, time of primary intervention, type of surgery performed, and patients' visits to the outpatient clinic were evaluated. The status of the postinjury and postoperative (primary surgery) aesthetic status and functional status were evaluated. The periorbital region was identified. Anatomical categorization of periorbital injuries included periocular, frontal, temporal, and malar regions. Injuries/deficits were categorized into simple, composite, complex, and isolated bony injuries according to the depth and involved tissues. Subsequently, the classification was formulated. In the retrospective study, the incidence of extended simple injuries was the highest, while the least was the extended complex injuries. Functional deficits occurred in 24 patients (9.23%) and aesthetic deficits occurred in 55 patients (21.15%). Required secondary operations for this group included redo of fixation, correction of medial canthal ligament, repair of canalicular system, scar revisions, fat grafting, and creation of natural creases. The results of this study demonstrated that unsatisfactory aesthetic and functional results occurred when injuries of important structures were overlooked, aesthetic units were not respected, and when management was delayed. A three-dimensional, oriented, new classification of periorbital trauma based on anatomical and clinical categorization is proposed to help in identifying injured structures, stimulate the search for other injuries, structure preoperative evaluation, and recommend a surgical plan that would ultimately achieve precise primary repair with best aesthetic and functional outcome.

Gun-related eye injuries: A primer

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

Predictive value of quick surgical airway assessment for trauma (qSAT) score for identifying trauma patients requiring surgical airway in emergency room

Background

A surgical airway is usually unpredictable in trauma patients. The aim of this study was to develop a predictable scoring system to determine the need for a surgical airway by using a database from a large multicenter trauma registry.

Methods

We obtained data from the nationwide trauma registry in Japan for adult blunt trauma patients who were intubated in the emergency department. Based on a multivariate logistic regression analysis in the development cohort, the Quick Surgical Airway Assessment for Trauma (qSAT) score was defined to predict the need for a surgical airway. The association of the qSAT with surgical airway was validated in the validation cohort.

Results

Between 2004 and 2014, 17,036 trauma patients were eligible. In the development phase (n = 8129), the qSAT score was defined as the sum of the three binary components, including male sex, presence of a facial injury, and presence of a cervical area injury, for a total score ranging from 0 to 3. In the validation cohort (n = 8907), the proportion of patients with a surgical airway markedly increased with increasing qSAT score (0 points, 0.5%; 1 point, 0.9%; 2 points, 3.5%; 3 points, 25.0%; P <  0.001). Multivariate analysis revealed that qSAT score was an independent predictor of surgical airway (adjusted OR, 3.19 per 1 point increase; 95% CI, 2.47–4.12; P <  0.0001). The qSAT score of ≥1 had a had a good sensitivity of 86.8% for predicting the requirement for surgical airway; while qSAT score of 3 had a good specificity of 99.9% in ruling out the need for surgical airway.

Conclusions

The qSAT score could be assessed simply using only information present upon hospital arrival to identify patients who may need a surgical airway. The utilize of qSAT score in combination with repeated evaluations on physical finding could improve outcomes in trauma patients.

An Algorithmic Approach to the Management of Ballistic Facial Trauma in the Civilian Population

Annual incidence of non-fatal ballistic civilian has been increasing for the last decade. The aim of the present study was to clarify the optimal reconstructive management of civilian ballistic facial injuries. A systematic review of PubMed was performed. Articles were evaluated for defect type and site, reconstructive modality, complications, and outcomes. A total of 30 articles were included. Most common region of injury was mandibular with a 46.6% incidence rate. All-cause complication rate after reconstruction was 31.0%. About 13.3% of patients developed a postoperative infection. Gunshot wounds had overall lower complication rates as compared with shotgun wounds at 9.0% and 17.0%. By region, complications for gunshot wounds were 35% and 34% for mandible and maxilla, respectively. Immediate surgical intervention with conservative serial debridement is recommended. However, for patients with pre-existing psychiatric disorders, secondary revisions should be delayed until proper psychiatric stabilization. When there is extensive loss of soft tissue in the midface, aesthetic outcomes are achieved with a latissimus dorsi or anterolateral thigh free flap. Radial forearm flap is favored for thin lining defects. Open reduction is suggested for bony-tissue stabilization. The fibula flap is recommended for bony defects >5 cm in both midface and mandible. For bony defects, <5 cm bone grafting was preferred. Delaying bone grafting does not worsen patient outcomes. Surgical treatment of ballistic facial trauma requires thorough preparation and precise planning. An algorithm that summarizes the approach to the main decision points of surgical management and reconstruction after ballistic facial trauma has been presented in this study.

