war surgery afghanistan & iraq atlas_chap2

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Chp IIaCe, NeCK,aNd eye trauma



faCe, NeCK, aNd eye trauma | 55

II.1Coplx facial

Wounds

CASE PRESENTATION

al soli in his i-hiis ws inj b n ipovis

xplosiv vic (Ied) on clos o hi whil h soo

n conc bi. H ssin lipl injis o h

c (igs. 1 n 2), sclp (ig. 3), n xiis. th pin ws

oll inb in h l. a hoogh xinion h incl

iogphs vl c cil n sclp wons ipgnwih ocks n i, n pill glov nibl (ig. 2). alhogh

xpos, h ws no g o h bon cil sklon. His vision

ws inc. ding sg, ssiv iigion n bin o his

wons w po. dviliz iss ws bi, h pn

iss ws xplo, n ocks n i w ov wih iclos

c. th inol cos ws s o cov h xpos nibl

n o sp h ol cvi o h c. mois w-o- sil

ssings w plc on h pin’s sclp n c. H ws kn

o h innsiv c ni (ICu) o conin c. th pin ws

vc b i o lvl IV icl cili o h n.

TEACHING POINTS1. No h ii cogniion n ppopi ngn o

iw copois ciicl o svivl. a sv o ssoci

(poposis, ppil siz), (p pn), n h

is ipiv. Pins xpos o blss xpinc iioplgi

(plsis o h ppil), which os no inic scon c o

cnl nvos ss ss lsion o hniion.

2. Po won bin o hooghl vl h xn o h

inj.

3. Po copl inol n xol xinions o l o

cil cs.

4. Clns wons hooghl wih scb solions n slin. us scb

bsh o ov ll i picls o h is. Copios iigion,ocps (c n no. 11 bl ip, ong oh insns), n

song scion ks o civ clnsing.

5. rov oign bois wih iclos c in o no o povok

inj o nling scs. th o i kn iniill will

ipov h cosic oco o h pin.

6. t vscl injis sing hos o ic pss o isscion

n ligion o h oning vssl. Blin clping o bling s

shol b voi bcs ciicl scs, sch s h cil nv



56 | War SurGery IN afGHaNIStaN aNd Iraq: a SerIeS Of CaSeS, 2003–2007

Figure 2. Degloved mandible and extent o wounds.Figure 1. Multiple acial wounds impregnated with

sand, rocks, and debris.

Figure 3. Scalp injuries.

n poi c, sscpibl o inj. us shp

bin o won gs h viliz.

7. us nibioics wih g-posiiv covg o

pning injis o cs h incinc o

incion n o hlp poo opil won

hling. Consi ns oxoi.

8. In gnl, in cons o xi wons, pi

clos is n ipon spc o nging cil

lcions. Whn pi clos is possibl, h

won shol b ppoxi in pop ls

o opiiz n shic oco o h pin

(igs. 4 n 5). In his cs, h wons w so

conin h pi clos ws l,

n iionl iigion n bin w

qi.

CLINICAL IMPLICATIONSIn cons o siil wons o oh bo gions,

pi clos o sll cil wons is con

ollowing hoogh clnsing. Clos o p wons

involving n ls o hs clos bo q

iigion n bin, howv, cn l o h

ollowing vs ocos:




Figure 4. Scalp healing 1-year post-op. Figure 5. Facial wound healing 1-year post-op.

1. Inc wons.

2. dviliz isss bing invnl incopo

ino h wons.

3. Inq bin o wons wih nion

o oign bois.

4. tooing s sl o inq i ovl.

DAMAGE CONTROL

o il bling, s copssion. o signicn

bling, po ligion o h vssl. dic visl

locion o h vssl is ncss bo vssl ligion

o pvn ging h poi c o cil nv.

miclos iigion n bin o gossl

conin wons vil o pvn incion.

SUMMARY

ap o ov ll obvios bis o wonsing h s opion o cili o vobl

oco o h pin. I h iss gin looks o

c bon pi, i shol b ov p o 1 o

2 o cili o shic won clos. Bcs

o h highl vscl iss in h c, sll picls o

iss cn sviv. Niv iss will lws look b

hn fps n gs. alhogh h c is v vscl,

i is no con h pl conin wons

b piil clos ing iniil sg. In hvil

conin wons, lipl ons o iigion n

bin con wih l pi

clos, i possibl. roionl fps n skin gs

b ncss o obin opil sls.

SUGGESTED READING

Chp 13: c n nck injis. In: Emergency War

Surgery, Third United States Revision. Wshingon, dC:

dpn o h a, Oc o th Sgon Gnl,

Bon Insi; 2004.

Chp 22: So-iss injis. In: Emergency War



Bon Insi; 2004.

onsc r, Wlk r. Oral and Maxilloacial Trauma.

2n . Phillphi, P: W. B. Sns; 1997.

row N, Willis J. Maxilloacial Injuries. 2n . Nw

yok, Ny: Chchill Livingson; 1994.




