Lecture No. 1
Traumatic injuries
maxillofacial region in children.
Birth trauma.
Department of Surgical Dentistry and Maxillofacial Surgery
KBSU, Nalchik, head. department prof. Mustafaev M.Sh.

Lecture outline

Traumatic injuries of the maxillofacial
areas in children.
Frequency of various soft tissue and bone injuries
facial skeleton.
Classification of injuries of the maxillofacial region.
Birth trauma.
Consequences of birth trauma maxillofacial
areas.

Facial injuries in children

Frequency of maxillofacial injuries
area in children is 10.0 per 1000
children's population.

Facial injuries in children

Traumatic injuries to the maxillofacial area in
children are:
o 9-15% in relation to injuries of other locations
o 25-32% - to the number of all facial injuries in adults.

Facial injuries in children

Every fourth patient with maxillofacial trauma is a child.
In cities, facial injuries in children occur 10 times more often than
in rural areas.

Facial injuries in children

Soft tissue injuries - 50%
Injuries to the bones of the facial skeleton - 30%
Combined injuries – 20%

Facial injuries in children

In children of a younger age group
(up to 6 years) - soft tissue injuries
In children of the older age group
(14-17 years) - facial bone injuries

Periods of childhood

Newborn – up to 1 month
Infant – 1 – 12 months
Pre-school – 1 - 3 years
Preschool – 4 – 6 years
Junior school – 7 – 11 years old
Secondary school – 12 – 14 years old

Periods of childhood

Thoracic – the beginning of the eruption of baby teeth

10. Periods of childhood

Pre-school – completion of teething
baby teeth

11. Periods of childhood

Preschool – increased jaw growth,
eruption of the first permanent teeth

12. Periods of childhood

Junior school - active shift
permanent baby teeth

13. Periods of childhood

Secondary school – completion
formation of permanent bite

14. Features of facial injuries in children

1. In the facial area, in tissues
oral cavities are localized
–
–
–
sense organs,
speeches,
initial sections of the respiratory
and digestive systems.
Therefore, if they are damaged
various
violations.

15.

16. Features of facial injuries in children

2. Proximity to the maxillofacial area
vital organs
sharply worsens the condition
sick
– brain damage
brain,
– organ damage
sight and hearing,
– damage to the pharynx

17. Features of facial injuries in children

3. The face plays an aesthetic role
– deformations resulting from
injuries, have a detrimental effect on the child’s psyche
– He feels inferior
– This creates isolation, aggressiveness and
other negative character traits

18. Features of facial injuries in children

That's why
traumatic
facial injuries
should
regard as
psychosomatic
disease.

19. Features of facial injuries in children

– Soft tissue wounds gape and make an impression
very severe injuries incompatible with life

20. Features of facial injuries in children

4. For injuries of the maxillofacial area
there is a discrepancy between the external
type and severity of damage.
– Correct primary surgical treatment of the wound
immediately changes the patient's appearance and reduces
functional disorders.

21. Features of facial injuries in children

5. In case of damage
organs of the oral cavity and
maxillofacial
natural areas
feeding frequently
difficult.

22. Features of facial injuries in children

6. Impossibility or
difficulty
closing the mouth and
swallowing
saliva flowing out of
oral cavity
chest skin cools
cells and macerated
may arise
contact pneumonia

23. Features of facial injuries in children

7. Damage to facial and jaw tissues is common
complicated by different types of asphyxia.

24. Features of facial injuries in children

8. The presence of damaged teeth and their
fragments may cause
obstructive asphyxia
secondary infection in the respiratory tract and
lungs
osteomyelitis

25. Features of facial injuries in children

9. In case of trauma to the face and jaws in children
growth zones are damaged
the harmonious development of tissues is disrupted
various parts of the face
post-traumatic and post-operative
deformation
secondary disorders of various functions

26. Features of facial injuries in children

10. Good
vascularization and
tissue innervation
faces
emergence
significant bleeding
hypovolemic shock

27. Features of facial injuries in children

1. Tendency to develop generalized
reactions to trauma;
2. They do not tolerate blood loss well;
3. Clinical and radiological difficulties
examinations;
4. Rapid healing of wounds and fractures.

28. Classification of injuries to the maxillofacial area

lower and lateral areas of the face
By localization:
A. Soft tissue injuries with damage:
a) language
b) salivary glands
c) large vessels
d) large nerves

29. Classification of injuries to the maxillofacial area

Mechanical damage to the upper, middle,
lower and lateral areas of the face
By localization:
B. Bone injuries:
a) lower jaw
b) upper jaw
c) cheek bones
d) nose bones
e) two bones or more

30. Classification of injuries to the maxillofacial area

According to the nature of the injury:
o end-to-end,
o blind people,
o tangents,
o penetrating into the oral cavity,
o do not penetrate into the oral cavity, penetrating
into the maxillary sinus and nasal cavity

31. Classification of injuries to the maxillofacial area

According to the mechanism of damage:
A. Firearms: bullet, fragmentation, ball,
arrow-shaped elements.
B. Non-firearm

32. Classification of injuries to the maxillofacial area

Combined
defeats
Burns
Frostbite

33. Types of childhood injuries

Generic
Street
Transport
Domestic
Sports
Training
Other

34. Birth trauma

Birth trauma of newborns -
pathological condition that developed during
time of birth and characterized
damage to the child’s tissues and organs,
accompanied, as a rule,
disruption of their functions.

35. Birth trauma

Predisposing factors:
incorrect position
fetus;
size mismatch
fetus basic parameters
bony pelvis
pregnant woman (large fetus
or narrowed pelvis);

36. Incorrect fetal position

37. Birth trauma

Predisposing factors:
features of intrauterine development of the fetus
(chronic intrauterine hypoxia);
prematurity, postmaturity;
duration of labor (both rapid and
prolonged labor).

38. Birth trauma

Immediate reasons:
incorrectly performed obstetrics
aids for turning and removing the fetus;
application of forceps, vacuum extractor, etc.

39. Obstetric forceps

40. Vacuum extractor

Vacuum extractor

41. Use of a vacuum extractor and obstetric forceps

42. Birth trauma

Birth trauma:
soft tissues (skin, subcutaneous tissue,
muscles)
skeletal system
internal organs
central and peripheral nervous
systems.

43. Birth trauma of soft tissues

BIRTH TRAUMA OF SOFT TISSUE
Damage to the skin and subcutaneous tissue during
childbirth - abrasions, scratches, hemorrhages, etc.
local treatment - treatment with solutions
antiseptics, application of aseptic
bandages):
they usually disappear after 5-7 days.

44. Birth trauma of soft tissues

BIRTH TRAUMA OF SOFT TISSUE
Muscle damage
damage to the sternocleidomastoid muscle:
muscle hemorrhage or rupture
during childbirth in the breech position,
when applying forceps,
sometimes develops torticollis

45. Torticollis

46. ​​Birth trauma of soft tissues

BIRTH TRAUMA OF SOFT TISSUE
Treatment of muscle damage:
creation of a corrective position
(use rollers)
dry heat
potassium iodide electrophoresis
massage
If there is no effect - surgical
correction (in the first half of life
child).

Children who have suffered a birth injury of the soft Birth injury of the skeletal system Consequences of a birth injury

Features of a mandibular fracture
during childbirth there is a disturbance in its growth
and limitation of motor function of the temporomandibular joint, as a result of the development
ankylosis or deforming osteoarthritis.

Mechanical damage to the upper, middle, lower and lateral areas of the face

By localization:

A. Soft tissue injuries with damage:

b) salivary glands

c) large vessels

d) large nerves

B. Bone injuries:

a) lower jaw

b) upper jaw

c) cheek bones

d) nose bones

e) two bones or more

By the nature of the wound: through, blind, tangential, penetrating into the oral cavity, not penetrating into the oral cavity, penetrating into the maxillary sinus and nasal cavity

According to the mechanism of damage:

A. Firearms: bullet, fragmentation, ball, arrow-shaped

elements.

1. Combined lesions
2. Burns
3. Frostbite

Combined injury – damage to at least two anatomical areas by one or more damaging

factors.

According to various authors, the frequency of combined facial injuries ranges from 15.1% -15.6%. The value of this indicator largely depends on the depth of examination of patients, the use of electrophysiological research methods, and is also determined by such factors as the age composition of patients, the circumstances and causes of injuries, their severity, the nature of facial damage, and the profile of the medical institution.

Combined injuries are usually classified as the most severe type of injury. The severity of the clinical manifestations of such injuries is due to the emergence and development of “mutual burden syndrome,” which leads to aggravation of the course of the injury. The general condition of the victim with jaw fractures, combined with damage to other segments of the body, makes it extremely difficult to conduct an examination and establish a diagnosis. Most patients with such trauma are unconscious or have severely impaired consciousness. It is sometimes impossible to find out complaints from victims, much less collect anamnesis. It should also be emphasized that X-ray examination is difficult due to the motor agitation of unconscious patients. The examination of the maxillofacial area in such victims should be carried out most thoroughly. There is no doubt that a general surgeon (traumatologist), a neuropathologist (neurosurgeon) and often an otorhinolaryngologist and an ophthalmologist should take part in the examination of patients with combined trauma.

To objectively assess the severity of combined and multiple injuries to the face and the nature of the individual reaction of victims to injury, you can use the method of predicting the severity of traumatic shock, developed at the Leningrad Research Institute of Emergency Medicine named after. Dzhanelidze I. I. Based on several indicators of the victim’s condition, which are easily determined upon his admission to a medical institution, this method allows with a probability of up to 90% to predict the outcome of combined and multiple trauma (± T), i.e. whether the patient will survive or die , as well as establish the duration of shock with a favorable outcome and life expectancy with an unfavorable prognosis.

The presence of a plus sign (+) in front of the T indicator suggests a favorable outcome of the injury, and the numerical value characterizes the duration of the period of unstable hemodynamics in hours. The presence of a minus sign (-) indicates an unfavorable outcome, the death of the victim, and the digital indicator characterizes the life expectancy in hours.

To select rational treatment tactics in accordance with the prognosis data, all victims are divided into 3 groups:

1. with a prognosis favorable for specialized treatment if the time (T) of the expected duration of the period of unstable hemodynamics does not exceed + 12 hours.
2. with a prognosis questionable for specialized treatment, when the duration of the period of unstable hemodynamics (T) is expected from + 12 to + 24 hours.

III. with a prognosis unfavorable for specialized treatment, when the duration of shock (T) is expected to be more than 24 hours, or death is expected.

