Cellular Cytosolic Energy Replenishment Increases Vascularized Composite Tissue Tolerance to Extended Cold Ischemia Time

BACKGROUND

Vascularized composite allotransplantation (VCA) is a restorative surgical procedure to treat whole or partially disfiguring craniofacial or limb injuries. The routine clinical use of this VCA surgery is limited using compromised allografts from deceased donors and by the failure of the current hypothermic preservation protocols to extend the allograft's cold ischemia time beyond 4 h. We hypothesized that the active replenishment of the cellular cytosolic adenosine-5`-triphosphate (ATP) stores by means of energy delivery vehicles (ATPv) encapsulating high-energy ATP is a better strategy to improve allograft's tolerance to extended cold ischemia times.

MATERIALS AND METHODS

We utilized established rat model of isolated bilateral in-situ non-cycled perfusions of both hind limbs. Ipsilateral and contralateral limbs in the anesthetized animal were randomized for simultaneous perfusions with either the University of Wisconsin (UW) solution, with/without O2 supplementation (control), or with the UW solution supplemented with the ATPv, with/without O2 supplementation (experimental). Following perfusion, the hind limbs were surgically removed and stored at 4°C for 12, 16, or 24 hours as extended cold ischemia times. At the end of each respective storage time, samples of skin, and soleus, extensor digitalis longus, and tibialis anterior muscles were recovered for assessment using tissue histology and tissue lysate studies.

RESULTS

Control muscle sections showed remarkable microvascular and muscle damage associated with loss of myocyte transverse striation and marked decrease in myocyte nucleus density. A total of 1,496 nuclei were counted in 179 sections of UW-perfused control muscles in contrast to 1,783 counted in 130 sections of paired experimental muscles perfused with the ATPv-enhanced perfusate. This yielded 8 and 13 nuclei/field for the control and experimental muscles, respectively (P < .004). Oxygenation of the perfusion solutions before use did not improve the nucleus density of either the control or experimental muscles (n = 7 animals, P > .05). Total protein isolated from the muscle lysates was similar in magnitude regardless of muscle type, perfusion protocol, or duration of cold ischemia time. Prolonged static cold preservation of the hind limbs completely degraded the composite tissue's Ribonucleic acid (RNA). This supplementary result confirms the notion that that reverse transcription-Polymerase Chain Reaction, enzyme-linked immunosorbent assay, or the respiratory complex II enzyme activity techniques should not be used as indices of graft quality after prolonged static cold storage.

CONCLUSIONS

In conclusion, this study demonstrates that active cellular cytosolic ATP replenishment increases hind limb composite tissue tolerance to extended cold ischemia times. Quality indicators and clinically relevant biomarkers that define composite tissue viability and function during static cold storage are warranted.

Ballistic Facial Trauma Reconstruction: Incidence and Practice Patterns in the Civilian Population

BACKGROUND

Management of nonfatal ballistic facial trauma is well described in the literature for wounds secondary to military combat. However, there is little literature describing such management in civilian practice. We aimed to describe nonmilitary patients with recent nonfatal facial injuries from ballistic trauma using the California Office of Statewide Health Planning and Development patient database.

METHODS

A retrospective study was performed using the California Office of Statewide Health Planning and Development Ambulatory Surgery and Inpatient datasets. All adults with the International Classification of Diseases, 10th Revision codes of severe nonfatal facial trauma from firearms requiring emergent surgery during 2016-2018 were included. Outcomes assessed include number and type of facial procedures performed, hospital length of stay, number of admissions, timing of definitive management, and lifetime hospitalization costs.

