A FULL COVERAGE OF GUNSHOT WOUND AND ITS MANAGEMENT

1. GUN SHOT INJURIES
DR. ANKITA SARAF

2.  GSW is a form of physical trauma sustained from
discharge of arm
 It is the second most source of injury and death after
motor vehicle accidents.

3.  Most victims are young males (<38 yr).
 Suicides and assaults far outnumber unintentional and
accidental shootings.
 Firearms are implicated in 58% of male suicides and
37% of female suicides.
 Importantly, the number of patients surviving and
requiring treatment of gunshot injuries outnumber
firearm fatalities by approximately 5:1.
 Shotgun injuries more commonly involved the mandible
and midface

4. Ballistics
 Ballistics is the science of projectile motion.
 Ballistic science seeks to explain the behavior of the projectile and
is typically divided into three stages:
1. Internal (or interior) ballistics
 describes the forces that apply to a projectile from the time the
propellant is ignited to the time the projectile leaves the barrel.
 An important consideration is barrel length.

5. 2. External ballistics
 refers to forces that act on the bullet in flight.
 The primary factors that govern external ballistics are
the weight and shape of the bullet.

6. 3. Terminal ballistics
 is the study of bullet behavior once it impacts the target and is
primarily concerned with how much energy is transferred to the
target material and the resultant damage.
 The science of terminal ballistics is most important to the
surgeon

7. Factors that affect the degree of
injury
1. Type of missile –
Maxillofacial injuries are frequently as a result of solid
missiles.

8. 2. ENERGY AND WOUNDING POWER
 kinetic energy has been used as the basis to explain
wounds caused by a gunshot.
KE = mv2
 where KE is kinetic energy, m is the mass of the projectile,
and v is the velocity of the projectile.
 Wounding power is typically related to the amount of kinetic
energy transferred to the target:
P = m(Vimpact – Vexit)2
 where P is power and V is velocity.
 velocity of a projectile has traditionally been considered far
more important than its mass in wounding power.

9.  Bullet velocity is classified as –
1. Low - <1000feet/sec
2. Medium – 1000 – 2000 feet/sec
3. High - >3000 feet/sec
 Considering a typically sized projectile, a velocity of
approximately 50 m/sec is required to penetrate the
skin, and a velocity of approximately 65 m/sec will
fracture bone

10.  Practically, there is a balance between velocity, projectile
mass, and projectile size that governs the amount of
energy transferred to the target and resultant tissue
wounding.
 These factors govern the four components of projectile
wounding: penetration, permanent cavity formation,
temporary cavity formation, and fragmentation

11.  Penetration allows the projectile to transmit kinetic energy
and destroy tissue. A bullet must penetrate to a sufficient
depth to cause damage.
 The permanent cavity describes the space that results from
direct tissue disruption and destruction. It is a function of the
penetration and size of the projectile. It is generally
considered to be the most important factor in the wounding
and stopping power of a particular cartridge and bullet.

12.  Fragmentation – when a bullet strikes bone, the kinetic
energy is expended and transferred to fragments which
act as secondary missiles of much lower velocity. In
lining tissues the secondary missiles are thrown away
from the passage of bullet in a radial direction, causing
temporary cavity.

13.  The temporary cavity is produced as
the projectile travels through the target
tissue.
 Transfer of kinetic energy results in a
stretching of elastic tissues.
 Although they may remain intact, some
of these tissues may be irrecoverably
damaged.
 Arteries may suffer pseudoaneurysm
formation and rupture, and nerves may
fail to recover function.

14.  Occasionally, the tissues are unable to contain the
temporary cavity when the energy released is large and
this accounts for the explosive nature of some ultra high
velocity wounds.
 Cavitation cause – dissipation of kinetic energy of
missile produces steam which is contained under
pressure in the cavity. This causes irregular walls of
cavity with splitting of muscle. This pressure causes
damage to the tissues.

15.  A very small projectile traveling at high velocity striking
an area of low density (e.g., fat) may impart far less
damage than a larger projectile traveling at a lower
velocity and striking an area of high density (e.g., bone).