The clinical course of combined injuries is characterized by the fact that the number of complications is greater than with isolated injuries. They occur especially often with damage to the jaws and brain. With combined injuries, there is a significant impact on both the general condition of the body and the clinical course of damage to other organs. Damage to the jaws adversely affects the function of external respiration and pulmonary ventilation, even in the absence of thoracic injury. Almost every victim develops bronchopulmonary complications, which suggests a kind of oropulmonary syndrome. Aspiration of oral contents and limited opportunities for natural pulmonary ventilation contribute to the development of this syndrome.

A special place among the complications observed in patients with combined trauma are septic, often leading to death, as well as brain damage accompanied by the development of characteristic symptoms.

General cerebral symptoms

Complaints of headache, dizziness, nausea, and vomiting are observed in only 75% of patients with this type of traumatic brain injury. Despite the presence of skull damage, in almost 25% of patients no cerebral symptoms are detected.

The duration of loss of consciousness in relatively mild injuries ranges from several minutes to 1 hour, in more severe cases - from 1 hour to several days. Most victims with loss of consciousness experience retrograde amnesia.

It should be noted that when the frontal area is hit on a flat surface, loss of consciousness occurs more often than when hit by an object of limited shape. Loss of consciousness is observed less often, the closer the place of impact with a limited object is to the frontal sinuses. This is probably due to the peculiarities of the anatomical structure of the bones of the anterior parabasal part of the skull and the presence of cavities with high shock-absorbing properties.

Frontal lobe damage syndromes

Basal-hypothalamic syndrome. More often it is detected when the anterior parabasal parts of the skull hit a flat surface (falls, car injuries). The syndrome includes signs of damage to the orbital cortex of the frontal lobes and autonomic-endocrine disorders.

With a relatively mild degree of damage to the basal parts of the brain, mild euphoria and a decrease in criticism come to the fore. The victims consider themselves healthy, violate bed rest, refuse medications, injections, and examinations. Usually, after 10-15 days, these manifestations decrease and upon discharge from the hospital, no noticeable mental disorders are noted.

Dysfunction of the hypothalamic region is characterized by hyperhidrosis of the skin, tachycardia, and a slight symmetrical increase in blood pressure. Sometimes there is a slight increase in blood sugar, short-term transient attacks of facial flushing, accompanied by palpitations and hyperthermia.

With severe basal damage to the frontal lobes, euphoria is more pronounced, a tendency to flat jokes, increased sexuality, sudden personality changes (decreased memory, intelligence, incontinence, rudeness), and pronounced emotional lability are noted. These patients can instantly move from a state of complacency and euphoria to anger and aggressiveness. A good mood for no apparent reason is often quickly replaced by tearfulness and depression, and changes in emotions can occur several times during a conversation with the patient.

Polar-convexital syndrome. In relatively mild cases, there is a decrease in activity in speech and movement, minor disturbances in attention and thinking, and rapid fatigue.

Severe injuries to the polar parts are characterized by clear affective-volitional disorders: gross disturbances of attention and thinking, mental impoverishment, apathy, physical inactivity. These patients lie motionless in bed for a long time, are indifferent to their condition, relatives, and have little interest in others.

Premotor zone syndrome. In this case, motor or speech perseveration is noted: repeated movements of the limbs, fingers, repetition of individual words or phrases, and often a grasping phenomenon appears.

With more severe injuries, the premotor zone syndrome is combined with signs of damage to the basal and polar parts of the frontal lobes. In these cases, athetosis-like movements sometimes appear in the fingers of the contralateral limbs, rhythmic contractions of the facial muscles

During a targeted examination of patients with damage to the premotor zone (posterior parts of the 2nd frontal gyrus), a violation of voluntary eye rotation in the opposite direction is noted, while involuntary rotation is preserved. In the first hours after injury, it is often possible to detect a short-term deviation of the eyeballs towards the contusion focus of the frontal lobe.

Anterior central gyrus syndrome. The most common signs of damage are central paresis of the facial and hypoglossal nerves, mild tendon anisoreflexia of the limbs in the half of the body opposite the site of injury.

Treatment

The severity, uniqueness of the course and clinical manifestations of combined and multiple maxillofacial injuries, the complexity of determining the tactics of providing assistance for them dictate the need for a special approach to the treatment of this category of victims.

At the prehospital stage, medical care mainly consists of carrying out anti-shock measures, immobilizing bone fractures of the musculoskeletal system, and applying aseptic dressings to wounds. All victims with combined trauma at the scene of the incident should thoroughly clean and examine the oral cavity, palpate the bones of the facial skeleton and determine or exclude damage to the maxillofacial localization.

Every victim with facial injuries due to combined trauma is potentially dangerous in terms of the development of acute external respiratory disorders, and subsequently aspiration pneumonia, measures to prevent which must be carried out at all stages of treatment. During transportation of victims, it is necessary to ensure the patency of their respiratory tract and the outflow of discharge from the mouth and nose (mucus, blood, vomit). If possible, the victims are placed on their stomach or side, with their heads turned towards the facial injuries. When applying bandages to facial wounds, it must be taken into account that in case of fractures of the bones of the facial skeleton, they can cause additional displacement of fragments and make breathing difficult. Victims with confusion or loss of consciousness should undergo intubation and pharyngeal tamponade to prevent aspiration of oral contents, blood or cerebrospinal fluid flowing down the back wall of the pharynx. If intubation is not possible, S-shaped air ducts should be used to prevent obstruction and retraction of the root of the tongue.

Victims with combined trauma should be hospitalized in an emergency hospital or other multidisciplinary surgical hospital that carries out ambulance duties.

The best option is to hospitalize such victims in a multidisciplinary hospital, which, in addition to the maxillofacial department, has well-developed anesthesiological and resuscitation services.

Immediately after admission to the emergency department, an examination of the victim begins, and, if necessary, resuscitation measures or intensive therapy are simultaneously carried out. Maxillofacial traumatologists with experience in treating victims with combined trauma should take part in the examination, determination of treatment tactics and its implementation, along with specialists from other surgical profiles. To determine the nature of damage to the maxillofacial localization, clinical and radiological research methods are used. Clinical methods are the main ones, since X-ray examination of victims with combined injuries, as a rule, can be performed with non-standard installations and its results are not informative enough. Data from a qualified clinical examination in combination with the results of plain radiographs of the brain and facial skull are sufficient to identify facial injuries, draw up a plan and carry out specialized treatment. It is unacceptable to postpone treatment until comprehensive X-ray examination data is obtained.

Specialized treatment of facial injuries with combined trauma can be emergency, urgent and delayed.

Emergency specialized treatment. Includes measures aimed at stopping bleeding and improving external respiration conditions; they are carried out immediately after determining the appropriate indications. Urgent specialized treatment, carried out during the first 2 days, consists of primary surgical treatment of wounds, reduction and temporary or final fixation of fragments of bones of the facial skeleton. It is carried out in parallel or sequentially with surgical treatment of injuries in other locations: primary surgical treatment of wounds, diagnostic and decompressive craniotomy, puncture and drainage of the pleural cavity, laparocentesis, laparotomy, truncation or amputation of crushed limb segments, reduction and fastening of fragments of long tubular bones, etc. Specialized treatment carried out 48 hours after the victim’s admission or later is considered delayed.

System of resuscitation measures and methods of providing emergency and specialized care for combined injuries, including jaw fractures

• Replenishment of circulating blood volume and restoration of hemodynamics (transfusion of blood and its preparations, depending on individual characteristics from 0.5 to 3 liters);
• Ensures airway patency as soon as possible after injury;
• Immobilization of fragments during fractures is ensured in the fastest and most reliable ways;
• Surgical interventions are performed to stop bleeding and eliminate other life-threatening disorders;
• Adrenergic agonists are used to increase vascular tone. Neuroleptics are used for psychomotor agitation and arterial hypertension. Sodium hydroxybutyrate is also prescribed to increase the brain’s resistance to hypoxia;
• The bronchial tree is drained. To combat cerebral edema, urea, sorbitol, Lasix, and glucocorticoids are used;
• Correct the blood coagulation and anticoagulation systems;
• Acid-base balance is corrected. For acidosis, 200-400 ml of 4% sodium bicarbonate is administered, for alkalosis, a 5% solution of ascorbic acid is administered. Potassium chloride is prescribed orally;
• To prevent sepsis, antibiotics are used in massive doses: penicillin (up to 80 million units/day), ceporin (6 g/day), monomycin, etc. Forced diuresis is carried out (Lasix, Hemodez, glucose).

This complex also includes measures to combat anuria, fat embolism and other complications of combined trauma.

It is advisable to begin specialized treatment of facial injuries in a victim with a concomitant injury in the early stages; however, the time of its implementation, volume and nature depend on the severity of the injury and the individual reaction of the victim to the injury.

The experience of using the given methodology accumulated by LNIITO named after. R.R. Vredena showed that in victims of the first group, urgent specialized treatment of facial injuries should be carried out in full against the background of intensive therapy (on average 4-7 hours after injury). In victims of the second group, specialized treatment can be carried out in full, postponing it until stable hemodynamic stabilization (on average 12-24 hours from the moment of injury). In victims of the third group, only emergency surgical interventions aimed at stopping bleeding and combating impaired external respiration are permissible. In patients with severe concomitant trauma, all surgical interventions are preferably performed under endotracheal anesthesia.

Urgent (early) specialized treatment.

The first stage of treatment is primary surgical treatment of wounds, which is carried out according to general rules. Foreign bodies, non-viable tissues, and, if possible, all potential sources of inflammation are removed with special care, and bone wounds are demarcated from the oral cavity. The success of treatment of victims with combined trauma largely depends on the quality of the primary surgical treatment of facial wounds and the nature of their healing.

Treatment of fractures of the facial skeleton.

Treatment of isolated and multiple fractures of the facial skeleton in victims with traumatic shock Idegrees(according to the three-degree classification, M.P. Gvozdev et al., 1980), concussion and mild contusion of the brain should be carried out using generally accepted orthopedic and surgical methods of reduction and immobilization of fragments.

For traumatic shock II And III degree, moderate and severe brain contusions, to reduce and immobilize fragments of the bones of the facial skeleton, atraumatic, simple and reliable orthopedic and surgical methods should be used that do not interfere with resuscitation measures, sanitation of the tracheobronchial tree, facilitating care for victims and not requiring private control from the maxillofacial facial surgeon. Reduction of fragments in comminuted fractures of the bones of the middle zone of the face: nasal bones, walls of the paranasal sinuses, upper jaws, zygomatic arches should be carried out in a certain sequence. First, the fragments of the zygomatic arches are set, then the upper jaws and nasal bones.