II.2facial Lacations

CASE PRESENTATION

a35--ol l soli ssin cil injis o bis

hl o c bob xplosion. mlipl so-iss wons

w ppn, wih h os signicn bing igh chk

lcion (ig. 1). Bcs o h locion o h wons, vlions o h

poi c n cil nv w inic. Bling ws conoll wih

ic won copssion. th pin ws l n oin. Phsicl

n nologicl xinions vl no goss vinc o cil nv

wknss. th ws no vinc o inj o h bon cil sklon.

ding sg, no vinc o g o h poi c (o Snson)

ws on. mnl niplion o h gln poc n q

fow o sliv. th c ws cnnl wih lcil pobs n ch

bing. No ispion o h c ws sn. th pin’s won n vil

scs w xplo. oign bois w ov, n isss w

clos in ls. H cov wiho coplicions (ig. 2).

TEACHING POINTS

1. Vscl injis s b l o n pi bo pocing

wih h lcion pi.2. cil bling shol b conoll iniill wih copssion.

Ligion o h vssls b ncss. Howv, ic visl

locion o h vssl is ncss bo poing ligion o

pvn g o h cil nv o poi c.

3. th iponc o won xploion ns o b sss. th

lipl, nling vil scs h cn b g in

cil/chk lcion. th won s b cll xin o

ini n vl h ingi o h cil n nv n

is bnchs, h bccl p, n h poi gln n c.

4. alhogh no lws ncss, i silogph is po, s w-

solbl cons i (which is lss oxic) ins o hln bl.

5. C shol lso b kn o ns h sili o h poc no pvn inocion o ol bci ino h poi c.

6. Poi c lcions qi sn plcn, wih sing o h

lc ns (s ig. 4, pg 68). Cl onioing o poi

gln injis shol b po o l o h oion o

poi sl o silocl, which cn b wih nisilogogs

n pss ssings.




Figure 1. Cheek, scalp, and acial lacerations.

Figure 2. Wounds immediately post-op.

7. rpi cil nv lcions h occ poxil

o ppnicl lin wn o h ll cn-

hs o h .

8. Won clos is ipon in nging cil

lcions. Copios iigion, ovl o oign

bois, n nibioics wih g-posiiv covg

ncss o cs incion n o hlp

poo opil won hling. t o inin hbccl p, i possibl, o pvn cosic cs

(g, hollowing o h chk). Whn pi clos

is possibl, h won shol b ppoxi in

pop ls o opiiz n shic oco o

h pin (igs. 3 n 4).

CLINICAL IMPLICATIONS

1. Sipl chk lcions h spcil in ph

shol b ng lik n oh cil lcion in

n shic zon onc nologicl xinion hs

bn po.

2. Lg hogh-n-hogh lcions wonsh ponill involv inj o n o h

scs lis blow, n inj o n o hs

scs qi iionl pocs:

. cil nv injis.

b. dg o h poi gln n c.

c. dg o h cil n is bnchs.

. dg o h bccl p.

DAMAGE CONTROL

Chck vil scs. In conscios pin, ocn

h nologicl xinion o h cil nv boinising locl nshsi. In n nconscios pin,

nv silo cn b s o ssss cil nv g.

Conol bling: s copssion o il bling n

s ligion o h vssl o signicn bling. So iss

shol b clos in lipl ls. alhogh lking cn

b ncoobl, sv pin is no chcisic o

xillocil injis. avoi ovsion.

SUMMARY

cil lcions shol b hooghl vl o

l o inj o signicn nling scs,

spcicll h cil nv n poi c. I hclinicl siion llows, ii conscion

o hs scs is con. In his cs, h

pin i wll wiho n signicn coplicions.

alhogh so pins qs sc vision

h ppopi on o hling i, his pin

clin h n n pol ws his scs

s bg o cog.




Figure 3. Six months post-op.

SIALOGRAPHY

Silogph is h iogphic xinion

o h sliv glns. Wih h pin in

spin posiion, i noll involvs slowl

injcing nonionic w-solbl cons

i (350 g ioin/L) icl ino

h sliv c ss. th injcion issopp whn h pin ls iscoo

o 1 L hs bn injc. (No: plin

ls shol b kn bo injcing h

cons i o ini n clcli. also

o picl bn is plcing nl l in

h bccl slcs osi h pp ols

h poi c oic.) using l pobs,

h sliv c opning is xplo n

il. roin poscons X-s shol

incl obliq ll n ll viws,

posio-nio viw o h poi gln,

o nibl occlsl iogph o hsbnibl c.

SUGGESTED READING


Surgery, Third United States Revision. Wshingon,

dC: dpn o h a, Oc o th Sgon

Gnl, Bon Insi; 2004.

Chp 22: So-iss injis. In: Emergency War

Surgery, Third United States Revision. Wshingon,dC: dpn o h a, Oc o th Sgon


onsc r, Wlk r. Oral and Maxilloacial Trauma.

2n . Phillphi, P: W. B. Sns; 1997.

row N, Willis J. Maxilloacial Injuries. 2n .

