Primary treatment of shotgun injuries to the face

The treatment of close-range shotgun wounds to the face can be extremely difficult. Over the years, surgeons have progressed from the conservative approach of debridement and delayed reconstruction to that of immediate reconstruction. While the complex nature of these injuries requires treatment on an individual basis, the principles of conservative debridement, thorough wound cleansing, and primary replacement of soft-tissue defects will often result in a better functional and esthetic restoration in a shorter period of time. Five patients with shotgun facial wounds managed by individualized primary repair are discussed.     

Approaches to the management of shotgun injuries

Shotgun wounds present specific challenges for the surgeon. Multiple penetrating wounds frequently involve large anatomic areas with potential multi-system injury. Experience with 121 patients sustaining shotgun wounds over the 5-year period ending 31 December 1981 was reviewed to assess results and evaluate treatment protocols. Sixty-six patients had chest wounds with pleural penetration. Twenty-four wounds were minor and were observed. Each had less than five pellets penetrating the pleura. Twenty-two patients had close-range injuries. Fourteen of these required chest tube drainage alone and eight patients required thoracotomy for control of bleeding. Eleven patients died, six as a direct result of the chest injury. In 55 patients with abdominal-retroperitoneal wounds exploratory operations were done if more than four pellets were thought to be lodged intraperitoneally or if signs of peritonitis were present, while lesser wounds without peritoneal findings were observed. In the 15 patients who did not have exploratory operations, there were no deaths or major complications. Thirty-five patients had exploratory operations. Two patients had five intraperitoneal missiles and no clinical evidence of peritonitis but were found to have significant intestinal perforations. Four patients died. Eighty-three patients with extremity wounds were classified according to location of injury. Forty-five had upper extremity wounds, with nine vascular injuries. Two patients died and one limb was amputated because of soft tissue infection. Thirty-eight patients had lower extremity wounds. Five had major vascular injuries. Preoperative arteriography was obtained in 13 patients with extremity injuries; the results of one of these were falsely negative. There were no deaths or amputations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intracranial penetration due to BB air rifle injuries

The toy BB gun that was commonly available 20 years ago has been modernized into a weapon with lethal potential. We report four children who had intracranial penetration by BBs. Three were shot by another young child, and the fourth child was injured by an intoxicated adult. Two of the children have permanent, severe neurological sequelae. BB rifles should require the same safety precautions and considerations as more traditional firearms.     

Life-threatening air rifle injuries to the heart in three boys

Air rifles, or BB guns, are generally thought of as childhood toys. Although most injuries are not serious, life-threatening events have been reported. Within a 1-year period, 3 boys presented after BB gun shots to the chest, all requiring surgical intervention for penetrating injuries to the heart. A 15-year-old underwent window pericardiotomy for hemopericardium with thrombus 24 hours after admission. Another, 5 years of age, underwent emergent exclusion of the cardiac apex for a traumatic ventricular septal defect. The third, 8 years old, had a right ventricular injury requiring an urgent subxiphoid pericardial window for tamponade. All recovered uneventfully. Increased public awareness, adult supervision, safety training, and appropriate legislation are needed to decrease the risks of these potentially lethal weapons.     

Chain saw injuries to the face

Chain saws may produce devastating facial injuries when the blade kicks back after striking a hard object. A review of experience with 12 male patients indicates that in addition to extensive ragged lacerations of skin and soft tissues, bone and teeth are frequently fractured. Eye injuries are rare, but the eyelids may be extensively damaged. Management includes debridement and exploration of the wounds, repair of soft tissues, removal of fractured roots, and application of arch bars if the jaw is fractured.     

Principles and management of penetrating vascular injuries secondary to shotgun wounds

The characteristics of shotgun ammunition and ballistics are discussed to give an understanding of how shotgun wounds differ from all other types of civilian penetrating wounds. Five case examples of shotgun injuries to blood vessels involving the neck and extremities are presented to highlight problems encountered and to point out the principles of management. The importance of muzzle-to-victim range, preoperative arteriography and the definite place of conservation treatment are stressed.     

Peripheral vascular trauma from close-range shotgun injuries

This report summarizes an eight-year experience (1976 to 1983) with 49 close-range shotgun blasts with associated major vascular injuries seen in a large urban hospital. Injuries to the upper extremity (40%), lower extremity (56%), and neck (4%) were seen. A high frequency of associated deep venous injury (82%), nerve injury (37%), fracture (33%), massive soft-tissue loss (43%), and compartmental hypertension (39%) was observed. There were no deaths in this series, and the limb salvage rate was 96%. Neither patient with multiple carotid artery injuries suffered a neurologic deficit. We attribute our success in the management of these complex injuries to rapid fracture immobilization, early and aggressive use of fasciotomy, adequate débridement of devitalized tissue, repair of deep venous injuries, arterial repair with autogenous tissue, and extra-anatomic bypass grafting in selected cases.     

