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A severe maxillo-facial injury
A SEVERE MAXILLO-FACIAL INJURY By F. G. HARDMAN,M.B., Ch.B., B.D.S., F.D.S.R.C.S., M.R.C.S. North Wales
A 46-year-old man was injured whilst working on the Trawsfynydd atomic power station in North Wales on I2th January I96I. He was emerging from a horizontal pipe about six feet in diameter when the end section became loose. The patient reached the ground and turned round, receiving the edge of the falling section on his face. He was transferred without delay from the remote site to the oral surgical unit at the Caernarvon and Anglesey Hospital, Bangor. His general condition was good and at no time did he lose consciousness. Radiographs of the chest revealed undisplaced fractures of five ribs on the left side and a crack fracture of the right clavicle. No other injuries were detected. The right eye was clearly beyond aid (Fig. I): the left orbital floor had depressed a considerable distance and was exposed through the laceration (Fig. 3). The main injury was to the maxillm (Fig. 2). The upper jaw had been split in half and the two halves broken into several pieces. The mandible was, fortunately, intact and there were sufficient teeth for splinting. The nasal bones were in the facial flap which was carried away by the blow (Fig. 3). It was clearly important to operate on this patient as soon as possible. After the appropriate supportive therapy he was an~sthetised with oral endotracheal intubation. First a plaster headcap was applied (Fig. 4). Then the integrity of the left orbit was restored by raising the floor and wiring the zygomatico-frontal region. The comminuted fragments of the middle third of the facial skeleton were reassembled and wired into position as required (Figs. 5 and 6). Before the main skin flap was repositioned, an arch wire was fastened to the upper teeth (Fig. 7). With the soft tissues replaced and sutured into position, cheek wires were applied and fastened to the arch wire (Fig. 8). These first-aid measures having been completed the patient was returned to bed. The following day his general condition was satisfactory (Figs. 9 and IO), but it could be seen that the skin over the fronto-nasal junction was devitalised. The nasal tubes were inserted not primarily as an airway, but to support the loose nasal septum in a central position. During succeeding days cast-silver splints were applied to the teeth and craniomandibular fixation instituted (Fig. II). The mobile maxilla was drawn into its correct position by means of elastic traction (Fig. I2). Radiographs revealed that there was a separation at the right zygomaticofrontal junction which required to be closed. Also a skin graft had to be placed over the devitalised area on the nose. This was done at operation on 23rd January I96I (Fig. I3). Steady progress was made and the fixation appliances were removed ten weeks after injury (Fig. I4). Dentures were fitted before the patient's discharge to his
69
7°
BRITISH
JOURNAL
OF P L A S T I C
S U R G ER Y
home in Durham. A scaly eruption occurred on the left side of the nose which was probably unconnected with the injury and had occurred before. Final photographs (Figs. I5 and I6) taken a year after injury were sent from the University of Durham medical photographic unit. The transparencies of this case were taken by Mr G. I. Davies, B.D.S., of Bethesda, Gaernarvonshire, and prints were taken from these transparencies by Mr H. Leach and Mr Iorwerth N. Edwards of the Pathological Laboratory, Gaernarvon and Anglesey Hospital, Bangor.
A SEVERE M A X I L L O - F A C I A L I N J U R Y
FIG. I
~IG. 2
FIG. 3
FIG. 4
71
72
B R I T I S H JOURNAL OF P L A S T I C SURGERY
FIG. 5
FIG. 7
FIG. 8
A SEVERE M A X I L L O - F A C I A L
FIG. 9
FIG. II
INJURY
FiG. io
73
74
B R I T I S H JOURNAL OF P L A S T I C SURGERY
FIG. 13
FI~. 15
F m . 14
F m . 16
A 46-year-old man was injured whilst working on the Trawsfynydd atomic power station in North Wales on I2th January I96I. He was emerging from a horizontal pipe about six feet in diameter when the end section became loose. The patient reached the ground and turned round, receiving the edge of the falling section on his face. He was transferred without delay from the remote site to the oral surgical unit at the Caernarvon and Anglesey Hospital, Bangor. His general condition was good and at no time did he lose consciousness. Radiographs of the chest revealed undisplaced fractures of five ribs on the left side and a crack fracture of the right clavicle. No other injuries were detected. The right eye was clearly beyond aid (Fig. I): the left orbital floor had depressed a considerable distance and was exposed through the laceration (Fig. 3). The main injury was to the maxillm (Fig. 2). The upper jaw had been split in half and the two halves broken into several pieces. The mandible was, fortunately, intact and there were sufficient teeth for splinting. The nasal bones were in the facial flap which was carried away by the blow (Fig. 3). It was clearly important to operate on this patient as soon as possible. After the appropriate supportive therapy he was an~sthetised with oral endotracheal intubation. First a plaster headcap was applied (Fig. 4). Then the integrity of the left orbit was restored by raising the floor and wiring the zygomatico-frontal region. The comminuted fragments of the middle third of the facial skeleton were reassembled and wired into position as required (Figs. 5 and 6). Before the main skin flap was repositioned, an arch wire was fastened to the upper teeth (Fig. 7). With the soft tissues replaced and sutured into position, cheek wires were applied and fastened to the arch wire (Fig. 8). These first-aid measures having been completed the patient was returned to bed. The following day his general condition was satisfactory (Figs. 9 and IO), but it could be seen that the skin over the fronto-nasal junction was devitalised. The nasal tubes were inserted not primarily as an airway, but to support the loose nasal septum in a central position. During succeeding days cast-silver splints were applied to the teeth and craniomandibular fixation instituted (Fig. II). The mobile maxilla was drawn into its correct position by means of elastic traction (Fig. I2). Radiographs revealed that there was a separation at the right zygomaticofrontal junction which required to be closed. Also a skin graft had to be placed over the devitalised area on the nose. This was done at operation on 23rd January I96I (Fig. I3). Steady progress was made and the fixation appliances were removed ten weeks after injury (Fig. I4). Dentures were fitted before the patient's discharge to his
69
7°
BRITISH
JOURNAL
OF P L A S T I C
S U R G ER Y
home in Durham. A scaly eruption occurred on the left side of the nose which was probably unconnected with the injury and had occurred before. Final photographs (Figs. I5 and I6) taken a year after injury were sent from the University of Durham medical photographic unit. The transparencies of this case were taken by Mr G. I. Davies, B.D.S., of Bethesda, Gaernarvonshire, and prints were taken from these transparencies by Mr H. Leach and Mr Iorwerth N. Edwards of the Pathological Laboratory, Gaernarvon and Anglesey Hospital, Bangor.
A SEVERE M A X I L L O - F A C I A L I N J U R Y
FIG. I
~IG. 2
FIG. 3
FIG. 4
71
72
B R I T I S H JOURNAL OF P L A S T I C SURGERY
FIG. 5
FIG. 7
FIG. 8
A SEVERE M A X I L L O - F A C I A L
FIG. 9
FIG. II
INJURY
FiG. io
73
74
B R I T I S H JOURNAL OF P L A S T I C SURGERY
FIG. 13
FI~. 15
F m . 14
F m . 16