Treatment of Maxillofacial Gunshot Wound

Injuries

PRESENTER: DR. SIYUM (OMFSR-II)

04/23/2023 MODERATOR: DR. TSEGAYE (OMFS, CONSULTANT) 1
OUTLINE
1. Objectives
2. Introduction
3. Classification of bullets and firearms
4. Physics of ballistics
5. Gunshot wound Classification
6. Management of GSWs
7. Summary
8. References

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1. OBJECTIVES

 To discuss about types of bullets and firearms

 To discuss about the different treatment modalities suggested for gunshot
wounds.

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2. INTRODUCTION
 Gunshot wounds (GSWs) to the maxillofacial region continue to be a major
public health concern in the United States.
 In the United States, the number of deaths per year due to injury by
firearms is approximately 10.4 per 100,000.
 Causes of death due to firearm mortality include accidental discharge of
firearm, suicide, assault by firearm, and firearm discharge of
undetermined intent.

04/23/2023 4
Cont…
 Firearm-related injuries have declined 69% over the past two decades in
the United States.
 The majority of these GSW injuries are nonfatal but do require
hospitalization.
 Overall, 75% of those injured required medical attention, and 80% of those
requiring medical attention were hospitalized.
 Of those injured, approximately 6% of GSWs involve the face, and male
patients make up more than 80% of the population of GSW victims.

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Cont…
 The majority of civilian firearm injuries are sustained from handguns
(86%), followed by shotguns (8%) and rifles (5%).
 Approximately 12% to 14% of unintentional and assault gunshot injuries
involve the head and neck, whereas 51% of self-inflicted gunshot injuries
involve the head and neck.

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3. Classification of Bullets and Firearms
 Components of Ballistic Missiles
A round is one complete unit of ammunition.
This includes the bullet, the cartridge case, the powder, and the primer.
1. Projectile/ bullet: is the missile that is
expelled and strikes the target consisting of
core and jacket
2. Propellant is the accelerant that allows for
expulsion of the projectile from the weapon.
3. Primer is the device for igniting the propellant
and sending the projectile on its flight.
4. Cartridge case is a container that packages
the bullet, propellant, and primer as a single
unit.
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 TYPES OF BULLETS
 Types of bullets that are shaped or composed for a variety of purposes
include:
1. Round nose bullet is blunted at the end.
2. Hollow-point bullet has a hole that creates expansion when a target is
struck, creating greater damage.
3. Jacketed bullet the soft lead is surrounded by another metal, usually
copper, that allows the bullet to penetrate a target more easily.
4. Wad cutter has a flattened front end.
5. Semi-wad cutter is an intermediate between round-nose and wad cutter.

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Cont…

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 Types of Firearms
 There are three types of firearms: handguns, rifles,
and shotguns.
1. Hand Guns
 Is the smallest and the least powerful of all firearms.
 Results in pushing away or stretching of soft tissues
with out creating avulsive wounds.
There are three common types of handguns:
 Single shot pistol: holds only a single round of ammunition & needs
reloading.
 Revolvers :have many firing chambers in a revolving cylinder.
 Semiautomatic: can fire multiple shots.
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 Cont…

 Single shot pistol:

holds only a single  Revolvers: have many firing  Semiautomatic pistols:can
round of ammunition chambers in a revolving fire multiple shots, as
& needs reloading. cylinder where each chamber many as 15 to 19 rounds.
in the cylinder is loaded with a
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single cartridge.
Cont…
2. Rifles
 Is named for the spiral fluting (rifling) carved into the inner surface of its
barrel.
 This creates a self-stabilizing spin to the single bullets it fires.
 Rifles, with long barrels and higher velocities, are very powerful and very
accurate at long distances.
 They have the potential to destroy a large amount of tissue, as they are
high-velocity, high–kinetic energy (KE) projectiles with the tendency to
yaw, tumble, and fragment.

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Cont…
 There is usually an exit wound, which may be stellate and larger than the
entry wound.
 The existence of avulsive soft/hard tissue wounds and significant
fragmentation of bone can be characteristic findings of rifle wounds.