Immobilization of facial bone fragments with multiple or unstable fractures has a number of features. In case of comminuted unstable fractures of the zygomatic arches, to maintain the position achieved during reduction, the body of the zygomatic bone is suspended from the bones of the skull on a wire or polyamide loop. To secure fragments of the upper jaws, mouthguard occlusal pads or an individual maxillary splint with occlusal ridges can be used. In case of comminuted unstable fractures of the upper jaws and zygomatic arches with significant displacement, mobility of fragments and sagging of the facial skull, to maintain the position achieved during reduction, suspending the bones of the facial skull to the bones of the brain skull is used. They use the Adams technique, hanging from an individual wire or plastic maxillary splint with occlusal pads, a maxillary denture or a standard plastic spoon. These measures can eliminate or reduce liquorrhea. In cases where it is not possible to immediately set and hold in the correct position the fragments of the bones of the middle zone of the face, in victims with a questionable and unfavorable prognosis, traction is used through a block using a dental wire splint placed on the upper jaw, or using knitting needles passed through the body of the upper jaw. After the general condition of the victim has improved, intermaxillary traction, orthopedic or surgical techniques are used to finally eliminate the displacement of bone fragments and restore the bite.

In case of comminuted fractures of the nasal bones in victims with concomitant trauma, regardless of the prognosis of the acute period of the traumatic illness, it is necessary to reduce the fragments and secure the nasal tissue in a straightened position with two or three small-diameter Kirschner wires. The needles are passed in the transverse direction through fragments of the nasal bones and quadrangular cartilage. This fastening of fragments of the nasal bones is reliable, while the patency of the nasal passages and nasal breathing are restored. The method can be used for nasal liquorrhea.

Treatment of mandibular fractures.

In case of closed fractures of the lower jaw along the dentition and a favorable or questionable prognosis, it is necessary to reduce the fragments and secure them with a single-jaw splint with hooking loops. After the general condition of the victim improves, intermaxillary traction can be applied if necessary. For open fractures of the lower jaw and a favorable or questionable prognosis, osteosynthesis with titanium wire with a cross-section of 0.8-1 mm is indicated. To secure fragments, a simple and low-traumatic suture in the form of one or several single loops should be used. After osteosynthesis, the soft tissue wound is sutured layer by layer and drained. A single-jaw bent aluminum splint or a Vasiliev tape splint is additionally applied to the teeth of the lower jaw and reinforced with quick-hardening plastic. In the postoperative period, daily wound dressings must be performed for a week for timely detection and removal of hematomas. Graduates should be removed no earlier than the 4-5th day after surgery. In case of a serious condition of the victim and the need to limit the scope of surgical intervention, it is advisable to use osteosynthesis of fragments of the lower jaw with knitting needles.

In case of fractures of the condylar processes of the lower jaw with slight displacement of the fragments, combined with a fracture of the upper jaw that does not require reduction, fastening can be carried out with a maxillary splint and occlusal pads in combination with the elastic traction of a tubular bandage. In case of comminuted bilateral fractures of the rami or condylar processes with displacement of the condyles, skeletal traction of the lower jaw must be applied. In this case, the needles are carried out in the chin region of the lower jaw. Plastic spacers are placed between large molars or a maxillary splint with occlusal pads is used. Fixing the upper jaw fragments with an individual maxillary splint must be carried out for at least 3 weeks. In case of combined fractures of the upper jaw and the branches or condylar processes of the lower jaw, this fastening should be continued for up to 4 weeks.

Delayed specialized treatment.

Such treatment is carried out for victims in whom, due to the severity of the condition and unfavorable prognosis, early specialized treatment could not be carried out, as well as in cases of untimely detection of injuries to the maxillofacial localization. The tasks of delayed specialized treatment include the treatment of inflammatory complications that have arisen and their prevention, as well as the final reduction and immobilization of fragments in fractures of the facial skull.

When providing specialized care for combined jaw fractures, certain difficulties are encountered, since there is no consensus on the timing and methods of immobilization of fragments. Many authors believe that, depending on the severity of the victim’s condition, therapeutic immobilization should be postponed for 3-5 days. However, for example, in case of damage to the skull in combination with a fracture of the upper jaw of the upper type, if rigid fixation of the jaw is not ensured, saliva and wound discharge will flow through the cracks of the fracture to the base of the skull, which can subsequently lead to purulent complications from the brain and its membranes , on the contrary, repositioning of the zygomatic bone can be carried out at a later date (up to 4-6 weeks). This is explained by the fact that only thin fibrous adhesions are formed between the fragments, making it possible to place the zygomatic bone in the correct position without much difficulty. Speaking about methods of therapeutic immobilization of jaw fragments with combined, taking into account frequent bronchopulmonary complications, one should strive to avoid intermaxillary fixation. For fractures of the lower jaw, where possible, you should use a single-jaw splint or fix the fragments surgically. For fractures of the upper jaw, the OEK-1 complex shows good results.

PREVENTION OF COMPLICATIONS IN VICTIMS WITH DAMAGE TO THE MAXILLOFACIAL LOCALIZATION WITH COMBINED TRAUMA IN THE ACUTE PERIOD

In victims with combined and multiple trauma, the most common complications are traumatic osteomyelitis, nosebleeds, and aspiration pneumonia. Traumatic osteomyelitis develops when untimely, insufficient or improper fastening of bone fragments does not ensure their immobility. Treatment of local and general inflammatory complications should be carried out according to generally accepted methods. Nosebleeds also occur in victims when there is insufficient immobilization of fragments of the upper jaws during fractures at the upper and middle levels of weakness. The bleeding stops after the bone fragments are securely fastened.

In the acute period of a traumatic illness, aspiration pneumonia is a serious complication. At the hospital stage, without waiting for its clinical manifestations, it is necessary to carry out therapeutic measures aimed at sanitizing the tracheobronchial tree (systematic suction of secretions from the oral cavity, upper respiratory tract, lavage of the bronchi with antiseptic solutions, inhalation of phytoncides), antibacterial therapy, in the absence of contraindications - anti-inflammatory physiotherapeutic treatment. Equally important is the systematic cleaning of natural cavities (oral and nasal cavity, eyes), instillation of a 20% sodium sulfacyl solution several times a day.

The purpose of preventing complications is to organize adequate nutrition for victims. For jaw fractures, liquid food is required for the first 2 weeks, then the diet is expanded depending on the type of fixation of bone fragments and the course of the healing process.

OUTPATIENT FOLLOW-UP TREATMENT AND REHABILITATION OF VICTIMS WITH DAMAGE TO THE MAXILLOFACIAL LOCALIZATION WITH COMBINED TRAUMA

With proper treatment, healing of wounds and bone fractures of the maxillofacial area in victims with combined trauma occurs within the usual time frame, as with isolated injuries of this location. Often, the treatment of such patients is completed in the hospital, before healing of damage to other locations occurs. Such patients do not require outpatient treatment.

Victims with mild combined injuries of other locations can be discharged from the hospital and referred for outpatient follow-up treatment for injuries to the maxillofacial area. It can best be organized in rehabilitation centers at dental clinics.

Despite the correct and complete specialized treatment of facial injuries, victims may remain impaired in its form and function, due to the nature and severity of the injury. These victims require reconstructive operations on soft tissues and the facial skeleton. Such treatment is carried out in specialized maxillofacial hospitals and clinics of medical institutes.

Most victims who have suffered multiple jaw fractures with the loss of a large number of teeth require dental prosthetics, which should be provided as early as possible after the healing of facial bone fractures, even during hospital treatment for injuries to other locations.

Combined injury – damage resulting from exposure to various traumatic

factors (for example mechanical trauma and thermal burn).

Combined radiation damage–– this is a gunshot or non-gunshot wound of the maxillofacial area against the background of damage by radioactive substances causing radiation sickness. The latter can develop due to external irradiation gamma-particles and hard x-rays or upon admission alpha- And beta-particles into the body through the wound, respiratory tract, digestive tract. Radioactive burns are caused by beta-particles and soft x-rays.

In the pathogenesis of acute radiation sickness, the death of dividing cells and lymphocytes is of leading importance. Manifestations of radiation sickness depend on the absorbed dose of ionizing radiation. With radiation sickness, the immunobiological properties of the body are sharply suppressed, which significantly reduces the reparative capabilities of tissues: fractures heal slowly, healing of soft tissues occurs sluggishly and for a long time. Radiation sickness complicates wound healing, and mechanical trauma aggravates the course of radiation sickness (mutual aggravation syndrome).

Depending on the absorbed dose of radiation, there are several degrees of severity of radiation sickness:

When the dose of absorbed radiation is less than 1 Gy, radiation sickness does not occur and it is customary to talk about radiation injury. Mild radiation sickness in humans develops at a dose of absorbed radiation of 1-2 Gy, moderate severity – 2-4 Gy, severe – 4-6 Gy, extremely severe – over 6 Gy. A dose of 10 Gy or higher is absolutely lethal. The severity of radiation sickness largely depends on the presence of concomitant diseases.

During radiation sickness that developed as a result of irradiation, 4 periods (stages) are clinically distinguished:

Iperiod–– primary reactions (initial). It develops in the first 24 hours of radiation injury and can last from several hours to several days (usually up to 2 days). Victims report malaise, dizziness, headache, thirst, dry mouth, and perversion of taste. Hyperemia of the skin, a rise in body temperature, shortness of breath, tachycardia, and a drop in blood pressure are detected. There may be motor restlessness, agitation, and less commonly, lethargy and drowsiness. Meningeal symptoms and increased muscle tone are mildly expressed. There may be cramping pain in the abdomen, bloating, and signs of dynamic intestinal obstruction. Temporary leukocytosis is noted in the blood, ESR is increased. With mild radiation sickness, primary reactions are not clinically detected. At high absorbed doses, the patient's condition is comatose. During this period, it is impossible to carry out primary surgical treatment of the wound, since exposing the patient’s body to additional trauma can undermine its compensatory capabilities. Surgical interventions are allowed only for health reasons.