16. Firearms
 Firearms are generally classified as handguns, rifles, and shotguns.
 Most handguns and rifles have barrels with internal grooves referred to as
rifling that impart a spin to the bullet.
 The spin imparted by rifling keeps the projectile stable in flight over longer
distances.
 Eventually, all projectiles become unstable in flight because the center of
gravity lies well behind the center of resistance (the bullet tip) causing them
to take on various motions during flight.
 Oscillation around the long axis of the bullet is referred to as yaw. Rifling
seeks to stabilize yaw but imparts its own motion, referred to as precession
(circular yawing).
 to decrease these motions in flight; a “boat tail” bullet, intended to be stable
over longer distances.
 Upon encountering a denser substance such as tissue, the projectile
immediately starts tumbling (rotation of bullet around center). Increased
tumbling causes more tissue wounding because it presents a larger surface
area.
 Bullets which fragment on impact causes more tissue dectruction – jacketed
bullets.

17. SHOTGUN WOUNDS
 Shotgun pellets have significant aerodynamic resistance and give
up substantial amounts of kinetic energy during flight.
 In type I shotgun injuries (<5 m), the pellets strike the target as
a single mass, resulting in massive kinetic energy transfer, tissue
avulsion, and a high mortality rate (85–90%).
 Type II injuries (5–12 m) usually result in much less tissue
destruction. At these distances, there is significant dispersal of the
pellets and loss of energy. Penetration may occur through deep
fascia, but fractures are rare. mortality is less (15–20%).
 Type III, >12m, usually only the skin is penetrated and mortality
is rare (0–5%).

18. Patterns of injury
 Penetrating wounds – caused by missiles or low impact
velocity in which a small point of entry is found with
missile embedded in the tissue. Mass of missile is
important for determining the damage’
 Perforating wounds – high velocity missiles with entry
and exit wounds.
 Avulsive wound –medium velocity with various degrees
of spin. Massive wound with avulsion and loss of tissues.

19. 1. Tangential
2. Transverse – a. high level
b. mid level
c. low level
d. neck

20. Site of wounds
Upper face –
 most danegerous as they tend to involve the eyes and
cranial cavity.
 NOE injuries are related to vision loss or CSF leak
 If enters cranial cavity – risk of meningitis & damage to
cranial nerves.

21. Middle Face –
 Because of the relatively soft consistency of the
maxillary bone, shock waves do not produce fracture of
the teeth from the point of impact.
 Penetrating injuries to antrum – difficult in soft tissue
closure.
 Sever hemorrhage – maxillary at. & epistaxis due to ant
ethmoidal at
 Tangential injuries – parotid fistula & facial nv damage
 ZMC injuries & tmj causes Ankylosis

22. Lower face -
 From dentoalveolar fractures to comminuted mandible
fractures.
 Due to dense bone the shock waves causes fracture of
teeth below gingival margin.
 Comminuted symphysis / missiles passing through base
of tongue – airway obstruction

23. Neck –
 Elasticity of the BVs and nerves makes them push from
path of bullet.
 Direct damage of major vessels – hemorrhage
 If lodged close to esophagus – secondary infection
 Injury to brachial plexus , cervical pleura or spinal cord –
life threatining.

24. management
 The main objective in a gunshot injury is preservation of
life.
 Every 10 mins delaying definitive treatment drops
survival rate by 10%

25. Immediate management
 Airway
 Shock
 Infection
 Pain

26. A. Prevention of respiratory obstruction –
 causes – bleeding in airway
 foreign body – bone fragement
 fall of tongue
 edema of oropharynx & larynx
 laceration of soft palate causing
mechanical obstruction

27.  Toilet
 Posture
 Control of hemorrhage – pressure pack,
clamps, nasal packing.
 Tongue traction
 endotracheal intubation
 Tracheostomy – laryngeal edema, severe
hemorrhage, multistage treatment with IMF,
safe post op recovery.

28. B. Hemorrhage control
 Neurogenic shock –severe pain & mental stress.
Sweating, pallor, fall of BP and Pulse
 Oligaemic shock- severe blood loss. Facial Pallor, loss of BP, fast
thready pulse.
 The most commonly involved vessels in these cases were the
maxillary and facial arteries.