Nw yok, Ny: Chchill Livingson; 1994.

Figure 4. One year post-op.




II.3Conal Poation

CASE PRESENTATION

this 19--ol l soli ssin ol vssl lcion

n pning ocl inj o n ipovis xplosiv

vic (Ied). On psnion o h cob sppo hospil

(CSH), xinion o h vl sll sll poion o

his igh con (ig. 1). a gn ws psn in h vios cvi,

n poion o iis n vios ho plgg h won. His lnsws pill isloc, n h h ic cc. th nio

chb h bloo obscing ch o h iis ils (hph). a

h xi hohg ws conoll, Wck cll vico ws

po. Bcs i ws lss hn 6 hos o h i o inj, h

sll poion o iis ws posi ino h glob. Bloo ws wsh

o o h nio chb. Bl cnocl (conl gl) ws

nvilbl, n sing h sll poion wol hv l

sch signicn sigis h ponil visl ci wol hv

bn poo. 2-Ocl cnocl, givn is siil popis o bl

cnocl, ws s o clos h won.

TEACHING POINTS

1. Lin conl lcions il sighow o pi. Howv,

sll sll (o pnc won) igh pos o icl s

pi. evn hogh h won igh b sll, h chnics o clos

hv o lios c on posopiv visl ci. this

siion occs bcs vco ocs cs igl wpg o h

con (sigis) s sl o h nsion ncss o clos on

o sowh cicl c in cv con.

2. Bl cnocl (ig. 2) is vilbl in n conis, b i is

no ppov b h uS oo n dg ainision (da), n

is nvilbl in h uni Ss. Howv, 2-ocl cnocl

(ig. 3) is ppov b h da o skin s. alhogh h in

copons, h hv siil hsiv popis (g, fxibili,sngh, c).

3. o gl o h o h con, h ovling pihli s b

ov. usll, his poc is po sil in n inj con

bcs c is l psn in h pihli. th pocss sipl

involvs nlging h soning xpos .

4. I is ipon o ppl h gl o sc bcs n liqi ns

o solii h gl. Boh conl gl n skin gl will in in liqi




Figure 1. Right globe with peroration at 9 o’clock accompanied by the loss o at least two clock hours o iris

(blck ow). A portion o the iris and vitreous humor appears as a ne brownish halo at the edge o the cornea

protruding rom the anterior chamber (whi ow), which is lled with blood and an air bubble at 2 o’clock.




o nil conc wih fi o ois. In his cs,

h sgon sqz h skin gl ono h plsic

cov o spcin cp. H s 30-gg nl

on bclin sing o w p sll on

o i. a Wck cll spong ws s o h conl

sc h poion. th op o gl gnl

och h sc o h c, which cs

sligh sping. th qos ho qickl bgno solii h gl o h insi. [No: a

op o slin solion o solii h o poion

o h gl i h l os no l o his.

th c qi svl ops (s in his cs

psnion) o cov h c copll. B s

h no inocl conns (g, iis, vios ho,

lns il, c) poing hogh h c,

o i will h o h gl.]

5. di gl psns h h n igl sc

h is pinl o li ovn. evn i h gl

i o il sooh sc, h li ovn

cn islog h gl bo scin hling hsocc. tho, lws s bng conc

lns o pocion n coo (ig. 4). th bs

opion is s o spcic hpic lns h hs

no civ pow n is lg in i (18–24

). Howv, low-pow, sn conc lnss

cn lso b s (gnll bwn 13–15 ) s

bng. as long s h pin is wih

bo-spc nibioic (i, fooqinolon o

polxin/nocin) 2 o 4 is , h conc

lns cn in in plc.

6. as h c hls n h pihli covs h ,

h gl will b oicll islog. Gnll,his pocss qis 4 o 6 wks, pning on h

siz o h c. this ppoch is bs o conl

cs lss hn 2 , b i igh b possibl o

plc ss o c s scol h hn s

nsion-incing clos. th gl is hn plc on

his scol o sll cs.

CLINICAL IMPLICATIONSunonl, pning injis o h conin

o b coon in h. Inj o h is on

hisoicll in 5% o 10% o ll cob cslis.

tn o hs injis qis spciliz oph-

hlic pocs wihin 24 o 48 hos. micl

psonnl who povi iniil n shol no

h ollowing pincipls:

Figure 2. Butyl cyanoacrylate or corneal glue (MSI-

EpiDermGlu, Medisav Services, Inc, Markham,

Ontario, Canada).

Figure 3. 2-Octyl cyanoacrylate or skin glue.

Photograph: Courtesy o Ethicon, Inc, Somerville,

New Jersey.

DERMABOND

this opicl skin hsiv is sil, liqi

won hsiv sign o pi lcions

n o clos sgicl incisions. I cs wih

ois on h skin’s sc o o song,

fxibl bon. dermaBONd is s opicll

o hol clos sil ppoxi skin gs

o wons o sgicl incisions, incling

pncs o inill invsiv sg, n

sipl, hooghl clns, -inc

lcions. (See ull Prescribing Inormation

or use.)




