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The epidemiology of cranio-facial injuries caused by animals in southern-central China
Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 506e509
Contents lists available at SciVerse ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
The epidemiology of cranio-facial injuries caused by animals in southern-central China Qing-Bin Zhanga, *, Bi Zhangb, Zhao-Qiang Zhanga, Qing Chenc a
Department of Oral and Maxillofacial Surgery, Hospital of Stomatology (Chair: Dr. Ge Linhu), Guangzhou Medical College, 39 Huangsha Road, Liwan District, Guangzhou City, Guangdong Province, P.R. China b Department of Prosthodontics, School of Stomatology (Chair: Prof. Bian Zhuan), Wuhan University, 237 Luoyu Road, Wuhan City, Hubei province, P.R. China c Department of Epidemiology, College of Public Health (Chair: Prof. Cai Wenqing), Hebei Medical University, 361 Zhongshan East Road, Shijiazhuang City, Hebei Province, P.R. China
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 11 December 2010 Accepted 26 August 2011
A clinical investigation was conducted to demonstrate the epidemiology of cranio-facial injuries inflicted by animals in southern-central part of Chinadthe World’s most populous eastern country. It consisted of a retrospective study of 149 patients and was carried out in our department. All the patients were attacked by animals, such as buffalo, cattle, donkey, horse, dog, cat, and rat. There were 91 males and 58 females patients, aged from 5 to 65 years. 113 patients were from rural areas, and 36 from urban districts. Dogs, cattle, donkeys and buffalo, were the most common animals involved in this study. Bite was the predominant mechanism of injury, followed by kick, fall, trample, knock and scratch. The lip, chin and cheek were the commonest sites of soft tissue injury; Condylar process, symphysis, parasymphysis, and angle of mandible were the sites of fractures. Regarding the severity of injury, nearly half of the patients belonged to I and II classifications. The treatment results were satisfactory except for obvious scar formation, facial nerve palsy, and dysocclusion in a few patients. Facial injuries caused by animals are common in China, especially in rural areas. Timely treatment should be performed as soon as possible. Special attention should be paid to the prescription of antibiotics and vaccines. Psychotherapy may also be considered when necessary. It is suggested that adequate protective measures should be taken when animals are used for agricultural activities or kept as pets to minimize the incidence of facial injury. Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Animals Facial injury Management Vaccine Psychotherapy
1. Introduction Animal attacks to the head and upper-neck region can result in facial disfigurement with distressing physical and psychological consequences. Human facial injuries inflicted by animals are commonly seen in rural communities, as well as occurring in urban areas (Abuabara, 2006; Stefanopoulos and Tarantzopoulou, 2005; Ambro et al., 2010). Western countries have a reported incidence ranging from 375 to 740/100,000 people a year (Chomel and Trotignon, 1992; Knobel Freud et al., 1997; Wolff, 1998). In Africa, Ugboko also conducted a retrospective review in sub-Saharan Africa, which demonstrated the overall clinical data and management of 34 patients (Ugboko et al., 2002). However, few documents
* Corresponding author. Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guangzhou Medical College, 39 Huangsha Road, Liwan District, Guangzhou City, Guangdong Province, P.R. China. Tel.: þ86 (20) 61359010; fax: þ86 (20) 61359577. E-mail address: [email protected] (Q.-B. Zhang).
about the incidence and characteristics of such injuries have been reported in China. The animals that caused human facial wounds vary from one region to another. Generally speaking, the animals could be classified to small or medium size animals (cat, rat, dog, et al) and large size animals (cattle, buffalo, donkey, horse, et al). Cows, dogs and donkeys are the commonest animals involved in a previous report (Stucker et al., 1990; Stefanopoulos et al., 2004). Injuries inflicted by other animals have also been recorded such as horses, cats, pigs, goats, snakes and even rats (Metlich et al., 1986; Singh et al., 1994; Correira, 2003). In particular, Yaniv reported one case of human maxilla penetrated by needlefish jaws (Yaniv et al., 2009). In a review of literature, involvement of the head, face, and neck was found in 9e33% of all patients, and the majority of victims were old people and children (Knobel Freud et al., 1997). On the face, the predominant sites were the lips, cheek, chin, nose and auricles (Ambro et al., 2010). Generally, injuries caused by animals were superficial and minor, most of which were soft tissue wounds only, without a bone fracture. Only a few cases had deep lacerations,
1010-5182/$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2011.08.012
Q.-B. Zhang et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 506e509
damage to a blood vessel/ nerve or bony injury (Fourie and Cartilidge, 1995; Ogunbedede and Arotiba, 1997). In the mouths of animals and on the feet/horns, there are lots of different bacteria or virus that can lead to local or systemic infectious diseases. All over the world millions of people keep animals as part of their life (Temes et al., 1997; Ueeck et al., 2004). This is true in this region of China. In rural regions, animals such as dogs, buffalo, cattle and donkeys are used to guard a house, pull plows, assist in irrigation and transport agricultural products; in cities, animals, such as dogs, cats and even snakes are often bred as pets, thus, there are differences between rural and urban areas (Hon et al., 2007). On one hand, dog bite is the most common injury in city, followed by cat scratch/bite; on the other hand, in rural areas, dogs, buffalos and cattle injuries are regularly seen. In order to offer insight into the facial injury caused by animals in this region, this retrospective study describes the clinical data, treatment principles and preventive measures of facial injuries inflicted by animals, both in rural and urban communities in southern-central China.