29.  Fluid replacement- RL, Dextran(10ml/kg),
blood products.
Monitoring of the volume by urine output,
CVP(13 cm H2O) or when BP comes to
normal
 Injuries at the skull base may benefit
from angiography and embolization
 Lacerations of the internal jugular artery
are best controlled with ligation or repair

30. C. Prevention & control of infections –
 preventive measures –
 polyvalent antitoxin
 Ab – penicillin + streptomycin, second generation
cephalosporin, gentamycin (1.2mg/kg/) or
chloramphenicol – as soon as possible – for 3-4 weeks
 Booster dose of toxoid
 Toileting of the wound

31. D. Control of pain & discomfort –
 No powerful anlagesics – depression of respiration &
consciouness

32. Primary treatment
a. Soft tissue wound
o As whole wound track is available for
surgical excision & because of abundant
bloodsupply – early closure within 24
hrs(wound edges excised 1-2mm)
o Wounds seen later or caused by short
range shotgun blast – drainage with open
packing, delayed primary closure
o Watertight closure of mucosal surfaces
o Tension – undermining upto 5 cms

33. b. Mandible fracture –
o Proper debridement – 1% cetrimide (detergent
antisepttic solution)
o Dettached small fragements to be removed.
(controversial)
o All broken teeth – extracted. But if surgical ext is
required – delay.
o Reduction & fixation –
o Water tight closure of mucosa
o Drains – post operative irraigation of fracture site

34. C. mid face fractures –
o Alignment of maxillary arch easily achieved by
manipulation or arch bar.
o if antral perforation – WHV pack, ( supports comminuted
ZMC and orbital #)

35. D. Other structures –
 Dural tears – recognized by CSF leak.
air within cranial cavity. In such cases early reduction of
fracture will risk the chances of meningitis.

36.  Neck
 GSWs involving the face may be associated with an entrance or exit
wound in the neck, which is divided into three zones.
 Zone I is commonly defined as the area from the clavicles to the cricoid
cartilage. It contains the inferior aspect of the trachea and esophagus
along with the major vessels. Risk of injury to the great vessels is
common in this area, and consequently, injuries to zone I carry a high
mortality rate (~12%)
 Zone II represents the area from the cricoid cartilage to the angle of the
mandible. It contains the common carotid arteries, internal and external
carotid arteries, internal jugular veins, larynx, hypopharynx, and cranial
nerves X, XI, and XII. It is the largest area and, therefore, the zone
most commonly involved in penetrating neck trauma
 Zone III spans the region from the skull base to the angle of the
mandible. It contains the carotid arteries, the internal jugular veins, and
the pharynx along with multiple cranial nerves exiting the skull base.

37. computed
tomographic

38. Imaging
 Following the ATLS protocol, standard cervical spine and
chest radiographs should be obtained
 Spiral computed tomography (CT) combined with three-
dimensional reconstructions allows the surgeon an
unparalleled view of the extent of damage to the
maxillofacial skeleton
 Computed tomographic angiography can also be useful
in certain situations for evaluating vascular damage
 Panoramic radiographs – dental assessment.

39. Intermediate care
1. Diet & feeding
 Liquid diet
 Ryles tube – extensive injury
 Saliva shield – oral sphincter could not be corrected.
2. Oral hygiene
 Encourage to brush
 Sodium perborate mouthwash
 4% sodium bicarbonate – irrigation
 1% hydrocortisone ointment over lips

40. 3. Control of infection-
 The heat generated by the discharge of the propellant as
well as the friction between the bullet and the barrel is
not sufficient to sterilize the bullet.
 Contamination can occur from the bullet and also from
skin flora and foreign bodies (clothing) carried into the
wound.
 Devitalized tissue and vascular congestion lead to an
ideal environment for bacterial growth.
Bacterial invasion may cause –
 Septicaemia
 Pulmonary complications – aspiration of infected bodies
 Meningitis
 Thrombophlebitis
 Secondary hemorrhage – septic breakdown of a clot
 Non union of fracture sites

41. Secondary treatment
 Minimal bone & soft tissue loss – reconstruction of bone
precedes soft tissue closure
 Severe injury -
reconstruction of soft tissue precedes bone continuity

