Immediate management of severe facial war-injuries

Immediate management of severe facial war-injuries

30 J. max.-fac. Surg. 11 (1983) J. max.-fac. Surg. 11 (1983) 30-36 © 1983 Georg Thieme Verlag Stuttgart • New York Immediate Management of Severe F...

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J. max.-fac. Surg. 11 (1983)

J. max.-fac. Surg. 11 (1983) 30-36 © 1983 Georg Thieme Verlag Stuttgart • New York

Immediate Management of Severe Facial War-Injuries Sabri Shuker Dept. of Maxillo-Facial Surgery (Head: S. T. Shuker, BDS, MMSC, FDSRCS) Basrah Republic Hospital, Basrah, lraq

Summary The immediate treatment of severely war-wounded maxillo-facial patients is presented. The cases are of avulsion injuries of the face suffered by Iraqi soldiers where means of reduction, stabilization and immobilization were difficult. Kirschner wire was adapted successfully for immobilization in cases of anterior mandibular segment loss. The application of the Kirschner wire is presented for bridging of bony mandibular defects, preservation of soft tissue position; and making use of small and large pieces of denuded bone.

Key-Words War injury - Kirschner wire - Immediate repair

Introduction hnmediate restoration of function and appearance in severe wounds involving the middle and lower third of the face is very important both for the rehabilitation and peace of mind of the patient. One of the principles of surgical care of avulsion wounds should be the maintenance of any viable tissue which may be of use in the reconstruction of lost tissue, which allows a decrease in the amount of tissue under tension, particularly in the area of a reconstructed mandibular arch. Clinical experience has shown that the proximal mandibular stumps, if not stabilized either by replacement of the lost segment or by intermaxillary traction, will be drawn superiorly and medially (Cuttino and Green, 1972). For this reason, and considering the poor results of late reconstruction of soft and hard tissue in severely wounded men such as those in war zones, the placement of qualified oral surgeons at forward medical installations, i.e. mobile surgical and evacuation hospitals, or similar, has resulted in the inception of definitive treatment of faciomaxillary injuries at the initial operation (Kwapis, 1954). In the treatment of severe facial war-injuries many problems are frequently encountered in the repair and stabilization of these structures, whether they result from high or low velocity missiles. The cardinal principles of reduction, stabilization and immobilization may on occasions have to be ignored because of factors beyond the control of the attending oral surgeon. The severity of injury, the large number of wounded and the relative inadequacies in facilities, may indicate some compromise in treatment. In cases with absence of an adequate dentition, with mandibular segmental loss or associated maxillary loss, modification of treatment may be required in keeping with the available facilities in forward positions in war zones. Kirschner wire has been used to reconstruct mandibular defects (MacDougall, 1965; Clarke, 1966), and for treatment of comminuted fracture (Bromige, 1971) but here its use is reported for the first time in the management of such defects following war injuries. In these cases the wire has been used where other means of fixation and immobilization were not possible. To date 24 such cases have been treated by the same method. Nine cases are reported where the maxilla was either shattered or there was no bony tissue left, making mandibular fixation and immobilization difficult. Eight cases had lost most of the mandibular body and in one of these cases, a

child, a large segment of the lower jaw as well as the associated soft tissue was lost. In two cases presented, the use of the more readily available Kirschner wire is considered to be easier than the wire mesh which has previously been used to manage such defects (Bear et al., 1971; Cuttino and Green, 1972).

Case Reports

Case 1 A 7-year-old child was admitted to hospital having sustained high velocity wounds during artillery shelling. He had suffered injuries involving the liver and both legs. In the facial area he had sustained a large soft tissue avulsion of the left mandibular area and lower lip. There was an associated comminuted fracture of the mandible with a 5 cm. bony defect and no sound upper jaw teeth remaining which could have been used for immobilization purposes. Following resuscitative procedures and management of his other injuries, surgical repair of his severe facial wounds was undertaken. Anaesthesia was administered through an endotracheal tube. The wound was cleaned with sterile water and identifiable foreign bodies were removed. The use of pre-formed prosthetic splints being technically impossible and other means of immobilization and fixation considered unsuitable in this critically ill child, it was decided that some compromise solution must be reached. For this reason a single 2 mm. diameter Kirschner wire was used, being suitably fashioned in length and curvature. A smaller wire was used to drill a hole in the lower border of the two mandibular stumps and inserted to a depth of 3 cm. The bent K. wire was then inserted into the drill holes, the size of the space left giving good stabilization and occlusion of the remaining and intact mandibular segment (Fig. 1 a, b). The w o u n d was closed in layers over the wire: the skin of the neck being undermined to allow adequate cutaneous approximation. The patient was fed for the first ten days by nasogastric tube. Full movement of the lower jaw then allowed satisfactory oral feeding and from the point of view of his facial injuries, the patient's recovery was uneventful and he was able to return to school within months (Fig. 1 c).