11. disingish jo ocl injis o ino injis.

(this cn b icl pocss.)

12. avoi nonsoil niinfo gs wih in-

ocl injis. I vlion o n ophhlologis is

l o o hn 24 hos, consi n

wih opicl b-block (iolol, lvobnolol,

c) wic o hlp pvn inocl pss

lvion.

DAMAGE CONTROL

Wih sspc ocl inj, plc igi ssing

ov h , s nibioics, n vc o

h ns ili n cili h hs nophhlologis.

SUMMARY

Bcs o h n o high-vloci pojcils n

xplosiv gnion vics, lipl cil n

ocl injis qi coon on h bll.

Pi gnion o Ieds o scon

pojcils (g, ocks, i, glss, o llic gns)

cn b sponsibl o pning glob injis,

incling ic poion o h con. micl

psonnl s b v vigiln bo pins wih

injis, picll pins wih sspcpning glob injis. this cs povis ips on

h pi o nonlin conl poion.

SUGGESTED READING

Chp 14: Ocl injis. In: Emergency War




thch aB, . Ophthalmic Care o the Combat Casualty

(a Textbook o Military Medicine). Wshingon, dC:

dpn o h a, Oc o th Sgon Gnl,Bon Insi; 2003.

1. Sppl pocion in h cob zon. this

is no n s b phsiz o solis

n cons b ll icl psonnl ll

lvls o c.

2. din h svi o ocl wons. Psonnl

lvl I n lvl II icl n ciliis

shol vc ll pins wih pning glob

injis o icl n cili wih n

ophhlologis.3. No h loss o vision—nis b h inbili

o nol pin, cop wih h oh —

is sggsiv o sios inj.

4. do no ppl pss ssing i pning inj

is sspc. appl igi shil ins.

5. do no ppl opicl icions.

6. S cipofoxcin 500 g oll o invnosl.

7. rivl o inocl oign bois is no

con in h ow sgicl sing.

8. Pvn sis.

9. ainis ns oxoi i inic n vc

h pin.10. tig pins wih injis n n o h

a–B–Cs n h li-hning injis s. thn

sigh n lib injis.

Figure 4. Therapeutic contact lens (l; Kontur

Kontac Lens Company, Richmond, Caliornia)

and standard contact lens (igh; Bausch & Lomb,Rochester, New York).

Plain flms or CT must be obtained to rule

out an intraocular or intraorbital oreign

body prior to perorming any MRI.




II.4maxilloacial rconstuction

CASE PRESENTATION

t his hos nion l ssin gnsho wons o h igh

si o his c. H h coin xill n nibl

cs. aiionll, h w lipl issing n sh

h, gns pning nck zons I o III, sh poi

gln, sv Snson’s c, n cil nv nscion. H h

signicn so-iss o h igh si o h c (ig. 1). a

h cob sppo hospil (CSH), h nwn ngiogph, nck

n c xploion, n choo. th ns o h poi c

w ini n lig. th won ws loosl ppoxi n

ss. L, h ws ns o noh hospil o o niiv

n. Pio o conscion o h i n ch, ch bs w

plc on h pin’s niion bin o ooh picls

n gns. th xill ws bokn ino o pics. th pin

civ xillonibl xion h ns goo, pocibl

occlsion (ig. 2). tini pls n scws w s o sbiliz s

n bon gns s possibl, wih cl ppoxiion h

L o I lvl. Woking ogh, h ol n xillocil sgon

n h ciohocic sgon hvs wo ibs (nos. 4 n 6) oh pin’s igh si. th pin’s conl h ws ov,

bcs i ws copll c o h s o h coin

nibl. th zgoic ch ws xl coin, wih

lipl gns onl svl illis in lngh. On ib ws

s o consc h pin’s igh nibl conl n s,

n h oh ib ws s o consc h igh zgoic ch.

tinin pls n scws w s o sc h bon gs o

sbl bons. th inio lvol nv col no b pi, bcs

oo ch scion h occ ( conscion wol involv

icosgicl g pi). a poico ws lso po. No

ns o h cil nv col b ini. th pin ws ls

o xion o chck h occlsion, ins n scion h ol cvi,n ov h ho pck. H ws hn plc bck ino xion o

sbiliz h sgn xill bcs no pll sn ws vilbl.

miclos ppoxiion o h so isss ws ccoplish in

ls. a Pnos in ws plc. th pin ws givn invnos

(IV) nibioics, n won c ws povi. Wi cs w wih

h pin ll is. mxillonibl xion ws plnn o 6

wks o l h xill hl. H ws xb wihin h wk n

ns o h CSH. Goo cil s ws chiv (ig.




3). Long- ollow-p ws no vilbl. h

icosgicl conscion wol hv bn

bncil, b h ovll shics n bsic ncion

w psv sing his chniq.

TEACHING POINTS

1. this cs is n xpl o pin who qi

xnsiv conscion wihin h liiions o

lvl III icl n cili.