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Cont…

3. Shotguns
 Are smoothbore firearms designed to fire a number of shots.
 Shotguns are similar in external appearance to rifles, but differ in the lack
of rifling inside the barrel, which is the basis for their legal definition.

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Shotguns 14
Cont…
 Shotguns have a large impact area with considerably less range and
accuracy.
 Close-range it causes massive tissue destruction.
 The pellets rarely exit the body by transferring all of the KE to the target.
 There is a higher degree of contamination.

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 Cont…
 Two types of shotgun wound classification systems are described.

1. Sherman and Parrish:

 Classified based on distance in yards
or meters from muzzle to target.
Type I wounds:
Long-range,
Distance is from 7 yards,
Penetration of subcutaneous
tissue or deep fascia.
Fig, facial appearance of a patient sustaining a shotgun wound from a distance having multiple punctate
entry wounds without significant disruption of the facial features. (Sherman and Parrish, class I);
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 Cont…
Type II wounds:
Short range,
Distance from 3 to 7 yards,
There is deeper pellet penetration of
tissue.
Type III wounds:
Distance is less than 3 yards.
Dramatic soft and hard tissue
injuries and avulsion of tissue.

Fig. Significant hard and soft tissue disruption and

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avulsion (Sherman and Parrish, type III) 17
Cont…
2. Glazer and colleagues:
 Described the second classification system for shotgun wounds.
 Their system is based on pellet scatter as follows:-
Type I: pellet scatter is within an area of 25 cm2,
Type II: pellet scatter is within an area of 10 to 25 cm2, and
Type III: pellet scatter is within an area of <10 cm2.

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4. The Physics of Ballistics

 Is the study of motion of a projectile from the instant of firing until impact
at the target and is divided into three distinct phases:
1. Internal ballistics: motion of a projectile from the time of propellant’s
ignition until the projectile exits the gun barrel.
2. External ballistics: phase of free flight of the projectile from the time it
exits the gun until it reaches the target.
3. Terminal ballistics: deals with the effect of the projectile on the target.

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Cont…
 There are three basic determinants of the external ballistics of the bullet:
1. Mass of the bullet (the greater the mass of the bullet, the harder it is to
propel with the same amount of gunpowder),
2. The amount of gunpowder in the cartridge (the larger the amount of
gunpowder, the greater the explosion),
3. The length of the barrel (the longer barrels, for example, the rifle, are
able to attain significantly higher bullet velocities than handguns).

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Cont…
 Three key terminologies are important in
understanding external ballistics:
Yaw: rotation of the nose of the bullet
away from the line of flight.
Increases the destructive capacity of the
projectile.
Precession: an angular force applied to a
rotating object caused by its torque
rotation of the bullet around the center of
mass.
Nutation: small circular movements at the
bullet tip.
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Cont…
 A short, high-velocity bullet begins to yaw more severely and turn, and
even rotate, upon entering tissue.
This causes more tissue to be displaced, increases drag, and imparts more of the KE
to the target.
 A longer, heavier bullet might have more KE at a longer range when it hits
the target, but it may penetrate so well that it exits the target with much
of its KE remaining.

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 Cont…
 Kinetic energy (KE) is equal to half the product of the mass (M) and velocity
squared (V2): KE = ½MV2.
 Doubling the mass doubles KE, but doubling the velocity quadruples KE.
 The total energy released to the target can be represented by:
Change in KE = KE entry − KE exit
 Higher KE, which is increased by increasing bullet mass or velocity, has higher
potential for wounding.
 However, if the exit KE is still high, then relatively minor tissue damage may
result.

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Cont…
 Handguns and shotguns are low to medium velocity.
 Some of the ballistic energy may be transferred to bone fragments, teeth,
and dental prostheses, converting them to secondary projectiles that cause
additional injuries.
 Two major mechanisms of wounding occur:
1. Crushing of the tissue struck by the projectile, forming a permanent
cavity.
2. Radial stretching of the projectile path walls, forming a temporary
cavity.

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Cont…
 The effect and damage of the temporary cavitation can vary greatly
depending on the elasticity of the injured tissue, the size of the cavity, and
its anatomic location.
 Temporary cavitation, which follows the path of least resistance, causes
shearing and compression, sometimes tearing structures or stretching
inelastic tissue similar to blunt trauma.