RESULTS

A total of 331 traceable patients were identified over this 3-year period. The average age was 35.4 years (SD, 15.2), and 87% were male. The median index admission length of stay was 8 days (interquartile range, 3-15 days). Subsequent readmission was required for 123 (37.2%) patients with 10% mortality in the index admission. Total median charges per patient for all admissions were $257,804 (interquartile range, $105,601-$531,916). A total of 215 patients (65%) had at least 1 facial repair performed. Of all 331 patients, 64.3% underwent musculoskeletal repair (n = 213), 31.4% underwent digestive system repair (n = 104), and 29.6% underwent respiratory system repair (n = 98). The average number of repairs per patient was 2.52 (SD, 3.38), with 35% not having any of the specified International Classification of Diseases, 10th Revision repair codes. A total of 27% of patients had 1 procedure performed, whereas 38% received 2 or more, for an average of 3.87 (SD, 3.5) repairs over the study duration.

DISCUSSION

To our knowledge, this is the first assessment of civilian characteristics of nonfatal ballistic facial trauma in California. Nonfatal facial ballistic trauma results in complex injuries to multiple body systems, requiring long admissions, costly hospital stays, and coordination of care across several surgical specialties. Many patients require a variety of procedures over multiple admissions, highlighting the overall morbidity of these injuries. Future studies will look at how care for these patients differs between various hospitals and geographic regions and whether current civilian management aligns with well-defined military reconstructive protocols for facial ballistic injuries.

Traumatic maxillofacial injuries: Patterns, outcomes, and long-term follow-up of a military cohort

BACKGROUND/AIMS

Maxillofacial trauma poses a distinct challenge on the modern battlefield, and data on its long-term implications are scarce. The aim of this study was to investigate maxillofacial injury characteristics, outcomes, and complications along the continuum of care among hospitalized military personnel from the pre-hospital setting through long-term rehabilitation.

MATERIALS AND METHODS

A registry-based study was undertaken of three national trauma and rehabilitation registries: The Israel Defense Forces Trauma Registry (IDF-TR), which records pre-hospital data. The Israeli National Trauma Registry for in-hospital data and the Israel Ministry of Defense Rehabilitation Department (MOD-RD) registry contain long-term disability data. The cohort comprised IDF soldiers who suffered maxillofacial injuries between 1997 and 2020.

RESULTS

A total of 672 patients with maxillofacial injuries were included in the study, and 6.4% of all trauma admissions were related to maxillofacial injuries. Of these, 366 (54%) were injured in non-military (NMC) circumstances, and 306 (46%) were wounded in military circumstances (MC). The mechanisms of injury were mainly traffic-related among the NMC group compared with an explosion in the MC group. Maxillofacial fractures were frequently associated with traumatic brain injuries with higher rates in the NMC group than in the MC group (55% vs. 30%, p < .001). In a multivariate analysis, zygomatic and orbital fractures were associated with higher odds of concomitant head injury. The most common categories of long-term disability included central nervous system disorders, skull injuries, epilepsy, hearing impairment, ophthalmologic conditions, and post-traumatic stress disorder.

CONCLUSIONS

Maxillofacial injuries are often associated with concomitant traumatic brain injury. Long-term disabilities associated with these injuries included the central nervous system, hearing, ophthalmologic impairments, and post-traumatic stress disorder.

The New Face of War: Craniofacial Injuries from Operation Inherent Resolve

INTRODUCTION

During the last 20 years of conflict in the Middle East, improvements in body armor and the use of improvised explosive devices has resulted in an increased incidence of complex craniofacial trauma (CFT). Currently, CFT comprises up to 40% of all casualties. We present new data from the recent conflict in Iraq and Syria during Operation Inherent Resolve.

METHODS

Data was collected for patients treated at Role 1, Role 2, and Role 3 facilities in Iraq and Syria over a one-year period. During this time, a specialized Head & Neck surgical augmentation team was deployed and co-located with the central Role 3 facility. Data included for this cross-sectional study: injury type and mechanism, triage category, initial managing facility and subsequent levels of care, and procedures performed.

