Emergency Treatment of Blast, Shell Fragment and Bullet Injuries to the Central Midface Complex.

PURPOSE: Current ballistics and high-energy explosion possess unnoticed, new and significant biophysics and pathophysiology wounding effects that are unique in comparison with civilian trauma. The primary blast wave effects of compressed air due to explosion lead to tattered and crushed eggshell injuries to the upper central midface (UCM). High-energy shell fragments of various shapes and sizes cause extensive destruction and are different from assault rifle's bullets that cause high energy transfer to the tissue by creating a temporary cavitation. METHODS: Twenty-one patients with unquantifiable war injuries were selected. The emergency managment of lifesaving facial war injuries starts with life threatening hemorrahge or air compramise. This article describes immediate management of medial canthal tendon (MCT), intercanthal region and severe nasal war injuries. RESULTS: The utilized procedure obtained good results compared to the results of cases treated only by applying a classic approach of civilian fractures. CONCLUSION: Treatments of UCM injuries are the most difficult since UCM includes the esthetic, physiologic, and anatomical regions of the face. The proposed technique provides immediate excellent stability for soft tissues, bone, and cartilage and is well tolerated in the long term by both the tissue and the patient. Most of the times, victims are treated with limited resources, deficient subspecialty, massive injuries, during mass casualties, and a single surgeon must have to handle all these within a short period of time. UCM injuries are really concerning since this region is the core of facial esthetic and function.

Emergency Management of High-Energy Shell Fragment Midface Complex Injuries.

Distinctive mechanisms of heavy artillery and improvised explosive device detonation result in a blast and "spray" of high-energy fragments of diverse shapes, sizes, and characteristics. Associated midface complex injuries differ in both severity and complexity of the anatomical structures involved. Management challenges begin with lifesaving, which is complicated by airway compromise, severe hemorrhage, and unique injuries of the maxillae, nose, and naso-orbitoethmoid.The patients presented fragment impact on the face lateral side directed to other side leads to tissues blown away at the point of high-energy exits, while no survival seen of enface shrapnel hit directed antroposterior toward "cervical spine, intracranial, internal and external carotid arteries and internal jugular vein."Twenty-two patients were selected from unquantified patients who had sustained massive midface shell fragment injuries. To preserve midface architecture, healing, and function, iodoform paste on ribbon gauze packs were utilized successfully. An iodoform paste on ribbon gauze pack serves the dual purpose of preserving the shape and scaffolding of the crushed maxillary sinus wall and buttresses fragments in position for healing. It also acts as a wet pack dressing for denuded bone fragments, stopping bleeding and having antimicrobial properties for severely lacerated wounds. For total or partial nasal tissue loss, a successful procedure consists of definitive early scaffolding stabilization using an intranasal, modified portex tracheostomy tube stent to preserve the internal shape of the nasal pyramid.

Resection of Giant Hemangioma of the Tongue Utilizing a Miniature Tourniquet Technique.

With the progress of multidisciplinary vascular anomaly treatment, the use of radiotherapy, cryotherapy, laser therapy and medical treatments, the corticosteroid, sclerotherapy, and many more, the role of surgery has been refined. Surgical treatment has historically been the mainstay of treatment and will maintain.A miniature tourniquet technique applied to the tongue was successfully utilized in reducing bleeding to a minimum during surgical resection of a massive cavernous hemangioma involving the tongue and lower lip without any postoperative complications.Comprehensions of the neurovascular anatomy of the tongue, vasculature, innervations, and muscles physiological functions are very important for selecting the right surgical approach.A 9-year-old girl presented with giant hemangioma resulting in severe protrusions of the anterior and lateral two-thirds of the tongue with an extensive anterior open bite jaw deformity and oral physiological dysfunctions as speech, mastication, and deglutition. Such a presentation is a unique surgical challenge due to the high risk of bleeding, tongue swelling, and airway compromise.Postsurgical results showed oral physiological function improvement and the elimination of interaction effects on anterior open bite.

Expanding Hematoma's Life-Threatening Neck and Face Emergency Management of Ballistic Injuries.