2. cil conscion is ios n i consing.

th pi gol in ing uS pins is

sbilizion n vcion. On h oh hn,

non-uS pins qi niiv n in

h. this n qis qipn h is

no sn iss in h plo lvl III icl

cili. B ncssi, lvl III ciliis hv cqi

iionl spciliz qipn o hnl hs

icl pins.

3. alniv ppochs col hv bn iliz in

h cil conscion o his pin. exnl

xion o conscion bs col lso hv

bn s. th g o coinion n h

conl h nn inic h bon

ging ws h logicl choic o consc h

nibl. Cosochonl ging is niiv

n o plc nibl conl h,

whs conscion b wol b po.

th ib g lso povi xclln cono o

h conscion o h zgoic ch, hs

soing h pojcion o h ic.4. this cs lso onss h n o sb-

spcilis wihin h lvl III icl n

cili. Nosgons, ol n xillocil

sgons, n ophhlologiss who vilbl

in h gl nhnc h cpbiliis o

h lvl III icl cili. ths icl po-

Figure 1. Intraoperative exploration o wounds. Note neck wounds and sot-tissue avulsion o the ace.




Figure 2. Final closure obtained and patient placed back into maxillomandibular xation.

ssionls povi high lvl o xpis

n pin c bon bsic sbili whn

vcion is no n opion o whn vcion

col psn g isk o obii.


1. aologos bon gs sl n ccp

w o consc cil injis niivl.

Cosochonl gs cn b s o consc

h nibl s n h zgoic ch.

Ilic cs bon gs o cnil bon gs cn

b s o consc h obil foo.

2. mlipl sgon wok xpis ios, i-

innsiv conscion. mission n opionl

po on n liiing oping i o

s clos o 2 hos s possibl. usll, niiv

conscion cnno b ccoplish h qickl.

I s no vilbl, sging o conscion

is on.

3. a choo is n il iw o pins

wih xnsiv cil . ths pins hv

xnsiv n ngo svl opions

o conscion. th choo is niiv

iw h is o sil sc n inin.

4. rpi o Snson’s c (no on in his cs) is

ccoplish b cnnlion wih sll gg

ngioch. th c is hn ppoxi

wih n bsobbl ss ov h cnnl o

inin pnc (ig. 4).

5. Sspc cil nv injis shol b xplo

n piil pi i possibl. cil nv

bnchs h lc si nio

o vicl lin wn own o h ll

cnhs o h o no n o b sgicll

ppoxi bcs hs bnchs v

sll n will sponnosl gn wih goo

n o cil ncion (ig. 5). I h won




Figure 3. Note symmetry obtained at mandibular

ramus and zygomatic arch. Bone screws and plates

are radiopaque.

Figure 4. Repair o parotid duct.

TemporalBranches

Zygomatic

Branches

BuccalBranches

Marginal

MandibularBranch

CervicalBranch

Figure 5. Branches o the acial nerve, parotid duct injury.

is hvil conin n cnno b clos

piil, h sv ns o h nv shol b

loc n gg o inicion n pi

h i o won clos.

6. Pins plc ino xillonibl xion

s hv wi cs wih h ll is in

cs h n o b c loos bcs o iw

copois. us bilicl p o shion

ncklc so h h wi cs on hpin’s nck ing nspo. I medeVaC

cws lcn o nspo pin in wi

xillonibl xion, sll lsics cn b

s o chiv xillocil xion nil h

pin ivs sbl locion.

DAMAGE CONTROL

dg conol o ooxillocil injis will cn

on iw n hohg conol. egnc

cicohoioo b ncss wih nsbl cil

cs wh niiv iw cnno b pil

sblish. appoxiion o lg bon gns wihloos clos o ovling so iss llow q

hohg conol o g h pin o o h oping

oo o h ssciion.




ERICH ARCH BAR

th eich ch b (lso known s h

eich nl b o h eich ch b

coil)— l ch b sc wih so,

sinlss wis—is n ch b coonl

s in h pi o nibl cs.

th eich ch b is n ipon ool inocclsl soion, picll in css o

coin n obliq cs n h

loss o conini o h nibl.

Advantages• Rigidity.

• Maxillomandibular xation easily applied.

• Easily adaptable to elastic traction.

• May be prefabricated or adapted.

• Continuous occlusal (superior tension

bn) conol.

SUMMARY

this cs onss ho o niiv cil

conscion n highlighs h n o ivs

spcilis wihin lvl III icl n cili.

I lso povis so pcicl vic o ling wih

xnsiv cil .

SUGGESTED READINGChp 4: aoicl vcion. In: Emergency

War Surgery, Third United States Revision. Wshing-

on, dC: dpn o h a, Oc o th

Sgon Gnl, Bon Insi; 2004.