42. 1. Loss of specialized organs which cant be replaced – prosthesis
of teeth, eyes , ears
2. Loss of specialized tissue whose function cant be restored –
nerve grafting (full restoration can never be achieved)
 In heavily contaminated wounds, repair should be delayed for
48 to 72 hours, given the possibility that grafts will be required
to span damaged segments.
 Beyond 72 hours, distal branches of the facial nerve will not
respond to a nerve stimulator, making their identification
difficult. If possible, tagging the branches with suture at the
initial surgery is invaluable.
 Extensive damage to the proximal nerve may require a
temporal bone dissection to identify a viable proximal nerve for
grafting.
 Injuries distal to a line dropped vertically from the lateral
canthus (zone of arborization) do not typically require repair
because of the multiple interconnections distal to this line and
the reasonable expectation of return of function, even if the
nerve is temporarily nonfunctioning

43. Salivary Ducts
 Transected salivary ducts may be repaired or ligated
depending on the amount of damage.
 The parotid duct can be repaired over an intravenous
catheter or polymeric silicone tubing, which is then
sutured to the buccal mucosa.
 In injuries that penetrate the parotid-masseteric fascia,
there is a potential for development of a sialocele or
fistula.
 These typically resolve with drainage and pressure
dressings. Aspiration may be required multiple times,
and rarely, antisialagogues may be indicated

44. 3.Soft tissue reconstruction -
 forehead flaps – central
lateral
scalping/converse
Neck – platysmal
Hairy scalp – beard area
Post auricular – with cartilage
Delto pectoral
Myocutaneous – PMMC
latissimus dorsi
trapezius
Free flaps

45. 4. bone reconstruction
 replacement of true loss of bone (avulsive injuries) or in
cases in which comminuted and misplaced fragments need
to be replaced or reinforced.
 early bone grafting to stabilize and support soft tissues and
to decrease scar contracture and distortion.
 delayed grafting of discontinuity defects of the mandible is
still indicated because of the high risk of exposure and loss
of bone grafts in this site and that immediate grafting in the
mandible should be avoided.
 Clark and colleagues13 reported a 35% incidence of wound
complications in patients undergoing immediate
reconstruction of significantly comminuted mandible
fractures resulting from GSWs
 primary bone grafting in the early phase of GSW
management can be useful, but it should be limited to the
upper and midface
 Bone grafts >5mm grafting (iliac crest, rib, cranium)
 Onlay
 Osteotomies
 DO
 Condylar prosthesis after tmj ankylosis surgery

46.  delayed repair - point to a higher incidence of infection
and to benefits of closed treatment
 primary management report improved functional and
aesthetic outcomes. Early return to function and
decreased numbers of revision surgeries
 low energy – ORIF. The reported rate of infection with
open reduction and fixation of mandible fractures
resulting from a gunshot is around 16% to 17%
 Surgeons should avoid the application of a set protocol
to every GSW situation and should instead rely on a
careful appraisal of the wound and decide on the amount
of early repair that is indicated
CONTROVERSIES: DELAYED VERSUS
EARLY MANAGEMENT AND CLOSED
VERSUS OPEN FRACTURE MANAGEMENT

47.  Postoperative complication rates:
 cranial nerve palsy (19%),
 blindness (17%),
 hemiparesis (12%),
 visual disturbance (12%),
 wound dehiscence (4.7%),
 generalized sepsis (2.4%),
 epiphora (2.4%).
 Other isolated complications reported were cerebral
vascular accident, speech difficulty, cerebrospinal fluid leak,
facial nerve palsy, seroma, acute renal failure, disseminated
intravascular coagulation, and ptosis of the upper eyelid
 Carotidcavernous sinus fistula

48. EXTERNAL FIXATION
 External fixation of mandible fractures is a technique in
which segments are manipulated in place by pins and then
fixated with some type of connectors.
 It is often considered a subtype of closed reduction and
provides semirigid fixation to the fractured mandibular
segments
 In situations in which comminution is combined with a large
amount of periosteal, muscle, or mucosal damage, an
increased incidence of nonunion and infections can be
expected
 In theory, by treating these fractures in a closed fashion,
the viability of the fragments is maintained without
disrupting their blood supply.
 These comminuted fractures then consolidate for 8 to 10
weeks before secondary surgery, if considered. At that time,
the fractures are debrided or reconstructed.
 During the initial stabilization period of 8 to 10 weeks, the
soft tissue is also allowed to be restored, optimizing future
potential operations.

