Gunshot wounds to the head and neck

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.

Clinical complications of surviving gunshot wounds to the head in children and adolescents: the Miami experience

BACKGROUND

Gunshot wounds (GSWs) to the head in the pediatric population are both rare and devastating, with the clinical course of pediatric survivors poorly understood. Correspondingly, the aim of this study was to summarize the clinical complications clinicians can expect of survivors of GSW to the head in children and adolescents in hospital and after discharge.

METHODS

A retrospective review of our Level 1 trauma center database between 2011 and 2021 was performed. Clinical data was extracted for those patients aged ≤ 18 years old who survived initial hospitalization with at least one documented follow-up. Categorical data were then compared using Chi-squared test.

RESULTS

A total of 19 pediatric survivors of GSW to the head satisfied all selection criteria with an average age was 15.3 years. The majority of cases were isolated head injuries (63%), with an average Glasgow Coma Score (GCS) of 11.9. Bullet trajectory was intraparenchymal in 11 (58%) cases and extraparenchymal in 8 (42%) cases, with 15 (79%) patients treated by surgical intervention. A total of 13 (68%) patients experienced a complication during their hospitalization, with the most common being sympathetic hypertension and endocrinologic salt wasting, each occurring in 5 (26%) patients. With respect to complication categories, the intraparenchymal patients experienced statistically more complications than extraparenchymal patients that were infectious (54% vs 0%, P = 0.01) and sympathetic (45% vs 0%, P = 0.03) in nature. However, with respect to overall neurologic (P = 0.24), endocrinologic (P = 0.24), and traumatic (P = 0.24) complications, their incidences were statistically comparable. All patients were successfully discharged on average post-injury day 22 with an average GCS of 14.0. Mean follow-up for the cohort was 42.6 months, with an average GCS of 14.3. A total of 6 (32%) patients experienced a complication relatable to their initial GSW injury after discharge. The most common individual complication was new-onset seizures in 3 (16%) patients.

CONCLUSIONS

Survivors of pediatric GSW to the head can experience multi-systemic complications during both initial hospitalization and afterwards, and bullet trajectory involving the parenchyma may be associated with specific complications more than others. Dedicated inpatient management and outpatient follow-up involving surveillance for complications across all systems, not just neurological, are recommended to ensure patients receive the best care possible.

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.

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.

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.

Post-infectious ankylosis of the cervical spine in an army veteran: a case report

Background

Vertebral osteomyelitis is a rare, life-threatening condition. Successful management is dependent on prompt diagnosis and management with intravenous antibiotic therapy or surgery in addition to antibiotics. Reoccurrence is minimal after 1 year. However, very little is reported in the conservative spine literature regarding the long-term follow-up and the changes to the spine following management of the spinal infection. We report the dramatic radiologic findings of the long-term sequela of a cervical spine infection following a gunshot wound from 1969. Most impressive to the spine specialist is this patient’s ability to return to work despite significant alterations to spinal biomechanics.

Case presentation

A 69 year-old caucasian male presented to the chiropractic clinic at a Veterans Affairs Medical Center with complaint of chronic left shoulder pain secondary to an associated full thickness tear of the left infraspinatus. An associated regional assessment of the cervical spine ensued. Radiological imaging on file revealed ankylosis C2/C3 to C7/T1. The patient reported a history of multiple fragment wounds in 1969 to the left anterior neck and shoulder 45 years earlier. Osteomyelitis of the cervical spine resulted from the wounds.

Conclusion

Potential sequela of osteomyelitis is ankylosis of affected joints. In this particular case, imaging provides evidence of regional ankylosis of the cervical spine. Considering the patient did not complain of cervical pain or related symptoms apart from lack of cervical range of motion, and his Neck Disability Index score was 2 out of 50 (4%), no intervention was provided to the cervical spine. The patient reported he self-managed well, worked full-time as a postal worker after he was discharged due to the injury to his neck, and planned to retire in less than one month at age 70. The patient demonstrates successful return to work with pending retirement at age 70 following spondylodiscitis and subsequent ankylosis of the cervical region.

Higher Complication Rates in Self-Inflicted Gunshot Wounds After Microvascular Free Tissue Transfer

OBJECTIVES/HYPOTHESIS

Microvascular free tissue transfer is often employed to reconstruct significant facial defects from ballistic injuries. Herein, we present our comparison of complications between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer.

STUDY DESIGN

Retrospective case review.

METHODS

Approval was obtained from the JPS institutional review board. We performed a retrospective review of cases of ballistic facial injuries between October 1997 and September 2017 that underwent vascularized free tissue transfer for reconstruction. Comparisons were made between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer. The χ² test was used for all comparisons. P value and 95% confidence interval (CI) were reported.

