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Contemporary management of ballastic injuries
- 2. CONTEMPORARY MANAGEMENT OF MAXILLOFACIAL BALLISTIC TRAUMA British journal of Oral and Maxillofacial Surgery : 2017 Muhammad Ramzan Adeel Resident Oral and Maxillofacial Surgery
- 3. PRESENTATION LAYOUT Introduction Pathophysiology Timing of treatment • Immediate management • Damage control Maxillofacial Surgery • Early management • Long term rehabilitation
- 4. INTRODUCTION • Injuries directly by or secondary to firearms and explosive devices • 79% by IED’S • 2-3 % mortality
- 5. PATHOPHYSIOLOGY • Bullet wound from high velocity rifles • Transfer of energy and cavitation • Secondary formation of missiles by hard tissue • Most commonly by IED’S
- 6. PATHOPHYSIOLOGY • IED’S • Primary blast injuries • Secondary blast injuries • Tertiary blast injuries • Quaternary blast injuries
- 7. IED’S PRIMARY BLAST INJURIES • Sudden increase in air pressure • Air sinus containing bones are primarily effected • Isolated orbital blow out fractures
- 8. IED’S SECONDARY BLAST INJURIES • Energised fragments or soil overlying a buried IED
- 9. IED’S TERTIARY BLAST INJURIES • Thrown by explosion • Collision with nearby objects
- 10. IED’S QUARTERNARY BLAST INJURIES • Thermal effects • Burns
- 11. TIMING OF TREATMENT • Different mechanisms of injury in civilian and military • Different timings of treatment • Damage control maxillofacial surgery within an hour • Exsanguination • Airway
- 12. IMMEDIATE MANAGEMENT • 0-120 Min • Based on ATLS principles • Modification in military • Hemorrhage precedes the airway • Cervical spine injury • Cricothyroidotomy airway of choice
- 13. DAMAGE CONTROL MAXILLOFACIAL SURGERY Surgical operations are shortened to the minimum to prioritise short- term physiological recovery over anatomical reconstruction in seriously injured and compromised patients
- 14. DAMAGE CONTROL MAXILLOFACIAL SURGERY • < 120 Minutes • Rapid initial assessment of injuries • Life threatening injuries prioritized • Seriously injured patients • By pass emergency department • Taken directly to OT • CT Scan if possible
- 15. DAMAGE CONTROL MAXILLOFACIAL SURGERY • First facial examination • Review of CT Scan • Meticulous examination • Laceration of scalp • Nasal fractures • Missing teeth • Deep damage from small fragments
- 16. DAMAGE CONTROL MAXILLOFACIAL SURGERY • Heamorrhage • early and aggressive debridement • Temporary reduction and fixation of mandibular fractures
- 17. HAEMORRHAGE • Packing and Compression • Radiological guided embolization • Ligation of external carotids • Blind clamping should be avoided • Facial nerve and parotid duct damage • Anterior and posterior nasal packing • Rule out base of skull fracture
- 18. EARLY AND AGGRESSIVE DEBRIDEMENT • To prevent infection • Scrubbing brushes, pulsed lavage, surgical dermabrasion • Remove ragged margins 1-2 mm • Severed branches of facial nerve and parotid ducts tagged • low threshold for tracheostomy • delayed swelling of airway suspected
- 19. EARLY AND AGGRESSIVE DEBRIDEMENT • Most facial wound closure within 36 hours of injury • Delayed closure not necessary like rest of the body • Serial debridement highly unusual • Primary closure • Viable tissue • Tension free closure • Delayed primary closure • Tissue vitality questionable • Iodine soaked gauze pack
- 20. TEMPORARY REDUCTION AND FIXATION OF FRACTURES • Reduce bleeding and pain • Comminuted and open to cutaneous and mucosal surface • Orbital compartment syndrome • Lateral canthotomy • Inferior cantholysis
- 21. TEMPORARY REDUCTION AND FIXATION OF FRACTURES • Mandibular fractures • External fixators • Generic hoffman device • Mandible specific external fixators • External fixators • No compromise of airway as in IMF • Easy debridement of tissues • Oral hygiene maintainace • Good nutrition • Trismus due to fibrosis and scarring is reduced
- 22. TEMPORARY REDUCTION AND FIXATION OF FRACTURES • External fixators for midface • Lavant frame • Maxilla or zygoma attached to supraorbital ridges • Better than box frame • Mini plate fixation of smaller segments
- 23. Hoffman external fixator mandible
- 24. Lavant frame
- 25. Box frame
- 26. Halo frame
- 27. EARLY MANAGEMENT • 120 min -28 days • Asses extent of necrosis in 36 hours • Primary closure if possible • Debridement and suture of deep spaces • Surgical drains
- 28. EARLY MANAGEMENT • local rotation and advancement flaps • Preserve facial vessels for future anastomosis • Skin grafts are best avoided for first 5-7 days • Risk of infection • More prone to contracture • once a scar has contracted then it is almost impossible to rectify later
- 29. EARLY MANAGEMENT • Infection rates range from 7 – 19% • Bullets and fragment wounds are contaminated • Contrary to popular belief • Patient from iraq and afganistan • Actinobacter baumanni • Empiral broad spectrum antibiotic for 10-14 days • Clostridium perfringens and clostridium tetani
