Developing a craniomaxillofacial and cervical equipment module for surgeons in the austere environment: a systematic review.

The treatment of craniomaxillofacial and cervical wounds in a disaster relief setting is done by clinicians from local medical treatment facilities, non-governmental organisations (NGO), or the military. Although each group and individual surgeon will need specific equipment, this will be restricted by weight, portability and interoperability. We systematically reviewed scientific and commercial publications according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The papers we identified described the portable equipment that is required to treat patients who need damage-control surgery (decompressive craniectomy, temporary stabilisation, and internal and external fixation of the facial bones) for craniomaxillofacial and cervical injuries in austere or military settings. Austere settings are those in which there is an inherent lack of infrastructure, such as facilities, roads, and power. A total of 35 papers or scientific articles recommended the equipment that is needed to manage these injuries, but we could find no module that was specifically designed for use in these environments. Multiple modules are currently required to provide comprehensive surgical care and many of the items in the existing maxillofacial and neurosurgical kits are rarely used, which increases the cost of initial procurement and resupply. Duplications in equipment between modules also increase the size, weight, and financial cost. We suggest the equipment that is required to make up a rationalised, lightweight, and compact module that can be used for all craniomaxillofacial and cervical operations in austere settings.

Skill sets required for the management of military head, face and neck trauma: a multidisciplinary consensus statement.

INTRODUCTION: The evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons. METHOD: A systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management. RESULTS: Head, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair. CONCLUSIONS: The identification of those skill sets required for deployment is in keeping with the General Medical Council's current drive towards credentialing consultants, by which a consultant surgeon's capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.

Optimising ballistic facial coverage from military fragmenting munitions: a consensus statement.

VIRTUS is the first United Kingdom (UK) military personal armour system to provide components that are capable of protecting the whole face from low velocity ballistic projectiles. Protection is modular, using a helmet worn with ballistic eyewear, a visor, and a mandibular guard. When all four components are worn together the face is completely covered, but the heat, discomfort, and weight may not be optimal in all types of combat. We organized a Delphi consensus group analysis with 29 military consultant surgeons from the UK, United States, Canada, Australia, and New Zealand to identify a potential hierarchy of functional facial units in order of importance that require protection. We identified the causes of those facial injuries that are hardest to reconstruct, and the most effective combinations of facial protection. Protection is required from both penetrating projectiles and burns. There was strong consensus that blunt injury to the facial skeleton was currently not a military priority. Functional units that should be prioritised are eyes and eyelids, followed consecutively by the nose, lips, and ears. Twenty-nine respondents felt that the visor was more important than the mandibular guard if only one piece was to be worn. Essential cover of the brain and eyes is achieved from all directions using a combination of helmet and visor. Nasal cover currently requires the mandibular guard unless the visor can be modified to cover it as well. Any such prototype would need extensive ergonomics and assessment of integration, as any changes would have to be acceptable to the people who wear them in the long term.

Operative treatment of paediatric penetrating head injuries in southern Afghanistan.

The operative management and early post-operative outcome of 16 consecutive cases of paediatric penetrating head injury treated by a single surgeon at a military trauma centre in Southern Afghanistan are retrospectively analysed. The majority of cases of injury were caused by fragments from exploding munitions. The aim of neurosurgical intervention in penetrating head injury is the prevention of wound infection and treatment or prevention of a critical rise in intracranial pressure. In 14 cases in this study, these aims were fulfilled without resort to brain resection, although a delayed cranioplasty procedure was required in 6 patients. Despite the ongoing conflict, families, local communities and coalition forces transport teams combine to make the latter a viable option in Southern Afghanistan, with an excellent short-term outcome.

Surface wound mapping of battlefield occulo-facial injury.