RESULTS

There were 73 patients requiring free flap reconstruction after gunshot wounds to the face during the study period. There was a statistically significant difference in the rates of nonunion between self-inflicted and non-self-inflicted wounds (P = .02, 95% CI: 0.9 to 35.8) There were also no significant differences in flap failure (P = .10, 95% CI: -2.8 to 24.2), plate exposure (P = .28, 95% CI: -6.7 to 33.0), wound infection (P = .40, 95% CI: -8.9 to 31.2), scar contracture (P = .60, 95% CI: -8.1 to 25.1), and fistula formation (P = .13, 95% CI: -2.8 to 28.8) between patients with self-inflicted and those with non-self-inflicted wounds. Overall, complication rates were significantly higher in the self-inflicted group compared to the non-self-inflicted group (P < .0001, 95% CI: 32.6 to 68.6).

CONCLUSIONS

Patients with self-inflicted injuries had more complications postoperatively than those with non-self-inflicted injuries. This is likely helpful in surgical planning and patient counseling.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:837-840, 2019.

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.

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.

Comparison of gunshot entrance morphologies caused by .40-caliber Smith & Wesson, .380-caliber, and 9-mm Luger bullets: a finite element analysis study

Firearms can cause fatal wounds, which can be identified by traces on or around the body. However, there are cases where neither the bullet nor gun is found at the crime scene. Ballistic research involving finite element models can reproduce computational biomechanical conditions, without compromising bioethics, as they involve no direct tests on animals or humans. This study aims to compare the morphologies of gunshot entrance holes caused by.40-caliber Smith & Wesson (S&W), .380-caliber, and 9×19-mm Luger bullets. A fully metal-jacketed.40 S&W projectile, a fully metal-jacketed.380 projectile, and a fully metal-jacketed 9×19-mm Luger projectile were computationally fired at the glabellar region of the finite element model from a distance of 10 cm, at perpendicular incidence. The results show different morphologies in the entrance holes produced by the three bullets, using the same skull at the same shot distance. The results and traits of the entrance holes are discussed. Finite element models allow feasible computational ballistic research, which may be useful to forensic experts when comparing and analyzing data related to gunshot wounds in the forehead.

Surgical management of chronic traumatic pseudomeningocele of the craniocervical junction: case report

PURPOSE

Chronic traumatic pseudomeningocele (PM) is a rare complication of gunshot injuries of the craniocervical junction in pediatric patients. Impairment of the CSF dynamics may cause severe symptoms and should be treated.

METHODS

We report the case of a 6-year-old girl who was accidentally shot in the neck during tribal clashes. On being admitted, she was neurologically intact with cerebrospinal fluid (CSF) leakage through the wounds. She underwent primary closure of the wounds in a rural medical facility. After two episodes of meningitis, CSF leakage resolved spontaneously. Nine months later, the patient was presented with a disfiguring mass growing in the posterior neck, severe headaches, and constitutional symptoms such as loss of appetite and a failure to thrive.

RESULTS

Neurosurgical intervention was performed with the patient in the prone position. Occipital pericranium graft was used to repair the defect, and the cavity of the PM was obliterated with muscle layers. The patient's symptoms improved at 1 year follow-up without PM recurrence.

CONCLUSION

This is a rare presentation of gunshot injuries in an environment with limited neurosurgical resources. Restoring the normal pattern of CSF circulation should be the aim of any neurosurgical intervention.

Inpatients with gunshot wounds to the face

Microvascular free tissue transfer (FTT) is an increasingly used method of reconstruction for traumatic defects of the head and neck. We describe the immediate management, FTT reconstruction techniques, and outcomes of 6 individuals who sustained maxillofacial gunshot trauma and were treated at a single tertiary-care level I trauma center. All 6 patients were white men with a mean age of 33 years. The mandible, nose, and orbital contents were the most frequently affected critical structures. All patients initially underwent primary wound debridement and tracheostomy, with concurrent maxillomandibular wire fixation and/or midface or mandible plate fixation in 5 patients. The mean time from injury to definitive FTT was 38 days. Five patients underwent fibula osteocutaneous FTT and 1 underwent radial forearm fasciocutaneous FTT. One patient also underwent concurrent local tissue rearrangement and pedicled flap surgery for nasal reconstruction. The mean hospital length of stay after FTT was 6 days. All FTT survived without necrosis. Oral incompetence and poor cosmesis from undesirable scarring patterns were the most common long-term complications. In summary, successful reconstruction of head and neck defects caused by gunshot trauma begins with airway stabilization, wound management, and bony fracture reduction and fixation. Definitive microvascular FTT is a useful method of repairing traumatic head and neck defects, although long-term functional and cosmetic complications may still occur.