This article aims to bring attention to the morbidity and fatality of hemorrhage, how expanding hematoma and air compromise neck/face N/F injuries and present challenges. Large neck vessel ballistic injuries may lead to hemorrhage and expanding hematoma, resulting in airway compromise, due to injuries to the internal and/or external carotid arteries, internal jugular veins "internal carotid artery, external carotid artery, internal jugular vein," and the external carotid artery deep branches. This also leads to injuries to the cervical fascial layers (barriers of deep spaces) that facilitate pooling blood and hematoma into compartmental and large potential space which effects the pharynx, larynx, esophagus, and trachea.The expanding hematomas distort neck anatomical landmarks so "no neck zones" classifications are applicable. As the spectrum of injuries continues to evolve, the clinical characterization needs a new categorization based on compartmental hematoma and potential space anatomical location like retropharyngeal, parapharyngeal, sublingual, submandibular spaces, retrobulbar, and cheek compartment space hematomas.Presence of symptoms and location of the hematoma generally dictate what type of procedure is needed and how urgently it needs to be appropriately performed.Two unusual patients of pseudoaneurysms facial artery injuries with extravasation of blood producing a pulsating hematoma are referred to. Another patient considers large internal carotid artery injuries pseudoaneurysms revealed in angiography.The immediate management of life-saving patients requires aggressive airway maintenance at the scene, conscious victim will often obtain a posture that clears his airway and the semiconscious or unconscious put him in prone position. Air compromise may need emergency intubation, large bore cannula cricothyroidotomy, cricothyrotomy and at medical facilities tracheostomy.

Mandibular Nonvascularized Bone Grafts of Critical Sizes and Complex Warfare Defects With Interrami Intraoral Fixation.

The reconstruction of mandibular bone grafts of critical size complex defects and posterior segments malpositioned due to modern warfare injuries is a difficult, challenging task. The condition becomes even more complex if primary reconstruction is carried out inexpertly, which leads to severe disfigurement, rami mesial superior shift, tongue prolapsed, loss of speech, etc.A new interrami intraoral Kirschner wire fixation (IRIF) technique is presented for the reconstruction of large mandibular defects by nonvascularized iliac bone grafts. Twelve symphysis, parasymphysis, and lateral mandibular avulsed or chopped off with bone loss ranging from 5 cm to "ear-to-ear" rami defects underwent nonvascularized iliac bone block graft. A direct stainless steel wire fixation was carried out between bone blocks and original bone. Indirect rigid fixations were applied using a 2-mm horseshoe-shaped K-wire IRIF technique. Two complications were reported: one due to infection and the other due to the mucosa dehiscing where 2 cm of sequestrated bone was removed. The biomechanics (stress/strain distribution and strength) along the K-wire substitute the tension on the alveolar part of the mandible, creating a zone of resistance in the rami zone. This successful bone healing between the mandibular bone and the graft may have resulted from prolonged periods of sufficient stabilization during function of the mandible and bone graft function as one mandible unit during the healing period by IRIF. This new technique is quick, cheap, easy, and well tolerated by the patient for many months without complications and has been successful in modern warfare reconstructions of mandibular bone graft large defects.

Interrami intraoral fixation technique utilized as a conservative approach to edentulous/atrophic mandibular fractures.

Interrami intraoral Kirschner wire fixation (IRIF) technique is presented as new conservative successful indirect rigid fixation utilized for the reduction and fixation of edentulous/atrophic mandible fractures. This technique is carried out under local anesthesia without the need for open reduction internal fixation, which can lead to a compromise in the blood supply of fracture region. It is also quicker, easier, requires fewer postoperative visits, and cheaper than small or large bone plate fixations.Five edentulous mandibular fractures, 2 of them atrophic, 2 non-atrophic, and 1 partial edentulous, were successfully treated. In all cases, the IRIF technique was utilized to establish an indirect rigid fixation using horseshoe-shaped Kirschner wire with a 2-mm diameter. No complication was reported during these cases. This technique prevails over the Gunning splint and external edentulous fracture fixation techniques as it provides adequate fracture site stability, is more comfortable, and is better tolerated for a longer period of time by the patient. In addition, there are fewer complications caused by malunions from direct intraoral or extraoral small and large plate fixation techniques. Other advantages of the IRIF technique are that it enables the mandible to function as a single unit and preserves its function and anatomical position immediately after surgery. In contrast, the Gunning splint acts only to preserve the balance of a single segment's position.

Thermal shell fragment craniofacial injury: biophysics, pathophysiology, and management.

This article aims to bring attention to unique risks and burns by thermal shell fragment craniofacial soft tissue injury. Hot shrapnel may inflict burns to major vessel walls and lead to life-threatening hemorrhaging or death, which adds a new challenge for craniofacial surgeons. Morbidity of thermal deep tissue may lead to deep tissue necrosis and infection.Thermal energy (TE) physics, biophysics, and pathophysiological effects relate directly to the amount of heat generated from shell casing detonation, which transfers to skin, deep tissue, as well as brain and leads to life-threatening burning of organs; this is different from shrapnel kinetic energy injury.The unprecedented increase in using a large range of explosives and high-heat thermobaric weapons contributes to the superfluous and unnecessary suffering caused by thermal injury wounds.Surgeons and medics should recognize that a surprising amount of TE can be found in an explosion or detonation of a steel-encased explosive, resulting in TEs ranging from 400 F up to 1000 F.