RESULTS

Ninety-six patients sustained CFT over the study period. The most common injuries were soft tissue (57%), followed by cranial (44%) and orbital/facial (31%). Associated truncal and/or extremity injuries were seen in forty-six patients (48%). There were marked differences in incidence and pattern of injuries between mechanisms (Figure, all p < 0.05). While IEDs had the highest rate of cranial and truncal injuries, GSW and blunt mechanisms had higher incidences of orbital/facial and neck injuries. Overall, 45% required operative interventions including complex facial reconstruction, craniotomy, and open globe repair. Mortality was 6% with 83% due to associated severe brain injury. Most patients were local nationals (70%) who required discharge or transfer to the local healthcare system.

CONCLUSION

Complex craniofacial trauma is increasingly seen by deployed surgeons, regardless of subspecialty training or location. Deployment of a centrally located Head & Neck team greatly enhances the capabilities for forward deployed management of CFT, with excellent outcomes for both U.S. and local national patients.

LEVEL OF EVIDENCE

Level 4, retrospective study.

The Orthodontist's Role in Post-Battlefield Craniomaxillofacial Trauma Reconstruction

INTRODUCTION

In modern conflicts, deployed members are more vulnerable to craniomaxillofacial (CMF) injury than in previous conflicts. Patients presenting with CMF trauma are susceptible to post-trauma dental malocclusion and may require lengthy rehabilitation to achieve pre-injury function. This study surveyed military health care professionals who are potential contributors to CMF trauma rehabilitation teams to evaluate the orthodontist's inclusion in treating to the final outcome.

METHODS

Following approval from the Defense Health Agency Information Management Collections Office (Control Number: 9-DHA-1031-E) and the Air Force 59th Medical Wing Institutional Review Board (Reference Number: FWH20210061E), a survey study was conducted from April 2021 to July 2021. Volunteer participants were recruited from orthodontists, oral maxillofacial surgeons, medical specialists, and other dental specialists who have worked in military healthcare. Respondents reported their current practice treating CMF trauma, self-evaluated their knowledge of different aspects of the process, and submitted their perceptions on system and patient-limiting factors which affect outcomes. Descriptive statistics were conducted for ordinal data and chi-square tests for categorical data. Kruskal-Wallis analyses of variance compared cohorts with further Mann-Whitney U tests to distinguish the difference in cohorts.

RESULTS

Valid responses were collected from 171 participants. The responses were mostly from active duty military (93%) and well distributed among orthodontists, oral maxillofacial surgeons, other dental specialists, and medical specialists. When reporting current CMF trauma treatment practices, the majority of dental specialists stated they most commonly participate in a multidisciplinary team that addresses any CMF trauma case (68.4%) whereas medical specialists most commonly act as solo independent provider practice (53.6%). Dental specialists reported follow-up with post-trauma patients greater than 1 year and medical specialists reported the shortest post-trauma follow-up time with a median of 0 to 3 months. The majority of participants selected at least one system factor limiting CMF trauma care (78.7%) and at least one patient factor limiting CMF trauma care (86.3%). When asked about orthodontic participation in multidisciplinary teams, the responses showed a great range with orthodontists never included in CMF trauma care 23.1% of the time and always consulted regarding trauma cases 10.7% of the time. Other survey data collected allows the investigators to draw conclusions regarding specific limitations to treatment and recommendations for improvement, along with qualitative responses from survey participants.

CONCLUSIONS

Orthodontics, while available in the military, is underutilized in treating post-warfare or other CMF trauma. There are both system- and patient-limiting factors in the treatment of battlefield and non-battlefield CMF trauma. In addition, there are limitations to the inclusion of orthodontists in CMF trauma care which include the physical distance from primary treating specialists and the absence of standard referral protocols. Oral maxillofacial surgeons reported the highest understanding of the military orthodontist's contribution to a CMF trauma treatment team and medical specialists reported the lowest understanding. Advanced technology tools could help improve outcomes and multidisciplinary interactions. Further research is needed to study the complete CMF trauma rehabilitation process in military treatment facilities, evaluate the efficiency of cross-specialty referrals, and highlight best practices and protocols of functioning multidisciplinary teams.