2. Patients and methods Between November 1992 and November 2008, 149 patients with facial injuries registered in our hospital were included in this retrospective study. Personal details, the animals involved, the location and nature of injury, duration and mechanism of the injury, treatment and complications were retrieved, as well as details of associated injuries. All the patients were classified by the severity of facial injuries according to a five-degree scale: (I) superficial injury with no muscle involvement; (II) deep injury with muscle involvement; (III) deep injury with muscle involvement and tissue defect; (IV) stage III with vessel and nerve injury; (V) stage III with bone involvement. Of the 149 patients, 78 cases presented immediately for medical treatment, 22 patients within 24 h, 20 cases within 48 h, and 29 cases after at least 2 days (6 of the adults sustained their injury in childhood). Inflammatory symptoms were found in only 2 cases of the 78 patients who presented immediately, but occurred in 31 patients of the delayed group. Inflammatory symptoms included erythema, swelling, and pain on pressure in the area of wound, and most cases had fever and lymphadenitis. Therapeutic measures were determined by the stage of the injury and the presence of clinical symptoms. Saline irrigation of the wounds with hydrogen peroxide was always performed as a primary principle, and all non-infected wounds were closed primarily with sutures when possible. The wound edges were only minimally excised for stage I injuries, but more generously in stage II wounds. Patients with lip defects who showed no inflammatory symptoms underwent primary plastic reconstruction with small local flaps or forearm flap transfer. Patients with large tissue loss were left for secondary reconstruction. Bacteriology of animal wounds, especially bite injuries usually included Pasteurella multocida, Staphylococcus aureus, Viridans streptococci, Capnocytophaga animorsus, and oral anaerobes (Table 1). Antibiotic therapy against these bacteria was indicated both for infected wounds and fresh wounds considered at risk for Table 1 Bacteria generally involved associated with different animals. Bacteria mainly detected in the injuries
Common animals involved
Pasteurella multocida Staphylococcus aureus Viridans streptococci Capnocytophaga canimorsus Oral anaerobes
Cattle, donkey, cat, horse, buffalo Almost all the animals Dog, cat, rat Dog, cat, rat Almost all the animals
507
infection. Amoxicillinclavulanate (and other combinations of extended-spectrum penicillins with betalactamase inhibitors) and moxifloxacin offer the best in vitro coverage of the pathogenic flora. The need for prophylaxis against systemic infectious complications, particularly tetanus and rabies, was routinely emphasized in the management. 3. Results Of the 149 patients, there were 91 male and 58 female patients, aged from 5 to 65 years (Table 2). 113 patients were from rural areas, and 36 from urban districts (Table 3). Dogs (n ¼ 40), cattle (n ¼ 35), donkeys (n ¼ 23) and buffalo (n ¼ 18), were the commonest animals involved in this study (Table 2), accounting for 77.78% (116/149). Bite (n ¼ 54) was the predominant mechanism of injury, followed by kick (n ¼ 36), fall (n ¼ 33), trampling (n ¼ 29), knock (n ¼ 22) and scratch (n ¼ 8) (Table 4). The, lip (n ¼ 35), chin (n ¼ 33) and cheek (n ¼ 32) were the commonest sites of soft tissue injury (Table 5); the condylar process, symphysis, parasymphysis, and mandibular angle were the sites of fractures. Most of the injuries were not severe, and 43.6% (65/149) of the patients fell into groups I and II (Table 6). In this study, 6 patients had extensive tissue loss. 4 patients were reconstructed with a forearm flap to reconstruct lips and cheek. 