Immediate Management of Severe Facial War-Injuries

Fig. 1 a Postero-anterior radiograph showing destruction of left mandible with 5 cm. defect.

Fig. 1 b Postoperative radiograph with Kirschner wire in position four months later.

J. max.-fac. Surg. 11 (1983)

Fig. 1 c

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Patient four months after surgery.

Fig. 2 a High velocity missile wound with bone involvement and avulsion of soft and bony tissues. Note the Kirschner wire in position. Fig. 2 b Lateral preoperative radiograph showing destruction of anterior part of the mandible.

Fig. 2a

Fig. 2 b

Fig. 2c

Fig. 2d

Fig. 2 c Postoperative radiograph with Kirschner wire in position.

Fig. 2 d, e

Fig. 2 e Patient two months after surgery with full range of mouth movement,

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Fig. 3a Patient with large shell-fragment wound with loss of most of mandibular bony and soft tissues and loss of upper alveolar and palatal bone.

S. Shuker

Fig. 3 b Showing Kirschner wire in position.

Fig. 3c, d Postoperative radiograph showing loss of mandibular bony tissue from the left condylar neck to the right upper part of the ramus, with no alveolar bone of the maxilla and palate left.

Fig. 3 e Photograph of the patient one week later; note the tongue tissue covering the soft tissue left of the mandibular neck around the Kirschner wire, giving very good support. Fig. 3d

Fig. 3e

Case 2 A 28-year-old man was seen with a severe laceration and avulsion of soft tissues of the lower jaw area and destruction of the mandible from the third molar tooth on the left to the first molar tooth on the right. No bony tissue was left due to the high velocity missile which had caused the damage and soft tissue loss extended from the chin to one whole jaw width (Fig. 2 a). Radiographically the extent of the injury is shown in (Fig. 2 b). Immediate surgery to stabilize the mandible and close the facial wounds was undertaken. The left posterior mandibular body was identified at the region of the third molar and a hole was drilled for about 3 cms. into the lower border using a smaller gauge Kirschner wire. The same procedure was repeated on the right side in the region of the first

molar tooth. A 2 mm. Kirschner wire was then bent into a horseshoe, approximately the size of the missing 10 cms. anterior segment, and placed so as to prevent the proximal mandibular stumps from displacing superiorly and medially. The horseshoe shape of the wire acted as a spring, keeping the mandibular stumps just at the occlusal position (Fig. 2c). The wire was then covered with soft tissue flaps from the floor of the mouth and the labial and buccal mucosa. Undermining of the skin of the chin and neck was necessary to effect satisfactory closure. This patient had an uneventful postoperative recovery being initially fed by nasogastric tube, but orally after 10 days. He had normal tongue movements, without its falling back, and was able to project it forwards and upwards freely (Fig. 2d, e). He was discharged on the 25 th day

Immediate Management of Severe Facial War-Injuries

Fig. 4 a Postero-anterior view showing the horseshoe-shaped Kirschner wire in position.

Fig. 4 c Occlusal palatal radiograph showing simple interosseous wiring of palatal bones which were denuded of soft tissue before simple interosseous wiring.

postoperatively and three months later underwent removal of the wire and bone grafting.

Case 3 This 28-year-old male presented with gross loss of the soft and hard tissues of the mandible and fragmentation of the maxilla due to a high velocity missile injury. There was also avulsion of tissue from the left mandibular ramus to the right condylar neck of the mandible with tethering of the tongue and total avulsion of the lower lip and floor of the mouth as well as the hyoid bone. The alveolar process and hard palate were also lost with an associated fracture of the nasal bone (Fig. 3 a). Radiologically the whole of the body of the mandible was seen to be lost. After resuscitation and tracheostomy, the area was cleaned with sterile water and all identified foreign bodies removed together with the detached genio-hyoid and genio-glossus muscles which were removed with all other non-viable tissue. Fragments of the medial sinus were identified and

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Fig. 4 b

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Postoperative photograph three months later.

sutured to the maxillary fragments superiorly and the lateral fragments internally. As there was no alveolar bone or hard palate left, the palatal mucosa, with a few palatal bone fragments still attached to it, was sutured to the sulcus. This provided a floor for the nasal fossa and both maxillary sinuses, which were packed with iodoform gauze. The left and right mandibular segments were identified and drilled as previously described and a horseshoe-shaped Kirschner wire inserted (Fig. 3 b, c, d). The tissue left was approximated over the wire and sutured; the tethered piece of the anterior two thirds of the tongue was sutured over the muscle and tissue of the floor of the mouth. The patient was fed by nasogastric tube. The wire was found to give good support to the tongue and the soft tissue of the lower jaw and floor of the mouth (Fig. 3 e). The anterior part of the tongue could be used just as easily as mucosa of the lower lip and meantime maintains healthy healing tissue underneath it.

