Maxillofacial Gunshot Injuries at an Urban Level I Trauma Center—10-Year Analysis

Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols

Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.

What Factors Influence the Hospitalization of Self-Inflicted Craniomaxillofacial Gunshot Wounds?

Study Design

The following retrospective cohort study was competed using data from the Nationwide Inpatient Sample a database from the Healthcare Cost and Utilization Project (HCUP).

Objective

The objective of this retrospective cohort study is to compare the hospitalization outcomes of managing maxillofacial trauma attempted suicide among handguns, shotguns, and hunting rifles.

Methods

The primary predictor variable was the type of firearm. The outcome variables were the hospital charges (U.S. dollars) and length of stay (days). We used SPSS version 25 for Mac (IBM Corp., Armonk, NY, USA) to conduct all statistical analyses.

Results

A final sample of 223 patients was statistically analyzed. Relative to patients within the Q2 median household income quartile, patients in the Q4 median household income quartile added +$ 172'609 (P < .05) in hospital charges. Relative to patients living in "central" counties of metro areas, patients in micropolitan counties added +13.18 days (P < .05) to the length of stay. Relative to patients in the Q2 median household income quartile, patients in Q3 added +9.54 days (P < .05) while patients in Q4 added +11.49 days (P < .05) to the length of stay.

Conclusions

Being within the highest income quartile was associated with increased hospital charges. Patients living in micropolitan counties have prolonged hospitalization relative to patients in metropolitan counties. Relative to the second income quartile, length of stay was higher in the third income quartile and highest in the fourth income quartile. Increase income grants access to deadlier firearms.

Evidence-Based Medicine for Ballistic Maxillofacial Trauma

Ballistic trauma is a serious health issue with significant costs to physical, psychosocial, economic, and societal well-being. It may be caused from firearms, explosive devices, or any other projectile forces, and is characterized by severe tissue loss and evolving tissue devitalization. This review covers mechanism, diagnosis, and management of ballistic maxillofacial trauma, specifically. Initial evaluation includes stabilization of airway, bleeding, and circulation, followed by assessment of other injuries. The overall degree of tissue damage is determined by intrinsic patient factors and extrinsic projectile factors. Management of ballistic injuries has shifted toward advocation for early operative repair with the advent of antibiotics and advanced techniques in maxillofacial reconstruction. Appropriate timing and method of reconstruction should be carefully selected on a case-by-case basis. While ballistic trauma research is limited to studies biased by institutional practices, areas for further study identified from current literature include guidelines directing timing of reconstructive surgery; thresholds for free tissue transfer; handling of retained projectiles; incidence of surgical complications; and clinical outcomes for computer-aided surgical repair of these highly destructive injuries.

Socioeconomic Profile is Associated with the Type of Firearm Injuries to the Head and Neck

PURPOSE

Socioeconomic status (SES) describes social standing of an individual or a group. SES has been directly associated with violence. The purpose of this study is to measure the association between SES profiles and firearm injuries (FIs) to the head and neck.

METHODS

This cross-sectional study reviewed patients at Grady Memorial Hospital in Atlanta, Georgia from January 2016 to June 2021. The study included patients who sustained FIs to the head and neck. The primary predictor variable was Distressed Community Index as a surrogate for SES. The primary outcome variable was type of FI (assault-induced firearm injury [AFI] or self-inflicted firearm injury [SFI]). Covariates were patient characteristics, distribution, and severity of FI. Univariate and bivariate analyses were calculated. The χ² test was used for categorical variables. Independent t test was used for continuous variables. Statistical significance was P < .05.

RESULTS

Six hundred ninety-four patients met inclusion criteria. AFIs were statistically more frequent in young (AFI = 32.2; SFI = 42.2; P ≤ .001) and/or Black patients (AFI: n = 483, 86.3%; SFI: n = 40, 29.9%; P ≤ .001). Patients who sustained AFIs were statistically more likely to live in areas associated with high Distressed Community Index score (AFI: 64.8, range = 3.7 to 99.7; SFI: 54.4, range = 2.8 to 98; P ≤ .001). A statistically significant number of SFI patients presented with lower Glasgow Coma Scale score (AFI: 10.7, range = 3 to 15; SFI: 5.5, range = 3 to 15; P ≤ .001), and/or required tracheostomy (AFI: n = 56, 10%; SFI: n = 27, 20.1%; P = .005).