2 cases were treated with the traditional Filator flap to reconstruct the nose. Associated injuries were recorded in 28 cases, injuries of other soft tissue were seen in 17 cases, fractures of other bones were found in 7 patients, 1 patient became blind in the left eye, 1 patient died because of an abdominal injury, 1 patient died falling down a cliff when driven by a donkey, and 1 case died of rabies. As to the medical follow-up, we could track only 82 patients, and information on the others was not available. The results were satisfactory except for clear scar formation in 9 patients, facial nerve palsy in 3 patients and dysocclusion in 2 patients. 4. Discussion Injuries caused by animals commonly occurred on the upper extremities and the majority were located on the face and head. The animals involved are dogs, cattle, donkeys, and horses in most studies. The incidence of such injuries has great regional variation Table 2 Age distribution of patients correlating to different accident animals. Animal
Cattle Buffalo Donkey Dog Cats Rats Horse Total
Age distribution 1e10
11e20
21e30
31e40
41 and elder
3 1 2 12 5 4 1 28
10 3 8 18 5 1 4 49
7 5 6 4 3 0 3 28
9 5 6 1 2 0 2 25
6 4 1 5 2 0 1 19
Table 3 Distribution and contrast of animal incurred facial injury in different regions. Animal
Urban
Rural
Cattle Buffalo Donkey Dog Cats Rats Horse Total
0 0 2 18 13 0 3 36
35 18 21 22 4 5 8 113
508
Q.-B. Zhang et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 506e509
Table 4 Distribution of injury mechanisms according to accident animals involved. Mechanism of injury
Cattle
Buffalo
Donkey
Dog
Cat
Rat
Horse
Kick Fall Trampled Knock (from horn) Bite Scratch
12 8 9 16 0 0
6 11 8 6 0 0
13 7 9 0 0 0
0 0 0 0 38 2
0 0 0 0 11 6
0 0 0 0 5 0
5 7 3 0 0 0
Table 5 Distribution of 176 facial wound locations in 149 patients. Sites
Number
Forehead Periorbital Temple Ear Nose Cheek Lip Chin Floor of mouth Tongue
27 8 9 11 12 32 35 33 4 5
Table 6 Severity classification of animal incurred facial wounds and patients distribution. Stage
Clinical appearance
Number
I I III IV V
Super-facial injury with no muscle involvement Deep injury with muscle involvement Deep injury with muscle involvement and substance defect Stage III with vessel and nerve injury Stage III with bone involvement
19 46 55 23 6
(Ching et al., 2004). The demographic investigation of this study was consistent with those of previous reports (Sacks et al., 1989; Morgan et al., 1995; Abuabara, 2006). The ages of most patients were in the second and third decades of life coinciding with the period of increasing involvements in farming and animal husbandry (Oginni et al., 2002; Norwood et al., 2000) despite other reports, where the patients were mostly in their childhood and elderly (Bernardo et al., 2002). In this study, 30 of 40 dog-bite patients were teenagers. This is attributable to the easier access to the face of a child. Lips, noses and cheeks are the commonest structures of the face to be attacked by a dog. Cattle, buffalo and donkeys are the important farming and transportation animals in the rural mountainous areas. Adults are the manpower in agricultural activity and most of the agricultural animals are tended by teenage boys, which expose them to possible attacks from their herds. There were 76 patients who were assaulted by cattle, buffalo and donkeys. Only 11 of 149 patients were attacked by horse, a much lower incidence compared with that from cattle and donkeys. The reason may be that not many people in this area are actually engaged in horse riding or use horses for transportation. As to the mechanism of injury, kicks, knocks, falls and bites from the animals may be from cattle, buffalo, donkeys and dogs; Knocks may be from cattle or buffalo horns, trampling may be from donkeys, cattle, buffaloes and horses. Statistically, the dog is the commonest among the above animals. Cat may be kept to catch rats in rural area and kept as pets by some urban families, occasionally some cats may attack adults, children and newborn babies. Most of the fractures occurred because of falls to the ground or direct tramples/ kicks by large-sized animals. In all, for small or medium-sized animals, the mechanism of injury is generally associated with a bite or scratch, which can easily transmit infectious diseases.