Padrão espacial e diferencial de renda dos domicílios de adolescentes e adultos jovens vítimas de traumatismo maxilofacial por agressão com arma de fogo

Resumo O estudo investigou o padrão espacial dos casos de traumatismo maxilofacial decorrentes de agressão com arma de fogo em adolescentes e adultos jovens a partir do local de domicílio das vítimas e analisou comparativamente os diferenciais de renda dessas áreas. Estudo transversal com dados de vítimas atendidas em três hospitais de Belo Horizonte-MG, entre janeiro de 2008 e dezembro de 2010. Endereços foram georeferenciados por geocodificação. Tendências de aleatoriedade e densidade de pontos foram analisadas por Função K de Ripley e mapas de Kernel. A interação espacial entre os domicílios de adolescentes e adultos jovens foi verificada através da Função K12. Encontrouse registros de 218 casos de agressão com arma de fogo, com predomínio do sexo masculino (89,9%) e adultos jovens (70,6%). Os domicílios se distribuíram de forma agregada no espaço urbano com nível de confiança de 99% e níveis de agregação espacial semelhantes. Os clusters de domicílios convergiram para 7 favelas ou regiões vizinhas com população de maior renda revelando propagação de eventos. Os hotspots se concentraram em favelas com histórico de crimes ligados ao narcotráfico. A incorporação do espaço na dinâmica dos eventos mostrou que a condição econômica isoladamente não limitou a vitimização.

Management of High-energy Avulsive Ballistic Facial Injury: A Review of the Literature and Algorithmic Approach

Background:

High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author’s early and definitive staged reconstructive approach to these challenging patients.

Methods:

A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes.

Results:

Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics.

Conclusions:

Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries.

Soft Tissue Management in Facial Trauma

The management of soft tissue injury after facial trauma poses unique challenges to the plastic surgeon, given the specialized nature of facial tissue and the aesthetic importance of the face. The general principles of trauma management and wound care are applied in all cases. The management of severe injuries to the face is discussed in relation to the location and the mechanism of injury. Facial transplants have arisen in the past decade for the management of catastrophic soft tissue defects, although high morbidity and mortality after these non-life-saving operations must be considered in patient selection.

Unusual route of a bullet: From scapula to eye

Herein, an awkward case of globe perforation with a bullet-entering from the right posterior scapular region and leaving the body from the right orbit through the eye - is reported. Route of the bullet could be devastating - as it passed through the neck and the maxillofacial region-however by chance no vital damage occurred. Its path was assessed by plain radiography and computed tomography scans. Sometimes prediction of the trajectory is very difficult without additional radiological investigations. Especially, in the case of any high velocity projectile wounding, physician must be aware of the fact that the bullet's course will not be a linear but most probably a complicated one. Prognosis of the injury depends on the path of the bullet or shrapnel fragment, close clinical observation, an open-minded approach, and the multidisciplinary care. Moreover, even the crime investigation might be needed.