II period –– hidden (latent, or imaginary well-being). Its duration is 12-14 days (with mild to moderate severity of the lesion). This stage of the disease is characterized by temporary clinical well-being, the disappearance of the above symptoms, and normalization of blood counts. It is optimal for primary surgical treatment, and, if indicated, for secondary treatment (in case of wound suppuration). Thus, in case of combined radiation damage to facial tissues, not early, but delayed primary surgical treatment is performed (from 24 to 48 hours from the moment of injury). It must be immediate, radical and final and end with the mandatory application of closed sutures. Only strict compliance with these requirements makes it possible to provide conditions for wound healing by primary intention before the height of radiation sickness, when even a small non-epithelialized surface can turn into a long-term non-healing ulcer. Novocaine blockade of mechanically damaged tissues is especially indicated. The use of antibiotics is mandatory. Late primary surgical treatment (after 48 hours from the moment of injury), while not preventing suppuration in the wound, still creates more favorable conditions for its course and reduces the severity of infectious complications. When performing primary surgical debridement, tissue should be excised less sparingly than in a conventional wound. It is necessary to carefully remove all (even the smallest) foreign bodies that may subsequently cause bedsores. Bleeding vessels are not just bandaged, but must be sutured (even small ones). If there is bleeding from a large vessel, it is bandaged both in the wound and along its length (usually the external carotid artery). If bleeding occurs in the midst of radiation sickness, it is very difficult, and sometimes simply impossible, to stop due to the manifestation of hemorrhagic syndrome. The teeth located in the fracture gap must be removed, and the sharp edges of the fragments are smoothed. When treating a bone wound, all bone fragments and teeth located in the fracture gap are removed. Bone fragments are reduced and secured (permanent immobilization is performed) using surgical osteosynthesis methods that allow the wound to be tightly sutured (bone suture with wire, knitting needle, staple, bone plates or frames, etc.). Devices with bone clamps are used when it is not possible to apply the indicated methods of immobilizing fragments. Dental splints cannot be used, as they do not exclude injury to the gum mucosa. After reliable fixation of the jaw fragments, the bone wound is carefully isolated from the oral cavity, suturing the mucous membrane. Then the perimaxillary soft tissues are tightly sutured from the outside. It is acceptable to use plastic techniques with local tissues to close defects. The wound is drained with rubber drainers for 24-48 hours and local antibiotics must be administered.

If for some reason the wound could not be sutured tightly, it heals slowly by secondary intention, with significant complications.

It is believed that the duration of the latent period is inversely proportional to the radiation dose. With a significant absorbed dose of radiation, the latent period may be absent altogether, and after the first period, signs of the third period can be immediately determined.

III period–– the period of pronounced clinical manifestations or the height of radiation sickness. Its duration is about 1 month. However, it may take longer to determine. If death does not occur, then III period goes into IV. At the height of radiation sickness, persistent hypotension is determined, hemorrhagic syndrome is expressed, bone marrow function is depressed, agranulocytosis, neurological disorders, changes in skin trophism, vomiting, and diarrhea are noted. Erosion and ulcers form on the mucous membrane of the gastrointestinal tract. The function of the endocrine glands is inhibited. The body's resistance is sharply reduced. Characteristic changes in the oral mucosa. Hyperemia and swelling appear, as well as in the tonsils and pharynx, and painful cracks in the lips and tongue. They are bleeding. Then aphthae and ulcers appear, covered with mucus with a fetid odor. Ulcers can spread into the tissue, bone tissue can be exposed, and with minor trauma to the oral mucosa, the development of necrotizing ulcerative stomatitis is inevitable. Therefore, any dental appliances, poorly fitted removable dentures, poorly made artificial crowns and incorrectly applied fillings can cause the development of necrotic ulcers . To prevent this complication, the oral cavity should be sanitized and dentures should be carefully adjusted during the latent period of radiation sickness. There is no need to remove metal fillings and fixed metal prostheses, since they can be a source of induced radiation only in case of general exposure that is incompatible with life. No surgical interventions are performed except for health reasons.

IV period–– restorative, or recovery period (for mild lesions), or transition to the chronic stage.

Treatment

Immediate evacuation from the active affected area. Removal of radioactive isotopes from the skin, from wounds, from mucous membranes with mandatory dosimetric monitoring. If radioactive substances enter the body, it is recommended to administer a 5% solution of unithiol – 5-10 ml intramuscularly (if polonium is ingested); 10% solution of tetacin-calcium (calcium-disodium salt EDTA) – 20 ml in 500 ml of 5% glucose solution intravenously for 3-4 hours (in case of exposure to heavy rare earth metals and their salts); 10% solution of disodium salt EDTA – 20 ml in 500 ml of 5% glucose solution intravenously (if strontium is ingested). The administration of a hypertonic glucose solution (40-60 ml of 40% solution), 10% calcium chloride solution (10 ml), 5% ascorbic acid solution, antihistamines, and active detoxification therapy is indicated. The administration of barbiturates, analgesics, opium and pyrazolone derivatives, sulfonamides and other drugs that inhibit hematopoiesis is contraindicated.

Wounded people with combined radiation injuries are given complex therapy by dentists, surgeons and therapists with experience in treating radiation sickness. Appropriate therapy should be initiated as early as possible to improve the outcome of traumatic injury and radiation sickness.

Timely and correctly performed primary surgical treatment of combined radiation injuries to the tissues of the face and jaws, proper immobilization of bone fragments, the use of antibiotics, specialized care and balanced nutrition in combination with treatment of radiation sickness contribute to the recovery of the victim and reduce the possibility of an unfavorable outcome.

Facial injuries can be open or closed. Open injuries are accompanied by protrusion of bone fragments of the maxillofacial region (MFA) of the skull into the wound surface.

Injuries to the maxillofacial area occur due to the mechanical impact of a blunt object. In percentage terms, injuries to the maxillofacial area are divided: domestic - 62%; transport - 17%; production - 12%; street - 5%; sports - 4%.

The maxillofacial region has a powerful vascular network and a large array of loose subcutaneous tissue, so injuries to the maxillofacial area are accompanied by significant swelling, hemorrhages, and a seeming discrepancy between the size of the wound and the amount of bleeding. Often, facial injuries are combined with injuries to the facial nerve and parotid salivary gland, injuries to the lower jaw are combined with damage to the nerves of the larynx, pharynx and large vessels.

Urgent Care for injuries of the maxillofacial area:

• relief (if necessary) of signs of acute respiratory and cardiovascular failure;
• to prevent asphyxia, the victim is placed face down, turning his head to the side;
• carry out sanitation of the oral cavity;
• in case of threat of obstructive asphyxia, an S-shaped air duct is installed for the victim;
• bleeding is stopped with a pressure bandage, tight wound tamponade, or application of a hemostatic clamp;
• a pressure bandage is applied to the site of soft bruises;
• the victim is hospitalized in a medical facility.

Damage to teeth

In case of maxillofacial injuries, the following dental injuries occur: crown fracture, tooth dislocation, tooth root fracture.

A fracture of the tooth crown is accompanied by pain, the presence of sharp edges of the remaining teeth, exposed tooth pulp or root canal, and bleeding is possible. When a tooth dislocates, it comes out of its socket and becomes pathologically mobile. With an impacted dislocation, the crown moves inside the alveolar process.

Emergency care for dental damage consists of anesthesia with a 2% solution of novocaine; a cotton ball soaked in 1 g of carboxylic acid, 3 g of camphor and 2 ml of ethyl alcohol is placed on the exposed pulp stump.

A completely dislocated tooth is removed from the socket and then replanted into the same socket. A partially dislocated tooth is reduced and fixed to adjacent teeth with a metal ligature.

Fracture of the alveolar process of the mandible

When a fracture occurs, the alveolar process of the lower jaw is mobile, bleeding from the gums, buccal mucosa, lips, and nosebleeds is observed. In case of damage to the maxillary sinus, foamy blood is released from the wound.

Emergency care consists of removing blood clots, fragments of mucous membrane, and loose fragments of the alveolar process from the mouth to prevent possible aspiration and asphyxia. Local anesthesia is performed with a 2% novocaine solution, the victim is hospitalized in a hospital, where the fracture site is permanently fixed and measures are taken to preserve the teeth.

Fracture of the body of the lower jaw

Such fractures are considered open, primarily infected, since the fracture occurs within the dentition with damage to the mucosa. Most often, the fracture line lies at the level of the fangs and mental foramina, in the area of ​​the lower 8th tooth and the angle of the jaw.

With fractures of the lower jaw, the mobility of mouth opening is limited, the bite is disturbed, there is profuse salivation, bleeding, fragments of the lower jaw are pathologically mobile, multiple fractures can be accompanied by asphyxia due to the retraction of the tongue.

Emergency care consists of removing foreign bodies from the mouth; if necessary, an S-shaped air duct is inserted into the mouth in order to prevent the tongue from retracting and the development of acute respiratory failure. Pain relief is performed with a 50% analgin solution intramuscularly in a volume of 2-4 ml; if it is ineffective, narcotic analgesics are indicated. The victim is hospitalized in the department of maxillofacial surgery. During transportation, a sling bandage is used to temporarily immobilize the damaged jaw.

Dislocation of the lower jaw

Dislocation of the lower jaw can occur with maximum opening of the mouth, trauma, insertion of an endotracheal tube, gastric tube, or mouth dilator.

When the lower jaw is dislocated, the head of the articular process of the lower jaw is displaced beyond the limits of the articular cavity, while the victim cannot close his mouth, he is drooling, and he feels pain in the area of ​​the temporomandibular joint. With a bilateral dislocation, the chin moves downwards, with a unilateral dislocation - to the healthy side.

Dislocation of the lower jaw is treated by reduction. The patient is given anesthesia and seated on a low chair so that his head rests against the headrest and is at the level of the doctor’s elbow joint.

The doctor places his thumbs in the retromolar region of both sides of the lower jaw, and with the remaining fingers covers the outer surface of the jaw from the angle to the chin. After this, the jaw is pressed down with the thumbs, after which the chin is sent upward with the remaining fingers.

After reduction of the dislocation, the patient is given a fixing sling-like bandage for 10-12 days.

Maxillary fracture

There are three types of maxillary fractures:

1. Fracture of the body of the upper jaw above the alveolar process from the base of the pyriform to the pterygoid processes - bleeding from the mucous membrane of the mouth and nose, lengthening of the middle zone of the face, hemorrhage in the conjunctiva, eyelids, impaired closure of teeth.
2. Complete separation of the upper jaw - the symptoms are the same, but the symptom of “glasses” is more pronounced, when the entire upper jaw with the root of the nose is pathologically mobile without movement of the zygomatic bones. A combined fracture of the upper jaw with a fracture of the base of the skull may occur with symptoms of irritation of the meninges.
3. Complete separation of the bones of the facial skull - is characterized by a serious condition of the patient with pronounced signs of damage to the base of the skull.