CONCLUSIONS

Patients who lived in economically distressed areas were positively associated with AFIs to the head and neck. However, SFIs were statistically more sever. More studies on the impact of current gun prevention programs and how to be addressed to at-risk populations is needed.

Is Maxillofacial Gunshot Wound Location Associated With Operative Intervention?

PURPOSE

Gunshot wound (GSW) injuries are an important public health concern in the United States. The study purpose was to measure the association between GSW location and need for operative treatment.

METHODS

This was a retrospective cohort study. Sample consisted of all patients treated for maxillofacial gunshot wound injuries at Cook County Health from 2008 to 2018. The sample data were collected through a retrospective charts review and review of computed tomography imaging. The predictor variable was the region of the face involved with the GSW and it was divided into 3 levels, upper face (UF), middle face (MF), and lower face (LF). The outcome variable was whether operative intervention was rendered or not (operative vs no intervention). Other variables of interest collected included patient demographics, the type of surgical intervention, disposition (home vs rehab/morgue), rate of intracranial injury, and need for blood transfusion. Data analysis was performed using Chi-square for proportions and relative risk (RR) with 95% confidence interval (CI).

RESULTS

A total of 180 patients were identified to have sustained GSW injuries to the face during abovementioned time frame. Of those, 120 patients had isolated GSW injuries with no other organs involvement. The median age was 25 years. Majority of the patients were males (94%). The involved facial region appeared to influence the need for operative management and this reached statistical significance (Chi-square 22.703, P < .001). GSW injuries to LF were 2.94 times more likely to require operative intervention than injuries to the MF (RR = 2.94, 95% CI = 1.625-5.327). Injuries of the UF were 2 times more likely to require operative intervention than injuries of the MF (RR = 2.03, 95% CI 1.023-4.008). Injuries to the UF were more likely to be associated with intracranial injuries (Chi-square = 20.522, P < .001).

CONCLUSIONS

In patients with facial GSW injuries, there is an association between injury location and the need for operative intervention. Injuries to the LF were most likely to require surgical intervention followed by the UF and MF, respectively.

Treatment of Gunshot-Related Mandibular Fracture with Splint-Guided Reduction: Case Report

Background/Aim: Gunshot injury-related mandibular fractures often have a complex pattern, characterized by comminution, bone loss, and soft-tissue avulsion. The management is difficult and varies between individual cases.

Case Report: A 41-year-old male patient presented with marked swelling and ecchymosis in the left mandibular region. Intraorally, he had a deviated open bite on the left side. A unilateral comminuted mandibular fracture was diagnosed by panoramic radiograph and computed tomography. An acrylic dental splint-guided open reduction and internal fixation, including intermaxillary fixation through brackets and intermaxillary elastics, was planned. No complications were observed throughout the healing period, and healing at the fracture site was satisfactory. The occlusion returned to the preinjury position and was stable.

Conclusions: This case report shows that successful functional and esthetic results can be achieved with a strict patient-specific treatment protocol for a comminuted mandibular fracture due to gunshot injury.

[Ballistic trauma of the face: A new scourge in Tunisia]

INTRODUCTION

Ballistic trauma of the face has aroused growing interest since the proliferation of conflicts in the world and particularly in the fight against terrorism. Their polymorphous and disfiguring character, their particular evolution and prognosis due to the ballistic aetiology, differentiate them from classic maxillofacial trauma. Tunisia did not escape this scourge after the revolution of 2011, and must therefore face the challenge of ballistic trauma in general and of the face in particular.

MATERIALS AND METHODS

We conducted a descriptive retrospective study on 30 patients who were victims of ballistic trauma of the face in the otolaryngology and maxillofacial surgery and ophthalmology departments of the Main Military Hospital of Tunis during the period from January 2011 to April 2018. Our objective was to assess the prevalence of these traumas in Tunisia after the revolution, and to assess their clinical and therapeutic aspects.

RESULTS

Our results showed a clear upward trend in these traumas, mainly caused by the opposition of our armed forces to the terrorist threat. The discussion of our results was therefore descriptive, comparing them to the literature.

