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Penetrating injury of the facial skeleton through the orbit, by a massive metallic shotgun block: A case report
British Journal of Oral and Maxillofacial Surgery 45 (2007) 586–587
Short communication
Penetrating injury of the facial skeleton through the orbit, by a massive metallic shotgun block: A case report F. Polini ∗ , M. Robiony, C. Toro, F. Costa, S. Sembronio, M. Politi Department of Maxillo-Facial Surgery, Faculty of Medicine, University of Udine, P.le Santa Maria della Misericordia, 33100 Udine, Italy Accepted 21 August 2006 Available online 5 October 2006
Abstract We present a case of invasion of the orbit and the infra-temporal fossa by a massive breechblock from a shotgun. The block was removed and two months later the orbit was reconstructed with iliac crest. Six months after that the patient had plastic surgery and insertion of ocular prosthesis. © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Orbital trauma; Orbital reconstruction
Introduction The sequence of penetrating orbital injuries and the prognosis for the patient depend on many factors including the size, the nature (material), the kinetic energy, and the trajectory of the penetrating object. Downward penetration into the maxillofacial area by a foreign body through the orbit is less usual and less likely to be life-threatening than the upward orbitocranial route. We report case of downward penetration through the facial skeleton by a shotgun bolt, with a satisfactory reconstruction.
Case report A 26-year-old woman was injured by a malfunctioning gun, while out hunting. During recoil, her shotgun exploded, and
∗ Corresponding author at: Cattedra di Chirurgia Maxillo-Facciale, Policlinico Universitario, P.le S. Maria della Misericordia, 33100 Udine, Italy. Tel.: +39 0432 559455; fax: +39 0432 559868. E-mail address: [email protected] (F. Polini).
projected the breechblock backwards and downwards, into her orbit, so that it emerged under the skin in the lateral cervical area. Penetration resulted in crushing of the ocular globe, with little bleeding (Fig. 1). The patient was immediately operated on to remove the block, through combined coronal, preauricular, and cervical approach. We first did an orbitozygomatic osteotomy to facilitate removal of the projectile and only conventional haemostasis was indicated. Postoperative computed tomography showed a wide communication between the orbit and the infratemporary and pterygomaxillary fossas, with multiple fragments of the orbital floor, papiraceous lamina of the ethmoid, posterolateral, medial, and anterior walls of the maxillary sinus, and of the zygomatic bone. The main maxillary resistance pillars remained intact (Fig. 2). Two months later, she had an autogenous bone graft harvested from her iliac crest to reconstruct the orbit. The remains of the ocular globe were enucleated and a titanium miniplate was placed to fix the inferior orbital rim. Six months later she had a plastic operation to conform the lower eyelid with a graft of auricular cartilage, and the conjunctiva was reconstructed with a palatal mucosal graft. Finally a silicone ocular prosthesis was inserted (Fig. 3).
0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.08.007
F. Polini et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 586–587
587
Fig. 1. (a) Operative view of the patient at the time of the removal of the block. (b) Lateral radiograph showing the breechblock running into the facial skeleton, through the orbit.
Discussion
Fig. 2. CT scan of the patient, performed after breechblock removal, showing a communication between the orbit and the infra-temporary and pterygomaxillary fossas, multiple fracture fragments and no collapse of the main maxillary resistance pillars.
The surgical approach to the orbit and the infratemporal fossa is usually conservative for benign conditions and is through a temporal or preauricular incision.1 In some cases that require wider exposure of the region, a coronal or cervical incision, or both, could be necessary. Wider osteotomies could also be indicated to increase the exposure of the medial aspect of the trauma and to ensue eventual control of the life-threatening damage to the main vascular bundles. In traumatic rather than neoplastic events, evisceration should be preferred to enucleation, because it necessitates the restitution of an adequate cavity, and hence better results for the prosthetic replacement of the eye.2,3 Autogenous bone grafting from the iliac crest should be preferred when multiple wall reconstruction (orbital floor and lower part of lateral and medial orbital wall) is required, because of the extent of the bony defect.4
References 1. Mansuor OI, Carrau RL, Snyderman CH, Kassam A. Preauricular infratemporal fossa surgical approach: Modifications of the technique and surgical indications. Skull Base 2004;14:143–51. 2. Dortzbach RK, Woog JJ. Choice of procedure. Enucleation, evisceration, or prosthetic fitting over globes. Ophthalmology 1985;92:1249– 55. 3. Genevois O, Millet P, Retout A, Quintyn JC. Comparison after 10-years of two 100-patient cohorts operated on for eviscerations or enucleations. Eur J Ophthalmol 2004;14:363–8. 4. Fonseca RJ. Oral and maxillofacial reconstruction. Philadelphia: Saunders; 2000. p. 235. Fig. 3. Front view of the patient after prosthetic rehabilitation.