Effect of biomechanism mine explosion on children: craniofacial injuries and management.

The significant bodily violence and harm to children from blast injuries continue to be substantially caused by unexploded ordnance and improved explosive devices. Children have many unique anatomic and pathophysiologic attributes that potentially affect their susceptibility to injury. Consequently, this provides a characteristic profile to mine blast effects and projectile injuries. As a result, children's injuries inflicted on craniofacial tissues, airway compromise, hemorrhage, and brain injuries vary significantly from those inflicted on adults. In children more than adults, it is relevant that the simplest, immediate repair of maxillofacial injury is preferable to a major complex surgical approach that is significantly delayed because of availability.Twenty-one cases of mine blast/shrapnel pediatric maxillofacial injuries were selected to represent categorical varieties of a significant but unknown number of casualties treated successfully. The high number of mortality and morbidity caused by mine blast/projectile necessitates a reappraisal of pediatric craniofacial management training. "Losing a single child's life" is especially unacceptable if that loss was found to be due to the medical preparedness being inadequate or the lack of pediatric knowledge.

Interrami intraoral fixation technique for severe mandibular rifle fragmented bullet injury management.

Interrami intraoral Kirschner wire fixation technique is presented for the reduction, stabilization, and immobilization of a pulverized and avulsed lower jaw caused by rifle fragmented bullet injuries. This indirect mandibular war injury fixation technique was tolerated by the patients and tissue more than any indirect external fixation. In addition, it is easier than open reduction using large bone plates for disrupted ballistics mandibular injury defects. An interrami intraoral fixation is appropriate for severely disrupted mandibular hard and soft tissues, and has been adapted in cases of mass casualties and limited resources. Benefits of use include limited hospital beds and fewer follow-up visits. Rifle fragmented bullet injuries need more attention for several reasons: not only because of the higher mortality and devastating nature of the injuries, but also because these injuries are responsible for an unreported type of bullet biomechanism wounding in the craniofacial region. In turn, this necessitates specialized victim management. The survival rates depend on immediate proper execution of airway, breathing, and circulation, which become more complicated as it relates to airway compromise and oropharyngeal hemorrhage resuscitation. Survival is predicated on the implementation of feasible, sensible, life-saving techniques that are applied at the appropriate time.

Emergency treatment strategy and the biodynamic effects of massive, "chopped off", mandibular tissue and a prolapsed tongue.

Current weaponry possesses unobserved new, biodynamic wounding effects. For many victims, high velocity, large shell fragments have resulted in massive lower jaw "chopped off" hard and soft tissues injuries accompanied by tongue prolapse. The management challenges begin with lifesaving which is possibly complicated by airway compromise, severe hemorrhage, massive lower jaw loss, and a prolapsed tongue. Consequently, the goal shall be "No patient should die from massive facial tissue injuries alone". That is, if feasible, sensible, lifesaving techniques are applied at the appropriate time. Following general condition stabilization, the surgical management steps of massive lower jaw tissue loss should begin with immediate lost tissue reconstruction. Seventeen cases were selected from an unquantified number patients who had massive mandibular tissue losses in which the tongue, surprisingly, remained intact. In these cases, definitive, early scaffolding stabilization was accomplished by joining the remaining two lower jaw intact segments. The successful procedure consists of using a 2 mm horseshoe shaped Kirschner wire bridging the gap of the mandibular arch which effectively is used as a "scaffold" for rebuilding the soft tissue. Proper, initial, surgical management resulted in protecting lacerated tissue, diminishing subsequent morbidity and disfigurement, preventing a prolapsed tongue and preserving the intact tissues physiological functions. As the spectrum of injuries continues to evolve the clinical characterization of the severity of facial wounds need an expanded classification, appropriate to massive facial injuries. It is suggested it has the following descriptors: blast, penetration, perforation, avulsions and "chopping off" (BPPAC).

Management of penetrating medial and retro-bulbar orbital shrapnel/bullet injuries.

The presence of shrapnel or a bullet lying in the medial orbital and retrobulbar area is rare. A review of the literature revealed only a few reports. Recently eye/orbital penetrating trauma has increased dramatically, mainly due to IEDs or conventional weaponry in civilian and military casualties. Our experience in the management of these types of injuries prompted this report. Practical techniques for correctly determining the location of retained projectiles in the orbit are described. Surgical techniques for treatment are presented, based on safe and successful practices used in the missile retrievals. Six shrapnel and three bullet injuries, mostly in the medial orbital region, were removed without increasing morbidity and with limited orbital tissue injury.