Head Face and Neck Surgical Workload From a Contemporary Military Role 3 Medical Treatment Facility

INTRODUCTION

Previous analyses of head, face, and neck (HFN) surgery in the deployed military setting have focused on the treatment of injuries using trauma databases. Little has been written on the burden of disease and the requirement for follow-up care. The aim of this analysis was to provide the most comprehensive overview of surgical workload in a contemporary role 3 MTF to facilitate future planning.

METHOD

The operating room database and specialty surgical logbooks from a U.S.-led role 3 MTF in Afghanistan were analyzed over a 5-year period (2016-2020). These were then matched to the deployed surgical TC2 database to identify reasons for treatment and a return to theatre rate. Operative records were finally matched to the deployed Armed Forces Health Longitudinal Technology Application-Theater outpatient database to determine follow up frequency.

RESULTS

During this period, surgical treatment to the HFN represented 389/1989 (19.6%) of all operations performed. Surgery to the HFN was most commonly performed for battle injury (299/385, 77.6%) followed by disease (63/385, 16%). The incidence of battle injury-related HFN cases varied markedly across each year, with 117/299 (39.1%) being treated in the three summer months (June to August). The burden of disease, particularly to the facial region, remained constant throughout the period analyzed (mean of 1 case per month).

CONCLUSIONS

Medical planning of the surgical requirements to treat HFN pathology is primarily focused on battle injury of coalition service personnel. This analysis has demonstrated that the treatment of disease represented 16% of all HFN surgical activities. The presence of multiple HFN sub-specialty surgeons prevented the requirement for multiple aeromedical evacuations of coalition service personnel which may have affected mission effectiveness as well as incurring a large financial burden. The very low volume of surgical activity demonstrated during certain periods of this analysis may have implications for the maintenance of surgical competencies for subspecialty surgeons.

[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.

Neck injuries - israel defense forces 20 years' experience

BACKGROUND

Neck injuries are an important cause of combat mortality and morbidity. This study's objective was to examine the characteristics and causes of neck injuries among Israel Defense Forces (IDF) and emphasize the best treatment protocols for the advanced life support providers in the prehospital combat environment.

METHODS

The IDF Trauma Registry (IDF-TR) includes prehospital data regarding casualties treated by the IDF's medical forces. This study was a retrospective, observational study that included all casualties who were injured between January 2006 and December 2018.

RESULTS

Between January 2016 and December 2018, 3294 casualties were recorded. During the study period, 1% (41/3,394) of all injury casualties in the registry were isolated neck injuries compared to 94% (3185/3,394) without neck injury. 42% (14/41) percent of the neck casualties were classified as urgent compared to 26% (830/3185, P = 0.09) in the no neck group. The most frequent type of injury mechanism in the neck casualties was penetrating injury (54% 22/41), mostly due to shrapnel (68% 15/22). 60% of neck injured personnel were injured during the 2nd Lebanon War and Operation Protective Edge in high-intensity conflicts. As for life-saving interventions, advanced airway interventions were performed in 12% of neck injured group (5/41) compared to 3% (104/3185, P = 0.02) in the no neck group. We revealed that cricothyroidotomy was performed in almost 10% (4/41) of neck injured casualties compared to only 1% (19/3185, P<0.0001) in no neck casualties. As for damage control resuscitation, neck injury casualties received higher amounts of Fresh Dried Plasma 7% (3/41) Vs. 1% (32/3185, P = 0.02) and Tranexamic acid 15% (6/41) Vs. 4% (124/3185, P = 0.01) compared to non-neck casualties.

CONCLUSIONS

Military neck injuries are a significant cause of substantial disability and result in incompatibility with combat duties in previously healthy soldiers. Prompt medical care, especially urgent hemodynamic and airway management, is paramount in these injuries. Routine use of designated neck protection might lower the number of neck injuries, mitigate their severity, and even decrease mortality.

LEVEL OF EVIDENCE

Level III (Retrospective study with up to two negative criteria).

Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: A comparison of treatment at US and United Kingdom medical treatment facilities

Supplemental digital content is available in the text.