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Cont…
 Less elastic tissues (e.g., brain, liver, or spleen) fluid-filled organs (heart,
bladder, gastrointestinal tract), and dense tissue (e.g., bone) may be
severely damaged when they are contacted by a large temporary cavity.
 Highly elastic tissues(lung and muscle), are less affected or damaged by
the formation of the temporary cavity.

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Cont…
 Generally, tissue injury or severity is dependent on:
1. The Type of the firearm firing the projectile (rifle vs. handgun);
2. The projectile’s physical characteristics:
Deformation and fragmentation(increases the surface area of the
bullet.
KE(mass and velocity of the missile)
3. The biologic characteristics of the tissues
Example, tissue elasticity.
4. The nature of the projectile—
Example, fully jacketed versus expanding bullet;
5. The efficiency of energy transfer
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5. Gunshot wound Classification
I. Earliest and simplest classification of GSWs are:
1. Nonpenetrating: grazing or blast wound.
2. Penetrating: missile strikes the victim without exiting the body.
3. Perforating: with entrance and exit wounds without more tissue loss.
4. Avulsive injuries: entrance and exit wound with loss of tissue.
II. Typically GSWs are classified as:
1. Low-velocity (<1200 feet/second),
2. Medium velocity (<2000 feet/second),
3. High-velocity (>2000 feet/second).

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6. MANAGEMENT

General Principles
 Gunshot injuries are best managed by standard ATLS protocols.
 Ophthalmologic and neurosurgical consultations if indicated.
Approximately 17% of patients have associated brain injuries, 8% have
associated cervical spine injuries and in 13% have associated eye
injuries.

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I. Airway

 Loss of the airway is the single most likely cause of death in an isolated
GSW to the face.
 Definitive airway can be established through:
 Intubation (required in 25% -36% of patients).
Surgical airway: if intubation is not possible.
 Wounds involving the mandible have the highest rate of intubation (37–
53%) followed by those of the midface (18–36%).
 Gunshot injuries to the neck may result in tracheal damage and require an
emergent surgical airway (cricothyrotomy).

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 Cont…
 Indication for tracheostomy
 Need for easier repair of injuries involving the mandible and midface.
For multiple return trips to the OR for wound débridements.
Anticipated delayed swelling with trauma to the upper aerodigestive tract
including the tongue.
Associated tracheal injuries.
Multiple system injuries with anticipated long-term ventilation.

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II. Hemorrhage Control

 Life-threatening hemorrhage is unusual in civilian gunshot injuries.

 Low-velocity handgun injuries typically do not involve the great vessels.
Demetriades and coworkers reported:
7.5% of patients with isolated GSWs to the face were in shock upon
admission.
28.3% of the total required angiography, and 4% of these required
embolization.

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Cont…
Indications for angiography include:
Expanding hematoma
Bleeding that persists despite local measures.
 Gunshot injuries associated with high-velocity weapons or fractures,
however, can result in significant blood loss.
 The most commonly involved vessels in these cases were the maxillary and
facial arteries.

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 Cont…
Hemorrhage control can be done by:
1. Direct pressure and packing.
2. Foley catheters (for midface bleeding).
3. Temporary reduction of the fracture
4. Angiography and embolization( skull base
injuries)
5. Ligation of multiple vessels is required.
Blind clamping should be avoided due to risk
of damage to other vital structures.

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 Penetrating Neck Injuries
 GSWs involving the face may be associated with an entrance or exit wound
in the neck which is divided into three zones (Monson and colleagues).
Zone I
 Is the area from the clavicles to the cricoid cartilage.
 It contains:
 Inferior aspect of the trachea and esophagus.
Major vessels of the thoracic inlet(common carotid arteries, Internal
jugular veins, and spinal cord.
 Invasive studies recommended: angiography, bronchoscopy, esophagoscopy
 High mortality rate (~12%).
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Cont…
Zone II
 Area from the cricoid cartilage to the angle of the mandible.
 It contains:
Common CA, Internal CA, External CA, Internal JV,
Larynx, hypopharynx, and cranial nerves X, XI, and XII.
 Invasive studies recommended: none
 Most commonly involved in penetrating neck trauma.