A 14-Year Review of Craniomaxillofacial Gunshot Wounds in a Resource-Limited Setting

This study analyzed the prevalence, clinical characteristics, and management of civilian-type craniomaxillofacial gunshot wounds (CGSWs) seen over a 14-year period in a Northern Nigerian teaching hospital. A retrospective study of all hospital records relating to CGSWs from January 2000 to December 2013 was conducted to determine the prevalence of CGSWs. Information retrieved included site of injury, type of projectile, management protocol, as well as duration of hospitalization. A total of 46 admissions for CGSWs were recorded during the period under review from a total of 2,228 maxillofacial admissions. This gave a prevalence of 2.1% for CGSWs (95% confidence interval = 1.56-2.81). Sex distribution was 14.3:1 (M:F) with overall mean age of 32.9 ± 8.4 years. Average length of hospitalization was 17.7 (±15.56) days. Management of CGSWs consisted of emergency care, preliminary intervention, definitive reconstruction, revisions, and rehabilitation. Conclusively, analysis of the yearly incidence of CGSWs showed that the incidence and severity increased within the past 2 years under review (18 cases, 39.13%; χ² trend = 7.7, p = 0.006). This period was noted to correspond with heightened violence within the region mostly due to the acts of unknown gunmen and insurgents.

Reconstruction and rehabilitation of short-range gunshot injury to lower part of face: A systematic approach of three cases

Gunshot injuries are always known to cause severe morbidity and mortality when head and neck are involved. They vary in morbidity, which can occur in civilian surroundings. The wound largely depends on the type of weapon, mass and velocity of the bullet, and the distance from where it has been shot. Close-range gunshot wounds in the head and neck region can result in devastating aesthetic and functional impairment. The complexity in facial skeletal anatomy cause multiple medical and surgical challenges to an operating surgeon, demanding elaborate soft and hard tissue reconstruction. Here we presented the successful management of three patients shot by short-range pistol with basic life support measures, wound management, reconstruction and rehabilitation.

High-velocity facial gunshot wounds: multidisciplinary care from prehospital to discharge

A case is presented in which a high velocity rifle (shotgun) was fired into the inferior part of a patient's face in an attempted suicide causing widespread trauma to the inferior and left side of the patient's face. He presented to his general practitioner where an ambulance was called. The patient is followed from prehospital care (air ambulance) to resuscitation in accident and emergency and through the first stages of reconstructive surgery. The article focuses on the multidisciplinary approach to the patient's prehospital care and initial resuscitation at a major trauma centre. CT reconstruction images of the patient's skull allow visualisation of the extent of bone damage at presentation. Medical photography allows visualisation of the extent of the initial damage and shows how reconstructive surgery was undertaken early and in progressive stages. A literature review was performed allowing discussion of the current evidence and best practice in the management of facial gunshot wounds.

Ballistic Reconstruction of a Migrating Bullet in the Parapharyngeal Space

A 21-year-old male suffering from severe throat pain after being hit by a bullet in Syria claimed that he was shot through his eye and that the bullet subsequently descended behind his throat. Even though the first medical report stated that this course is implausible, meticulous workup provided evidence that the bullet might have entered the parapharyngeal space in a more cranial position than the one it was found eight months later. Our case highlights that bullets are able to move within the body, rendering ballistic reconstruction difficult. However, after removal of the bullet the patient's symptoms completely resolved.

Maxillofacial Gunshot Injuries: A Comparison of Civilian and Military Data

PURPOSE

To compare military with civilian gunshot wounds (GSWs) in the maxillofacial region in order to establish differences in presentation, morbidity, and surgical management.

MATERIALS AND METHODS

A cross-sectional study design was used. The University of Florida at Jacksonville oral and maxillofacial surgery operating room census and hospital trauma registry were both reviewed to identify maxillofacial GSW cases from 2005 through 2011. Military GSW data (2005 through 2011) were obtained from the US Department of Defense (DOD). The predictor variables were civilian versus military GSW events. The outcome variables of interest included the region of the face involved, race, gender, death during admission, hospital length of stay, and number of days in the intensive care unit (ICU). Descriptive statistics were computed.