Case 4 This 25-year-old man was admitted with a severe high velocity shell injury which had caused an avulsion with creation of a ragged defect of the right middle facial bones, loss of the right nostril, right eye, destruction of the maxillary sinus, fragmentation of the palate and loss of half of the upper lip. The right side of the lower jaw was avulsed with the associated soft tissue, extending from the middle of the lower lip to the ramus. There was also a comminuted fracture of the left mandibular body. After performance of a tracheostomy under local anaesthesia, the patient was anaesthetized and the wounds thoroughly cleaned. The fractured bones of the palate, including the denuded fragments, even though they had been exposed for over 10 hours, were fixed by interosseous wiring and mucosa applied over them (Fig. 4c). The right malar portions of the zygoma were found to be stable. Iodoform gauze was packed into the right maxillary sinuses in order to support the fragmented portion of the orbital floor and keep the shape of the right middle part of the face as well as covering the lacerated tissue of the right nostril. A Kirschner wire was fashioned for the lower jaw, as described previously, and the large denuded fragments of the bones fixed around this Kirschner wire (Fig. 4 a), by

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S. Shuker

Fig. 5 a Exit wound produced by high velocity missile shows total avulsion of right maxillary bone and whole palatal bone, entrance through left body of the mandible.

Fig. 5 b Left lateral oblique view of the mandible showing Kirschner wire in position. This was left for five months without complaint.

Fig. 5 c Five months postoperative photograph showing defect in the lower jaw.

Fig. 6 a Avulsed soft and hard tissue of the mandible; note free segment of alveolar bone 654 used after teeth extraction in bridging the gap with other pieces.

Fig, 6 b Postero-anterior view showing Kirschner wire in position with the free segments of bones wired bridging the gap.

Fig. 6 c

Postoperative photograph.

Fig. 6 d Orthopantomogram showing occlusion and alveolar segment bridging the gap.

Immediate Management of Severe Facial War-Injuries stainless steel wire. Small fragments of bone were laid around the wire and the area covered by soft tissue, followed by available skin and mucosa. The result was aesthetically quite good in giving chin shape (Fig. 4 b), as well as good immobilization and stabilization of the lower jaw fragments. After being fed for the first 15 days by nasogastric tube, the patient was then able to take a fluid diet orally. He made an uneventful recovery and at six month review, was found still to have a stable wire with very good bony union without any complication. He is now ready for further plastic surgical reconstruction.

Case 5 This 23-year-old man suffered a severe facial injury involving avulsion of the maxillae and left mandibular body due to a high velocity missile. After a tracheostomy under local anaesthesia in the emergency department, the patient was then taken to surgery and general anaesthesia administered. The w o u n d was cleaned and debrided. The bilateral comminuted maxillary fractures were stabilized in good position by packing of the sinuses, in order to hold the fragmented portion of the middle part of the face laterally. All the palatal process with alveolar bone was avulsed (Fig. 5 a). Mandibular stabilization was achieved with a 2 ram. Kirschner wire introduced through a small hole below the apex of the left lower canine tooth extending to the remaining segment of the ramus. Denuded fragments were wired to each other and to the sound bone around the Kirschner wire (Fig. 5 b). The soft tissues were sutured in layers over the area. Recovery was uneventful in so far as the facial injuries were concerned and at three months postoperatively, the patient was ready for further reconstructive surgery (Fig. 5 c).

Case 6 This 25-year-old soldier received a severe laceration and avulsion of the soft tissue of the lower jaw with gross destruction and avulsion of the mandible from the right second molar region to the left canine tooth. A fragment of bone was freely detached from the soft tissues with an associated w o u n d of the lower lip and chin skin (Fig. 6 a). The wound extended to the floor of the mouth where there was mucosal and soft tissue loss extending to the chin and submental region. Radiographically the extent of the wound is seen in Fig. 6 b, d. The patient was prepared for surgery and debridement was undertaken. The right posterior mandibular body fragment was identified and a hole drilled in the lower border. A 2 mm. Kirschner wire was then inserted in it and a similar hole in the fragment on the left side, length 4 cm. Following extraction of teeth from the detached alveolar bone, the fragment was cleaned in sterile water and then fixed across the gap by interosseous wires just below the Kirschner wire together with other smaller fragments. Left longitudinal fractures of the bone were fixed by application of circumferential wires. The Kirschner wire and bone fragments were covered with soft tissues from the floor of the mouth together with labial and buccal mucosa. The skin was approximated without too much difficulty after undermining of the skin of the chin and submental regions (Fig. 6 c). Postoperatively this patient, like the other patients, had an uneventful recovery and without the tongue falling back.