49. Other indications –
 large amount of bone loss in such conditions as
pathologic fractures occurring through tumors, cysts, or
severely atrophic mandibles
 Severe osteoradionecrosis of the mandible with fracture
of the inferior border
 Grossly infected fractures with significant soft tissue
edema, cellulites, and osteomyelitis
 patients with compromised health
 intracapsular fractures in children

50. ADVANTAGES
 it is possible to place
them with local
anesthesia
 control of bone
fragments by
manipulating the pins
and connectors
 improved stomatognathic
function, oral hygiene,
and patient comfort
 Retains periosteal blood
supply
 Simultaneous mandible
and midface treatment
DISADVANTAGES
 often cumbersome for
patients.
 Scarring around the pins
 difficult to achieve
precise bony anatomic
reduction
 When nonunion or
malocclusion occurs after
the healing period, a
secondary open
procedure is most likely
required.

51.  The external pin fixation device gives a high degree of
freedom for the frame assembly as the pins can be
placed selectively into each segment and connected with
short bars to constitute a subunit.
 Subsequently, the subunits are joined with further
connecting elements to make up the complete
framework.
 In this process each subunit can be manipulated into a
reduced position until final tightening of the whole
construct.
 If jaw immobilization required – halo headframe (head
cap)

52. biphasic pin fixation
 An alternative to the modular technique is the biphasic
pin fixation (also known as Joe Hall Morris fixation).
 Subsequent to the first phase where fracture alignment
is achieved with adjustable connecting rods between the
pin pairs, is the second phase when the aligned pins are
covered with a silicon tube, eg, endotracheal tube,
injected with methyl methacrylate resin. Alternatively
the pins can be connected with a moldable plastic shield
that hardens after application.
 Finally the adjustable rods are removed. This procedure
is highly flexible and results in a lean construct.


53. To optimize the framework stability it is recommended to:
 Choose large pin diameters
 Use at least two pins in each fragment
 Keep a large distance between the pin pairs
 Place pins next to fracture line as close as possible to
the fracture line but not less than 1 cm
 Place the connecting rods or plastic bar close to the skin
surface in order to keep the lever arms short.

54.  Make a small stab incision to prepare for pin insertion at the
predetermined screw locations in the posterior mandible
 According to histologic studies, the optimal drill speed is 500 rpm to
minimize bone necrosis
 The pin insertion is done through the soft-tissue envelope overlaying the
safe zones.
 Pins are typically placed at 70 from bony surfaces in a divergent fashion
(toward the operator), thereby maximizing bony screw retention.
 At least two pins are placed in each of the segments approximately 25
mm apart and at least 10 mm from the fracture margins.
 The length of the threaded portion of the pins is chosen to attain bicortical
engagement.

55.  The two pins in each
fragment are connected with
a rod and two clamps
 Apply a connecting rod
loosely between two subunits
using rod-to-rod clamps.
 One fracture is manually
reduced by manipulating two
subunits.
 Connectors should be placed
at a sufficient distance from
the skin to allow for
anticipated soft tissue edema

56.  When a large circumference of the mandible requires
external fixation, a bow-shaped rod can be directly
attached to the pins

57.  Vaseline-impregnated gauze is then placed around the
pins for a few days during the early healing phase.
 After 8 to 10 weeks of healing, the fixation devices may
be removed.
 Connectors are loosened, and pins are then twisted out,
usually under local anesthesia

58. Complications
 Postoperative infections, cellulitis around the pins,
nonunions, malocclusions, and pin loosening are
potentially frequent with this fixation technique
 Rare - injury to the inferior alveolar nerve, especially
with atrophic mandibles. damage to the facial vessels
 damage to the parotid gland and subsequent mucocele
and sialocele or salivary fistula formation
 Skin burn from the acrylic polymerization

59. The principles of triage, as described in Emergency War Surgery, are as follows:
 Injury priority or severity (from highest to lowest: airway, breathing,
circulation, and neurologic changes)
 Salvageability
 Available resources or personnel
 Treatment time, distance, or environment (aeroevacuation capability or
availability).
They prioritize care for those patients with the most acute care needs while
preserving resources for patients with the best chance of survival:
 Immediate (red)
 Delayed (yellow)
 Minimal (green)
 Expectant (black)