Chp 5: aiw/bhing. In: Emergency War











II.5mandibl Gunshot

Wound

CASE PRESENTATION

ahos nion l s gnsho won o his l nibl

(ig. 1). His iw ws inc, n his vil signs w sbl

on psnion o h gnc pn. H nwn

opiv bin n wsho o h won. th ws no ol n

xillocil sgon (OmS) no , nos, n ho (eNt) sgon

ssign o h lvl III cili h i. In iion, n ooxillocilsg/icopl s ws no vilbl. a svl s, h won

pp cln n o viliz iss n coninion (ig. 2).

a consling wih ol ssign OmS, o gnl n

ohopic sgons ook h pin o h oping oo o niiv

pi (ig. 3). using n ohopic hns, h jo gns w

c n ppoxi wih singl pl (ig. 4). Oh gns

w lg scw ino posiion. a h bin n iigion,

h so iss ws clos (ig. 5). ach bs w plc o inin h

cion n sbiliz h nibl (ig. 6). th wons hl wll.

a 5 wks, h ch bs w ov, n h pin ons

nol occlsion n ncion.

TEACHING POINTS

1. Iniil n o high-vloci issil injis involvs h bsic

pincipls o won bin n libl iigion o ov

viliz iss n oign bis, glss o h noicl si

o inj.

2. ixion n sbilizion o cs wih so-iss clos (whn

possibl) shol b ccoplish onc h won is cl o

iss n bis. this cn b ccoplish wihin svl s o

woning, pnn on h xn o so-iss inj n h g

o won coninion.

3. Bcs his pin col no b ns o high lvl o c,

niiv pi h o b ccoplish on-si. using liisciplin o gnl sgons (who l wih so-iss wons gll)

n ohopic sgons (who l wih pl-n-scw chnolog

il), sching h sgicl opions n consling wih

n OmS, h pin nwn niiv conscion wih n

xclln oco.

4. ach bs plc o hlp c h c n povi nsion

bn. th nibl b c n innll x pio o




plcn o h ch bs i h c is sil

noicll c. Howv, coc sqncing

shol b ch b plcn o hlp c

h c, hn innl xion goo

cion.


On, in h plo sing, sgons ncon clinicl siions nili o h. In n

gnc siion—b ollowing avnc t

Li Sppo (atLS) gilins— pin cn on

b sbiliz nogh o nspo o high lvl

o c. o pins who s in o niiv

c (picll n pisons o w o hos nion

civilins), consi h ollowing:

Figure 1. Gunshot wound to let mandible.

1. ollow h bsic pincipls o sgicl c:

. Won bin n wsho.

b. anibioics s ppopi.

c. Sbilizion o cs.

. Wons l opn nil cln nogh o clos

(wih ih won VaCs o w-o- ssings).

. Niionl sppo.

2. Consl oh sgons/phsicins i in niliio.

. On, gnl sgons hv wil in

sgicl xpinc.

b. Oh sg spciliss hv iionl xp-

is h col b sngisic in pin’s c.

c. avilbl spciliss cn b consl ol

ih b lphon o -il.




Figure 2. (top) Wound

several days postinjury.

Figure 3. (Boo)

Operative repair. Sterile

gloves are used to cover

operating room light

handles.




Nonhlss, b ollowing bsic sgicl pincipls,

b hooghl sching sgicl opions, n b

sking ssisnc o locll vilbl—s wll s

ol ssign—spciliss, sccssl oco iso pobbl.

SUGGESTED READING





3. Consl vilbl ncs n h Inn.

4. do no sohing h hs lil chnc o sccss.

DAMAGE CONTROLWih xnsiv jw o cil injis, gnc ci-

cohoioo b ncss h os o h

ssciion phs.

SUMMARY

Cob sg cn on chllng h os xp-

inc sgons o h liis o hi cpbiliis.

Figure 4. (top) Approximation o mandible

ragments with plate.

Figure 5. (Boo L) Wound closure.

Figure 6. (Boo righ) Arch bar stabilization.




COmmeNtary

High-engy facial Injuis by COL Karen M. Keith, DDS

Sinc 2003, in h os cn confics o Iq n

aghnisn, ppoxil on hi o cob

injis involv h h n nck. to’s soli

ws o civ psonl pociv qipn

ino cob hn n oh i in hiso. mon

bo o pocs h oso, n h Kvl hl

povis xclln pocion o h h n bin. as

h confic hs pogss, bllisic w pocion

hs bn noc. Consqnl, nonlhl b xl

obi wons o xpos libs n h cil hv

incs ispopoionl in h ovll isibion o

injis. th ol n xillocil (Om) sgon hs

ncssil pl signicn ol in h ngn

o hs pins. th niq ining o Om sg

ks h sgon oc lipli in is o cisis.

th Om sgon cn povi nshsi; po

choois; lv cnil fps; hvs bon gs

o h clvi, ilic cs, ibi, n ib; n lv

h polis, pcolis, n oh ocnos fps.