The immediate lifesaving management of maxillofacial, life-threatening haemorrhages due to IED and/or shrapnel injuries: "when hazard is in hesitation, not in the action".

Maxillofacial/neck vascular injuries caused by improvised explosive devices IEDs or ballistics injuries are life threatening when they cause severe haemorrhage resulting in airway compromise. One should always keep in mind that the best technique used is that which saves the patient's life and not the most expensive and/or technologically advanced. Medical professionals on the scene should have the necessary experience to handle the emergency situations of airway compromise and haemorrhage control. In this instance there is only, "one to a few minutes" to clear airway obstruction and arrest haemorrhage to prevent death. The patients in this study had life-threatening shrapnel injuries of the carotid and/or jugular vessels, and facial primary blast affect implosion of facial middle third air-containing cavities injuries. In a massive casualties arenas, where time=lifesaving, we should need to replace "non-battlefield" civilian techniques with "time driven", combat management for IEDs injuries. In these cases, the immediate and effective compression tamponade using digital, Foley catheter tamponade, packs and/or vessels ligation for severe facial/neck haemorrhage were used successfully.

Base-of-skull/infratemporal fossa shell fragment retrieval.

PURPOSE: Shell fragments and bullets are frequently observed to have settled in the skull base and infratemporal fossa (ITF) with the impact resulting in a new surgically complicated trauma. This compact region is one of the most difficult and dangerous locations for lodged objects. When called upon to retrieve these objects, the surgeon faces a complicated challenge. The complexity of the task depends on many factors, such as size, deformation, and surface hooks, as well as identification of the precise anatomic location. MATERIALS AND METHODS: New surgical approaches and successful methods of treatment are presented. The practicability of correctly determining the location of the foreign body is also described. These methods are based on safe and successful practices used in the retrieval of 212 shell fragments from the ITF. RESULTS: In this study, 79% of the ITF fragments and bullets were retrieved by the transoral ITF method. The remaining 21% were removed via the facial path of missile entrance and a transantral approach. CONCLUSION: This article describes feasible, sensible, time-saving practices resulting in lower surgical morbidity in one of the most challenging regions from which to extract lodged missiles. Osseous landmarks are used for proper localization of trajectories in the ITF by use of posteroanterior and true lateral skull radiographs, which assist in locating metal fragments. The intraoral approach, which is successfully used as a short pathway with minimal tissue damage, may encourage surgeons not to leave fragments unattended.

Facial skin-mucosal biodynamic blast injuries and management.

PURPOSE: The blast biodynamic presents maxillofacial injuries of a different type. The analysis of facial skin lacerations and intense flash burns will add new clinical findings that will assist in the early diagnosis of life-threatening airway compromise due to the inhalation of hot gases and toxic fumes. Improvised explosive devices most likely result in blast injuries and severe incendiary situations. Consequently, we require a better understanding of blast pathophysiologic effects, as well as the diagnosis and emergency management of facial soft tissue injuries, which create and provoke new challenges in lifesaving techniques and procedures. MATERIALS AND METHODS: This article reviews the physics and biophysics of blast facial skin shredding, extensive contusions, lacerations, multiple puncture wounds, partial scalping, flash and thermal burns, thermal inhalation, and toxic fume injuries, as well as detailing the management of blast and thermal wound injuries. In addition, the initial and immediate care of related airway compromise resulting in life-threatening conditions is reviewed. RESULTS: A new type of conflict-related blast injury is described and evaluated. These explosion wounds result in facial soft tissue injuries, edema of the mucosa of the upper respiratory region, and lung trauma. The understanding of the blast biodynamic injuries associated with thermal burns and inhalation of hot toxic fumes that cause serious respiratory injuries requiring special management should be shared globally with our colleagues. CONCLUSIONS: Recently, many victims of improvised explosive devices have shown varying degrees of facial injuries in different patterns with or without flash burns. In addition, patients have had intense thermal inhalation that leads to oral-nasal-pharyngeal edema and toxic fume inhalation that may require the management of life-threatening airway compromise. This report will contribute to the lexicon of maxillofacial surgery diagnosis and procedures, including lifesaving airway management, by the appraisal of patients exposed to blast injuries and strong momentary thermal effects on soft tissue wounds.

Craniomaxillofacial falling bullet injuries and management.