Emergency care consists of eliminating signs of acute respiratory and cardiovascular failure, cold in the area. Anesthesia is carried out with a 2% solution of promedol in a volume of 2 ml. The damaged jaw is immobilized using a parietal-mental or sling-shaped bandage, and the victim is transported in a lateral position to a medical facility.

Fracture of the zygomatic bone

The victim feels pain and numbness in the area of ​​the wing of the nose and upper lip on the injured side, and a feeling of pressure in the eyes. Examination reveals the symptom of “spectacles”, limitation of movement of the lower jaw, and nosebleeds often develop. The irregularity along the lower orbital edge is determined by palpation.

Emergency care consists of adequate pain relief and cold in place. The victim is hospitalized in a hospital.

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CHAPTER 10 TACTICS OF PROGRAMMED MULTISTAGE SURGICAL TREATMENT OF WOUNDS AND INJURIES (DAMAGE CONTROL SURGERY)

CHAPTER 11 INFECTIOUS COMPLICATIONS OF COMBAT SURGICAL INJURIES

CHAPTER 20 COMBAT CHEST INJURY. THORACOABDOMINAL WOUNDS

CHAPTER 18 COMBAT TRAUMA OF THE MAXILLOFACIAL AREA

CHAPTER 18 COMBAT TRAUMA OF THE MAXILLOFACIAL AREA

Combat injuries of the maxillofacial area amount to gunshot injuries(bullet, shrapnel wounds, MVR, blast injuries), non-gunshot injuries(open and closed mechanical injuries, non-gunshot wounds) and their various combinations.

Injuries to the maxillofacial area are very diverse and cause disruption of important body functions, such as swallowing, breathing, chewing and speech. Gunshot wounds of the jaw during the Great Patriotic War of 1941-1945. accounted for 3.5% of the total number of all injuries ( YES. Entin). In local wars of recent years, the frequency of injuries to the face has increased 1.5-2 times, while the frequency of combined injuries to the face is 4.5-5%, and the proportion of all facial wounds reaches 9% ( N.M. Alexandrov).

18.1. TERMINOLOGY AND CLASSIFICATION OF DAMAGES TO THE MAXILLOFACIAL AREA

Among combat injuries, the most prominent ones are: isolated, multiple and combined injuries (wounds).

Isolated called a trauma (wound) of the maxillofacial area, in which there is one damage.

Multiple trauma (wound) of the maxillofacial area called a trauma (wound), in which there are several damages within the maxillofacial area. Multiple head trauma (wound) is called damage to several parts of the head (frontal area, ENT, organ of vision or brain) as a result of exposure to one or more MS. Simultaneous damage to the maxillofacial area with other anatomical areas of the body (neck, chest, abdomen, pelvis, spine, limbs) is defined as combined injury (wound) of the maxillofacial area.

Gunshot wounds There are some penetrating(in the mouth, nose and paranasal sinuses) and non-penetrating. The nature of the wound channel varies blind, through, tangent injuries . Injuries

MFA include damage to soft tissues, bones of the facial skeleton (upper and lower jaws, alveolar processes and teeth, zygomatic bones), facial organs (tongue, salivary glands), blood vessels, and nerves.

Injuries to the maxillofacial area may be accompanied by the development immediate consequences, i.e. pathological processes developing immediately after damage as a result of disruption of the anatomical structures of the maxillofacial area, of which the most dangerous life-threatening consequences(asphyxia and ongoing bleeding). All these characteristics must be taken into account when making a diagnosis. To correctly construct a diagnosis, a nosological classification is used, which to a certain extent is an algorithm for its formulation (Table 18.1).

Table 18.1. Classification of gunshot wounds and MVR of the maxillofacial area

Non-gunshot wounds of the jaw differ significantly from firearms, since they are usually applied with piercing and cutting objects and do not have areas of primary and secondary necrosis. They become significant when large vessels and nerve trunks (cranial nerves) are damaged by a wounding object, causing life-threatening consequences - the same as with gunshot wounds.

Mechanical injuries of the maxillofacial area depending on the condition of the integumentary tissues there are closed and open, penetrating and non-penetrating. Open injuries are those accompanied by a violation of the integrity of the skin or mucous membrane of the oral cavity, and penetrating injuries are those that communicate with the oral cavity, nose and paranasal sinuses. Fractures of the upper and lower jaw within the dentition are always accompanied by damage to the mucous membrane (attached gum), since in this part there is no submucosal layer, and the mucous membrane is fused with the periosteum.

The maxillofacial area is divided into the middle and lower facial zones.

Middle zone -bounded above by the base of the nose and brow ridges - arc. superciliaris, the posterior edge of the zygomatic bone and the lower edge of the zygomatic arch to a line drawn in front of the external auditory canal, and below - the line of closure of the dentition. The middle zone of the face includes: the nose area, eye sockets, cheekbones, cheek and infraorbital areas.

Injuries to the midface are accompanied by fractures of the nasal bones, damage to the zygomatic-orbital complex and fractures of the upper jaw. The main danger with nasal injuries is continued nosebleeds. Injuries to the zygomatic-orbital complex are usually combined with damage to the walls of the orbit, contusion of the eyeball, and may be accompanied by partial or complete loss of visual function. The second dangerous consequence of injuries to this area is damage to the paranasal sinuses. Due to impaired function of the ciliated epithelium and impaired sinus aeration, post-traumatic sinusitis is a common complication. For adequate diagnosis and treatment of injuries to the zygomatic-orbital complex, the joint work of an oral and maxillofacial surgeon, an otolaryngologist and an ophthalmologist is necessary.

Types of fractures of the upper jaw are presented in Figure 18.1. The most common classification of fractures of the upper jaw

Rice. 18.1. The main types of fractures of the upper jaw according to Lefort: a - Lefort I - craniofacial separation, or upper type of fracture; b - Lefor II - middle type of fracture, c - Lefor III - lower type of fracture

according to Lefort (1900), according to which fractures should be divided into three main types, caused by lines of weakness at the junction of the upper jaw with other bones of the skull. The most severe and difficult to treat are craniofacial separations or the upper type of fracture. This type of damage is combined with a fracture of the bones of the base of the skull and is manifested by the leakage of cerebrospinal fluid from the nose and external auditory canal.

The consequence of fractures of the upper jaw is external bleeding with a high risk of asphyxia due to aspiration of blood into the tracheobronchial tree.

Lower face area - from above it is limited by the line of closure of the dentition, from below - by the body of the hyoid bone and a line drawn along the projection m. mylohyoideus to proc.mastoideus.

Injuries to the lower area of ​​the face may be accompanied by fractures of the lower jaw. Fractures of the lower jaw are divided depending on the nature into single, double, multiple, unilateral or bilateral; by localization: alveolar part, chin and lateral region, angle of the jaw, branch of the jaw (the branch itself, condylar and coronoid process). Isolated fractures usually do not pose major problems in treatment if early adequate reduction and immobilization are performed. Multiple fractures can lead to dislocation asphyxia due to displacement of fragments and retraction of the tongue, obturation

upper respiratory tract thrombus. External bleeding with extensive tissue damage can be intense and lead to massive blood loss and aspiration of blood into the tracheobronchial tree.

Thus, damage to various structures of the maxillofacial area and their consequences are interconnected. They are presented in the form of nosological classification in table. 18.2 and should be taken into account when formulating the diagnosis of a maxillofacial injury.

Examples of diagnoses of injuries to the maxillofacial area.

1. Shrapnel blind wound of soft tissues of the midface on the right.

2. Bullet through wound of the lower area of ​​the face, penetrating into the oral cavity; a fracture of the lower jaw in the area of ​​35-36 and 43-44 teeth and extensive damage and defect of soft tissues. Aspiration of blood into the tracheobronchial tree. Aspiration and dislocation asphyxia. ODN 2nd degree.

3. A bullet through wound of the middle and lower area of ​​the face, penetrating into the oral cavity, with a fracture of the upper jaw in the area of ​​the 14-15 tooth, a fracture of the lower jaw with a defect in the alveolar part and extraction of the 34-36 tooth. Continued external bleeding. Traumatic shock of the first degree.

4. Mine-explosive multiple head wound. TBI. Concussion. Open severe maxillofacial trauma. Extensive damage to soft tissue and bones in the middle and lower areas of the face. Multiple fragmentation wounds penetrating into the maxillary sinuses and oral cavity with fractures of the walls of the maxillary sinuses and the alveolar process of the upper jaw in the area of ​​11-13, 21-23 teeth. Bilateral maxillary hemosinus. Aspiration of blood into the TBD. Dislocation asphyxia. Continued external bleeding. ARF II degree. Acute blood loss. Traumatic shock of the second degree (Fig. 18.2 color illustration).

5. Multiple head trauma. Open severe maxillofacial injury. Fracture of the lower wall of the left orbit with displacement of fragments, mild contusion of the left eyeball. Fracture of the zygomatic arch, anterior and lateral walls of the left maxillary sinus. Fracture of the anterior wall of the maxillary sinus on the right. Bilateral maxillary hemosinus. Multicomminuted fracture of the lower jaw with the formation of a defect in the alveolar region and extraction of 41-43 teeth. Continued external bleeding. Aspiration of blood into the tracheobronchial tree. Traumatic shock of the first degree (Fig. 18.3 color illustration, 18.4).

Rice. 18.4. X-ray of a multiple mandibular fracture

18.2. CLINICAL COURSE AND DIAGNOSTICS OF COMBAT TRAUMA OF THE MAXILLOFACIAL AREA

The clinical course of gunshot wounds of the maxillofacial area differs from the course of similar wounds of other localization in the following main ways: features:

Peculiar, sometimes very pronounced emotional and mental disorders associated with facial disfigurement;

Frequent discrepancy between the type of injury and its severity; frequent multiple nature of injuries within one anatomical area - the “head” (simultaneous damage to the maxillofacial area, brain, ENT organs and organ of vision), which requires the involvement of appropriate specialists in providing assistance; characteristic manifestations of wound infection and shortened healing time of infected facial wounds, which is due to the anatomical and physiological characteristics of the maxillofacial area (rich vascularization, innervation, etc.); the presence of specific secondary RS (teeth); the need for special nutrition and care

these wounded. The symptomatology of wounds and damage to the maxillofacial area is very characteristic, and their diagnosis in most cases is not difficult. Already at inspection In some cases, the wounded person is struck by the pallor of the skin, abundant soaking of the bandage with blood and saliva, shortness of breath and forced positioning, disturbances in chewing, swallowing, breathing and speech. The latter circumstance makes it difficult or even impossible to interview the wounded.