60.  Injuries from IEDs and other high-velocity weapons can
result in acute hemorrhage, tissue prolapse, and
massive edema that may result in significant airway
obstruction, necessitating emergent airway control. The
ability of the patient to give an intelligible and
appropriate reply implies a patent airway, adequate
ventilation to vibrate the vocal cords and generate voice,
and a Glasgow Coma Scale score of 8, indicating
adequate brain perfusion
 The soft tissue should be closed immediately after
extensive irrigation and conservative debridement with
only grossly contaminated and devitalized tissue being
removed.
 The primary goals during the initial surgery are to
reapproximate the wound edges with primary closure
and to achieve soft tissue coverage of the plates and
exposed bone.

61. Temporary reduction and fixation of mandible fractures with
intermaxillary fixation (IMF) screws can reduce both bleeding and pain
With the exception of fractures that compromise the airway or impair
haemastasis, repair may be delayed for up to 10 days after injury, especially
if a high-energy transfer mechanism is suspected. Open fractures should be
débrided, irrigated, and closed temporarily to prevent infection. The use of
an external fixator can provide anatomical reduction and fragment stability.

62. Soft tissue
 Skin grafts are best avoided initially because the risk of
infection remains, and they are more prone to wound
contracture.
 thrombosis in the facial vessels up to 3 cm from
macroscopic wound edge, which they attributed to the
effect of the temporary cavity. These vessels began to
repair between 7 to 10 days, after which point all of the
microvascular changes had resolved, with the
recommendation that all anastomoses should be
performed at least 2 weeks after injury should this
mechanism be suspected.

63. Hard tissue
 reconstruct the mandible as the first stage procedure.70,73
This often occurs within 2 to 3 days
 Early bone repair should be done when all infection has
been cleared and ideally within 3 to 4 weeks to minimize
fibrosis and collapse of the soft tissue envelope
 In pan facial fractures, the mandible fractures should be
repaired first to provide a guide of vertical height and the
form of the dental arch
 The use of heavy thicker profile (“reconstruction”) plates
has been successful in load-bearing osteosynthesis -
require extensive stripping of the periosteum
 The use of custom-made plates pre-bent on stereolithic
model
 miniplate between smaller fragments to produce fewer,
larger bony units, which were then stabilized by the
external fixator.

64.  Comminuted mandibular fracture management has traditionally adopted
conservative methods (Finn, 1996). These methods were advocated because
stripping periosteum from the comminuted bony segments could be
associated with significant bone loss and associated morbidity. Therefore, it
has been argued, comminuted fractures should be managed as a “bag of
bones,” with the clinician utilising closed techniques to establish normal
occlusion.
 both open and closed reduction methods are acceptable management options
for comminuted mandibular fractures. It is believed that because of the
excellent blood supply to the face, small fragments of bone will combine and
heal if open treatment is used, despite the disrupting of the covering soft
tissue by wires, screws, and plates.
 When the fragments are reduced, a reconstruction plate can be used to
rebuild the continuity of the damaged mandible, but cannot on its own
provide perfect alignment and fixation of the comminuted bony fragments.

65.  The principle of tight apposition of bone ends is important
for the success of plated osteosynthesis.
 To fix these small fragments we applied mini-plate,
micro-plate, screw, steel wire, and absorbable sutures to
the smaller fragments
 a fragment larger than 1 cm in size should be conserved,
reduced, and fixed, although fixing these small fragments
can be difficult. Caution should be taken not to discard
too many smaller fragments as a dead space will form,
which can lead to infection.
 MMF is helpful to maintain mandibular stability, which will
in turn contribute to the fracture’s union

66.  IMF bone screws may be used to
temporarily stabilize and reduce
mandibular fractures during the
placement of the external fixator.
 During healing they can be used to
support guiding elastics to optimize
function and obtain the correct occlusion
while the external fixator holds the
fracture parts in their correct position.
 a custom designed mandibular external
fixator II system that can be used to
treat complex, comminuted fractures.
 The system is adjustable and lightweight,
quick, robust, simple to apply, and allows
mouth opening during healing

67.  The rule of thumb was to remove only that bone that was
flushed out with aggressive irrigation. Any bone still with
soft tissue attachment was considered potentially viable.
 Treatment begins with rigid fixation of the teeth in
occlusion. When exposing the fracture (generally
extraorally), one needs to maintain thelingual periosteum, if
possible.
 Small fragments are fastened together with miniplates and
lag screws, the so-called ‘‘simplification’’ of the fracture.
 The simplified segments are then bridged with a locking
reconstruction plate and three or four screws on either side
of the fracture ends.
 For Defect Fractures, If the overlying soft tissue is healthy,
and wound closure is possible, grafting can take place at
the time of initial repair.