INTRODUCTION: Accurately determining the entry location of penetrating eye and face wounds and relating that to mortality and long-term morbidity is of vital importance in the design of future personal protective equipment. METHOD: Hospital and post mortem records for all UK servicemen sustaining penetrating battle injuries to the face or eye during the period 01 January 2005 to 31 December 2009 were analysed. RESULTS: Face and eye injuries were found in 391/1187 (33%) and 113/1187 (10%) of all battle-injured servicemen respectively. 27% of eye wounds from explosions resulted in blindness and a further 17% in significant permanently reduced visual acuity (<6/12). Those servicemen that chose not to wear Combat Eye Protection (CEP) were 36 times more likely to sustain an eye injury from explosive fragmentation than those that did. However only 36% of servicemen chose to wear CEP. 7 deaths could potentially have been prevented had the serviceman chosen to wear their CEP. The lower third of the face was most commonly injured (60%) followed by the upper third (24%). CEP reduced facial injuries as a whole (bone and soft tissue) by 15% (p<0.01). Potentially changing the existing material used for chinstrap and helmet covers to that with ballistic protection would further reduce this incidence by up to 9%. CONCLUSIONS: Although the lower third of the face remains poorly protected, the incidence of lower facial wounds could be further reduced by the use of ballistic visors by servicemen in exposed positions in vehicles (which represented 16% of facial injuries). Such a visor could potentially have prevented 17 deaths. A rigid attachment to the front of a ballistic helmet would allow either a visor, a high visibility LED lamp or a night vision goggle to clip in and we believe this capability should be investigated through future human factor trials.

Management of maxillofacial wounds sustained by British service personnel in Afghanistan.

UK service personnel sustaining maxillofacial wounds in Afghanistan are stabilised in a field hospital prior to evacuation for definitive treatment at the Royal Centre for Defence Medicine (RCDM). Descriptive injury data were gathered from the Joint Theatre Trauma Registry (JTTR) between 1 January 2008 and 31 December 2009 and matched to hospital clinical records. The mean Abbreviated Injury Severity (AIS) scores in service personnel sustaining maxillofacial wounds alone were compared with those with injuries to all body areas. Maxillofacial wounds were present in 21% of British servicemen sustaining battle injuries, but 30% of all evacuations despite the similar mean AIS of each group. This probably reflects the complex care these injuries often require that is not possible in the field. In the field hospital, maxillofacial wounds were predominantly debrided and definitive repair was deferred until evacuated to RCDM. AIS codes are an excellent predictor of mortality from face and eye wounds but they reflect morbidity poorly. The authors propose that instead of a single AIS code, each military face and eye injury should be ascribed a second separate Occulo-Facial Functional and Aesthetic (OFFA) outcome score that more accurately predicts the aesthetic and functional parameters of these wounds.

Oral and maxillofacial surgical contribution to 21 months of operating theatre activity in Kandahar Field Hospital: 1 February 2007-31 October 2008.

Our aim was to assess oral and maxillofacial operating theatre activity at the NATO Multinational Medical Unit at Kandahar Airfield (MMU KAF). We made a retrospective analysis of the theatre logbook of the MMU KAF between 1 February 2007 and 31 October 2008. During that period, 1778 operations were done for 1639 patients. A total of 563 local civilians (34% of all patients) were operated on. Oral and maxillofacial surgeons were involved in 322/1778 (18%), general surgeons in 943/1778 (53%), and orthopaedic surgeons in 716/1778 (40%) of operations. Neurosurgeons were present only between March and October 2008, resulting in them being involved in 73/789 procedures (9%). Debridement and closure of wounds were the most common procedures in all specialties. A total of 247 operations on the face, neck, and scalp made up 16% of the total operations for trauma (n=1556), but most for coalition service personnel (n=69, 24%). Only 28 operations (10%) on coalition service personnel were done on the torso. This could be accounted for by the increased numbers of blast injuries and the effectiveness of modern body armour among coalition forces. Brain injuries were also more common among this group of patients than among the other groups, showing that helmets have only a limited effect in protecting against the effects of blast injury. Of all procedures, 163 operations (9%) were done for children. Training of general surgeons is becoming more specialised, which may result in greater dependence on larger teams of subspecialists (including oral and maxillofacial surgeons) in future conflicts.

Use of a custom designed external fixator system to treat ballistic injuries to the mandible.

The authors describe 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, It is well suited to use in the modern war surgery environment. The authors present a case of successful treatment of a ballistic fracture of the mandible using this device.

Mandibular fractures in British military personnel secondary to blast trauma sustained in Iraq and Afghanistan.