Isolated soft tissue injuries are diagnosed based on visible disorders of the skin of the face and soft tissues of the oral cavity. Damage to the bones of the face, especially the jaws, is diagnosed on the basis of violations of the normal contours of the face and the relationship between the teeth of the upper and lower jaws - malocclusion (Fig. 18.5).

Rice. 18.5. Malocclusion in mandibular fractures

In addition, with jaw fractures, the wounded experience significant pain in the fracture area, which intensifies with the slightest movement of the lower jaw; mobility and displacement of fragments are observed. Displacement of fragments is especially typical for fractures of the lower jaw, and the fragments are displaced so characteristically that this provides grounds for topical diagnosis of the fracture even without an x-ray examination. The displacement always occurs in the direction of traction of the masticatory muscles.

Fractures of the upper jaw are diagnosed by lengthening and flattening of the midface, hemorrhages in the tissue surrounding the eyeball, displacement and mobility of fragments and malocclusion (the latter can only be detected during examination of the oral cavity).

Fractures of the zygomatic bones are recognized by damage to the soft tissue in this area, sometimes by the occurrence of a typical deformation in the form of tissue retraction, as well as by difficulty opening the mouth, which is always observed with these injuries.

Bones faces are palpated in the direction from the forehead to the chin:

Brow ridges;

Lateral edges of the orbits;

Inferior orbital margins;

Elevations of the zygomatic bones;

Zygomatic arches;

Upper jaw;

Nose bones;

Lower jaw.

In addition to the disorders listed above, diagnosed in those wounded in the jaw, it is very important to promptly recognize, especially at the advanced stages of evacuation, the life-threatening consequences of wounds to the face and jaws - bleeding and asphyxia.

Form of asphyxia	Frequency of occurrence,%	Pathogenesis	Help measures
Dislocation		Displacement (relapse) of the tongue, displacement of fragments of the lower jaw	Stitching and fixing the tongue in the correct position, fixing jaw fragments
Obstructive		Closure of the upper part of the breathing tube by a foreign body, blood clot, etc.	Removal of a foreign body, blood clot, and, if impossible, tracheostomy (conicotomy)
Stenotic		Tracheal compression (swelling, neck hematoma)	Tracheostomy (conicotomy)
Valve		Closing the entrance to the larynx with a soft tissue flap	Lifting and suturing the hanging flap or cutting it off
Aspiration		Aspiration of blood and vomit	Suctioning contents from the respiratory tract with a rubber tube inserted into the trachea

Instrumental research methods:

Radiography. To diagnose fractures of the facial skeleton, photographs are taken in several projections.

1. Standard projections (primary x-ray examination):

Photographs of the facial skull in anterior and two lateral projections; - occipitomental projection.

2. Images of the lower jaw (if necessary).

3. Special projections (if the results of the primary study indicate their need):

Photograph of the nasal bones;

Frontal-mental-parietal projection;

Orthopantomography.

Additional Research may be required when providing specialized assistance. They are carried out after stabilization of the wounded person’s condition: CT scan of the bones of the facial skeleton, eye sockets and lower jaw in horizontal and frontal projections; volumetric reconstruction of CT images (DDD mode). In diagnosing the nature of gunshot wounds of the major salivary glands, increasing importance is being attached to Ultrasound - a method widely used in peacetime injury surgery. Videoendoscopy makes it possible not only to identify the source of bleeding, but also to determine the nature of multiple damage to the ethmoidal labyrinth, the walls of the paranasal sinuses (maxillary, frontal sinuses and main sinus), as well as to audit and sanitize them in order to prevent the development of serious infectious complications, such as purulent meningitis and sepsis (Fig. 18.6 color illustration).

18.3. PROVIDING ASSISTANCE AT THE STAGES OF MEDICAL EVACUATION

First and first aid. The main task of first aid to those wounded in the face and jaws on the battlefield is to combat the life-threatening consequences of the wound - bleeding and asphyxia. Some of those wounded in the face are severely disfigured. Unconscious, their face covered in blood, they may appear hopeless or even dead. Therefore, paramedics, medical instructors, orderlies and simply military personnel must learn the rule that the severity of a wound to the face is not always determined by the appearance of the wounded person, and if there are even the slightest signs of life, such wounded people must be urgently provided with medical assistance and evacuated from the battlefield.

Bleeding is controlled by applying a pressure bandage. Most often, circular bandages are applied to the face and secured to the vault of the skull (Fig. 18.7).

For isolated wounds of the chin, upper lip or nose, a sling-shaped bandage is applied. For wounds that penetrate the oral cavity, ordinary bandages become saturated with saliva, which can lead to frostbite on the face in the winter. Based on this, at low ambient temperatures, the bandages are insulated with cotton wool. During the hot season, measures are taken to quench thirst. On the field

Rice. 18.7. Application of a circular bandage for facial wounds

During combat, you can use a flask with a piece of bandage placed in the neck.

In case of severe suffocation, it is necessary to free the oral cavity, pharynx and nasal passages from blood, mucus, vomit, and foreign bodies. To prevent asphyxia, all those wounded in the face, especially those who have lost consciousness, are laid face down or on their side - on the side of the wound. In the same position, the wounded are removed from the battlefield. This ensures better outflow of blood and saliva from the oral cavity and prevents them from entering the respiratory tract. In addition to first aid measures first aid includes the introduction of an air duct to the wounded with asphyxia due to loss of consciousness, mechanical ventilation with a manual breathing apparatus or a KI-4 oxygen inhaler.

First medical aid. To stop bleeding, primary pressure bandages are applied or previously applied pressure bandages are corrected. Only those bandages that are heavily soaked in blood or have become loose and do not cover the wound should be replaced. If the pressure bandage is ineffective, tight wound tamponade or ligation of a bleeding vessel in a wound. If you tie up a vessel in the depths

If it is not possible, it is permissible to leave the applied hemostatic clamp in the wound and secure it securely before evacuation.

Bleeding from the terminal branches of the carotid artery (except the lingual) usually stops on its own after applying a pressure bandage. A standard pressure bandage cannot be applied to injuries to the lower jaw and neck organs (risk of asphyxia!). Therefore, in case of profuse bleeding from the floor of the mouth, pharynx or posterior wall of the pharynx into the lumen of the trachea, which is detected by rapidly increasing suffocation and the release of bloody-foamy sputum when coughing, tracheostomy or conicotomy is performed, and then tight tamponade of the oral cavity and pharynx. To better hold the tampon, the jaws are closed and held in this position with a tight bandage.

In case of asphyxia, it is first necessary to find out its cause. In case of dislocation asphyxia, if the applied bandage does not create support for the tongue, insertion of an air duct or the wounded person is placed on his stomach. For other types of asphyxia, it is necessary to do tracheostomy. It is not recommended to apply sutures to the neck skin wound above or below the inserted tracheotomy cannula. Only with large neck wounds or long incisions is it permissible to apply 2-3 situational sutures. If bloody fluid is released from the trachea when coughing, suction should be used. aspirate blood and saliva flowing into the trachea, and pack the oral cavity and pharynx (Fig. 18.8).

It is necessary to first insert a thin, dense probe through the nose into the esophagus in order to give water to the wounded person.

Transport immobilization for wounded people with damage to the maxillofacial area, it is indicated for bone fractures, extensive soft tissue injuries, damage to the temporomandibular joints, damage to the great vessels and nerves, deep burns and frostbite.

For transport immobilization for jaw fractures, standard and improvised bandages are used, which allow the jaws to be fixed and held in this position for a certain time (Fig. 18.9).

Method of applying a chin splint. In case of fractures of the lower jaw, the support for its fragments is the teeth of the upper jaw. In case of fractures of the upper jaw, on the contrary, the lower jaw with teeth fixes its fragments in the optimal position. A standard headband consists of a supporting headband and

hard chin sling. It is applied over a regular cotton-gauze bandage that covers the wound. First, a supporting headband is applied and secured to the cranial vault. Then a lining of several layers of gauze and cotton wool is placed at the bottom of a rigid chin sling, a sling is applied, which is connected to the headband using elastic bands threaded into it in advance. When applying a headband, the elastic bands should be strictly on the sides of the face. The chin sling should only support the jaw fragments. Therefore, one or two elastic bands are put on each side.

To quench thirst and combat dehydration, those wounded in the face and jaw must be given water from a sippy cup with a rubber tube attached to its tip. During drinking, this tube is passed to the root of the tongue or into the cheek pocket to the back teeth.

To prevent wound infection, tetanus toxoid and antibiotics are administered.

Evacuation of the wounded, who are in serious condition or unconscious, is carried out in a prone position, face down or on their side

Rice. 18.8. Tamponade of the mouth and pharynx

Rice. 18.9. Immobilization with a standard Entin-Fialkovsky transport bandage for a wounded maxillofacial area

(on the side of the wound). In case of severe head injuries, not only immobilization is required, but also “depreciation” of it. A wounded person should be evacuated from a wounded area by placing an overcoat or other soft bedding under his head. Those wounded in a moderately severe wounded area are evacuated while sitting. This makes breathing easier and reduces pain in the wound from vehicle impacts. It must be borne in mind that at the time of injury to the maxillofacial area, a number of wounded people receive a concussion or contusion of the brain, therefore, wounded people with a history of prolonged loss of consciousness should be evacuated in a prone position.

Qualified medical care. All maxillofacial wounded people should be examined by a dentist in the dressing room for the seriously wounded with the bandages removed. The need to examine at this stage of evacuation all those wounded in the face and jaw is dictated, firstly, by the fact that the appearance and general condition of the wounded do not correspond to the actual severity of the injury, which can lead to serious complications during evacuation. Secondly, without removing the bandages from this group of wounded it is impossible to carry out evacuation and transport triage, i.e. determine the order of evacuation, type of transportation and place of further treatment.

According to the clinical course of the injury and the volume of damage those wounded in the ChLO are divided into three groups (Balin V.N., Prokhvatilov G.I., Madai D.Yu.): 1. Severely wounded:- wounded with extensive gunshot wounds of the soft tissues and bones of the maxillofacial area with tissue defects penetrating into the oral cavity, nose and paranasal sinuses, with damage to the temporomandibular joint (TMJ), salivary glands, trunk and branches of the external carotid artery and facial nerve; - wounded with extensive penetrating wounds of the eyelids, nose, ears

shells and lips with their defect; - wounded with detachments of parts and organs of the face (nose, lips, ears

shells and chin); - wounded with extensive gunshot wounds of the soft tissues and bone structures of the maxillofacial area, combined with damage to the ENT organs, eyes, penetrating into the cranial cavity and with damage to organs and tissues of other anatomical areas. The wounded of this group need early specialized care in the 1st turn, i.e. they must be evacuated by helicopter to the 1st echelon MVG without providing medical treatment.