PURPOSE: The purpose of this study was to bring attention to craniocerebral maxillofacial perforating/penetrating injuries due to AK-47 Kalashnikov falling bullets (FBs); these dangerous injuries to both civilians and soldiers are rare. A review of the literature shows no reports on AK-47 FBs leading to double craniocerebral perforation and settling into the maxillofacial region. The number of victims, the AK-47's availability, the associated morbidity and mortality rates, and the rarity of cases prompted this article. MATERIALS AND METHODS: The treatment of injuries to the craniocerebral facial clinical profile due to FBs is challenging, and an understanding of the neurosurgical and maxillofacial management of these low-velocity FB injuries is required. RESULTS: We treated 11 cases due to AK-47 rifle FBs and 1 due to anti-aircraft Dashka 12.7-mm FBs. Craniocerebral facial injuries were treated and lodged bullets removed from different challenging locations in the base of the skull, without increasing morbidity and with avoidance of unnecessary surgical trauma to the affected area by the bullets. CONCLUSION: The required identification of such injuries can be difficult, and the removal of the lodged bullet to prevent secondary complications and reduce the chance of secondary infection can be graver than in other parts of the body. AK-47 FBs are a major public health concern internationally and require serious attention in terms of protection and management for civilians and soldiers in uniform.

Maxillofacial air-containing cavities, blast implosion injuries, and management.

PURPOSE: Distinctive mechanisms of primary blast effects have produced a transitional era of facial trauma. Implosion mechanism damage is one of these. Implosion mechanism damage results in injury limited to the gas-containing structures of the auditory canal, paranasal sinuses, gastrointestinal tract, and lungs. Worldwide, the victims of explosive detonations have increased and advanced dramatically. The outcome is greater mortality and morbidity and new types of injuries, especially in the maxillofacial region. Thus, the knowledge of, and experience with, their management should be shared globally by colleagues through publications. MATERIALS AND METHODS: The implosion and mini re-explosion of compressed air sinuses leads to skeletal crush injury to the nasal-orbital-ethmoidal, maxillary sinuses, and nasal bones. A variety of surgical approaches were used successfully under conditions of war. The assessment of the associated injuries to the lung and/or brain is the initial priority to any life-threatening blast injury. This article describes the biophysical results of blast injuries to the middle third facial skeleton and associated injuries and details the management and protection of crushed air containing paranasal spaces. RESULTS: Easy, simple, and fast treatment and management were used successfully on the pulverized, fragmented skeletal architecture of the facial middle part without increasing morbidity and with the avoidance of unnecessary surgical trauma. CONCLUSIONS: Injuries in one of the most difficult esthetic, physiologic, and anatomic regions of the body is best treated with an understanding of the biophysical effects of the implosion mechanism on air-containing spaces in the maxillofacial region. The introduction of new methods for the management of severe destruction of hard and soft tissue will decrease the incidence of complications and the operative time.

Management of penetrating war injuries: bullet/shell fragments in the sphenoid sinuses.

PURPOSE: Penetrating sphenoid sinus injuries in both war and civilian practice are rare. A review of the literature shows no reports of shell fragments or bullets in this region; hence, the rarity of the cases prompted this report. MATERIALS AND METHODS: A variety of surgical approaches--transethmoidal, transnasal trans-septal, sublabial transnasal, and endoscopic techniques--and the feasibility, efficacy, and safety of these techniques used in the delivery and management of missiles lodged in the sphenoid sinus under conditions of war are described. RESULTS: Four shell fragments and 2 bullets were removed without increasing morbidity and with avoidance of unnecessary trauma to the area affected by the missile. CONCLUSIONS: In this series of patients with war missile injuries settled in the sphenoid sinus/base of the skull undergoing surgical treatment, there were no major intraoperative or postoperative complications. Differentiation in the approaches to this anatomic region is necessary based on whether there is a tumor or penetrating war injury.

The effect of a blast on the mandible and teeth: transverse fractures and their management.

Transverse mandibular fractures caused by blast waves have given us a better understanding of the physical and pathophysiological effects on this anatomical region. The external contour of the mandible, being rounded in parts (en face) and flat in others (lateral) will experience different effects of the blast. Impact of a spherical blast wave will inflict transverse lines of fractures on the mandibular body, and may be associated with transverse shearing of teeth at the cementoenamel junction. Fractures of the mandible caused by blast are different from those in the same region caused by any type of civilian trauma; these are the vertical to the longitudinal axis unlike comminuted fractures caused by shrapnel or bullet injuries. Fractures of the mandibular body by blasts are single or multiple parallel fractures in the lower border, between the apices of the roots and the mandibular lower border. Fractures are broken off by acceleration or deceleration of the blast wave.