Blast trauma is the primary cause of maxillofacial injury sustained by British service personnel on deployment, and the mandible is the maxillofacial structure most likely to be injured in combat, but there are few reports about the effect of blast trauma on it. The Joint Theatre Trauma Registry identified all mandibular fractures sustained by British servicemen secondary to blast injury between 1 January 2004 and 30 September 2009. These were matched to corresponding hospital notes from the Royal Centre for Defence Medicine (RCDM) for those evacuated servicemen and autopsy records for those who died of wounds. Seventy-four mandibular fractures were identified in 60 servicemen. Twenty-two soldiers were evacuated to the RCDM and the remaining 38 died from wounds. Fractures of the symphysis (39/106, 37%) and body (31/106, 29%) were more common than those of the angle (26/106, 25%) and condyle (10/106, 9%). This pattern of injury differs from that of civilian blunt trauma where the condyle is the site that is injured most often. Those fractures thought to result from the blast wave itself usually caused simple localised fractures, whereas those fractures thought to result from fragments of the blast caused comminution that affected several areas of the mandible. The pattern of fractures in personnel injured while they were inside a vehicle resembled that traditionally seen in blunt trauma, which supports the requirement for mandatory wearing of seat-belts in the rear of vehicles whenever tactically viable. All mandibular fractures in servicemen injured while in the turret of a vehicle had evidence of foreign bodies or radio-opaque fragments as a result of their exposed position. Many of these injuries could therefore be potentially prevented by the adoption of facial protection.

Lessons learned in oral and maxillofacial surgery from British military deployments in Afghanistan.

This article describes the combined lessons learned from two deployments of a cadre of British Oral and Maxillofacial surgeons to Kandahar between July 2006 to April 2007, and September 2008 to April 2009.

Five months of surgery in the multinational field hospital in Afghanistan with an emphasis on oral and maxillofacial injuries.

The aim of this review was to assess the workload of theatres in the role 3 Multinational Field Hospital in Kandahar, Afghanistan and to identify what period of day most emergency admissions arrived. During the period 05 August 2006 to 21 December 2006, 288 operations were performed on 259 patients and comprised 393 individually quantifiable procedures. 98% of these operations were to treat acute injuries. Oral and Maxillofacial surgeons were involved in 24% of operations. 63% of procedures done at these operations involved upper or lower limbs, 19% the head and neck and 18% involved the torso. An analysis of emergency admissions in November 2006 showed that most occurred between 18.00 and midnight. Although theatre timetabling made provision for this, whenever possible, elective surgery was scheduled for the following morning when emergency injury admissions were at their lowest.

Maxillofacial injuries in military personnel treated at the Royal Centre for Defence Medicine June 2001 to December 2007.

Since its formation in June 2001, the Royal Centre for Defence Medicine (RCDM) at Birmingham University Hospitals NHS Foundation Trust has treated most of the British military personnel who have sustained serious maxillofacial injuries while serving abroad. We retrospectively analysed all recorded maxillofacial injuries of personnel evacuated to the RCDM between June 2001 and December 2007. We know of no existing papers that describe oral and maxillofacial injuries of military personnel, or workload in the 21st century. During the period 119 personnel with maxillofacial injuries were evacuated to the RCDM for treatment 83% of whom were injured in Iraq or Afghanistan. In total 61% (72/119) of injuries were caused by improvised explosive devices, 9% (11/119) were gun shot wounds, and 1% were caused by aircraft incidents. A further 29% (35/119) of patients had injuries not associated with battle. The most common injuries were facial lacerations (106/119). There were 54 facial fractures of which 17 primarily affected the maxilla, and 15 the mandible. Associated injuries were to the brain (24%), torso (26%), upper limb (39%), and lower limb (31%). The number of maxillofacial injuries has risen over the last 7 years, and has also increased in proportion to the total number of injured soldiers evacuated between 2005 and 2007.

A randomised controlled trial comparing fixation of mandibular angle fractures with a single miniplate placed either transbuccally and intra-orally, or intra-orally alone.

This study compared fixation of simple mandibular angle fractures with a single miniplate either placed from a combined transbuccal and intra-oral approach, or intra-orally alone. 140 consecutive patients were randomly allocated to the two treatment groups. Complications were noted and compared. An email questionnaire to all the participating surgeons examined their personal preferences between the two methods. 20% of plates needed to be removed during the 3 month study period in the combined transbuccal/intra-oral group compared with 36% in the intra-oral alone group (p