2. Wounded moderate severity who received: - isolated injuries without soft tissue and bone defects

structures penetrating the oral cavity, nose and paranasal sinuses;

Isolated through wounds of the eyelids, wings of the nose, lips and ears without tissue defects;

Extensive injuries to the soft tissues of the face and neck without tissue defects and damage to the bones of the facial skeleton, salivary glands, TMJ, external carotid artery and facial nerve;

Gunshot fractures of the facial skeleton without a bone defect;

Isolated injuries of the alveolar process and teeth within 2 or more functional groups of teeth;

Festering hematomas and infected wounds of the maxillofacial area. The wounded of the 2nd group require early specialized care in the second place, or they can undergo standard staged treatment.

3. Lightly wounded who received: - isolated wounds of the maxillofacial area without defects of soft tissues and bones

and damage to the TMJ, major salivary glands, large branches of the external carotid artery and facial nerve, as well as non-penetrating into the oral cavity, nose and paranasal sinuses; - blind wounds of the eyelids, nose, ears and lips without defect

fabrics; - marginal and perforated fractures of the lower jaw without violation

its integrity; - isolated wounds of the alveolar process within

one functional group of teeth; - extensive tissue bruises and facial hematomas. The wounded of the 3rd group are subject to treatment in the VPGLR and evacuation in order of priority.

Help is provided in first of all to those wounded in the ChLO who need it for life reasons - wounded with asphyxia and ongoing external bleeding.

Elimination of asphyxia provides for the release of the respiratory tract from foreign bodies, bone fragments, tissue scraps, and blood; ensuring airway patency; elimination of tongue retraction. If these measures are ineffective, tracheal intubation or tracheostomy is performed. Inhalation in progress

oxygen using oxygen inhalers, and in severe respiratory failure - mechanical ventilation.

Stopping external bleeding carried out in various ways, depending on the type of bleeding, in particular, by applying hemostatic clamps, ligating blood vessels in the wound, and if these measures are not possible, by tightly tamponade of the wound or its suturing with fixation of tampons in the wound cavity with a ligature, carried out around the lower jaw and the mass of bleeding tissue. In case of bleeding from deep wounds of the face, especially the floor of the mouth, ligation of the external carotid artery along. With extensive and multiple wounds of the face, it is not always possible to determine which vessels are damaged and on which side the external carotid artery needs to be ligated. In such a situation, ligation of both external carotid arteries is acceptable, or a tracheotomy and tight tamponade of the oral cavity and pharynx should be performed (Fig. 18.8). The installed tampon is not removed from the oral cavity and pharynx until admission to the stage of specialized care. The wounded person is fed and fluids are administered through a tube inserted into the esophagus through the nose. It should be considered a rule to organize the provision of food and drink in the medical hospital (omedo) for all those wounded in the face and jaw.

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Security questions

1. List the features of traumatic injuries to the maxillofacial area.

2. What is meant by the concept of “discrepancy between the appearance and severity of damage”? What is the practical significance of this concept?

3. What vital organs and functions are affected by traumatic injury to the maxillofacial area?

4. The presence of what anatomical formations fundamentally distinguishes the maxillofacial region from other areas of the human body?

5. What feature do the vessels of the maxillofacial region have in contrast to the vessels of other areas of the body?

6. What features of the soft tissues of the maxillofacial area contribute to increased regeneration?

7. What are the positive and negative aspects associated with having teeth?

8. Is it possible to use a conventional gas mask for a wounded person, and if not, then why and what is used?

Chapter 3
GENERAL CHARACTERISTICS OF TRAUMATIC SOFT TISSUE DAMAGE MAXILLOFACIAL AREA

Soft tissue injuries can be open or closed.

Open injuries are considered injuries that are accompanied by a violation of the integrity of the integumentary tissues, which include the skin and mucous membrane. These injuries are referred to as a wound. A wound has three main signs - pain, bleeding and gaping (divergence of the edges). A closed injury is characterized by two signs - pain and bleeding. In this case, there is no gaping of the edges of the wound of the skin or mucous membrane. Closed soft tissue injury is manifested by bruises, which are the result of a mild blow to the face with a blunt object with damage to the subcutaneous tissue, facial muscles without tearing them and the vessels located in the affected area. There are two possible bleeding options:

– with the formation of a cavity – when blood flows into the interstitial space, in this case a hematoma is formed;

– imbibition of tissues with blood, that is, saturation of them without the formation of cavities.

Depending on the location, hematomas can be superficial or deep. Superficial hematomas are located in the subcutaneous tissue, and deep hematomas are located in the thickness or under the muscles (for example, under the masseter, temporal), in deep spaces (for example, the pterygomaxillary, in the infratemporal fossa, in the area of ​​the canine fossa), under the periosteum.

Superficial hematoma and imbibition of tissue by blood is manifested by a change in skin color. The skin over the hematoma initially has a purplish-blue or blue color (“bruise”). This color is due to the breakdown of red blood cells with the formation of hemosidirin and hemotoidin. Over time, the color changes to green (after 4–5 days), and then yellow (after 5–6 days); the hematoma finally resolves after 14–16 days.

A hematoma located in the pterygomaxillary, masseteric or subtemporal spaces can cause difficulty opening the mouth. A hematoma formed in the pterygomaxillary, peripharyngeal, sublingual areas and the area of ​​the tongue root can lead to difficulty swallowing. All of the above hematomas are deep, which is why their diagnosis, i.e., determining the presence of hematomas in the indicated spaces, can be difficult.

The presence of a hematoma in the area of ​​the canine fossa, due to compression of the lower orbital nerve, can cause a violation of sensitivity in the area of ​​​​innervation by this nerve (the skin of the infraorbital region and the wing of the nose, the incisors of the upper jaw), which should be taken into account in the differential diagnosis of a hematoma with a fracture of the upper jaw along the lower orbital edge.

Hematomas in the area of ​​the mental foramen may also be accompanied by loss of sensitivity in the area of ​​the chin and lower lip of the corresponding side, which should be taken into account in the differential diagnosis between a soft tissue contusion and a fracture of the lower jaw in this area.

Deeply located hematomas may appear on the skin after 3–4 days. Hematoma is always accompanied by post-traumatic edema. It especially manifests itself in case of injury in the eyelid area. At the same time, it should be remembered that when the infraorbital region is damaged, swelling of the eyelids often occurs not only due to hematoma, but also due to compression of the lymphatic vessels that provide lymphatic drainage, which in turn leads to lymphostasis and swelling of the eyelids. As a result, a hematoma can have three development options: resorption, encapsulation and suppuration. In the second and third cases, drainage of the hematoma is necessary in a hospital setting, followed by anti-inflammatory treatment.

Closed trauma includes skin abrasions, when only the epidermis of the skin is damaged, and superficial damage to the oral mucosa.

3.1. Clinical characteristics of non-gunshot injuries of the maxillofacial area

Characteristics of non-gunshot wounds:

– the wound channel is usually smooth, there is no tissue defect, with the exception of lacerations, bruises and bite wounds;

– the zone of primary necrosis depends on the type of weapon;

– the zone of secondary necrosis is associated with the development of inflammatory processes, the presence of a soft tissue defect, concomitant damage to the bones of the facial skeleton, impaired blood circulation and innervation;

– the severity of the damage is determined by the area of ​​contact of the weapon with soft tissues, the type of weapon, the force and speed of the blow, and the structure of the tissues.

Incised wounds can be caused by a straight razor, safety razor blade, glass shards, a knife or other cutting objects.

The nature of the wound in this case differs significantly from the nature of a gunshot wound. The inlet and outlet openings are usually the same size, the wound canal is smooth, and the tissue along the wound canal is rarely necrotic. The edges of the wound are well brought together and juxtaposed. The edges of damaged blood vessels and nerves are smooth, which greatly facilitates their detection and subsequent ligation or suturing. Penetrating wounds into the paranasal cavities and oral cavity should also be classified as through wounds. In terms of severity, through wounds of the soft tissues of the face are lighter than blind ones. However, if the muscles involved in the movement of the lower jaw, large vessels (facial and lingual arteries), soft palate, large salivary glands (parotid, submandibular, sublingual) are damaged, the clinical course of the injury should be assessed as moderate.

Puncture wounds occur after injury with a sharp, thin weapon (stiletto, needle, bayonet, awl) or any other weapon with a long, thin body. The peculiarity of puncture wounds is that with small visible damage their depth can be significant. The wound channel can affect not only muscles, but also deep-lying vessels, nerves, salivary glands, spaces of the maxillofacial region and cavities. That is why a thorough inspection of the wound and examination of the patient is necessary. Puncture wounds are often accompanied by the development of deeply located purulent processes (cellulitis, abscesses), which is facilitated by infection of the wound, the absence of wound discharge due to the small size of the inlet, and the presence of an interstitial hematoma, which forms in depth and is a good breeding ground for the development of purulent processes.

Chopped wounds. The nature of the chopped wound depends on the sharpness of the chopping weapon, its weight and the force with which the injury was inflicted. Chopped wounds are the result of a blow from a heavy sharp object (for example, an ax). They are characterized by a wide gaping wound, bruising and concussion of tissues, and may be accompanied by damage to the bones of the facial skeleton with the formation of fragments.

Bruised and lacerated wounds- the result of impact from a blunt object. They are characterized by the presence of crushed tissue. The edges of such wounds are uneven. There may be a tissue defect, as well as damage to the bones of the facial skeleton. Blood vessels often become thrombosed, which in turn leads to disruption of the blood supply to the affected area and to necrosis. Hematomas may occur. The course of such wounds due to infection and impaired blood supply is accompanied by the development of an inflammatory process. In this case, the wound heals by secondary intention, scars form, which leads to facial disfigurement. A bruised wound can be patchy.

Bite wounds occur when soft tissue is damaged by human or animal teeth. Characteristic signs of bite wounds are damage in the form of two arcs; in the center - oblong-shaped segments, and at the edges - rounded (funnel-shaped) from the fangs. Bite wounds are characterized by ragged edges, often accompanied by tissue defects, especially protruding parts of the face - nose, lips, ears, and tongue, and a high degree of infection. Complicated wounds heal by secondary intention with the formation of deforming scars. In case of soft tissue defects, plastic surgery is necessary. The pathogens of syphilis, tuberculosis, HIV infection, etc. can be transmitted through a bite.