RESULTS

The sample was divided into military maxillofacial GSWs (n = 412) and civilian maxillofacial GSWs (n = 287 treated of 2,478 presented). A significant difference was measured between study groups regarding the region of the face involved (P = .0451), gender (P ≤ .0001), and race (P ≤ .0001). No significant relationship was measured regarding deaths during admission (P = .6510) for either study group. No standard deviation values for hospital length of stay or number of ICU days were provided by the DOD. The mean hospital length of stay for the military group was within the 95% confidence interval of the civilian group findings (6.0-7.6). The mean number of ICU days for the military group was not within the civilian group's 95% confidence interval (1.9-2.9).

CONCLUSIONS

These data showed important differences in anatomic location, gender, and race distribution of maxillofacial GSWs between military and civilian populations. Limited analysis of hospital length of stay and number of ICU days might indicate no meaningful difference in hospital length of stay, although there was a statistical difference in the number of ICU days between the 2 populations. Future research comparing surgical strategies in these 2 environments could assist maxillofacial surgeons in providing optimal care to their patients.

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.

Pediatric facial fractures as a result of gunshot injuries: an examination of associated injuries and trends in management

INTRODUCTION

Facial fractures are relatively uncommon in the pediatric population, especially those inflicted as a result of interpersonal violence in the form of gunshot injuries. Few studies have examined the unique management of such high-energy injuries in the pediatric population. Oftentimes the resultant damage to soft tissue and bony structures is so great that it challenges the previously accepted standards in the management of pediatric facial fractures. This study will examine a level 1 trauma center's experience with these unique injuries.

METHODS

A retrospective review of all facial fractures occurring in a pediatric population (those 18 years of age or younger) as a result of gunshot wounds in a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Descriptive information was collected regarding each case as well as information regarding concomitant injuries, treatment modalities, and selected outcomes.

RESULTS

During this time period, there were 3147 facial fractures treated at our institution, 353 of which were in pediatric patients. Of these, 17 were the results of gunshot wounds. Three patients were excluded due to insufficient data, leaving a total of 14 patients. The average age of patients was 16.5 (range 14-18); all patients were African-American males. The most common fracture was that of the mandible (n = 10), with 2 of those patients exhibiting panfacial fractures. The average Glasgow Coma Scale on admission was 13.5 (range 3-15). Six of the patients were intubated in the emergency department. The most common concomitant injury was a skull fracture (n = 3), followed by cervical spine fractures (n = 2) and intracranial hemorrhages (n = 2). All patients were admitted to the hospital for reasons other than fracture management. Seven patients ultimately went to the operating room for fracture management. The treatment modalities employed were conservative management with closed techniques (n = 11), rigid internal fixation (n = 2), and the use of an external fixator device (n = 1). Minimal to no soft-tissue debridement was performed in 10 of the 14 patients, 2 of which presented between 6 months and 10 years post-injury with soft-tissue complications related to retained material. The mean hospital length of stay was 8.2 days (range 1-18 days). One patient expired.

DISCUSSION

Pediatric facial fractures as a result of gunshot wounds represent a unique and fortunately rare entity that presents a challenge to all disciplines involved in treatment. In our patients, there was a tendency towards conservative management, with only 3 patients undergoing some form of fixation and only 7 undergoing some form of operative debridement. Concomitant injuries and the high-energy nature of gunshot wounds often preclude traditional management with rigid fixation to ensure adequate bony healing. However, it is important to adequately debride devitalized soft tissue and remove all foreign material to avoid future soft tissue-related complications.