68.  Sixty patients of gunshot injury were randomly allocated
in two groups. In group A, 30 patients were treated by
open reduction and internal fixation and in group B, 30
patients were treated by closed reduction and
maxillomandibular fixation. Up to 3 months after injury,
complications like infection, malocclusion, malunion of
fractured fragments, facial asymmetry, sequestration of
bone and exposed plates were evaluated and the
differences between two groups were assessed. The
follow-up period ranged from 3 months to 10 months.
 They found that malunion and non unioun of fractured
fragments, facial asymmetry was common in group B.
 Rigid internal fixation is best available method for the
treatment of gunshot mandible fractures without
continuity defect being superior to more conventional
techniques in spite of minor infection rates.

69.  Over the years there have been many modifications, including Barton
bandage, suspension wires, Ivy loops, arch bars, MMF screws, and
embrasure loops.
 Erich arch bars continue to be the most commonly used technique
 A combination between MMF screws and arch bars known as hybrid
systems are the newest advances to closed reduction. These systems
allow expeditious placement associated with MMF screws while
maintaining lugs at crown level, allowing traction vectors closer to the
occlusal table

70.  For those cases in which the soft tissue and hard tissue mandibular
defects are amenable to primary repair, local flaps, and/or
nonvascularized bone grafts, aided by VSP, can expedite the surgical
process.
 In grossly comminuted fractures or continuity defects, the contralateral
mandible can be mirrored to the injured side to approximate the
mandible’s pretraumatic form, which can then be used as prebend
plates or design custom plates
 placing patients in maxillomandibular fixation and taking a CT scan
using the specific VSP protocol. The fractured and displaced bony
segments are aligned virtually, the placement of the plate is virtually
planned.
 If a custom plate is to be used, the surgeon can decide the shape of
the plate, thickness.
 In segmental defects, cutting guides are made to precisely freshen the
edges of the defects to allow for easy buttressing with reconstructed
tissue

71.  There is some controversy over the method of fixation
used for these reconstructions.
 Advocates of mini-plates argue that a stress-shielding
phenomenon occurs with load-bearing reconstruction
plates that impedes osseous healing.
 However, reconstruction plates have been shown to have
less need for removal, lower infection rates, and greater
ability to accurately shape the neo-mandible to mimic
the native mandible.

73.  begin with the midfacial and orbital reconstruction because of their
importance in establishing proper facial width. A reciprocal relationship
exists between anterior-posterior projection of the zygoma and facial
width
 Stereo-lithographic models are created after virtually reducing midfacial
fractures and plates are contoured to them intraoperatively

74.  in self-inflicted GSWs, the condyle ramus unit tends to be
spared. This preservation facilitates establishing the vertical
dimension of the lower face against the already established
transverse width by virtually seating the condyles in the
fossa.
 Composite defects are then reconstructed with a fibula and
custom reconstruction plate or custom plate alone in the
case of adequate soft tissue and bone for a nonvascularized
bone grafts. butt joints between native mandible and
reconstruction to facilitate flap inset
 Internal orbital reconstruction begins by comparing the
internal orbital volume measured by the computer planning
engineer. Virtual correction is then made using the
uninjured or anatomically correct side by creating a mirror
image that superimposes the traumatized side.
 In bilateral fractures, the least comminuted orbit is virtually
corrected and then mirror imaged to the contralateral side.
 Custom orbital plates and/or stereo-lithographic models are
then fabricated using the virtually corrected orbits

75.  Early primary reconstruction can be successful for
patients with self inflicted facial gunshot wounds,
particularly when the entry point of the bullet is in the
upper and midface area.
 Delayed primary reconstruction was more common when
the bullet entered the lower face.