For the large-sized animals, the mechanism is kick, knock and trample, which often causes open soft tissue injury or bone fractures. In the management of animal injuries, it is important both to avoid infections and to achieve an aesthetically pleasing result (Méndez Gallart et al., 2002; Daniels et al., 2009). Therefore, the management principles are different to some degree. The treatment of each case will depend on the actual conditions, such as the nature of the injury, the expertise of the surgeon, time between attack and treatment, and the location of the injury. As there are large numbers of different bacteria in the animal’s mouths or on the feet/horns that can lead to local or systemic diseases, urgent management is necessary. For small or medium-sized animal bites and scratches, prevention of tetanus and rabies should be emphasized, besides routine management; For facial injuries incurred by large-sized animals, prevention of tetanus and infection should be considered, and early suture and bone fixation are equally important. Although most clinicians agree on the immediate wound irrigation, there is still no consensus on the timing of subsequent treatment in terms of wound debridement, primary or secondary repair even the routine use of prophylactic antibiotics (Agrawal et al., 1992; Talan et al., 1999; Meyers et al., 2008). Through long experience, the authors of this paper suggest initial wound management consisting of irrigation and debridement is at least equally important as antibiotics/vaccine for the prevention of infection, tetanus and rabies. Primary surgical suture and repair are optimal for most clinically uninfected facial wounds, whereas delayed closure should be reserved for high risk or already infected wounds. Management of the soft tissues involved thorough debridement and repeated irrigation with normal saline and 3% hydrogen peroxide. In secondary reconstruction, flap transfer was generally used, such as local transfer, forearm flap, and Filator flap (Rhee et al., 2004; Herford, 2004; Lengele et al., 2004). In fracture patients, open reduction and rigid internal fixation were performed just as other clinicians do (Tu et al., 2002). In all, the therapeutic measures should be performed according to the stage of injury and the actual clinical conditions. Immediate debridement, irrigation and primary closure should be performed when possible. Concomitant facial fractures should be reduced and immobilized as soon as possible. Patients with small tissue loss should be reconstructed with local flaps at the same time as other treatment. As to the extensive tissue loss of lip, cheeks, and nose, pedicle and forearm flaps are recommended for secondary reconstruction. The need for prophylaxis against systemic infection, particularly tetanus and rabies, should be heeded. Cranio-facial injuries caused by animals are complex due to the functional and cosmetic nature of the area. More clinical investigation is needed for an optimal outcome. In the past, unfortunately, psychological trauma has been underestimated, especially posttraumatic stress disorder in this region. With the development of overall therapy, specific and professional psychotherapy should be considered to ensure full recovery (Pitak-Arnnop et al., 2010). Preventive measures and awareness of the potential dangers of animals are needed to minimize the incidence of these injuries. 5. Conclusion Facial injuries caused by animals are common, especially in China, the largest agricultural nation in the world. It is strongly recommended treatment should be performed as soon as possible. Adequate protective measures are necessary when animals are used for agriculture or kept as pets. Special attention should be paid to the use of antibiotics and administration of vaccines. Psychotherapy should be given when necessary. Preventive measures and awareness of the potential dangers of animals are needed to minimize the incidence of these injuries.
Q.-B. Zhang et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 506e509
Conflict of interest There is no conflict of interest. Also, there was no financial support for this paper from any source. References Abuabara A: A review of facial injuries due to dog bites. Med Oral Patol Oral Cir Bucal 11: E348eE350, 2006 Agrawal K, Mishra S, Panda KN: Primary reconstruction of major human bite wounds of the face. Plast Reconstr Surg 90: 394e397, 1992 Ambro BT, Wright RJ, Heffelfinger RN: Management of bite wounds in the head and neck. Facial Plast Surg 26: 456e463, 2010 Bernardo LM, Gardner MJ, Rosenfield RL, Cohen B, Pitetti R: A comparison of dog bite injuries in younger and older children treated in a pediatric emergency department. Pediatr Emerg Care 18: 247e249, 2002 Ching CR, Adelgais KM, Daane SP: Dog bites in Oakland, California. Plast Reconstr Surg 114: 1669, 2004 Chomel BB, Trotignon J: Epidemioloical surveys of dog and cat bites in the Lyon area, France. Eur J Epidemiol 8: 619e624, 1992 Correira K: Managing dog, cat and human bite wounds. JAAPA 16, 2003 28e32,34, 37 Daniels DM, Ritzi RB, O’Neil J, Scherer LR: Analysis of nonfatal dog bites in children. J Trauma 66: S17eS22, 2009 Fourie L, Cartilidge D: Fracture of the maxilla following dog bite to the face. Injury 26: 61e62, 1995 Herford AS: Early repair of avulsive facial wounds secondary to trauma using interpolation flaps. J Oral Maxillofac Surg 62: 959e965, 2004 Hon KL, Fu CC, Chor CM, Tang PS, Leung TF, Man CY, et al: Issues associated with dog bite injuries in children and adolescents assessed at the emergency department. Pediatr Emerg Care 23: 445e449, 2007 Knobel Freud H, López Colomés JL, Serrano Sáinz C, Hernández Vidal P: Animal bites: study of 606 cases. Rev Clin Esp 197: 560e563, 1997 Lengele BG, Testelin S, Bayet B, Devauchelle B: Total lower lip functional reconstruction with a prefabricated gracilis muscle free flap. Int J Oral Maxillofac Surg 33: 396e401, 2004 Méndez Gallart R, Gómez Tellado M, Somoza Argibay I, Liras Muñoz J, Pais Piñeiro E, Vela Nieto D: Dog bite-related injuries treated in a pediatric surgery department: analysis of 654 cases in 10 years. An Esp Pediatr 56: 425e429, 2002 Metlich MA, Acosta JJ, Toranzo M: Reconstruction of the lower lip following pig bites: report of two cases. J Oral Maxillofac Surg 44: 478e482, 1986 Meyers B, Schoeman JP, Goddard A, Picard J: The bacteriology and antimicrobial susceptibility of infected and non-infected do bite wounds: fifty cases. Vet Microbiol 127: 360e368, 2008
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Morgan JP, Haug RH, Murphy MT: Management of facial dog bites injuries. J Oral MaxillofacSurg 53: 435e436, 1995 Norwood S, McAuley C, Vallina VL, Fernandez LG, McLarty JW, Goodfried G: Mechanisms and patterns of injuries related to large animals. J Trauma 48: 740e744, 2000 Oginni FO, Akinwande JA, Fagade OO, Arole GF, Odusanya SA: Facial dog bites in Southwestern Nigerian children: an analysis of eight cases. Trop Doct 32: 239e240, 2002 Ogunbedede EO, Arotiba JT: Camel bite injury of the orofacial region: report of a case. J Oral Maxillofac Surg 55: 1174e1176, 1997 Pitak-Arnnop P, Herve C, Coffin JC, Dhanuthai K, Bertrand JC, Meningaud JP: Psychological care for maxillofacial trauma patients: a preliminary survey of oral and maxillofacial surgeons. J Craniomaxillofac Surg 39: 515e518, 2010 Rhee ST, Colville C, Buchman SR: Conservative management of large avulsions of the lip and local landmarks. Pediatr Emerg Care 20: 40e42, 2004 Sacks JJ, Sattin RW, Bonzo SE: Dog-bite related fatalities from 1979 through 1988. JAMA 262: 1489e1492, 1989 Singh A, Gulati SK, Sigh Gp, Mander KS, Malhotra G, Singh M: Multiple fractures of the maxilla following camel bite of the face (a case report ). Acta Chir Plast 36: 85e88, 1994 Stefanopoulos P, Karabouta Z, Bisbinas I, Georgiannos D, Karabouta I: Animal and human bites: evaluation and management. Acta Orthop Belg 70: 1e10, 2004 Stefanopoulos PK, Tarantzopoulou AD: Facial bite wounds: management update. Int J Oral Maxillofac Surg 34: 464e472, 2005 Stucker FJ, Shaw GY, Boyd S, Shockley WW: Management of animal and human bites in the head and neck. Arch Otolaryngol Head Neck Surg 116: 789e793, 1990 Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ, Emergency Medicine Animal Bite Infection Study Group: Bacteriologic analysis of infected dog and cat bites. N Engl J Med 340: 85e92, 1999 Temes RT, White JH, Ketai LH: Head, face and neck trauma from large animal injury in New Mexico. J Trauma 43: 492e495, 1997 Tu AH, Girotto JA, Singh N, Dufresne CR, Robertson BC, Seyfer AE, et al: Facial fractures from dog bite injuries. Plast Reconstr Surg 109: 1259e1265, 2002 Ueeck BA, Dierks EJ, Homer LD, Potter B: Patterns of maxillofacial injuries related to interaction with horses. J Oral Maxillofac Surg 62: 693e696, 2004 Ugboko VI, Olasoji HO, Ajike SO, Amole AO, Ogundipe OT: Facial injuries caused by animals in northern Nigeria. Br J Oral Maxillofac Surg 40: 433e437, 2002 Wolff KD: Management of animal bite injuries of the face: experience with 94 patients. J Oral Maxillofac Surg 56: 838e843, 1998 Yaniv E, Daniel G, Dov O, Yehuda F: Penetrating injury of the maxilla by needlefish jaws. J Craniomaxillofac Surg 37: 235e238, 2009
Contents lists available at SciVerse ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
The epidemiology of cranio-facial injuries caused by animals in southern-central China Qing-Bin Zhanga, *, Bi Zhangb, Zhao-Qiang Zhanga, Qing Chenc a
Department of Oral and Maxillofacial Surgery, Hospital of Stomatology (Chair: Dr. Ge Linhu), Guangzhou Medical College, 39 Huangsha Road, Liwan District, Guangzhou City, Guangdong Province, P.R. China b Department of Prosthodontics, School of Stomatology (Chair: Prof. Bian Zhuan), Wuhan University, 237 Luoyu Road, Wuhan City, Hubei province, P.R. China c Department of Epidemiology, College of Public Health (Chair: Prof. Cai Wenqing), Hebei Medical University, 361 Zhongshan East Road, Shijiazhuang City, Hebei Province, P.R. China
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 11 December 2010 Accepted 26 August 2011