unlik pvios confics, soli cn now b v-

c o h o h uni Ss in s lil

s 4 s. ths, ssciion n sbilizion h

c ngn gols o hs solis. Howv,

h obii o coliion n hos nion oops no

vc o high chlons o c is lso ipov b

h skills n ingni o h cob sgons. ow

Sgicl ts (Sts) povi ii n, wih

pi vcion o lvl III chlon c h cob

sppo hospil (CSH). th Om sgon is ssign

o h CSH o o H n Nck t. Onl in vcn s (2003) hs n xnsiv Om sg s

bn l, which incls h ll ng o cniocil

pling ss n xnl xion qipn. this gl

xpns h cpbili o h Om sgon. th bsic

ns o sbilizion n xion, howv, in

ch bs n wi, n n ploing sgon ns o

nsn hi pop pplicion.

mn lssons ln ging cn inj pns

n iologis sl in oicion o n

poocols o injis o h h n nck. Ipovis

xplosiv vics (Ieds) cnl ccon o 40% o

60% o injis o solis n civilins. ths vics

cs wons gossl conin wih i, plsic,

gvl, il, n fsh. Oh high-vloci pojcil

wons sl o gnshos n o blss. Glob

p o pnion, oologicl bls g, bns,

pncs, n vlsiv so-iss wons wih xnsiv

h-iss coinion psn h inj pns

h psn n chllngs n consiions (igs. 1

n 2).

In n h n nck , h s consiion

shol lws b h iw. On, h pin is inb

in h l o soon psnion o h gnc

oo. mos on, pins inb oll bcs i

is si n s in sing hn plcing nslb. I h no concoin ic injis, h

pin cn b xb n inb nsll bo

ssing Om sg pi. I pin hs ic

cs, cion s b xcis whn plcing nsl

b o voi invn nnc hogh cnil bs

c, ponill csing cbl inj. anoh

ppoch o scing n nochl b is o pll n

oll plc b o hogh sbnl incision.

this povis sc iw wiho hping h

sgon’s bili o wi h h n jws clos. In css

o sv cil , in which vcion o polong

inbion (ol o nsl) nicip bcs o , vnilo wning icl, o lipl ns o

h oping oo, choo is songl voc.

Pins shol lso hv cicohoioois conv

o choois pio o vcion o h nx chlon

o c. this will gn sc iw o nspo

n o h nx phs o n.




Onc h iw is sc, hoogh xinion

s b po o in h xn n svi

o h inj. Om injis no li-hning

onc h iw n bling conoll. Bling

is conoll wih pcking, jicios c, o s

ligion. Pophlcic nibioics n ns pophlxis

inis. a iniil sbilizion, hoogh

ssssn o h xn o inj n conscivns po.

Hiso n ocs phsicl xinion gi h

iging. In n i h, plin ls n clinicl

cn cn sccssll gi sgicl n. Clinicl

xinion cn b hp b inbion n b

h cvicl coll. in-c (1–3 ) xil Ct igs,

whn vilbl, o h pin’s c hlp lin h

injis n o sl hn plin iogph.

I h pin’s cvicl spin is cl, coonl Ct

igs o iionl inoion. th-insionl

conscions picll sl whn plnningh pi o coplx Om sg injis (ig. 3). th

sgon vls ll h sis n ks h ignosis

n n pln. th sgon s consi h xn

o coinion, vlsion, n coninion o h

h- n so-iss scs. avlsiv o pning

in his gion cn involv g o sliv

cs, bnchs o h cil o iginl nv, n

vscl scs. th phsicl xinion shol

incl iniing sch g n gging scs

h cnno b hnl h cn chlon o c,

hb oing g chnc o sccssl

pi h nx chlon o c.

Consiion s b givn o h ovll coniion o h pin. dniiv pi is i-consing n cn

involv lipl, lngh pocs. I h pin cnno

ol polong sgis, h sgon cn consi

wshos n sho sg pocs bs on

pin pogss n sbili. o uS solis, niiv

conscion will no sll b po h lvl

III chlon o c.

Copios iigion n cl, sil bin

ssnil o iniiz h ponil o incion n

shic concns o Om wons. I is ipon no o

ovlook singl inconsqnil pnc wons.Cl xploion o won cviis cn vl n

xnsiv is o g n oign bis, sch s

plsic, i n sll glss picls, n occl cs

scon o h ipc o h gnion. Pls lvg

is n xclln jnc whn vilbl. Copios iigion

wih sgicl scb ssiss in ovll clnsing. Sll

Figure 1. Example o destructive, avulsive combat

injuries.

Figure 2. Example o destructive, avulsive combat

injuries in another patient.




pnc wons on h c h sil bi

shol b clos piil o shic concns h

hn llow o hl b scon innion.