When bitten by animals (dog, cat, fox, etc.), infection with rabies or glanders (horse) can occur. Therefore, it is necessary to find out which animal caused the bite (domestic, stray or wild). In all cases in which it is impossible to determine the condition of the animal, immunization against rabies is necessary, which is carried out by a trauma surgeon who has special training in providing anti-rabies care to the population. Immunization is carried out in outpatient or inpatient settings in accordance with the instructions for the use of anti-rabies drugs.

Non-gunshot wounds can be combined with the presence of a foreign body in the wound. This could be glass, brick, soil, pieces of wood, i.e. those materials that were at the site of the damage. In dental practice, a foreign body can be an injection needle, burs, teeth, or filling material. Their localization is possible in soft tissues, the maxillary sinus, and the mandibular canal. Endodontic instruments should also be considered a foreign body: drill bur, K-file, H-file, channel filler, pulp extractor, spreader, etc.

3.2. Clinical characteristics of gunshot injuries of the maxillofacial area

In the mechanism of formation of a gunshot wound, four factors are of primary importance:

– shock wave impact;

– impact of a wounding projectile;

– exposure to the energy of a side impact, during which a temporarily pulsating cavity is formed;

– impact of the wake vortex.

In case of non-gunshot wounds and damage, only one of four factors matters - the impact of the wounding projectile. Gunshot wounds, unlike non-gunshot wounds, are characterized by tissue destruction not only in the area of ​​the wound canal (primary necrosis), but also beyond it with the formation of new foci of necrosis within several days after the wound (secondary necrosis). Three damage zones can be distinguished:

– wound channel zone;

– zone of contusion or zone of primary necrosis, i.e. zone of simultaneous necrosis of soft tissues due to direct impact;

– zone of commotion (lat. commotio- concussion) or a zone of molecular concussion associated with the action of the force of kinetic energy that occurs when using high-velocity small arms. As a result, a pulsating high-pressure cavity is formed, tens of times larger in diameter than the wound channel and 1000–2000 times longer than the time of passage of the wounding projectile. This explains the appearance of areas of secondary necrosis, which is focal in nature.

The clinical picture of damage to the soft tissues of the maxillofacial region largely depends on the type and shape of the wounding object. Gunshot wounds, unlike non-gunshot wounds, are more severe and are often accompanied by damage to the bones of the facial skeleton, soft tissue defects, and disruption of vital functions (breathing, chewing, etc.).

According to data obtained from a comparative analysis of gunshot wounds of the maxillofacial area during the Second World War and modern LVK, their frequency, depending on the nature of the damage, is distributed as follows:

– end-to-end – 14.6% (VOV) and 36.5% (LVK);

– blind – 79.6% (VOB) and 46.2% (PWD);

– tangents – 5.7% (BOB) and 14.4% (DEF);

The increase in through-and-through gunshot wounds in the LVK compared to the WWII period can be explained by the increasing proportion of the use of high-velocity firearms.

More severe gunshot wounds are through and through. They are characterized by the presence of an inlet, a wound channel and an outlet. While the inlet hole may be small, the outlet hole is several orders of magnitude larger than the inlet hole. This is explained by the fact that when a bullet with a displaced center of gravity is introduced into the body, it, passing through the tissue, turns over and comes out in a transverse position. The presence of a pulsating cavity and the development of kinetic energy leads to extensive destruction along the wound channel. A large amount of necrotic tissue is formed, the edges of blood vessels and nerves are crushed.

Blind wounds are characterized by an entry hole, a wound channel, and a foreign body.

Foreign bodies are classified according to the following criteria:

1. In relation to Rg rays:

– radiopaque;

– not radiopaque.

2. By location:

– in subcutaneous tissue, in muscles;

– with bone damage;

– in the paranasal cavities;

– in the deep spaces of the maxillofacial region (pterygomaxillary, peripharyngeal, floor of the oral cavity);

– in the thickness of the tongue;

3. By type of wounding projectile:

- fragment;

– teeth that are outside the sockets (secondary wounding projectiles);

- other.

Reasons requiring mandatory removal of a foreign body:

– the foreign body is in the plane of the fracture;

– a foreign body is located near the vessels, which can lead to the development of pressure sores of the vessel wall and the occurrence of secondary early and sometimes late bleeding;

– presence of constant pain;

– restriction of movement of the lower jaw;

– breathing problems;

– prolonged inflammation;

– presence of a foreign body in the paranasal cavities.

The timing and location of foreign body removal depend on the environment in which the injury was sustained. During military operations, the operation to remove a foreign body is determined by the military and medical situation and evacuation conditions.

V.I. Voyachek (1946) identifies four combinations of the ratio of local and general reactions to the presence of a foreign body, on which the time of its removal depends:

1) easy access to a foreign body in the absence of unpleasant consequences associated with it (extraction is carried out under favorable conditions);

2) easy access, but there is a pronounced local or general reaction (removed at the first opportunity);

3) difficult access, but there is no reaction to a foreign body (removed only for special reasons);

4) difficult access, but in the presence of unpleasant sensations or threatening symptoms (removed with the necessary precautions).

In connection with the above, indications for the removal of foreign bodies can be divided into conditional, absolute and relative.

If the presence of a foreign body is safe, does not cause functional impairment and can be easily removed, then such indications relate to conditional and foreign body removal can be performed at any time and at any stage of medical evacuation depending on the medical and military situation.

If removal of a foreign body is not difficult, but its presence is life-threatening, then the indications for its removal are absolute. In this case, the operation is carried out as soon as possible.

If the removal of a foreign body is technically difficult and can lead to greater complications than the presence of the foreign body itself, then the removal is performed when qualified or specialized assistance is provided and then the indications for removal of the foreign body can be considered relative.

In peacetime, the wounded person is taken to a hospital, where he should be provided with specialized care to remove the foreign body. In the preoperative period, an X-ray examination is necessary. During a standard examination, two X-ray photographs are necessarily taken in two projections - frontal and lateral, in order to determine the localization of the body in space in relation to anatomical landmarks. Other methods of X-ray examination are also possible: orthopantomogram, computed tomography, etc.

During primary surgical treatment, revision of the wound canal and the areas adjacent to it is required. Visual detection of a foreign body is especially important when the presence of non-radiopaque materials is suspected. In the maxillofacial area, additional incisions are not possible to search for a foreign body. In addition to visual examination of the wound canal during primary surgical treatment, endoscopic examination can be used (Samoilov A. S. [et al.], 2006). In case of doubt about the presence of a foreign body, the application of a blind suture during primary surgical treatment is not recommended. A closed suture can be applied after 5–7 days, making sure that there is no inflammatory process. During the entire observation period, in order to reduce the gaping of the wound edges, it is possible to use strips of adhesive tape, apply lamellar or rare sutures (see Fig. 24, 25). In Fig. 4, 5, 6, 7, 8 show examples of foreign bodies of different types and locations.

The severity of damage to the soft tissues of the face depends on the location of the wound, the volume of tissue located in the area of ​​damage, and the type of wounding projectile. However, for any wound, the course of the wound process is typical, which is divided into four periods. (Conditionally, because the transition from one period to another does not occur abruptly, but gradually. During one period, the development of another begins.)

First period is limited to 48 hours and is characterized by traumatic edema due to an increase in the permeability of the vascular wall. Traumatic swelling can last from 3 to 5 days. However, already during this period, signs of necrosis are detected in the muscles and subcutaneous tissue. The discharge from the wound is serous in nature, but by the end of the period the discharge is serous-hemorrhagic in nature, and then purulent.

Rice. 4. X-ray of the facial bones of the skull in a lateral projection. A fragment of a knife is visible in the upper jaw area

Rice. 5. X-ray in the lateral projection of the lower jaw. Gunshot wound with pellets

Rice. 6. X-ray in the lateral projection of the upper jaw. There is an injection needle in the maxillary sinus

Rice. 7. X-ray in the lateral projection of the mandibular ramus. Foreign body - bullet

Rice. 8. Survey radiograph in a direct projection of the skull. Foreign body - Osa system bullet in the maxillary sinus

Second period limited to a period of 3 to 7 days and is characterized by an inflammatory process. Any wound is infected, and wounds of the maxillofacial area can be additionally infected through the adnexal cavities of the nose, oral cavity (penetrating wounds), due to destroyed teeth. The discharge from the wound becomes serous-purulent, then purulent. During this period, purulent “streaks” and the spread of the purulent process into the deep spaces of the maxillofacial region (pterygomaxillary, masseter, root of the tongue, peripharyngeal, temporal and infratemporal fossa, along the neurovascular bundle of the neck into the mediastinum, etc.) are possible. By the end of this period, in case of gunshot wounds, tissues damaged at the submolecular level are demarcated from undamaged ones. Already during this period, phenomena characteristic of the next period are noted: endothelial proliferation occurs in the subcutaneous fatty tissue and muscles, new vessels are formed, which subsequently forms the basis for the development of granulation tissue. Towards the end of the period, cleansing of the wound begins.

Third period lasts 8–10 days and is characterized by wound cleansing and development of granulation tissue. At this time, contraction of the wound begins due to the formation of fibrous tissue from its edges.

Fourth period can last from 11 to 30 days and is characterized by epithelization and scarring. Granulation tissue transforms into collagen fibers and becomes denser. Scar organization and epithelization are underway. The epithelium is formed from the edges of the wound and cannot compete with the rate of development of collagen fibers, since the rate of its growth from the edges of the wound along the perimeter is no more than 1 mm in 7–10 days. This is what determines secondary wound healing, which is always characterized by the presence of a scar.

The course of the wound process of soft tissues of the maxillofacial region differs from wounds of other localizations. Due to anatomical and physiological characteristics, wound healing occurs in a shorter time. Good vascularization, innervation, and the presence of low-differentiated mesenchymal cells of the soft tissues of the face determine good regenerative ability, shorten the wound healing period and make it possible to increase the time of primary surgical treatment of the wound to 48 hours.

The duration of periods of wound healing and the severity of the course depend on factors such as:

– duration of assistance and its adequacy at the prehospital (inpatient) stage;

– general condition of the patient (age, dehydration, nutritional exhaustion, etc.);

– concomitant diseases (CVD, diabetes, chronic kidney disease, liver disease, etc.);

– collateral damage.

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