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Cont…
Zone III
 Spans the region from the angle of the mandible to the skull base.
 Contains:
Carotid arteries,
Internal jugular veins,
Pharynx along with multiple cranial nerves exiting the skull base.
 Studies recommended: angiography, bronchoscopy, esophagoscopy
 It should be appreciated that GSWs that involve mandibular fractures are
accompanied by injuries to zone III.
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Cont…

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 Cont…
 Treatment should be guided by soft signs, hard signs, or no signs(Low and
co-workers )
 Soft signs include:  Hard signs include:

1. Venous oozing 1. Active hemorrhage

2. Non-expanding or non-pulsatile 2. Expanding or pulsatile hematoma
hematomas 3. Bruit or thrill in area of injury
3. Minor hemoptysis 4. Shock unresponsive to initial fluid
resuscitation
4. Dysphonia
5. Massive hemoptysis or hematemesis
5. Dysphagia
6. Air bubbling through injury site
6. Subcutaneous emphysema
04/23/2023
They found 90% of injured patients with hard signs had true injury. 39
 Nutrition
 The majority of civilian GSWs affect young, healthy males.
 Nutritional status becomes an issue only in patients whose injuries
preclude oral alimentation for an extended period (>4 or 5 days).
 Feeding via nasogastric intubation allows bypass of the oral cavity and
improved hygiene in the early days after injury.
 Percutaneous endoscopic gastrostomy can be considered in cases of:
If long-term bypass of the oral cavity is necessary,
If the patient will be unable to eat,
If the patient has a preexisting nutritional deficit.

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 Imaging

I. Standard cervical spine and chest radiographs:

 For visualizing the bullet fragments and to see the path of the bullet.
II. CT scan with three-dimensional reconstructions:
 Allows the surgeon to view the extent of damage to the maxillofacial
skeleton.
III. CT angiography:
Is the gold standard to evaluate vascular damage (for penetrating neck
injuries).
 Allows to intervene with embolization of active bleeding vessels.

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 Cont…

a. Lateral X-ray showing the bullet inferior to the  CXR of the patient shows a( bullet in
laminae of C1–2. the projection of left shoulder. 
b. Axial CT depicting the bullet within the spinal canal.
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Cont…
 Furthermore, these GSW victims may have a bullet fragment traverse
into the chest and/or below the diaphragm.
 The point of the algorithm is that when an exit wound is not found
and plain film head and neck radiographs do not reveal the missile in
local tissues, then another occurrence such as aspiration, ingestion, or
embolization should be suspected.
 The diaphragm is the landmark dividing the chest from the abdomen.

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Cont…
 When the bullet fragment is located above the diaphragm, aspiration or
embolization is suspected, and when it is found below the diaphragm in
the gastric air bubble, we would suspect ingestion.
 Proper assessment, consultation, and communication with other members
of the trauma team will help decrease morbidity for the patient.

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Flowchart for
bullet localization

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 Operative Procedure
 Paralleling the evolution of firearms has been development in the
management of gunshot injuries to the head and neck.
Kazanjian and Converse described their approach to GSWs as three
phases consisting of:
1. Initial débridement and suturing
2. Immobilization of bony fragments with splints and ligatures
3. Reconstruction after healing of the soft tissue.

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Cont…
 Many of the principles developed at that time persist today, with surgeons
advocating a phased approach with delayed closure of wounds,
débridement of tissue, secondary reconstruction.
Many surgeons still advocate closed reduction and division of care into:
1. Early phase (first 10 days)
2. Intermediate phase (10–60 days)
3. Late phase (>60 days).

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Cont…
 The development of rigid fixation techniques and their application to
GSWs was an important advance By allowing:
Early stabilization of bone segments,
Prevention of percolation of contaminated oral fluids.
Possible primary bone healing.
Minimization of scar contracture.
 This has led most surgeons to advocate early definitive repair of the
majority of civilian GSWs, which generally are inflicted with low-velocity
weapons.