Surgical management of a projectile within the temporomandibular joint

Facial gunshot wounds pose a challenge for head and neck surgeons as it is usually accompanied by significant soft and bone tissue loss and impairment of the stomatognathic system. This article reports the case of a patient who had sustained facial gunshot wound and had the projectile lodged at the upper disk space of the right-side temporomandibular joint, which caused mandible function impairment and pain. The projectile was surgically removed via endaural access, and the patient was later submitted to physiotherapy. After treatment, the function of the joint was reestablished, the pain disappeared, and the aesthetics results were considered excellent, with no sequels. The surgical removal of the projectile of the temporomandibular joint combined with the postsurgical physiotherapy showed to be an efficient treatment to the present case.

[Penetrating injuries in the face and neck region. Diagnosis and treatment]

Penetrating head and neck injuries often present with vascular lesions and airway compromise and may be life-threatening. Thus controlling bleeding and airway stabilisation take priority in emergency treatment. High-velocity projectiles, fragmentations from improvised explosive devices (IEDs) and shrapnel can cause severe tissue injury, representing a challenge for the head and neck surgeon. Since several organ structures, such as the eyes, midface, pharynx, larynx, trachea, esophagus, nerves, vessels and vertebral spine can be injured at the same time, patients should be referred to a specialized trauma center for interdisciplinary treatment following emergency treatment. High-speed ballistic injuries were once confined to the battle field and have been uncommon in Europe since World War II. For this reason, experience among civilian head and neck surgeons is at present limited. With the increased incidence of terrorism and the use of IEDs as the preferred weapon in terrorism it has become important for civilian head and neck surgeons to understand the role of ballistic injuries in mass casualty events. The present paper discusses current viewpoints in the diagnosis and treatment of penetrating head and neck injuries.

Facial gunshot wounds: trends in management

Facial gunshot wounds, often comprising significant soft and bone tissue defects, pose a significant challenge for reconstructive surgeons. Whether resulting from assault, accident, or suicide attempt, a thorough assessment of the defects is essential for devising an appropriate tissue repair and replacement with a likely secondary revision. Immediately after injury, management is centered on advanced trauma life support with patient stabilization as the primary goal. Thorough examination along with appropriate imaging is critical for identifying any existing defects. Whereas past surgical management advocated delayed definitive treatment using serial debridement, today's management favors use of more immediate reconstruction. Recent advances in microsurgical technique have shifted favor from local tissue advancement to distant free flap transfers, which improve cosmesis and function. This has resulted in a lower number of surgeries required to achieve reconstruction. Because of the diversity of injury and the complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is achieved.

Neck injuries

INTRODUCTION AND OBJECTIVE

Neck injuries are of great clinical interest because they can induce very significant consequences if not handled properly and can even lead to death. The aim of our study was to analyse external deep cervical trauma in our hospital.

MATERIAL AND METHODS

A retrospective study of all external deep neck injuries seen in a tertiary hospital over the course of 24 years that involved changes in structures related to otolaryngology.

RESULTS

Twenty patients were included in our study. From all the injuries, 45% were secondary to traffic accidents, 27% from assault with a knife and 23% from attempted suicide. The injuries were open in 15 (68%) cases and closed in 7 (32%). The most common symptom was bleeding (55%), followed by respiratory disorders (23%). On examination, the most frequent sign was the appearance of subcutaneous emphysema (27%). Only 50% of patients underwent imaging before treatment, most often a neck CT (27%). 59% of patients needed surgery, with 6 patients (27%) requiring a tracheotomy. Two of them died (9%) and 6 suffered permanent complications.

CONCLUSIONS

Cervical injuries involving ENT structures are rare in our environment, with the most common cause being traffic accidents. It is important to have standardised guidelines for the management of these patients, because they can often developed severe complications or even die if not treated properly very rapidly.

A civilian perspective on ballistic trauma and gunshot injuries

BACKGROUND

Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities.

METHODS

A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed.

RESULTS

Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity.With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference.

CONCLUSION

The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively.

[Penetrating gunshot wound in the neck. Case report and review of the literature]

Penetrating gunshot neck injuries present a serious challenge for the primary attending surgeon. By means of a case treated in the German Field Hospital in Mazar-e-Sharif (northern Afghanistan) and a review of the literature, the principles of diagnosis and treatment of penetrating zone II neck injuries due to gunshots or shrapnel are presented.

Contemporary issues in facial gunshot wound management

Facial gunshot wounds pose a significant challenge for reconstructive surgeons, particularly when composed of significant soft and bone tissue defects. Often the result of assault, accident, or suicide attempt, facial defects must be thoroughly evaluated to devise an appropriate tissue repair and replacement with the likely prospect of secondary revision. In the acute setting after injury, the primary concern is patient stabilization centered on advanced trauma life support. Thorough examination along with appropriate imaging is critical for identifying any existing defects. As opposed to past surgical management that advocated delayed definitive treatment using serial debridement, today's management favors the use of more immediate reconstruction. Recent improvements in microsurgical technique have shifted favor from local tissue advancement to distant free-flap transfers, which improve cosmesis and function. This has reduced the number of surgeries necessary to achieve reconstruction. Given the diversity and complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is ultimately achieved.