The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.

Definitive Management of a Traumatic Airway: Case Report

Maxillofacial and neck trauma from penetrating injuries present unique challenges for anesthesia providers and surgeons. In the austere conditions of a combat setting these challenges may be amplified due to limited resources and injury severity. Currently there is a lack of evidence and consensus on how to best manage a traumatized airway in this situation. The authors of this paper present the successful emergency management of a traumatized airway from a severe maxillofacial and neck-penetrating wound. A stepwise team approach using strong communication and a global mental model facilitated definitive airway management in this case allowing for safe transport to definitive care.

Facial injury management undertaken at US and UK medical treatment facilities during the Iraq and Afghanistan conflicts: a retrospective cohort study

OBJECTIVES

To perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.

SETTING

The US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011.

PARTICIPANTS

US and UK military personnel, local police, local military and civilians.

PRIMARY AND SECONDARY OUTCOME MEASURES

An adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables.

RESULTS

Facial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ²: 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066).

CONCLUSIONS

The capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future.

Diagnosis, management and treatment of neck trauma

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

Reconstructing the Face of War

Introduction

Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites.

Methods

A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images.

Results

Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed.

Conclusion

While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.

How are we currently training and maintaining clinical readiness of US and UK military surgeons responsible for managing head, face and neck wounds on deployment?

Introduction

The conflicts in Iraq and Afghanistan provided military surgeons from the USA and the UK with extensive experience into the management of injuries to the head, face and neck (HFN) from high energy bullets and explosive weaponry. The challenge is now to maintain the expertise in managing such injuries for future military deployments.

Methods

The manner in which each country approaches four parameters required for a surgeon to competently treat HFN wounds in deployed military environments was compared. These comprised initial surgical training (residency/registrar training), surgical fellowships, hospital type and appointment as an attending (USA) or consultant (UK) and predeployment training.

Results

Neither country has residents/registrars undertaking surgical training that is military specific. The Major Trauma and Reconstructive Fellowship based in Birmingham UK and the Craniomaxillofacial Trauma fellowship at Duke University USA provide additional training directly applicable to managing HFN trauma on deployment. Placement in level 1 trauma/major trauma centres is encouraged by both countries but is not mandatory. US surgeons attend one of three single-service predeployment courses, of which HFN skills are taught on both cadavers and in a 1-week clinical placement in a level 1 trauma centre. UK surgeons attend the Military Operational Surgical Training programme, a 1-week course that includes 1 day dedicated to teaching HFN injury management on cadavers.

Conclusions

Multiple specialties of surgeon seen in the civilian environment are unlikely to be present, necessitating development of extended competencies. Military-tailored fellowships are capable of generating most of these skills early in a career. Regular training courses including simulation are required to maintain such skills and should not be given only immediately prior to deployment. Strong evidence exists that military consultants and attendings should only work at level 1/major trauma centres.

Management of High-Velocity Injuries of the Head and Neck

Trauma centers must prepare to manage high-velocity injuries resulting from a mass casualty incidents as global terrorism becomes a greater concern and an increasing risk. The most recent conflicts in Iraq and Afghanistan have significantly improved understanding of battlefield trauma and how to appropriately address these injures. This article applies combat surgery experience to civilian situations, outlines the physiology and kinetics of high-velocity injuries, and reviews applicable triage and management strategies.

The Joint Facial and Invasive Neck Trauma (J-FAINT) Project, Iraq and Afghanistan: 2011-2016

Objective

Define the number and type of facial and penetrating neck injuries sustained in combat operations in Iraq and Afghanistan from 2011 to 2016. Compare recent injury trends to prior years of modern conflict.

Study Design

Case series with chart review.

Setting

Tertiary care hospital.

Methods

The Joint Theater Trauma Registry (JTTR) was queried for facial and neck injuries from Iraq and Afghanistan from June 2011 to May 2016. Injury patterns, severity, and patient demographics were analyzed and compared to previously published data from combat operations during January 2003 to May 2011.