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Cont…
Current management principles should be more properly considered
based on:
1. The characterization of the wound as low or high energy
2. The patient profile.
 After evaluation of the wound, a decision is made regarding early definitive
repair versus the need for delayed repair.
 High-energy GSW and blast injuries to the face are more likely to benefit
from serial débridements and delayed closure, especially in the military
arena.

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Cont…
 During debridement
 Extensive débridement of soft tissue is not indicated.
 Wound debris should be removed, and wounds should be lavaged with NS.
 A pulsating irrigator is useful to mechanically agitate debris from the tissue.
 Obvious devitalized and loose teeth should be removed.
 Fractures are reduced and fixed rigidly.

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Cont…
 Teeth should be maintained if possible to aid in restoration of occlusion
and proper jaw relations.
 Drains are often indicated; depending on the wound.
 Pressure dressings can be used to minimize dead space.
 In cases of true soft tissue avulsion, a decision must be made regarding
whether primary flaps or grafting is indicated.
 In wounds that are relatively clean, local flaps and skin grafts may be
appropriate.

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 Cont…
 In grossly contaminated wounds, delayed closure or grafting may be
necessary.
 Free tissue transfer, although useful, should be delayed until
 The initial phase of wound healing
Its accompanying vascular spasm have decreased
Its accompanying hypercoagulable state have decreased.

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Cont…
 In wounds with extensive soft and hard tissue damage and true loss of
soft and hard tissue,
An approach using early stabilization of bone fragments with MMF,
external fixation, or internal fixation with reconstruction plates
combined with conservative management of soft tissue is indicated.
 Second débridements should be performed 24 to 48 hours after the
initial surgery.

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Cont…
This allows for the maintenance of tissue considered “borderline,” which
can be excised if it truly becomes devitalized.
Skin grafts can be used as permanent or temporary replacement for
missing tissue to reduce deformity from scar contracture.
Once the soft tissues have stabilized, a decision can be made regarding
early replacement of lost tissues with free tissue transfer or delayed
reconstruction.

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Cont…
 In general, earlier repair leads to improved outcomes:
With less scar contracture
With less resultant deformity.
 Bone grafts at the time of initial surgery may be indicated in the midface.
Again, management strategies should be considered a continuum that is
modified as necessary rather than strict distinct stages.

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 CONTROVERSIES: Early management VS Delayed &
Open VS Closed management
 Proponents exist both for closed management of fractures with delayed
reconstruction and aggressive early management with open reduction of
fractures and replacement of missing tissue as soon as possible.
 Advocates of delayed repair point to a higher incidence of infection and to
benefits of closed treatment.
 Those who advocate more aggressive primary management report
improved functional and aesthetic outcomes.

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I. Early Reconstruction
 Advantages and disadvantages of Early repair over delayed repair:
Advantages:
Improved functional outcomes.
Improved aesthetic outcomes.
Decreased numbers of revision surgeries
Early return to function
Disadvantages:
Infection(16% to 17%).

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Cont…
 Currently, techniques involving open reduction and fixation of fractures
resulting from GSWs seem to be gaining in popularity.
 B/c of the advantages of aggressive early management are appealing.
 Given that most of these injuries are low energy.

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Cont…
Bone Grafting
 Bone grafts are frequently required in the management of GSWs to the
face (avulsive injuries).
 Iliac bone grafts were popular for late reconstruction.
 Surgical dogma was against early or primary bone grafting and stipulated
waiting until soft tissue healing had occurred.
 More recently, the use of bone grafts in the early setting has gained
popularity in an attempt to mitigate soft tissue contracture.

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Cont…
 Gruss and colleagues have published advantages of early bone grafting:
To stabilize and support soft tissues
To decrease scar contracture and distortion.
 Currently:
Many surgeons advocate the use of primary bone grafting in the
midface.
Some surgeons also advocate immediate bone grafting of mandible
defects.

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Cont…
 Clark and colleagues reported a 35% incidence of wound complications in
patients undergoing immediate reconstruction of significantly comminuted
mandible fractures resulting from GSWs.
 But, primary bone grafting was uniformly successful in the cranium and
midface.
 As a result, primary bone grafting in the early phase of GSW management
can be useful, but it should be limited to the upper and midface.