坐骨神经霰弹枪伤的手术治疗

目的探讨霰弹枪致坐骨神经损伤的临床特点及手术治疗方法、效果。方法19例坐骨神经霰弹枪伤中,臀部损伤2例,大腿部损伤14例,胭窝部损伤3例。枪伤射击距离在0．5—9．0m之间,按霰弹枪的Shermen分型划分,I型4例,Ⅱ型11例,Ⅲ型4例。伤后至入院手术时间除1例为4h外,其余均为2～14个月。1例行清创、神经外膜对端吻合术,7例行神经全干移值术,6例行神经电缆式移植,4例行神经松解术,1例行踝关节融合术。结果19例患者随访0．8～3．5年、平均19个月,根据英国医学研究院神经外科学会制定的MCRR标准,坐骨神经损伤恢复的优良率为52．6％。结论坐骨神经霰弹枪伤的伤情复杂,常合并开放骨折、血管损伤、软组织缺损及感染;神经损伤的性质多为Sunderland分度中的4～5度损伤;手术治疗方法以神经移植为主,但预后不佳;神经损伤后应给予正确的初始治疗,在对损伤神经恢复状况认真的连续、动态观察的基础上,正确评估神经损伤性质,采取积极、恰当的手术治疗,同时注重神经营养药物、康复理疗等综合治疗,才能获得较好的手术效果。     

Management of close-range shotgun injuries to the chest by diaphragmatic transposition: case reports

A method of reconstructing the chest wall following close-range shotgun injuries is described. This technique requires detaching the diaphragm peripherally and suturing it above the chest wall defect, resulting in an intact chest cavity and an abdominal wall defect. This latter problem can then be addressed by a variety of standard methods. Two patients are presented with excellent long-term results of diaphragmatic transposition, which should be in the armamentarium of all surgeons who deal with trunk trauma.     

Immediate reconstruction of gunshot injuries to the face.

In the past, severe traumatic injuries to the face resulting from shotgun injuries have been managed by primary wound healing followed by little or late reconstruction. This would involve a long period of convalescence by the patient, followed by years of living with his deformity. With recent demands to minimize the patient's suffering and disabilities and to lessen hospitalization costs, a method of immediate reconstruction of such crippling facial injuries using a partially de-epithelialized skin flap has been devised and successfully applied to the patient presented here.     

Combined injuries of the cranium and face

The neurosurgeon and plastic surgeon are increasingly called upon to manage the care of patients with combined injuries of the cranium and face. The authors briefly review the pathogenesis and classification of craniofacial fractures and outline historical approaches to them. Current principles of management are then discussed. Experience with 167 patients is presented with emphasis on surgical technique, the sequence of repair and early primary reconstruction. The controversial issue of fontal sinus fracture repair is addressed. The authors favour preservation of the frontal sinus cavity, where possible, and do not obliterate the nasofrontal duct. With injuries to the floor of the sinus, the base of the sinus and frontonasal duct are sealed with bone graft and a vascularised soft tissue flap and the sinus is cranialised. Immediate bone grafts, using split skull or rib, are used to reconstruct areas of bony destruction or loss. Ninety-eight patients required 402 grafts. Immediate bone grafting resulted in few complications and low incidence of secondary deformities needing correction.     

The problem of vascular shotgun injuries: Diagnostic and management strategy

This report details our diagnostic and management protocol derived from experience with 11 consecutive shotgun injuries. The injured vessels in nine men and one woman were: brachial artery (6), femoral artery (2), iliac artery (1), tibioperoneal trunk (1), and axillary vein (1). All those with arterial injuries had evidence of distal ischemia; 60% had absent distal pulses. Preoperative arteriography was obtained in seven who were stable and proved useful in outlining the local extent of their vascular injury as well as delineating available distal run-off vessels. Routine chest x-ray revealed evidence of pulmonary or cardiac missile emboli in three. Patients underwent primary repair (4), saphenous vein graft (4), and prosthetic graft (1). Associated venous disruption was noted in all patients with primary arterial injuries; this was either repaired (5/10) or ligated (4/10). Five patients had completion arteriograms, two of which revealed unsuspected distal arterial-arterial emboli. Associated soft tissue destruction included seven nerve injuries and three instances of extensive compartment injury which required fasciotomy. Average follow-up time was nine months, with the majority of complications due to associated nerve damage or soft tissue loss. We have evolved the following strategy: 1) After hemodynamic resuscitation, stable patients undergo arteriography to define the anatomic origin of complex injuries; 2) Surgery commences with rapid proximal and distal control of disrupted segments; 3) Following vessel debridement, continuity is restored either by primary repair or by an autogenous graft which is placed to allow coverage by viable muscle or by soft tissue; 4) On-table completion arteriograms evaluate patency and provide evidence of distal arterial emboli; 5) Fractures are stabilized and disrupted nerves isolated for subsequent repair; and 6) Fasciotomy is performed in the presence of distal swelling or prolonged ischemia.