- 30. EARLY MANAGEMENT • High energy transfer • Thrombosis 3 cm away from macroscopic wound • Consideration for microvascular anastomosis • 7-10 days for repair • Anastomosis after 2 weeks
- 31. EARLY MANAGEMENT • Complex military ballistic facial trauma in UK and US • Secure airway and reconstruct mandible in 3-5 days • Contemporary management of mandibular fracture • Miniplate osteosynthesis • Serious comminution, periosteal damage, through and through injury • Conventional direct osteosynthesis not recommended
- 32. EARLY MANAGEMENT • Open fractures • Debrided • Irrigated and closed temporarily • Repair be delayed upto 2 weeks for clearance of infection • Except • Fracture that compromise airway • impair hemostasis
- 33. EARLY MANAGEMENT • Longer delays not recommended • Fibrosis and collapse of fibrous tissue envelope • Dental impression • Splints and arch bar for mandible • Vertical height and form of dental arch • To prevent splay at angles
- 34. LONG TERM REHABLITATION • 1-3 months • Provision enough bone • Implants • bone loss replaced • Iliac crest deep circumflex iliac artery flap • Scapular flap • fibular flap
- 35. LONG TERM REHABLITATION • Distraction osteogenesis • Alloplastic methods • Ear, nose , orbit
Editor's Notes
- In the name of ALLAH SWT THE MOST BENEFICIENT THE MOST MERCIFUL
- This is the presentation layout
- Ballistic maxillofacial trauma encompasses all injuries that are sustained either directly by, or secondary to, firearms and explosive devices. 79 percent maxillofacial ballistic injuries were caused by ieds to british soldier in Iraq and afganistan Surprisingly these injuries have very low mortality rate of about 2 to 3%
- Bullet wounds from high velocity rifles result in the trans-fer of considerable energy and cavitation of tissue . Those that pass through the face and jaws often strike hard tissues (the bony skeleton and teeth), which results in deposition of energy and secondary formation of missiles from the hard fragments of tissue.
- Ieds cause injuries in four ways
- Primary blast injuries are caused by the sudden increase in air pressure after an explosion and in the maxillofacial region affect predominantly bones that contain air Evidence of isolated orbital blowout fractures without surrounding rim fractures has been reported
- 5Secondary blast injuries are caused by energised frag-ments, or soil overlying a buried IED
- tertiary blast,which occurs when the casualty is thrown by the explosion and collides with nearby objects; such blunt injuries
- Quaternary injuries are due to thermal effects which causes burns
- Timing of treatment varies in both civilian and military ballistic trauma But in both settings exsanguination and airway management should commence within an hour Excessive loss of blood due to hemorrhage How does exsanguination occur? Exsanguination or bleeding out occurs most often after a major artery is severed and the bleeding is not stopped
- Immediate management should commence from the moment trauma occurred. It is based on ATLS Protocols. However modified atls protocols are used in military setting. In which hemorrhage control is done before airway as there are less chances of airway damage in military setting than bleeding Choice of emergency air is cricothyroidotomy. Always suspect cervicle spine injury in a patients who are thrown away by blast
- Damage control maxillofacial surgery should commence before 2 hours. rapid initial assessment is made to rule out life threatening injureis to other parts of the body Seriously injured patient are often bypassed from emergency department and directly taken to ot. The author has suggested that if ct scan can be of great diagnostic value if it can be done before bringing patient to ot.
- For MAXILLOFACIAL DAMAGE CONTROL SURGERY facial examination is done and ct scan is reviewed. Then meticulous examination is performed to check if there are
- Damage control maxillofacial surgery consists of three parts
- There can be profuse bleeding in Maxillofacial region after trauama but it is rarely associated with appreciable mortality. Most of the hemorrhage in Maxillofacial region is stopped by packing and compression Other methods to control hemorrhage are ligation of external carotids under direct visualization . Anterior and posterior nasal packing in case of nasal bleed after ruling out of base of skull fracture . Blind clamping of vessels should be avoided as it can cause injury to facial nerve and parotid ducts
- Early and aggressive debridement should be performed to prevent infection. Scrubbing brushes pulsed lavage and surgical dermabrasion can be used. If margin are ragged then remove 1-2 mm. if severed branched of facial nerve or parotid duct are found ther must be tagged with no resorbable suture for future anastomosis. There should be a very low threshold to perform tracheostomy. Even if minor swelling of airways is suspected tracheostomy should be performed.