Maxillofacial Gunshot Wounds

The majority of maxillofacial gunshot wounds are caused by suicide attempts. Young men are affected most often. When the lower one-third of the face is involved, airway patency (1.6% of the cases) and hemorrhage control (1.9% of the cases) are the two most urgent complications to monitor and prevent. Spinal fractures are observed with 10% of maxillary injuries and in 20% of orbital injuries. Actions to treat the facial gunshot victim need to be performed, keeping in mind spine immobilization until radiographic imaging is complete and any required spinal stabilization accomplished. Patients should be transported to a trauma center equipped to deal with maxillofacial and neurosurgery because 40% require emergency surgery. The mortality rate of maxillofacial injuries shortly after arrival at a hospital varies from 2.8% to 11.0%. Complications such as hemiparesis or cranial nerve paralysis occur in 20% of survivors. This case has been reported on a victim of four gunshot injuries. One of the gunshots was to the left mandibular ramus and became lodged in the C4 vertebral bone.

MaurinO, de RégloixS, DubourdieuS, LefortH, BoizatS, HouzeB, CulomaJ, BurlatonG, TourtierJP. Maxillofacial gunshot wounds. Prehosp Disaster Med. 2015;30(3):14.

An interesting case of gunshot injury to the temporomandibular joint

The head and face are relatively common sites of gunshot injury, and the temporomandibular joint is often affected. These wounds usually produce major deformity and functional impairment, particularly when the temporomandibular joint is affected or when structures such as the facial nerve are damaged. Complications may include mandibular displacement at maximum mouth opening and in protrusion, limited mouth opening, limited lateral movement of the jaw, anterior open bite, and, more rarely, temporomandibular ankylosis. Projectiles that strike the mandible usually cause comminuted fractures; maxillary wounds, in turn, are most commonly perforating. The present report describes a case of gunshot injury in which the projectile lodged within the mandibular fossa but did not cause any fractures. Oral and maxillofacial trauma surgeons must be aware of the different types of gunshot injury, as they produce distinct patterns of tissue destruction due to projectile trajectory and release of kinetic energy into surrounding tissue.

Is tracheostomy suitable for securing airway after facial firearm injuries?

BACKGROUND

Head and neck region have many vital structures, and facial firearm injuries (FFIs) more likely lead to life-threatening situations than other body injuies. These injuries have high potential of airway compromise associated with significant morbidity and mortality.

METHODS

We describe an 11-year-old boy who had received tracheostomy after a FFI complicated with pneumothorax and subcutaneous emphysema 8 hours after the procedure. The patient was treated at the Department of Emergency and Critical Care, Gazi University School of Medicine, Turkey.

RESULTS

The patient was discharged without any complications from the Critical Care Unit after treatment for five days.

CONCLUSIONS

Airway management is of utmost importance in resuscitation of FFI, but it is always difficult to secure via the orotracheal route due to the deformed facial structures. Tracheostomy is an option for airway management in FFI affecting head and neck region. However, tracheostomy may be associated with life-threatening complications, which should be closely monitored with early intervention.

Gunshot-caused Facial Injury Combined with Lower Cervical Spine Injury: A Case Report

A 32-year old male patient was wounded by a pistol. As shown in computed tomography (CT) scanning images, there was comminuted fracture of the left mandible and the bullet was found in the left side behind the sixth cervical vertebra. After the patient was hospitalized, the debridement was done in the emergency room and the operation of open reduction and internal fixation for comminuted fracture of left mandible was performed successfully. Eighteen days later, the patient was taken to surgery for anterior cervical decompression and fusion with autogenous iliac bone grafting for the sixth cervical vertebra. Postoperative follow-up of the patient over two years indicated that the left biceps muscle strength was recovered to level 4. Gunshot wound to the face associated with injury of the low cervical spine has the possibility of survival. It is safe to treat facial wounds early in the patient's treatment course, even if the bullet remains in the cervical vertebral body and there is neurological function damage.

Gunshot wounds to the face: emergency interventions and outcomes

BACKGROUND

Gunshot wounds to the face (GSWF) may produce life-threatening injuries. Our objective is to describe outcomes of and factors related to interventions for urgent airway control (UAC) and urgent bleeding control (UBC) as well as to analyze complications associated with GSWF.

METHODS

This was a retrospective study of 155 GSWF patients who were admitted to two Level 1 academic trauma centers over an 11-year period. Demographic details, injuries sustained, interventions performed, and timing of the interventions were recorded. Morbidity and mortality data were evaluated.