CONCLUSION

Currently, it is imperative to develop a strategy for precise and effective management of ballistic trauma of the face due to the increase of armed conflicts, attacks and terrorist acts. Likewise, technological advances to develop soldier protection systems must be implemented.

Craniofacial injuries by firearms projectiles: An analysis of 868 deaths in the five regions of Brazil

Firearms injuries have a legal and medico-legal importance, and are especially lethal when they reach the craniofacial regions of the victim. The present study aims to identify the characteristics of craniofacial lesions resulting from firearm projectiles, to register the most affected craniofacial regions by this type of injury and to verify the demographic profile of the victims. A retrospective study was carried out on the autopsy records produced in the first semester of 2015, in five Institutes of Legal Medicine in Porto Velho, situated in the cities of João Pessoa, Vitória, Porto Alegre and Brasília. Data extracted included sex, skin color and age of the victim, craniofacial region reached, shooting distance, shape and size of the injuries and manner of death (homicide, suicide or accident). Based on the 868 reports analyzed, it was possible to observe 1700 entrance lesions of firearm projectiles in craniofacial regions. Among cases of known manner of death, homicides were the most frequent (97.0%). It was observed a higher frequency of male victims (93.3%), mixed race (62.0%), between the ages of 12 and 29 years (59.4%). In all cases considered as suicide or accident there was only one entrance wound, but in 82.8% of the homicides there were multiple gunshot wounds. The craniofacial most affected regions were temporal (25.2%) and occipital (19.8%). The most common sites of projectiles exit were the temporal (25.3%) and parietal (16.1%). All cases of suicide were related to contact shot (69.2%) or close-range shot (30.8%), and among the homicides the distant range shots were more frequent (54.0%). The shape of entrance wounds was mostly circular (56.8%) and oval (31.3%), and among the exit injuries, the lesions were irregular (43.3%) and starry (24.1%). The entrance wounds showed smaller sizes than the exit lesions (p < 0.0001). The data obtained are useful for guiding research that takes into account craniofacial trauma caused by firearm projectiles, makes it possible to compare this data with those of other countries and can base investigative conclusions based on the analyzes discussed in the present work.

The marks of gunshot wounds to the face

Introduction

This article deals with the occurrence of health problems due to gunshot wounds to the face among military police officers, in the metropolitan region of Rio de Janeiro, who were submitted to surgery at the Oral and Maxillofacial Surgery and Traumatology Clinic of Hospital Central da Polícia Militar.

Objective

To identify the profile of patients submitted to surgery as a result of gunshot wounds, the anatomical distribution of maxillofacial fractures, the identified sequelae and complications, the health specialties involved in the rehabilitation of these patients, and to discuss the social, emotional and work performance-related effects of work among these subjects.

Methods

A retrospective epidemiological study was carried out based on secondary data from military police officers who were submitted to surgery at Hospital Central da Polícia Militar due to gunshot wounds from June 2003 to December 2017.

Results

During the study period, 778 surgeries were performed in the operating room by the Oral and Maxillofacial Surgery and Traumatology service at Hospital Central da Polícia Militar, 186 of which were due to gunshot wounds (23.9%). All patients were males and the mean age 34.7 years. Bone segment loss was the most common sequela. Facial esthetic impairment and reports of insomnia were the most often identified late consequences of impact on health and social life. Regarding the occupational impacts of the sustained injury, the mean time away from work due to medical leave for the treatment of maxillofacial injuries was 11.7 months.

Conclusion

The treatment of gunshot wounds patients with facial injuries requires multiple surgical interventions and their rehabilitation requires the involvement of different health specialties. Further studies are needed to qualitatively analyze the impact of this type of facial trauma on the patients' lives and their social consequences.

Our Treatment Approaches in Severe Maxillofacial Injuries Occurring After Failed Suicide Attempts Using Long-Barreled Guns

Maxillofacial traumas with long-barreled guns may sometimes cause catastrophic results by means of smashing in facial structures. In these patients, reconstruction strategies of both fragmented/lost soft and hard tissues still remain controversial. In their clinic, the authors treated 5 patients with severely injured face after failed suicide attempt between 2008 and 2013. In this study, the authors aimed to present their clinical experiences on these severely injured maxillofacial gunshot traumas and offer a treatment algorithm to gain a result as possible as satisfactory in terms of functionality and appearance.