A clinical investigation was conducted to demonstrate the epidemiology of cranio-facial injuries inflicted by animals in southern-central part of Chinadthe World’s most populous eastern country. It consisted of a retrospective study of 149 patients and was carried out in our department. All the patients were attacked by animals, such as buffalo, cattle, donkey, horse, dog, cat, and rat. There were 91 males and 58 females patients, aged from 5 to 65 years. 113 patients were from rural areas, and 36 from urban districts. Dogs, cattle, donkeys and buffalo, were the most common animals involved in this study. Bite was the predominant mechanism of injury, followed by kick, fall, trample, knock and scratch. The lip, chin and cheek were the commonest sites of soft tissue injury; Condylar process, symphysis, parasymphysis, and angle of mandible were the sites of fractures. Regarding the severity of injury, nearly half of the patients belonged to I and II classifications. The treatment results were satisfactory except for obvious scar formation, facial nerve palsy, and dysocclusion in a few patients. Facial injuries caused by animals are common in China, especially in rural areas. Timely treatment should be performed as soon as possible. Special attention should be paid to the prescription of antibiotics and vaccines. Psychotherapy may also be considered when necessary. It is suggested that adequate protective measures should be taken when animals are used for agricultural activities or kept as pets to minimize the incidence of facial injury. Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Animals Facial injury Management Vaccine Psychotherapy
1. Introduction Animal attacks to the head and upper-neck region can result in facial disfigurement with distressing physical and psychological consequences. Human facial injuries inflicted by animals are commonly seen in rural communities, as well as occurring in urban areas (Abuabara, 2006; Stefanopoulos and Tarantzopoulou, 2005; Ambro et al., 2010). Western countries have a reported incidence ranging from 375 to 740/100,000 people a year (Chomel and Trotignon, 1992; Knobel Freud et al., 1997; Wolff, 1998). In Africa, Ugboko also conducted a retrospective review in sub-Saharan Africa, which demonstrated the overall clinical data and management of 34 patients (Ugboko et al., 2002). However, few documents
* Corresponding author. Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guangzhou Medical College, 39 Huangsha Road, Liwan District, Guangzhou City, Guangdong Province, P.R. China. Tel.: þ86 (20) 61359010; fax: þ86 (20) 61359577. E-mail address: [email protected] (Q.-B. Zhang).
about the incidence and characteristics of such injuries have been reported in China. The animals that caused human facial wounds vary from one region to another. Generally speaking, the animals could be classified to small or medium size animals (cat, rat, dog, et al) and large size animals (cattle, buffalo, donkey, horse, et al). Cows, dogs and donkeys are the commonest animals involved in a previous report (Stucker et al., 1990; Stefanopoulos et al., 2004). Injuries inflicted by other animals have also been recorded such as horses, cats, pigs, goats, snakes and even rats (Metlich et al., 1986; Singh et al., 1994; Correira, 2003). In particular, Yaniv reported one case of human maxilla penetrated by needlefish jaws (Yaniv et al., 2009). In a review of literature, involvement of the head, face, and neck was found in 9e33% of all patients, and the majority of victims were old people and children (Knobel Freud et al., 1997). On the face, the predominant sites were the lips, cheek, chin, nose and auricles (Ambro et al., 2010). Generally, injuries caused by animals were superficial and minor, most of which were soft tissue wounds only, without a bone fracture. Only a few cases had deep lacerations,
1010-5182/$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2011.08.012
Q.-B. Zhang et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 506e509
damage to a blood vessel/ nerve or bony injury (Fourie and Cartilidge, 1995; Ogunbedede and Arotiba, 1997). In the mouths of animals and on the feet/horns, there are lots of different bacteria or virus that can lead to local or systemic infectious diseases. All over the world millions of people keep animals as part of their life (Temes et al., 1997; Ueeck et al., 2004). This is true in this region of China. In rural regions, animals such as dogs, buffalo, cattle and donkeys are used to guard a house, pull plows, assist in irrigation and transport agricultural products; in cities, animals, such as dogs, cats and even snakes are often bred as pets, thus, there are differences between rural and urban areas (Hon et al., 2007). On one hand, dog bite is the most common injury in city, followed by cat scratch/bite; on the other hand, in rural areas, dogs, buffalos and cattle injuries are regularly seen. In order to offer insight into the facial injury caused by animals in this region, this retrospective study describes the clinical data, treatment principles and preventive measures of facial injuries inflicted by animals, both in rural and urban communities in southern-central China.