Results

A total of 5312 discrete facial and neck injuries among 922 service members were identified. There were 3842 soft tissue injuries (72.3%) of the head/neck and 1469 (27.7%) facial fractures. Soft tissue injuries of the face/cheek (31.4%) and neck/larynx/trachea (18.8%) were most common. The most common facial fractures were of the orbit (26.3%) and maxilla/zygoma (25.1%). Injuries per month were highest in 2011 to 2012 and steadily declined through 2016. The percentage of nonbattle injuries trended up over time, ranging from 14.7% to 65%. Concurrent facial/neck soft tissue trauma or fracture was associated with an overall mortality rate of 2.44%. Comparison of our data to that previously published revealed no statistical difference in concurrent mortality (3.5%-2.2%, P = .053); an increase in orbital fractures ( P < .005), facial nerve injury ( P < .0005), and ear/tympanic membrane perforations ( P < .0005); and a decrease in mandible fractures ( P < .005).

Conclusion

Penetrating neck and facial injuries remain common in modern warfare. Assessing injury characteristics and trends supports continued improvements in battlefield protection and identifies areas requiring further intervention.

Stab injury to the preauricular region with laceration of the external carotid artery without involvement of the facial nerve: a case report

Background

Open injuries to the face involving the external carotid artery are uncommon. These injuries are normally associated with laceration of the facial nerve because this nerve is more superficial than the external carotid artery. Hence, external carotid artery lesions are usually associated with facial nerve dysfunction. We present an unusual case report in which the patient had an injury to this artery with no facial nerve compromise.

Case presentation

A 25-year-old Portuguese man sustained a stab wound injury to his right preauricular region with a broken glass. Immediate profuse bleeding ensued. Provisory tamponade of the wound was achieved at the place of aggression by two off-duty doctors. He was initially transferred to a district hospital, where a large arterial bleeding was observed and a temporary compressive dressing was applied. Subsequently, the patient was transferred to a tertiary hospital. At admission in the emergency room, he presented a pulsating lesion in the right preauricular region and slight weakness in the territory of the inferior buccal branch of the facial nerve. The physical examination suggested an arterial lesion superficial to the facial nerve. However, in the operating theater, a section of the posterior and lateral flanks of the external carotid artery inside the parotid gland was identified. No lesion of the facial nerve was observed, and the external carotid artery was repaired. To better understand the anatomical rationale of this uncommon clinical case, we dissected the preauricular region of six cadavers previously injected with colored latex solutions in the vascular system. A small triangular space between the two main branches of division of the facial nerve in which the external carotid artery was not covered by the facial nerve was observed bilaterally in all cases.

Conclusions

This clinical case illustrates that, in a preauricular wound, the external carotid artery can be injured without facial nerve damage. However, no similar description was found in the reviewed literature, which suggests that this must be a very rare occurrence. According to the dissection study performed, this is due to the existence of a triangular space between the cervicofacial and temporofacial nerve trunks in which the external carotid artery is not covered by the facial nerve or its branches.

The surgical management of facial trauma in British soldiers during combat operations in Afghanistan

INTRODUCTION

The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan.

METHODS

Hospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013.

RESULTS

566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK.

CONCLUSIONS

The presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury.

Management of Battlefield Injuries to the Skull Base

High velocity skull base injuries on the battlefield are unique in comparison to most civilian sector trauma. With more than 43,000 United States military personnel injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), the most recent conflicts in Iraq and Afghanistan have significantly expanded the understanding of the physiology of modern battlefield trauma and how to appropriately address these injuries. The acute care principles of effective triage, airway management, and hemorrhage control in these injuries can be life saving and are reviewed here. Specific injury patterns and battlefield examples are reviewed as well, with a review of some of the lessons learned while providing care in a deployed setting. Utilization of the knowledge learned in Iraq and Afghanistan, which have improved casualty care of deployed service members, can be used both in future military conflicts and in civilian trauma care.