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Discussion

Prompt repair in severe facial war injuries aids in soft tissue healing, stabilization of structures, restoration of function and appearance and maintenance of patient morale. For this purpose, several procedures and techniques have been devised. In certain cases with excessive loss of hard and soft tissue of the symphysis and lateral body of the lower jaw, with gross mobility of fragments, wiring of the crowns of the teeth will not be adequate to control any rotational displacement caused by the muscles attached to the inner surface of the mandible. Rowe and Killey (1968) advised a 3 cm. screw pin inserted externally into the mandible and attached to a P.O.P. head cap~ This has been very successful in preventing displacement. The fixation should be reinforced by maxillary-mandibular tie wires when possible. Such immobilization however, cannot be kept for a long period of time especially in a hot climate and does not prevent the contraction of the soft tissues of the anterior part of the lower jaw, which renders later reconstruction of the facial contour difficult. Cast metal cap splints have been used but they are not practical as primary inean of fixation of the jaws in the case of severe mandibular war injuries. Even when facilities are available, it may not be possible to defer surgery of the soft tissues until splints have been constructed. Likewise plating was found to be inadequate because of the size of the space of the missing tissue and because most segments of bone are found to have horizontal or vertical undisplaced fracture lines making plating not feasible. Similarly, stainless steel wire mesh has been used in immediate stabilization and space maintenance in the resected mandibular symphisis segment in cases of tumours and severe injuries to the lower jaw. However, in contaminated wounds such as war injuries, whose blood supply may be affected, soft tissue closure without dead space is very important, this is unavoidable when using wire mesh; also a water-tight closure of the oral mucosa is difficult and this may result in complication and failure. Using the Kirschner wire is simple, convenient, rapid, versatile, reliable and gives adequate stabilization and immobilization, without dead space, and excellent healing. The occlusion was maintained in most cases; when there were teeth in an unilateral or bilateral mandibular segment or segments, intermaxillary fixation was applied and maintained for two weeks. When the mandibular segments were edentulous with presence of the upper teeth or with an edentulous or avulsed maxilla a Kirschner wire alone was usually adequate. The horse-shoe shape of the wire acted as a spring, keeping the mandibular stumps in position. This was effected by using the maxillary alveolar ridge as a guide for the shape of the wire anteriorly, making it 1 cm. wider posteriorly to all'ow for the springing action against the muscle pull medially. The superior pull is overcome by the weight of the anterior tissue built around the wire. My experience with 24 cases treated with this procedure has yielded very satisfactory results, there was only one tissue breakdown which was due to delayed evacuation. The other 23 cases made an uneventful recovery, adequate antibiotic therapy was usually given. Five of the cases have had the wire replaced by a bone graft. In others the wire has been kept to supplement the graft.

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S. Shuker: Immediate Management of Severe Facial War-Injuries

Conclusion

Acknowledgement

The use of a Kirschner wire in the early management of severe facial injuries with an avulsed anterior mandibular segment seen at an early evacuation hospital in a war zone, has been described. This method has been used successfully in the immediate restoration of shape and function in severe wounds involving the middle and lower thirds of the face where there is both hard as well as soft tissue loss. This allows early rehabilitation of the patients, and restoration to a socially useful and acceptable existence. This technique helps in the preservation of soft tissue position and makes use of small and large pieces of denuded bone, which w o u l d otherwise be lost. Furthermore, no need for tracheostomy was found in cases where a large segment of the symphysis and body of the mandible was avulsed w i t h o u t association with middle third injuries, when we used the Kirschner wire. It was found that it is much less difficult to immobilize the fractured fragments in the initial management of such patients than was previously believed. This belief had resulted from the p o o r results seen when similar cases had been immobilized by other means. It is hoped that this method will have introduced a new and more successful means of treating these severe, disfiguring and life threatening wounds.

1 wish to thank the Photographic Department of the Basrah Medical School for their assistance in the preparation of these photographs.

References

Bear, S. E., R. K. Green, W. William Wentz: Stainless Steel Wire Mesh: an Aid in Difficult Oral Surgery Problems. J. Oral Surg. 29 (1971) 27 Bromige, M. R.: Severe Compound Comminuted Fracture of the Mandible. Brit. J. Oral Surg. 9 (1971) 29 Clarke, P. B.: Brit. J. Oral Surg. 4 (1966) 2 Cuttino, C. L., R. K. Green: Immediate Management of Facial Gunshot Wounds. J. Oral Surg. 30 (1972) 674 Kwapis, B. W.: Early Management of Maxillofacial War Injuries. J. Oral Surg. 12 (1954) 293 MacDougall, J. A.: Management of Surgical Mandibular Defects. Amer. J. Surg. 110 (1965) 563 Rowe, N. L., H. C. Killey: Fractures of the Facial Skeleton. 2 "a Ed. 490. Livingstone, Edinburgh, London (1968)

Sabri Shuker Basrah Republic Hospital Basrah, Iraq