2. Patients and methods Between November 1992 and November 2008, 149 patients with facial injuries registered in our hospital were included in this retrospective study. Personal details, the animals involved, the location and nature of injury, duration and mechanism of the injury, treatment and complications were retrieved, as well as details of associated injuries. All the patients were classified by the severity of facial injuries according to a five-degree scale: (I) superficial injury with no muscle involvement; (II) deep injury with muscle involvement; (III) deep injury with muscle involvement and tissue defect; (IV) stage III with vessel and nerve injury; (V) stage III with bone involvement. Of the 149 patients, 78 cases presented immediately for medical treatment, 22 patients within 24 h, 20 cases within 48 h, and 29 cases after at least 2 days (6 of the adults sustained their injury in childhood). Inflammatory symptoms were found in only 2 cases of the 78 patients who presented immediately, but occurred in 31 patients of the delayed group. Inflammatory symptoms included erythema, swelling, and pain on pressure in the area of wound, and most cases had fever and lymphadenitis. Therapeutic measures were determined by the stage of the injury and the presence of clinical symptoms. Saline irrigation of the wounds with hydrogen peroxide was always performed as a primary principle, and all non-infected wounds were closed primarily with sutures when possible. The wound edges were only minimally excised for stage I injuries, but more generously in stage II wounds. Patients with lip defects who showed no inflammatory symptoms underwent primary plastic reconstruction with small local flaps or forearm flap transfer. Patients with large tissue loss were left for secondary reconstruction. Bacteriology of animal wounds, especially bite injuries usually included Pasteurella multocida, Staphylococcus aureus, Viridans streptococci, Capnocytophaga animorsus, and oral anaerobes (Table 1). Antibiotic therapy against these bacteria was indicated both for infected wounds and fresh wounds considered at risk for Table 1 Bacteria generally involved associated with different animals. Bacteria mainly detected in the injuries
Common animals involved
Pasteurella multocida Staphylococcus aureus Viridans streptococci Capnocytophaga canimorsus Oral anaerobes
Cattle, donkey, cat, horse, buffalo Almost all the animals Dog, cat, rat Dog, cat, rat Almost all the animals
507
infection. Amoxicillinclavulanate (and other combinations of extended-spectrum penicillins with betalactamase inhibitors) and moxifloxacin offer the best in vitro coverage of the pathogenic flora. The need for prophylaxis against systemic infectious complications, particularly tetanus and rabies, was routinely emphasized in the management. 3. Results Of the 149 patients, there were 91 male and 58 female patients, aged from 5 to 65 years (Table 2). 113 patients were from rural areas, and 36 from urban districts (Table 3). Dogs (n ¼ 40), cattle (n ¼ 35), donkeys (n ¼ 23) and buffalo (n ¼ 18), were the commonest animals involved in this study (Table 2), accounting for 77.78% (116/149). Bite (n ¼ 54) was the predominant mechanism of injury, followed by kick (n ¼ 36), fall (n ¼ 33), trampling (n ¼ 29), knock (n ¼ 22) and scratch (n ¼ 8) (Table 4). The, lip (n ¼ 35), chin (n ¼ 33) and cheek (n ¼ 32) were the commonest sites of soft tissue injury (Table 5); the condylar process, symphysis, parasymphysis, and mandibular angle were the sites of fractures. Most of the injuries were not severe, and 43.6% (65/149) of the patients fell into groups I and II (Table 6). In this study, 6 patients had extensive tissue loss. 4 patients were reconstructed with a forearm flap to reconstruct lips and cheek. 2 cases were treated with the traditional Filator flap to reconstruct the nose. Associated injuries were recorded in 28 cases, injuries of other soft tissue were seen in 17 cases, fractures of other bones were found in 7 patients, 1 patient became blind in the left eye, 1 patient died because of an abdominal injury, 1 patient died falling down a cliff when driven by a donkey, and 1 case died of rabies. As to the medical follow-up, we could track only 82 patients, and information on the others was not available. The results were satisfactory except for clear scar formation in 9 patients, facial nerve palsy in 3 patients and dysocclusion in 2 patients. 4. Discussion Injuries caused by animals commonly occurred on the upper extremities and the majority were located on the face and head. The animals involved are dogs, cattle, donkeys, and horses in most studies. The incidence of such injuries has great regional variation Table 2 Age distribution of patients correlating to different accident animals. Animal
Cattle Buffalo Donkey Dog Cats Rats Horse Total
Age distribution 1e10
11e20
21e30
31e40
41 and elder
3 1 2 12 5 4 1 28
10 3 8 18 5 1 4 49
7 5 6 4 3 0 3 28
9 5 6 1 2 0 2 25
6 4 1 5 2 0 1 19
Table 3 Distribution and contrast of animal incurred facial injury in different regions. Animal
Urban
Rural
Cattle Buffalo Donkey Dog Cats Rats Horse Total
0 0 2 18 13 0 3 36
35 18 21 22 4 5 8 113
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Table 4 Distribution of injury mechanisms according to accident animals involved. Mechanism of injury
Cattle
Buffalo
Donkey
Dog
Cat
Rat
Horse
Kick Fall Trampled Knock (from horn) Bite Scratch
12 8 9 16 0 0
6 11 8 6 0 0
13 7 9 0 0 0
0 0 0 0 38 2
0 0 0 0 11 6
0 0 0 0 5 0
5 7 3 0 0 0
Table 5 Distribution of 176 facial wound locations in 149 patients. Sites
Number
Forehead Periorbital Temple Ear Nose Cheek Lip Chin Floor of mouth Tongue
27 8 9 11 12 32 35 33 4 5
Table 6 Severity classification of animal incurred facial wounds and patients distribution. Stage
Clinical appearance
Number
I I III IV V
Super-facial injury with no muscle involvement Deep injury with muscle involvement Deep injury with muscle involvement and substance defect Stage III with vessel and nerve injury Stage III with bone involvement