- Most facial wounds can be closed primarily within 36 hours and delayed closure like the rest of the body is not advocated. Serial debridement is highly unusal in facial ballistic wounds. Primary closure can be done if tissues are viable and tension free primary closure is achievable. In case primary closure is not possible or tissue vitality is questionable then wound is packed with iodine soaked gauze pack.
- Temporary reduction and fixation of fractures reduces bleeding and pain. Fractures due to ballsit trauma are often comminuted and are open to cutaneous and mucosal surfaces Explosion can cause orbital blow out fractures and burns which results in orbital compartment syndrome . In this case lateral canthotomy and inferior cantholysis is necessary.
- Mandibular fractures are best reduced and fixed with external fixator like Generic hoffman device and Mandible specific external fixators. External fixatior are preferable to imf because there is no No compromise of airway as in IMF Easy debridement of tissues can be done Oral hygiene maintainace is easy Good nutrition is not compromise and there is less Trismus due to fibrosis and scarring i
- External fixators for midface are lavant frame these are attached to maxilla or zygoma. These better than box frame as there is less interference when patient is lying or sleeping Miniplates can be used to fix small fragment to make large fragrmen which then can be attached to external fixators
- External fixators for midface are lavant frame these are attached to maxilla or zygoma. These better than box frame as there is less interference when patient is lying or sleeping Miniplates can be used to fix small fragment to make large fragrmen which then can be attached to external fixators
- External fixators for midface are lavant frame these are attached to maxilla or zygoma. These better than box frame as there is less interference when patient is lying or sleeping Miniplates can be used to fix small fragment to make large fragrmen which then can be attached to external fixators
- External fixators for midface are lavant frame these are attached to maxilla or zygoma. These better than box frame as there is less interference when patient is lying or sleeping Miniplates can be used to fix small fragment to make large fragrmen which then can be attached to external fixators
- External fixators for midface are lavant frame these are attached to maxilla or zygoma. These better than box frame as there is less interference when patient is lying or sleeping Miniplates can be used to fix small fragment to make large fragrmen which then can be attached to external fixators
- The early management phase last from 2 hours till 28 days. In first 36 hours assess th extent of necrosis if tension free primary closure is possible it can be performed at this stage. Deep spaces should be further debride if it needs and sutured with resorbable suture to remove dead spaces. Surgical drains can be placed.
- Local rotation and advancement flaps can be utilized if facial vessel are not ligated. Because they can be used in future for anastomosis . Skin grafts are best avoided for first 5 to 7 days due to risk of infection and contracture.
- Infection rates from ballistic trauma are poorly charachterized which range form 7 to 19 % Bullets and fragement of ied are contaminated contrary to popular belief Patient who returned from Iraq and afganistan were infected with Actinobacter baumanni Limited evidence exist to guide the choice of antimicrobial. It is Generally accepted that broad spectrum antibiotics should be used for 10 to 14 days.
- High energy transfer can cause thrombosis of vessels 3 cm away form macroscopic wound margin. This should be considered for microvascular anastomosis. These vessels take 7 to 10 days for repair . It is recommended that anastomosis be performed after 2 weeks
- In cComplex military ballistic facial trauma , surgeons in both uk and us secure airway and reconstruct mandible in 3-5 days Contemporary management of mandibular fracture is largely dependant on Miniplate osteosynthesis. However in Serious comminution, periosteal damage, through and through injury Conventional direct osteosynthesis not recommended
- open fractures should be debrided, irrigated, and closed tem-porarily to prevent infection. With the exception of fractures that compromise the airway or impair haemostasis repair may be delayed for up to two weeks after injury to clear any infection
- Longer delays increase the chance of fibrosis and collapse of the soft-tissue envelope,which makes it harder for them to assume their premorbid anatomy. Dental impressions can be taken for the manu-facture of splints and arch bars using the mandible as there ference point. This will provide a guide to vertical height and the form of the dental arch, as it is easy to splay the angles, which results in excess facial width.
- The longer-term rehabilitation of those patients with gross maxillofacial bony injuries revolves around provision of enough bone to enable placement of dental implants Bone loss may be replaced by either free or vascularised bone grafts, with the latter generally taken from the iliac crest deep cir-cumflex iliac artery flap, scapular flap, or fibular flap.
- . In later reconstruction distraction osteogenesis can pro-vide additional bone, with the advantages of no donor site morbidity and slow growth that enable the overlying soft tissues to adapt to the new bony shape. alloplastic methods using prostheses still have a role in those tissues that are cur-rently challenging to reconstruct aesthetically, such as the ears, nose, and orbit.
- . In later reconstruction distraction osteogenesis can pro-vide additional bone, with the advantages of no donor site morbidity and slow growth that enable the overlying soft tissues to adapt to the new bony shape. alloplastic methods using prostheses still have a role in those tissues that are cur-rently challenging to reconstruct aesthetically, such as the ears, nose, and orbit.