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Cont…
 Maintenance of mandibular segments with rigid reconstruction plates
combined with delayed grafting, distraction osteogenesis or free flap
reconstruction offers a more predictable result, and in most cases, primary
grafting of the mandible is not indicated.

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II. Late Reconstruction
 Once soft tissues injuries have stabilized, definitive reconstruction can
occur.
 Delayed bone reconstructions frequently suffer from a scarred
hypovascular environment that does not support free bone grafts well.
 In addition, there is typically a deficiency in soft tissue that becomes more
pronounced when wounds are opened.
 In these cases, vascularized tissue transfer offers the ability to import soft
tissue and/or bone into the site.

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Cont…
 Futran has offered a review of the Seattle experience in utilizing free tissue
transfer for complex facial trauma in which he outlines the success of free
tissue transfer in the management of avulsive injuries when incorporated
into a three-phase approach.
 Some surgeons have advocated delayed reconstruction in GSWs that
resulted from suicide attempts;
Because of the potential for repeat suicide attempts until patients are
psychologically stabilized.

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Cont…
 Contamination
 It should be remembered that projectiles from firearms are not sterile.
 Contamination can occur from the bullet and also from skin flora and
foreign bodies (clothing) carried into the wound.
 Historically, streptococcal bacteremia was the most important cause of
death on the battlefield in the preantibiotic era.
 Wounds in which the bullet traverses the aerodigestive tract or paranasal
sinuses are at particular risk.

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Cont…
 Devitalized tissue and vascular congestion lead to an ideal environment for
bacterial growth.
 Prophylactic coverage with broadspectrum antibiotics, typically
cephalosporin and tetanus prophylaxis, should be initiated.
 Extensive surgical débridement to prevent infection is rarely indicated in
wounds consistent with low-velocity projectiles.

04/23/2023 66
Cont…
 The need for the removal of bullets must be balanced against the real risk
of increasing damage.
Indications for Bullet removal:
1. Intra-articular bullet fragments due to increased risk of lead toxicity.
2. Brass- or copper-jacketed bullets that are in close proximity to central
or major peripheral nerves because of potential neurotoxicity.
3. If there is risk of bullet embolization.
4. If bullet fragments are potential evidence and an appropriate chain of
custody is required.

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 SPECIALIZED STRUCTURES
Facial Nerve
 Damage to the facial nerve is present in only 3% to 6% of civilian GSWs to
the face.
 Careful documentation at the earliest possible opportunity is important.
 If a functioning nerve becomes nonfunctional secondary to swelling, the
surgeon can be reasonably confident that function will return.

04/23/2023 68
Cont…
 Obvious transection of the nerve requires repair.
 In heavily contaminated wounds, repair should be delayed for 48 to
72 hours, given the possibility that grafts will be required to span
damaged segments.
 Beyond 72 hours, distal branches of the facial nerve will not respond
to a nerve stimulator, making their identification difficult.
 If possible, tagging the branches with suture at the initial surgery is
invaluable.

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Cont…
 Injuries distal to a line dropped vertically
from the lateral canthus (zone of
arborization) do not typically require repair.
Because of the multiple interconnections
distal to this line and the reasonable
expectation of return of function, even if the
nerve is temporarily nonfunctioning.

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Cont…
Salivary Ducts
 Transected salivary ducts may be repaired or ligated depending on the
amount of damage.
 The parotid duct can be repaired over an I.V catheter or polymeric silicone
tubing, which is then sutured to the buccal mucosa.
 It is best to avoid bringing the tubing out of the mouth because of the
tendency for it to be dislodged.

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Cont…
 In injuries that penetrate the parotid-masseteric fascia, there is a potential
for development of a sialocele or fistula.
 These typically resolve with drainage and pressure dressings.
 Aspiration may be required multiple times.
 In addition, removal of any associated foreign bodies may be necessary to
resolve the fistula and hasten healing.
 Dermal grafts can be used at the time of repair

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7. Summary
 Evolution of more efficient weapons continues to force surgeons to
improve techniques of management.
 Improvements in imaging and fixation techniques have resulted in an
evolution in management, with an emphasis on earlier repair and a focus
on improvement in quality of life.

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8. References

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 THANK YOU!!!

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