RESULTS

Overall, 115 (74 %) patients suffered isolated GSWF, and none died. Of the 90 (58 %) patients requiring UAC, only three had a cricothyroidotomy. Of the 41 (26 %) patients requiring UBC, only four had angiographic embolization. Intraoral involvement and extrafacial injuries were associated with both UAC and UBC. Overall, 75 patients (48 %) required operations on the bones, eyes, or both. Complications developed in 14 and were treated successfully.

CONCLUSIONS

UAC and UBC are required frequently after GSWF and are associated with intraoral involvement and injuries beyond the face. Simple methods, such as orotracheal intubation and packing, are typically sufficient for successful management. About half of the patients need further surgery, with infrequent morbidity.

Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multi-institutional study of 720 patients

BACKGROUND

Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality.

METHODS

We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome.

RESULTS

From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001).

CONCLUSION

GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Rehabilitation of a patient with gunshot injury through the iliac graft and implant-retained restorations with a 3-year follow-up: a brief clinical study

Trauma is one of the most common causes of teeth loss. Assault with a gunshot and bullet shot is life threatening, and for patients who survive the injury, it results in hard and soft tissue loss in the tissues and organs crossed by the bullet. The tissue loss results in the loss of structure and function. Rehabilitation of these patients to function and aesthetics requires surgical and prosthodontic procedures over time. This report is of a 24-year-old male patient who had a bullet injury resulting in hard and soft tissue deficiency. The ridge deficiency was augmented with iliac bone graft, and 3 months later, implants were placed. Five months later, hybrid prosthesis was delivered. At 3-year follow-up visit, the hybrid prosthesis was replaced with porcelain fused to a metal bridge. The bone levels on all the implants were stable.

Atypical gunshot injury to the right side of the face with the bullet lodged in the carotid sheath: a case report

Introduction

Gunshot injuries of the head and neck from the AK-47 rifle (a common assault rifle, submachine gun type) are a significant contributor to morbidity and mortality among civilians in Sub-Saharan Africa. They may cause significant damage to the closely arranged structures in this region, and the bullet’s trajectory can be very difficult to determine. We present an unusual case of gunshot injury with an atypical bullet entry wound, profound injury to the face, lodgment in the right carotid sheath, and 'wandering’; a first of its kind in East Africa.

Case presentation

A 27-year-old African-Ugandan woman of Nilotic ethnicity was referred to the Accident and Emergency Department of a tertiary hospital in Uganda, having sustained complex injuries due to an inadvertent AK-47 rifle gunshot injury. The gunshot injury was to the right side of her face with a large ragged entry wound and no exit wound. Prior basic wound care and radiological imaging showed a comminuted fracture of her mandible with lodgment of the bullet in her neck, anterior to her sixth and seventh cervical vertebrae. Standard debridement of her wound was done. A computed tomography scan showed an apparent cephalad shift ('wandering’) of the bullet, leaving it lying partially anterior to her fifth cervical vertebra as well as within her carotid sheath. Other injuries were to her facial and trigeminal nerves, and her middle ear. The 'wandering’ bullet was successfully removed surgically. It had caused no damage to any part of her neck structure.

Conclusion

AK-47 rifle bullet injuries may present with uncharacteristically large entry wounds and cause complex structural injuries at the area of impact. The consequent trajectory is difficult to predict making regional examination and radiological investigations essential in management. Bullets may be retained, leaving no exit wound. Securing the airway, controlling hemorrhage and identifying other injuries are the first vital steps. This case illustrates all these interventions and the important decision to extract the entrapped bullet from the patient’s neck because it had started to 'wander’ and could have caused grave injury over time with further migration. Maxillofacial, plastic, trauma, general and military surgeons, otorhinolaryngologists and emergency physicians can gain from this experience because it calls for a multidisciplinary team approach.