Short communication
Penetrating injury of the facial skeleton through the orbit, by a massive metallic shotgun block: A case report F. Polini ∗ , M. Robiony, C. Toro, F. Costa, S. Sembronio, M. Politi Department of Maxillo-Facial Surgery, Faculty of Medicine, University of Udine, P.le Santa Maria della Misericordia, 33100 Udine, Italy Accepted 21 August 2006 Available online 5 October 2006
Abstract We present a case of invasion of the orbit and the infra-temporal fossa by a massive breechblock from a shotgun. The block was removed and two months later the orbit was reconstructed with iliac crest. Six months after that the patient had plastic surgery and insertion of ocular prosthesis. © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Orbital trauma; Orbital reconstruction
Introduction The sequence of penetrating orbital injuries and the prognosis for the patient depend on many factors including the size, the nature (material), the kinetic energy, and the trajectory of the penetrating object. Downward penetration into the maxillofacial area by a foreign body through the orbit is less usual and less likely to be life-threatening than the upward orbitocranial route. We report case of downward penetration through the facial skeleton by a shotgun bolt, with a satisfactory reconstruction.
Case report A 26-year-old woman was injured by a malfunctioning gun, while out hunting. During recoil, her shotgun exploded, and
∗ Corresponding author at: Cattedra di Chirurgia Maxillo-Facciale, Policlinico Universitario, P.le S. Maria della Misericordia, 33100 Udine, Italy. Tel.: +39 0432 559455; fax: +39 0432 559868. E-mail address: [email protected] (F. Polini).
projected the breechblock backwards and downwards, into her orbit, so that it emerged under the skin in the lateral cervical area. Penetration resulted in crushing of the ocular globe, with little bleeding (Fig. 1). The patient was immediately operated on to remove the block, through combined coronal, preauricular, and cervical approach. We first did an orbitozygomatic osteotomy to facilitate removal of the projectile and only conventional haemostasis was indicated. Postoperative computed tomography showed a wide communication between the orbit and the infratemporary and pterygomaxillary fossas, with multiple fragments of the orbital floor, papiraceous lamina of the ethmoid, posterolateral, medial, and anterior walls of the maxillary sinus, and of the zygomatic bone. The main maxillary resistance pillars remained intact (Fig. 2). Two months later, she had an autogenous bone graft harvested from her iliac crest to reconstruct the orbit. The remains of the ocular globe were enucleated and a titanium miniplate was placed to fix the inferior orbital rim. Six months later she had a plastic operation to conform the lower eyelid with a graft of auricular cartilage, and the conjunctiva was reconstructed with a palatal mucosal graft. Finally a silicone ocular prosthesis was inserted (Fig. 3).
0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.08.007
F. Polini et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 586–587
587
Fig. 1. (a) Operative view of the patient at the time of the removal of the block. (b) Lateral radiograph showing the breechblock running into the facial skeleton, through the orbit.
Discussion
Fig. 2. CT scan of the patient, performed after breechblock removal, showing a communication between the orbit and the infra-temporary and pterygomaxillary fossas, multiple fracture fragments and no collapse of the main maxillary resistance pillars.
The surgical approach to the orbit and the infratemporal fossa is usually conservative for benign conditions and is through a temporal or preauricular incision.1 In some cases that require wider exposure of the region, a coronal or cervical incision, or both, could be necessary. Wider osteotomies could also be indicated to increase the exposure of the medial aspect of the trauma and to ensue eventual control of the life-threatening damage to the main vascular bundles. In traumatic rather than neoplastic events, evisceration should be preferred to enucleation, because it necessitates the restitution of an adequate cavity, and hence better results for the prosthetic replacement of the eye.2,3 Autogenous bone grafting from the iliac crest should be preferred when multiple wall reconstruction (orbital floor and lower part of lateral and medial orbital wall) is required, because of the extent of the bony defect.4
References 1. Mansuor OI, Carrau RL, Snyderman CH, Kassam A. Preauricular infratemporal fossa surgical approach: Modifications of the technique and surgical indications. Skull Base 2004;14:143–51. 2. Dortzbach RK, Woog JJ. Choice of procedure. Enucleation, evisceration, or prosthetic fitting over globes. Ophthalmology 1985;92:1249– 55. 3. Genevois O, Millet P, Retout A, Quintyn JC. Comparison after 10-years of two 100-patient cohorts operated on for eviscerations or enucleations. Eur J Ophthalmol 2004;14:363–8. 4. Fonseca RJ. Oral and maxillofacial reconstruction. Philadelphia: Saunders; 2000. p. 235. Fig. 3. Front view of the patient after prosthetic rehabilitation.