19 46 55 23 6
(Ching et al., 2004). The demographic investigation of this study was consistent with those of previous reports (Sacks et al., 1989; Morgan et al., 1995; Abuabara, 2006). The ages of most patients were in the second and third decades of life coinciding with the period of increasing involvements in farming and animal husbandry (Oginni et al., 2002; Norwood et al., 2000) despite other reports, where the patients were mostly in their childhood and elderly (Bernardo et al., 2002). In this study, 30 of 40 dog-bite patients were teenagers. This is attributable to the easier access to the face of a child. Lips, noses and cheeks are the commonest structures of the face to be attacked by a dog. Cattle, buffalo and donkeys are the important farming and transportation animals in the rural mountainous areas. Adults are the manpower in agricultural activity and most of the agricultural animals are tended by teenage boys, which expose them to possible attacks from their herds. There were 76 patients who were assaulted by cattle, buffalo and donkeys. Only 11 of 149 patients were attacked by horse, a much lower incidence compared with that from cattle and donkeys. The reason may be that not many people in this area are actually engaged in horse riding or use horses for transportation. As to the mechanism of injury, kicks, knocks, falls and bites from the animals may be from cattle, buffalo, donkeys and dogs; Knocks may be from cattle or buffalo horns, trampling may be from donkeys, cattle, buffaloes and horses. Statistically, the dog is the commonest among the above animals. Cat may be kept to catch rats in rural area and kept as pets by some urban families, occasionally some cats may attack adults, children and newborn babies. Most of the fractures occurred because of falls to the ground or direct tramples/ kicks by large-sized animals. In all, for small or medium-sized animals, the mechanism of injury is generally associated with a bite or scratch, which can easily transmit infectious diseases.
For the large-sized animals, the mechanism is kick, knock and trample, which often causes open soft tissue injury or bone fractures. In the management of animal injuries, it is important both to avoid infections and to achieve an aesthetically pleasing result (Méndez Gallart et al., 2002; Daniels et al., 2009). Therefore, the management principles are different to some degree. The treatment of each case will depend on the actual conditions, such as the nature of the injury, the expertise of the surgeon, time between attack and treatment, and the location of the injury. As there are large numbers of different bacteria in the animal’s mouths or on the feet/horns that can lead to local or systemic diseases, urgent management is necessary. For small or medium-sized animal bites and scratches, prevention of tetanus and rabies should be emphasized, besides routine management; For facial injuries incurred by large-sized animals, prevention of tetanus and infection should be considered, and early suture and bone fixation are equally important. Although most clinicians agree on the immediate wound irrigation, there is still no consensus on the timing of subsequent treatment in terms of wound debridement, primary or secondary repair even the routine use of prophylactic antibiotics (Agrawal et al., 1992; Talan et al., 1999; Meyers et al., 2008). Through long experience, the authors of this paper suggest initial wound management consisting of irrigation and debridement is at least equally important as antibiotics/vaccine for the prevention of infection, tetanus and rabies. Primary surgical suture and repair are optimal for most clinically uninfected facial wounds, whereas delayed closure should be reserved for high risk or already infected wounds. Management of the soft tissues involved thorough debridement and repeated irrigation with normal saline and 3% hydrogen peroxide. In secondary reconstruction, flap transfer was generally used, such as local transfer, forearm flap, and Filator flap (Rhee et al., 2004; Herford, 2004; Lengele et al., 2004). In fracture patients, open reduction and rigid internal fixation were performed just as other clinicians do (Tu et al., 2002). In all, the therapeutic measures should be performed according to the stage of injury and the actual clinical conditions. Immediate debridement, irrigation and primary closure should be performed when possible. Concomitant facial fractures should be reduced and immobilized as soon as possible. Patients with small tissue loss should be reconstructed with local flaps at the same time as other treatment. As to the extensive tissue loss of lip, cheeks, and nose, pedicle and forearm flaps are recommended for secondary reconstruction. The need for prophylaxis against systemic infection, particularly tetanus and rabies, should be heeded. Cranio-facial injuries caused by animals are complex due to the functional and cosmetic nature of the area. More clinical investigation is needed for an optimal outcome. In the past, unfortunately, psychological trauma has been underestimated, especially posttraumatic stress disorder in this region. With the development of overall therapy, specific and professional psychotherapy should be considered to ensure full recovery (Pitak-Arnnop et al., 2010). Preventive measures and awareness of the potential dangers of animals are needed to minimize the incidence of these injuries. 5. Conclusion Facial injuries caused by animals are common, especially in China, the largest agricultural nation in the world. It is strongly recommended treatment should be performed as soon as possible. Adequate protective measures are necessary when animals are used for agriculture or kept as pets. Special attention should be paid to the use of antibiotics and administration of vaccines. Psychotherapy should be given when necessary. Preventive measures and awareness of the potential dangers of animals are needed to minimize the incidence of these injuries.
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