Wih cs h involv h ic o nibl, ch

bs n xillonibl xion (mm; ig. 4) n

o b plc pio o cion n xion. Iicion o h c n ipovn o occlsion

cn b obin wih bil wi (24 o 25 gg) plc

on ls wo h on ih si o h c. I

h pin hs nonisplc sbconl c n

nol occlsion, h cn b wih so i n

poscipions on wing hl n pociv (“gs”)

sk. Occlsion is sohing h h Om sgon

ins picll niv o bcs i cn gi

nl ppoxiion n xion o h iss. Wiing

h pin’s h clos sblishs h coc occlsion,

which b spcill poblic wih vlsion o

bon gns. No h h in h lin o c

cn b inin i sbl n no ining wih

sblishing h occlsion. I c wih xpos plp,

o v loos, h shol b ov. Onl sing n

noicl cion, wiho mm, o c cs

cn isk giving h pin posopiv locclsion

h cn hn ncssi iionl xnsiv sg

Figure 3. Three-dimensional CT reconstructions in AP(L) and oblique (righ) views o acial trauma. Note

comminuted mandible racture and maxillary Le Fort

level injury.

o ci. Onc h c is x, h mm is

ls. th ch bs sll in in plc nil h

c is hl (6 wks) in cs lsics o iionl

niplion is qi.

an pin who will in in mm (clos cion)

shol hv wi cs vilbl ll is. ubiliclp is s o hng h on h nck. Wi cs

o h povi ssising h pin o ls h

mm i ncss o iw isss. this is v

occnc. esis is no sll isl n inicion

o ls. I h pin is vc, lsics (6-onc

Figure 4. Clinical example o maxillomandibular

xation with arch bars and wire loops.




Figure 5. Joe Hall Morris appliance system.

JOE HALL MORRIS DEVICE

th Jo Hll mois vic (o h biphsic ss) is n xpl o n xnl-pin xion pplinc.

I llows xion o nibl c wih no jo incisions. this chniq is il o s

wih signicn so-iss loss o incion. this biphsic vic svs s h pin’s nibl nil

h c si hs copll hl. th Jo Hll mois vic ws s xnsivl in Wol W

II, b i is no s so wil n o. Sgons, howv, shol b ili wih his chniq n

incl i s p o hi sgicl ni. I is picll sl in nlos pins wih

coin cs.




ohoonic lsics) cn b s ins o wi o

clos cion. this iniizs pin iscoo nil

h nx chlon o c is ch, b is o sibl

o pin ngn ing vcion. rb

o iscss xion wih h vcion .

Coin, vls, n conin cs

on bs iniill wih xnl xion h

hn wih opn cion n innl xion. th

biphsic ss, known s h Jo Hll mois vic

(ig. 5), is h os coon n ili vic o hOm sgon. Howv, h ohopic hn n wis

xnl xion vic woks civl n is sipl

ss h qis lss i o plc (ig. 6). this is il

in s o signicn so-iss loss o incion (ig. 7).

I is lso picll bncil in n nlos nibl

wih coin cs (ig. 8). th sgon cn lso

lc o plc conscion pl coss coin

nibl c (igs. 9 n 10). th si s b

hooghl iig n bi, n h pl s b

cov wih so iss (ig. 11). I h is n inq

so-iss nvlop, so-iss fp cn b o o

cov h c (igs. 12 n 13), o h sgon cnchoos o conv o xnl pin xion.

Bns n o b vl o iw concns wih

bopic inbion o l choo i o

inhlion inj css spio isss. associ

chl o lngl inj ns o b ssss. Obil

Figure 6.

Wrist external

pin xation

system.

copn sno qis ll cnhoo n

cnholsis. Silvn shol b voi on h c

bcs o is csic n.

In cob, h Om sgon cn b conon wih n

chllnging n coplx inj pns in lss hn

opil nvionn. th gols o cil bon c

pi lignn n xion o h gns in

h coc noicl posiion wih h pop occlsion.

mm (clos cion wih wi) is inio, b on

si n os il vilbl. Pls n scws,conscion pls, n xnl pin xion lso

p o h ni. dpning on h xn

o inj, svl sg pocs will b qi o

niivl consc pin. Plnning shol b

on h-insionl conscion o Ct scns

n solihogph ol bicion. th bili o

psv so iss nhncs h shics, pschologicl

cov, n ncion o h ovll conscion.

lps, bon gs, n lloplsic ils cn b s

o povi h bs consciv os o ipov h

pin’s qli o li. tining in ocnos fps n

jnciv pocs wih oh sgons hs slin n civ n vsil conscion chniqs.

tho, h sgon s consi h pin’s ss,

sppo sss, vilbl chnolog in h, n h

long- gols o conscion n vlop h bs

cos o cion o ll ssss pins.




Figure 7. Comminuted mandible ractures with

avulsion o hard and sot tissues.

Figure 8. Comminuted mandible ractures with

avulsion o hard and sot tissues in another patient.

Figure 9. Clinical example o an open reduction with

internal xation during initial surgery.

Figure 10. Open reduction with internal xation

during initial surgery in another patient.




Figure 11. Primary closure established over hardware using available local sot tissue.




SUGGESTED READING Chp 13: c n nck injis. In: Emergency War



Bon Insi; 2004.

Pows dB, Hg rH. th ol o h ol n

xillocil sgon in wi, gncis n

ois cks. Oral Maxil Surg Clin North Am.

2005;17:xi–xii (pc).

Figure 12. Pectoralis major fap is used to cover deect.

Figure 13. Pectoralis major musculocutaneous fap.

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