Management and reconstruction of blast wounds of the head and neck

PURPOSE OF REVIEW

The purpose of this review is to highlight recent literature related to the initial management and reconstruction of blast injuries to the head and neck.

RECENT FINDINGS

An increasing percentage of combat-related injuries are caused by blast trauma. Management of blast trauma over the last 10 years has improved understanding of the unique nature of these injuries and the importance of thoughtful management and reconstruction. Blast trauma is associated with an increased need for definitive airway management. As a result, initial triage principles of airway management and hemorrhage control are extremely important in the acute setting. Blast trauma results in high-velocity injuries that can lead to extensive soft tissue damage, which has important implications for reconstruction. Staging reconstruction is an important consideration for more extensive injuries.

SUMMARY

Experience on the battlefield with blast injuries over the last decade has led to efficient triage with focus on hemorrhage and airway control. The lessons learned in Iraq and Afghanistan with the unique physiology of blast trauma have improved the casualty care of service members and can be used both in future military conflicts and in civilian trauma care.

Impact of Injury Mechanisms on Patterns and Management of Facial Fractures

Mechanisms causing facial fractures have evolved over time and may be predictive of the types of injuries sustained. The objective of this study is to examine the impact of mechanisms of injury on the type and management of facial fractures at our Level 1 Trauma Center. The authors performed an Institutional Review Board-approved review of our network's trauma registry from 2006 to 2010, documenting age, sex, mechanism, Injury Severity Score, Glasgow Coma Scale, facial fracture patterns (nasal, maxillary/malar, orbital, mandible), and reconstructions. Mechanism rates were compared using a Pearson χ2 test. The database identified 23,318 patients, including 1686 patients with facial fractures and a subset of 1505 patients sustaining 2094 fractures by motor vehicle collision (MVC), fall, or assault. Nasal fractures were the most common injuries sustained by all mechanisms. MVCs were most likely to cause nasal and malar/maxillary fractures (P < 0.01). Falls were the least likely and assaults the most likely to cause mandible fractures (P < 0.001), the most common injury leading to surgical intervention (P < 0.001). Although not statistically significant, fractures sustained in MVCs were the most likely overall to undergo surgical intervention. Age, number of fractures, and alcohol level were statistically significant variables associated with operative management. Age and number of fractures sustained were associated with operative intervention. Although there is a statistically significant correlation between mechanism of injury and type of facial fracture sustained, none of the mechanisms evaluated herein are statistically associated with surgical intervention. Clinical Question/Level of Evidence: Therapeutic, III.

Blunt traumatic injury in the Arab Middle Eastern populations

BACKGROUND

Trauma represents a global public health concern with an estimated 5 million deaths annually. Moreover, the incidence of blunt traumatic injuries (BTI) particularly road traffic accidents (RTAs) and workplace-related injuries are rising throughout the world-wide.

OBJECTIVES

We aimed to review the epidemiology and prevention of BTI, in the Arab Middle East.

MATERIALS AND METHODS

A traditional narrative literature review was carried out using PubMed, MEDLINE and EMBASE search engines. We used the keywords "traumatic injuries", "blunt" "epidemiology", "Arab Middle East" between December 1972 and March 2013.

RESULTS

The most common mechanisms of BTI in our region are RTAs, falls from height, struck by heavy objects and pedestrian motor vehicle trauma crashes. The rate of RTA and occupational injuries are markedly increased in the region due to rapid industrial development, extreme climatic conditions and unfamiliar working environment. However, lack of reliable information on these unintentional injuries is mainly responsible for the underestimation of this trauma burden. This knowledge deficit shields the extent of the problem from policy makers, leading to continued fatalities. These preventable injuries in turn add to the overall financial burden on the society through loss of productivity and greater need of medical and welfare services.

CONCLUSION

In the Arab Middle East, population-based studies on the incidence, mechanism of injury, prevention and outcome of BTI are not well-documented. Therefore, region-specific BTI studies would strengthen surveillance to better understand the burden of these injuries in the region.